Published in Contact Lens

The Impact of the Ocular Surface On Contact Lens Comfort

Alan G. Kabat, OD, FAAO

Alan G. Kabat, OD, FAAO

Cory J. Lappin, OD, MS, FAAO

Cory J. Lappin, OD, MS, FAAO

This is editorially independent content
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Learn how optometrists can take a proactive approach to ocular surface optimization and contact lens selection and fit to maintain ocular surface health.

The Impact of the Ocular Surface On Contact Lens Comfort
According to current research, the most common reasons cited for discontinuation of contact lens wear—or, in the more common vernacular, contact lens dropout—are lens discomfort (24.4%) and dryness (19.9%).1
When patients are no longer able to remain comfortable in their contact lenses throughout the day, they are likely to resort to other means, usually spectacles, rather than seeking new materials, different contact lens options, or treatment of underlying dry eye and ocular surface disease.
This can translate to patient dissatisfaction and lost practice revenue, both of which can potentially be remedied by proper lens selection, ocular surface optimization, and effective doctor-patient communication.
Although there are numerous considerations and management options that can be implemented when patients report discomfort or dryness with their contact lenses, we can also act preemptively to avoid finding ourselves in this scenario. One of the best strategies to prevent contact lens dropout is to always thoroughly evaluate and maximize ocular surface health whenever fitting or refitting patients in contact lenses.

Taking a proactive approach to contact lens dropout

A large study focusing on office workers revealed that contact lens wearers displayed a 2.37 times greater risk of having dry eye disease symptoms than non-contact lens wearers.2 Of course, it’s always easier to fix a problem when we’re aware of it, but unfortunately, not all patients recognize their limitations, or even recognize that discomfort is not “normal.”
Many individuals will simply tell us that things are “fine” with their habitual lenses, even if that isn’t always the case, oftentimes simply because they are unaware that contact lens wear does not intrinsically have to entail some degree of discomfort. In order to have the greatest success with contact lenses, it is incumbent upon eyecare providers (ECPs) to conduct a comprehensive ocular surface evaluation in all contact lens patients, whether they are new to the practice or have been with us for decades.
We know that dry eye disease is a dynamic process and can gradually develop over time, so even established patients with a long history of comfortable contact lens wear may be showing signs of ocular surface distress. However, if we never look for these early signs of dysfunction, we may not realize something is wrong until the patient develops contact lens discomfort or even lens intolerance.

Common disruptions in ocular surface homeostasis

Contact lenses are amazing devices that are used for their refractive capabilities in visual correction, therapeutically in the form of bandage lenses, and even interventionally with myopia control.3,4 However, contact lens wear also presents a unique homeostatic challenge. Contact lenses have been described quite accurately by some of the foremost key opinion leaders as “purposeful foreign bodies to correct vision.”5
Although they are designed in such a way as to minimize their impact on ocular surface homeostasis and maximize comfort, by placing a foreign body on the ocular surface, homeostasis is intrinsically disrupted.6 Therefore, we will take a look at the various components of the ocular surface and how contact lens wear can impact their function, and vice versa, as well as strategies to balance successful contact lens wear and ocular surface homeostasis.

Tear film

Perhaps contact lens wear’s greatest impact on the ocular surface is on the tear film. When functioning adequately, the tear film provides protection, nourishment, and a stable refractive interface.7 However, when placed on the cornea, contact lenses essentially bisect the tear film into two parts—a pre-lens and a post-lens tear film, which can destabilize the tear structure.2
Consequently, this can result in reduced lipid layer thickness, tear volume, tear film turnover, and tear breakup time, as well as increased tear evaporation and osmolarity.8-10 Due to this effect, patients with a normal tear film may experience symptoms of dryness,11 whereas dry eye patients, who already have a poor-quality tear film, may experience an exacerbation of their symptoms,12 such as irritation, foreign body sensation, redness, or fluctuating vision.3,12
The practical impacts of tear film disruption can include reduced contact lens wear time,13 discomfort,13 increased risk of contact-lens associated complications,14 or even contact lens intolerance and discontinuation.13 The increased evaporation rate associated with an unstable tear film may lead to dehydration of lens materials resulting in tightening of the lens and increased mechanical friction.3
Also, the quality and quantity of tears are critical to successful contact lens wear, as a dysfunctional tear film can cause irritation or discomfort and can even affect the clarity of vision.15 Accordingly, we need to ensure our patients have a healthy ocular surface and tear film capable of supporting contact lens wear.
This starts with systematically evaluating each component of the ocular surface, including the eyelids and lashes, the meibomian glands, lacrimal glands, goblet cells, conjunctiva, cornea, and corneal nerves as dysfunction of any of these elements can potentially affect—or be affected by—contact lens wear.3,12

Eyelids and lashes

The eyelids and lashes provide protection and play a critical role in tear secretion through blinking mechanics. When it comes to contact lens wear and the eyelids and lashes, each can impact the other. Contact lens wear has been associated with an increased incidence of ptosis, which is thought to be from repeated mechanical manipulation of the lids during insertion and removal of lenses rather than lens wear itself.3
Proper blinking behavior is essential for tear secretion, distribution, and renewal of the tear film across the lens and ocular surface.7,16,17 However, contact lens wear can potentially alter blink dynamics, as wearers display an increased blink rate.3 While we know altered blink behavior can play a major role in dry eye, it is incomplete blinking rather than blink rate that tends to have the most impact on dry eye.18 The increased blinking observed in contact lens wear may be secondary to reflex blinking due to the presence of the lens itself.
Eyelid health can also impact contact lens comfort, especially in the context of blepharitis. Demodex are ectoparasitic mites naturally found on our skin, but when they overpopulate it can cause Demodex blepharitis.19 Just like in the average overall population, the presence of Demodex in contact lens wearers is common, as one study found Demodex in 51% of contact lens wearers.20
Additionally, Demodex blepharitis may play a role in contact lens-associated discomfort as 93% of wearers experiencing contact lens intolerance had Demodex blepharitis.21 Additionally, bacterial blepharitis, which can result from overgrowth of normally present staph bacteria species, can produce enzymes that degrade and destabilize the tear film, which can negatively impact contact lens wear.22-24

Meibomian glands

The meibomian glands produce the lipid component of the tear film which is responsible for preventing premature evaporation of the tear film.7 Assessing meibomian structure and function for signs of meibomian gland dysfunction (MGD) is critical in contact lens patients, as the quality of the lipid layer can have a significant impact on successful lens wear.3
That being said, the impact of contact lens wear on the meibomian glands is somewhat controversial, with conflicting findings being reported. However, there are trends that have emerged. It is generally agreed upon that contact lens wear alters meibum composition and increases its melting point regardless of structural changes.3,25
Additionally, contact lens wearers have been reported to have worse obstruction of the meibomian gland orifices in addition to poorer quality meibum, which negatively impacted contact lens wear time.26 The presence of MGD, such as poor meibum expressibility, meibum quality, and reduced lipid layer thickness, has also been suggested to be associated with discomfort in contact lens wearers.27
In terms of changes to meibomian gland anatomy, the impact is less clear. While some studies have found no changes to gland anatomy others have noted gland loss associated with lens wear.3,28 In the studies where gland loss was noted, it was found that loss typically occurs after 1 year of contact lens wear,29 and loss tends to worsen with longer duration of wear,30 although other studies found loss stops after 2 to 3 years of lens wear.31,32
Additionally, the upper glands have been reported to be more affected than the glands of the lower lids, and gland loss tends to start at the distal end of the glands.30 The exact reason for these changes is unknown, however chronic mechanical microtrauma, chronic irritation, inflammation, and/or physical obstruction of meibomian gland orifices by sloughed epithelial cells have all been suggested as contributing factors.3

Conjunctiva

The conjunctiva is critical for immunologic function and production of the mucin component of the tear film as the goblet cells that produce mucins are primarily found in the conjunctival fornices.33 Contact lens wear has been associated with reduced goblet cell density and a subsequent reduction in mucin production, therefore the status of the tear film should be monitored closely in contact lens wearers.3
While standard soft contact lenses typically have little physical overlap and contact with the conjunctiva, the lenses can still potentially impact the structure primarily in the form of lens fit and lens edge interaction.3 Hyperemia associated with contact lens wear is a sign of stress, which can be due to several factors including hypoxia, poor fit, or mechanical irritation.3
This is especially true in cases of circumlimbal injection and limbal staining, which can be a sign of a tight-fitting lens, inadequate lens edge clearance of the limbal region, or excessive lens movement.3 For this reason, assessing lens edge fit and interaction is vital in maintaining ocular surface health.

Lid-parallel conjunctival folds (LIPCOF)

There are several contact-lens-related conditions and findings that are specifically related to interactions with the conjunctiva. Lid-parallel conjunctival folds (LIPCOF) are small folds in the conjunctiva thought to be caused by friction between the lid and the conjunctiva due to dryness of the lens and ocular surface.34 These folds differ from conjunctivochalasis as they are smaller in size and they disappear when the lid is lifted, thereby removing the source of friction, unlike conjunctivochalasis folds that remain.3
It is important to identify the presence of LIPCOF as the finding has been associated with contact lens discomfort, likely stemming from friction between the palpebral conjunctiva and the surface of the lens.3

Giant papillary conjunctivitis (GPC)

Giant papillary conjunctivitis (GPC) refers to the presence of large (~0.3 to 1.0mm) papillae that are thought to develop due to friction and a hypersensitivity reaction between the palpebral conjunctiva and deposits on the lens surface.35,36 It has been shown that GPC is relatively common, as 6 to 12% of hydrogel wearers will eventually develop GPC.3
However, the use of daily disposable lenses significantly decreases the likelihood of developing GPC, therefore it is advisable to refit GPC patients wearing reusable lenses into a daily disposable whenever possible.37

Lid wiper epitheliopathy (LWE)

Lid wiper epitheliopathy (LWE) is another ocular surface condition associated with contact lens wear. The lid wiper region is posterior to the line of Marx on the upper and lower eyelids and is responsible for spreading tears over the ocular surface with each blink.3
However, in cases of dryness, mechanical friction results in irritation of the area corresponding to the lid wiper, which manifests as staining of this region and is referred to as LWE.38 Lid wiper epitheliopathy can occur in non-contact lens wearers, however, it is more common with lens use, likely due to increased friction between a poor wetting lens surface and the lid wiper region.3,39

Cornea

The cornea provides protection and a transparent refracting structure for visual function.40 Given the direct interaction between contact lenses and the cornea, in addition to the disruption to the tear film that protects and nourishes the structure, it comes as no surprise that contact lens wear can have a major impact on corneal health.
Issues such as corneal hypoxia and edema fortunately are less common with modern high Dk lens materials and designs, however, risks for these conditions still exist when lenses are abused.3 Corneal staining, which is a sign of stress or damage to the corneal surface,3 is still relatively common as it is estimated that staining can occur in up to 54% of contact lens wearers, although it may be less common in silicone hydrogels.41
The location and pattern of staining observed in contact lens wear can provide crucial information. For instance, one common staining pattern is an infero-central band of staining referred to as a “smile” pattern. This location corresponds to the area of the interpalpebral fissure and it is thought that excess drying in this region due to incomplete blinking or excess exposure leads to focal desiccation of the lens in this area resulting in a corresponding staining pattern.3
Limbal staining, much like perilimbal hyperemia, can be a sign of excess lens movement or a tight-fitting lens.3,42 It is imperative to closely evaluate the limbal region in contact lens wearers as the limbal stem cells responsible for replenishing the corneal epithelium arise from this region.43 However, if chronic mechanical irritation, hypoxia, or inflammation occurs it can permanently destroy these cells causing limbal stem cell deficiency.44,45

Corneal hypoxia

As previously mentioned, corneal hypoxia is less common with modern high Dk lens materials.3 However, it can still occur with lens misuse, especially overnight wear.3 Hypoxia results in reduced epithelial cell metabolism46 and mitosis,47 as well as epithelial thinning.48 Additionally, hypoxia can increase the binding of bacteria to the corneal surface, increasing the risk of infection.49,50 Corneal edema, also less common with modern lens materials outside of overnight wear, is related to hypoxia.3
A lack of adequate oxygen causes an increase in anaerobic metabolism by corneal epithelial cells resulting in a buildup of lactic acid.3,49,50 This lactic acid byproduct diffuses into the corneal stroma and alters the osmotic gradient causing water to enter the stroma and resulting in edema.3 This manifests as stromal striae or folds and patients may report symptoms of rainbows, glare, or halos.3
Two findings associated with corneal hypoxia and edema are epithelial microcysts and vacuoles, although these, too, are uncommon with modern lenses.3 Epithelial microcysts are thought to be degenerated basal epithelial cells caused by hypoxia that display “reversed” illumination, as they appear dark when retroilluminated.51,52
Microcysts are more associated with hydrogel wear, being a rare occurrence in silicone hydrogels.3 Vacuoles are thought to be due to an accumulation of fluid between epithelial cells and are characterized by unreversed illumination, appearing bright when retroilluminated.53,54

Corneal neovascularization

One complication of contact lens wear that persists even with modern lenses is corneal neovascularization. The cornea is avascular by necessity to maintain optical clarity, however, in instances of chronic hypoxia, abnormal vessel growth can occur with vessels invading the corneal tissue in the form of neovascularization.3
Corneal neovascularization is more common in contact lens abuse, especially overnight wear.3 If left unchecked, this abnormal vessel growth can lead to scarring and negatively impact vision.3 Although the development of relatively minor peripheral neovascularization is unlikely to cause any visual disruptions, its presence is a warning sign and should be addressed, especially if it is progressing.

Nerves

The cornea is the most densely innervated structure in the body with 7,000 nerve endings per mm2.55 The nerves are vital to homeostatic function of the cornea including providing sensation, regulating normal blinking and tear production, and maintaining corneal epithelial cell health and facilitating wound healing.55-66 Contact lens wearers display reduced corneal, lid margin, and palpebral conjunctival sensitivity, suggesting an impact on nerve function.3
However, a reduction in corneal sensitivity tends to be minimal in high Dk lenses, underscoring the importance of oxygen transmissibility in nerve health.3 There is an increase in sensitivity in the limbal region in contact lens wear, however this is thought to be due to the presence of specialized pressure receptors in this area.3
Reduced corneal nerve density has also been shown in long-term contact lens wear.67 Additionally, nerve growth factor (NGF) expression is increased in cases of contact lens discomfort, which is associated with nerve damage and suggests a potential relationship between lens discomfort and nerve dysfunction.8
It is important to note that if the corneal nerves experience too much stress, damage can occur leading to neurotrophic keratitis (NK), which is a loss of corneal sensation that can lead to impaired blinking, tearing, epithelial cell turnover, and wound healing and can ultimately result in vision-threatening ulceration and perforation.55,56,60,62,63-66,68-70
Given the impact of contact lens wear on corneal sensitivity and the fact that contact lens wear, especially lens misuse, has been associated with NK, we should actively be screening our contact lens patients for the disease.71 Fortunately, corneal sensitivity testing can be performed quickly and easily using items found in any clinic, such as taking a cotton wisp and gently touching it against a patient’s corneal surface to assess their sensitivity.72
Contact lens “adaptation” refers to the idea that lens awareness or mild discomfort will improve with continued wear, ostensibly because the patient’s eyes “get used” to the presence of the lens.3 However, the finding that contact lens wearers display reduced corneal sensitivity coupled with the fact that reduced corneal sensation is the hallmark of neurotrophic changes,56,60,62,63,65,73,74 suggests that this “improvement” in comfort may not be a positive phenomenon but rather an early sign of nerve dysfunction.

Therefore, it is again crucial to monitor our contact lens patients’ nerve health through routine evaluations such as corneal sensitivity testing.

Inflammation

A major challenge posed by contact lens wear is that it may be intrinsically inflammatory,6 although this inflammation may be subclinical.3 Using dendritic cells (DCs), which act as biomarkers for an immune response,75 the presence of inflammation in contact lens wear has been assessed.
It was found that there was a transient increase in DCs on the bulbar conjunctiva and lid margin with reusable lenses but not daily disposables, therefore this inflammatory response was believed to be associated with lens deposits and microbes transferred from the lens case rather than the lens itself.3
Similarly, a transient increase in DCs was noted in the cornea, possibly also due to physical microtrauma from the lens itself, but this response was less pronounced in daily disposables.3

The challenge of contact lens discomfort (CLD)

Contact lens discomfort (CLD) poses a unique challenge as it is unrelated to external conditions, that is to say the discomfort experienced by CLD patients is due to the contact lens itself rather than dry eye causing contact lens wear to be uncomfortable.8 Consequently, patients with CLD will only report discomfort when wearing the lens, with the discomfort improving upon lens removal.
While the exact mechanism of CLD is unknown, it is likely a multifactorial condition that can be influenced by lens material, design, or wear schedule.8 Additionally, there is likely a visual component to CLD as well, so optimizing vision is vital to addressing CLD and ensuring successful lens wear overall. Therefore, if a patient is experiencing CLD, ensuring that visual quality is maximized and refitting the patient into a different lens is recommended.

Ocular allergies

Ocular allergies warrant a specific mention when discussing contact lens wear as 40% of contact lens wearers suffer from allergies.76 The itching and mucus production associated with allergies can make contact lens wear difficult, therefore, addressing any allergic component will be essential to successful contact lens wear.
The use of antihistamine-mast cell stabilizer combination drops such as Pataday Once Daily Relief Extra Strength (olopatadine hydrochloride ophthalmic solution 0.7%, Alcon) or Lastacaft (alcaftadine ophthalmic solution 0.25%, AbbVie) are excellent options for allergy management. Additionally, there are contact lenses that elute ketotifen to specifically help mitigate an allergic response.77
Another drop that can be particularly helpful for allergies and environmental irritation in general is Optase Allegro (SCOPE). The drop is safe to use while wearing contact lenses and contains ectoin, an extremolyte, which is a molecule produced by extremophilic microorganisms to help them survive harsh environments.78-80
Ectoin has a high affinity for water molecules, so when placed on the ocular surface it pulls the water molecules of the tear film closer together, creating a “water shield” that helps prevent allergens and irritants from reaching the ocular surface proper and eliciting an allergic reaction.79

Maximizing success: Lens selection and ocular surface optimization

A thorough contact lens evaluation should always include an assessment of the tear film and ocular surface. For those with advanced diagnostic capabilities, a comprehensive workup incorporating symptom questionnaires, non-invasive tear break-up time, tear meniscometry, meibography, lipid layer assessment, and point-of-care testing, such as MMP-9 detection or osmolarity, can provide a wealth of information relative to occult ocular surface disease.
However, even without advanced diagnostic equipment, basic exam techniques can be helpful. Simply asking open-ended questions such as, “Do you ever experience any eye irritation or discomfort?” can go a long way in screening for potential ocular surface disorders. Likewise, the use of our observational skills can key us into potential problems; for example, if a patient blinks frequently while taking their health history or during their preliminary exam workup, this may be reflex blinking due to dry eye.81
Once a patient is behind the slit lamp, we may notice telangiectasia and erythema of the lid margins, suggestive of ocular rosacea, or perhaps an incomplete blink that portends lagophthalmos, which can also complicate lens wear. We may even notice the patient unconsciously rubbing their eyes, suggesting discomfort even if it is not verbalized.
Furthermore, the use of vital dyes like sodium fluorescein and physical manipulation of the lids can yield a wealth of critical information about the status of the tear film, the integrity of the cornea and conjunctiva, lid-globe apposition, blink dynamics, and meibomian gland health, provided one inspects and notes these important structures.
At minimum, all contact lens evaluations should include the following diagnostic elements and patient education:
  • Detailed history of vocational and avocational visual needs and habits
  • Gross observation of the eyes and blink dynamics
  • Subjective refraction, looking for a highly stable endpoint
  • Slit lamp biomicroscopy, with thorough assessment of the:
    • Eyelids (particularly the margins and lashes)
    • Lid-globe apposition and patency of the puncta
    • Cornea and conjunctiva, using sodium fluorescein and/or lissamine green vital dyes
    • Tear film breakup time (invasive or non-invasive)
  • Assessment of contact lens fit
    • Coverage
    • Centration
    • Movement
  • Education surrounding proper contact lens wear and care, and risks associated with misuse, such as:
    • Replacement schedule (daily, biweekly, monthly)
    • Care system (multipurpose, hydrogen peroxide)
    • Avoid sleeping in lenses
    • Topping off solution
    • Frequent changing of lens cases
    • Discontinue lens use if redness or irritation occur

Contact lens selection and care

When it comes to successful contact lens wear, proper lens selection is equally important to optimization of the ocular surface. This starts with an understanding of the lens material properties, design parameters, lens polymers, wear/replacement schedules, and lens care systems. The following section provides an overview of the characteristics and properties of soft contact lenses, however many of these are outside of our control.
Therefore, when fitting lenses, especially in dry eye patients, it is recommended to start by focusing on parameter availability based on the patient’s prescription and then prioritize the factors we can control such as wear and replacement schedule (i.e., daily vs. reusable), fit (diameter), material (hydrogel vs silicone hydrogel), and care system (if a reusable lens is selected).

Contact lens material properties

  • Dk/t
    • Measure of oxygen permeability82,83
    • Value of ~25Dk/t units needed for daily wear3
    • Values of 175 to 211Dk/t units still cannot completely prevent corneal swelling with overnight lens wear3
  • Modulus
    • Rigidity/Flexibility: A lower modulus lens may be perceived as being more comfortable82
  • Lubricity
    • Friction: A lens with higher lubricity will have less friction between the lens surface and the palpebral conjunctiva, especially with blinking,84 and therefore potentially be more comfortable83
  • Wettability
    • Tear spread and adherence: A lens with better wettability will more easily allow the tear film to spread over and adhere to the lens surface83,85
  • Surface treatments
    • Surfactants: Amphiphilic substances that have both hydrophobic and hydrophilic ends that bind to the lens surface and tear film, respectively, improving wettability and comfort82,84,85
    • Plasma treatment: Improves lens lubricity and wettability82
    • Common wetting agents
      • Polyvinyl alcohol: Surfactant82,83
      • Hyaluronic acid: Enhances water retention82,83,86

Contact lens designs

  • Base curve
    • Flatter
    • Steeper
  • Diameter
    • Larger
    • Smaller
  • Lens edge design
    • Rounded
    • Knife
    • Chisel
  • Thickness
Choosing the appropriate lens parameters is critical to ensuring a proper fit. Avoiding a lens that is too tight or too loose, ensuring proper limbal clearance, and lens edge contact will ensure optimal lens-surface interaction.42

Contact lens materials

  • Polymers/Silicone hydrogels82,83,87-89
    • High oxygen permeability
    • Silicone is intrinsically hydrophobic
      • Requires surface treatments
    • Lower water content
    • Lipid deposition
    • “Stiffer” (rigid) modulus
  • Hydrogels82,83,87-89
    • Lower oxygen permeability
    • More hydrophilic
    • Higher water content
    • Protein deposition
    • “Softer” (flexible) modulus
Though there is no clear consensus on which contact lens material provides better comfort, there are potential advantages and disadvantages of the different lens materials. Hydrogels have a higher water content and are more hydrophilic. Hydrogels also have a lower modulus, so the lens may feel “less rigid” than silicone hydrogels.82,83,87,89
However, due to their higher water content they can counterintuitively have a greater propensity for drying out, as water contained within the lens evaporates it can cause water to then be pulled from the tear film resulting in dryness.83,89 Additionally, hydrogels have a relatively lower oxygen permeability compared to silicone hydrogels.82,83,87,89
Silicone hydrogels are highly oxygen permeable due to their silicone content, but silicone is intrinsically hydrophobic making wettability a challenge.82,83,87,89 However, most modern silicone hydrogels have been treated with surface treatments making wettability a relative non-factor.82
Silicone hydrogels also tend to have a higher modulus and therefore be a more “rigid” lens.82,83,87,89 Within the silicone hydrogel category is a unique lens design referred to as a “water gradient” that utilizes a silicone hydrogel core with a high-water content surface which allows for both excellent oxygen transmissibility and a highly wettable surface.42,83,89

Contact lens wear/replacement schedules

  • Daily disposable contact lenses:
    • Deposits negligible3
    • Increased comfort42
    • Care solutions not required42
    • Parameter limitations (relative)
    • Convenience/improved compliance90
    • Potential cost concerns90
    • Environmental concerns90
  • Monthly and biweekly replacement contact lenses:
    • More prone to deposit buildup, lens degradation3,82
    • Variable performance (comfort and vision) with wear duration91
    • Require care solutions91
    • Wider parameters (relative)91
    • Cost-effective
    • Compliance issues42,90
Like comparing lens materials, there are advantages and disadvantages to the different replacement schedules, however when it comes to dry eye and ocular surface disease, daily disposables are often the better option for the vast majority of patients. Daily disposable lenses tend to be more comfortable,42 and although lens deposits can develop on the surface they are negligible because the lens is replaced daily.3
Additionally, daily disposable lenses do not require care solutions which increases convenience while eliminating potential complications associated with care solutions as patients simply discard their lenses after use.42,92 Daily disposable lenses are also associated with a lesser inflammatory response compared to reusable lenses.93
The potential downsides of daily disposable lenses have less to do with the lenses themselves, but rather with outside factors such as higher potential cost and relatively limited parameters when compared to reusable lenses—however both of these factors are gradually becoming less of a concern as the use of dailies becomes more common.90,91
As well, patients may not factor in costs associated with multipurpose solutions and cases that are eliminated with daily disposable wear. Some patients may be concerned about the environmental impact of daily lenses, however many of the contact lens manufacturing companies have lens and lens packaging recycling programs to lessen this impact.90
The advantages of reusable lenses are also external factors—a relatively lower cost and wider parameter availability. However, comfort can potentially be a greater issue as lens deposits on the surface can accumulate with time and the lens can degrade over the wear period.3,82,91
Additionally, the required use of care solutions increases the likelihood of potential compliance issues by pure statistical probability via the introduction of further steps for safe wear, especially as it has been found that 99% of contact lens wearers display at least one contact lens hygiene risk behavior.94

Contact lens care systems

  • Multipurpose:
    • Compliance concerns95,96
    • Two-step (rubbing and rinsing)97
    • Preservative-containing (antimicrobial agents)
      • Polyquaternium-1 (PQ-1) / Polyquad (BAK-derived)95,98
      • Polyhexamethylene biguanide (PHMB)95
    • Potential preservative toxicity95,98,99
  • Hydrogen peroxide:
    • Convenience
    • One step95
    • Preservative-free95
    • Better comfort100
    • Better protection
      • Stronger coverage against acanthamoeba95
Although both multipurpose and hydrogen peroxide care solutions can be used safely and effectively, hydrogen peroxide solutions tend to get the edge. Hydrogen peroxide solutions are a one-step care system, making their use easy and convenient. Additionally, hydrogen peroxide has been shown to provide better lens-related comfort100 and provide better coverage against acanthamoeba.95
Multipurpose solutions, on the other hand, pose a few challenges, including the fact the they require several steps including rinsing and rubbing of the lens, daily replacement of the solution, and routine replacement of the lens case all of which increase the likelihood of noncompliance with each additional step.95,96 Additionally, multipurpose solutions by necessity must have antimicrobial agents to clean and disinfect the lenses, however many of the agents used in multipurpose solutions can be toxic to the ocular surface.95,98

Lens packing solution

  • Borate
  • Phosphate
  • Both potentially cytotoxic to corneal epithelium101
An often-overlooked part of the contact lens system is the lens packing solution (i.e., the solution the lens is stored in the blister pack). This solution has to contain antimicrobial agents to prevent contamination of the lenses. Borate and phosphate are commonly used in packing solutions, but both can be cytotoxic.101
Therefore, it can be beneficial to recommend all contact lens wearers rinse their lenses with sterile saline after removing them from the packing solution and before insertion.

Optimizing the ocular surface

While choosing the appropriate lens will minimize its impact on ocular surface homeostasis and maximize comfort, we should also optimize the ocular surface itself to create an environment that is conducive to lens wear. This begins with identifying any ocular disease present and initiating the appropriate treatment.
Although there are many treatments available that can be beneficial in the management of dry eye and ocular surface disease, including for contact lens wearers, some are foundational treatments that can benefit nearly all dry eye patients and others have shown specific benefits for this group, which are discussed here.

Supplementation

Dietary supplementation is often considered a part of foundational dry eye treatment. The use of a high-quality, re-esterified, triglyceride-based omega-3 fatty acid supplement with a 3:1 EPA to DHA ratio and a combined 2g of EPA and DHA, such as De3 Omega Benefits (PRN Physician Recommended Nutriceuticals) has been shown to improve dry eye and meibomian gland function.102-104
Additionally, the use of omega-3 fatty acid supplementation has been found to be beneficial in improving contact lens comfort.105 The use of antioxidant-based supplements like Blink NutriTears (Bausch + Lomb) that include lutein, zeaxanthin, and curcuminoids, such as turmeric, have been shown to decrease inflammation, increase tear production, and improve ocular comfort.106

Lid hygiene

Lid hygiene is another staple of proper ocular surface care. The use of hypochlorous acid and okra- or tea tree oil-based cleansers can be used to keep microbial populations on the lids and lashes in check, such as:107-114
  • Hypochlorous acid cleansers
    • HyClear (hypochlorous acid 0.01%, Contamac)
    • Optase Protect (hypochlorous acid 0.015%, SCOPE)
    • Avenova (hypochlorous acid 0.01%, NovaBay Pharmaceuticals),
  • Okra-based cleansers
    • ZocuFoam (Zocular)
  • Tea tree oil-based cleansers
    • Advanced Formula 2% Tea Tree Eyelid & Facial Cleanser (PRN/EyeEco)
    • Daily Lid Wipe (Myze)
Otherwise, these microbes can disrupt the tear film and damage the ocular surface in the form of blepharitis and MGD.107-114 Because hypochlorous acid, tea tree oil, and okra-based cleansers are widely available and accessible in different forms, such as sprays, wipes, and foams, the use of such treatments is a key element of foundational dry eye and ocular surface disease management.
What is not recommended, however, is the use of baby shampoo which can actually be detrimental to the ocular surface as it can disrupt the tear film and is relatively ineffective when compared to these other more modern cleansers.19,110

Lubricating/Rewetting drops

Although artificial tears are primarily palliative in nature, they can provide quick relief when needed. Additionally, artificial tears specifically designed for use with contact lenses or any preservative free-drops in general can help improve comfort when wearers experience irritation.115
The use of artificial tears is considered a starting point for intervention, however if a patient reports the need to use drops multiple times throughout the day (i.e., three or more times a day), more advanced treatment is typically necessary.

Warm/Cool compresses

Warm compresses can provide comfort for patients with dry eye and MGD,116 but should be used with caution in patients with ocular rosacea as the heat can dilate pro-inflammatory telangiectatic vessels and exacerbate symptoms.117 These patients may benefit from cool compresses instead, which can also provide soothing comfort.

Lifestyle changes

For some patients, the issue of contact lens dryness and discomfort can be traced to their daily routine, such as extended hours at the computer or working in a dry or dusty environment. Addressing these issues may help to avoid time-consuming and frustrating refits or even contact lens dropout.
Encouraging proper blinking behavior and appropriate visual breaks through blink exercises and the 20-20-20 rule can help promote healthy visual habits in our modern screen-based lifestyle.118

Microblepharoexfoliation

Microblepharoexfoliation with devices such as NuLids PRO (NuLids), BlephEx (BlephEx), and ZEST (Zocular) can be used to quickly debride the lashes and lid margin in-office.119-122
They can also remove pro-inflammatory biofilm, debris, and meibomian gland obstructions that can negatively impact ocular surface health and tear film stability119-122 and make comfortable contact lens wear more difficult.

Immunomodulators

CEQUA (cyclosporine ophthalmic solution 0.09%, Sun Pharmaceuticals), VEVYE (cyclosporine ophthalmic solution 0.1%, Harrow), and RESTASIS (cyclosporine ophthalmic emulsion 0.05%, AbbVie) are cyclosporine-based immunomodulators that reduce inflammation by inhibiting the action of T cells.123 The use of cyclosporine has been shown to be beneficial in patients displaying contact lens intolerance.124
XIIDRA (lifitegrast ophthalmic solution 5%, Bausch + Lomb), is another immunomodulator that inhibits the action of T cells, however it does so through a novel mechanism by blocking the binding of LFA-1 and ICAM at the ocular surface.125,126 Lifitegrast has also demonstrated efficacy in improving comfort in contact lens wearers.127

Antiparasitic

XDEMVY (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals) is the only FDA-approved treatment for Demodex blepharitis (DB). Dosed twice daily for 6 weeks, the drop addresses the root cause of DB by paralyzing and killing the mites and reducing the number of collarettes present at the base of the eyelashes, which are pathognomonic for the condition.128-138

Thermal treatments

Thermal based treatments including LipiFlow (Johnson & Johnson), iLux (Alcon), and TearCare (Sight Sciences) improve MGD by delivering heat at a level sufficient to melt stagnant meibum (42.5°C)139-141 followed by automated,142 integrated,143 and manual gland expression,144 respectively.
Such treatments can be beneficial for contact lens wearers with MGD, as a single treatment with LipiFlow has been shown to increase comfortable contact lens wear time by 4 hours, and can be repeated as needed.145-147

Intense pulsed light (IPL)

Intense pulsed light (IPL) has been shown to improve dry eye by improving meibomian gland structure and function,148-154 destroying proinflammatory telangiectatic vessels associated with ocular rosacea,155-158 decreasing inflammation,148,158-166 and reducing the microbial burden on the lids.148,155,167,168
Currently, Lumenis’ light technology is the only IPL treatment FDA-approved for MGD and dry eye.153 Additionally, IPL treatment has been shown to improve contact-lens related dry eye.169

Punctal occlusion

Although the majority of dry eye patients exhibit issues of tear quality rather than quantity,170 punctal plugs may be beneficial in cases of diminished tear volume. This may be especially applicable to contact lens wearers, as it was shown that the increase in tear menisci associated with plug placement improved comfort with lens wear.171
However, before punctal plugs are placed, it is vital to ensure any inflammation of the ocular surface is well controlled, as patients with ocular surface disease have been shown to have elevated levels of inflammatory factors in the tear film and occluding the punctum in such cases risks creating a “cesspool” effect by keeping a pro-inflammatory tear film on the ocular surface for a longer period of time.172-174 For this reason, temporary plugs can be used to assess the benefits of punctal occlusion before considering longer-term options.
In cases where punctal occlusion may be helpful, the use of crosslinked hyaluronate gel (Lacrifill Canalicular Gel, Nordic Pharma) as a lacrimal filler may provide several benefits over traditional punctal plugs as it does not require punctal sizing, avoids the potential for mechanical irritation posed by silicone plugs, is reversible via irrigation, and has demonstrated efficacy for up to 6 months.175

Biologic/Regenerative treatments

Given the potential impact of contact lens wear on nerve health, it is vital to address any nerve dysfunction present before it progresses to more severe disease.
Therefore, patients displaying neurotrophic keratitis, as shown by reduced or absent corneal sensitivity with epithelial irregularity, persistent epithelial defects, or ulcers depending on stage, can be treated with Oxervate (cenegermin-bkbj ophthalmic solution 0.002% [20 mcg/mL], Dompé), which is a recombinant form of human nerve growth factor that directly addresses the underlying nerve damage and is effective at all stages of the disease.176-179
Other treatments with anti-inflammatory and regenerative properties that can also be beneficial in cases of corneal nerve dysfunction include:180-193

Clinical pearls for navigating dry eye and contact lenses

In our clinical experience fitting contact lenses, especially in populations with dry eye and ocular surface disease, several trends have emerged that can aid in recognizing warning signs at the ocular surface and ultimately help this demographic achieve successful contact lens wear.
  • The development of contact lens intolerance is often the first sign of dry eye disease in many patients, especially if a patient has been previously wearing that same brand of lens comfortably.
  • Do not rely on “adaptation”—if a patient has any degree of discomfort when initially trying a lens, switch to a different lens. The chances are their discomfort will only become more pronounced as the day progresses rather than improve. The goal should be to fit patients into contacts where they are not even aware they are wearing lenses from the start.
  • Redness that occurs with contact lens wear, even if there is no associated discomfort, should be seen as a warning sign that the ocular surface is under stress and the patient should either be refit into another lens and/or any untreated ocular surface disease should be addressed.
  • In our clinical experience, dry eye and ocular surface disease patients tend to find the most success with daily disposable lenses. The frequent replacement schedule provides a major benefit in a population that often struggles to achieve consistent comfortable lens wear with reusable lenses.
  • If a patient is experiencing any level of discomfort even after their dry eye has been addressed, this is a sign the discomfort may be coming directly from their lens and they should be refit.

Conclusion

Contact lenses are powerful medical devices that have numerous uses beyond simply correcting refractive error. However, by their very nature, contact lenses disrupt ocular surface homeostasis once they are placed on the eye.
This presents a unique clinical challenge where we as ECPs have to strike a balance between fitting a lens that will provide excellent visual quality while also minimizing the disruption that inherently occurs when placing a foreign body on the ocular surface.
Achieving this starts with understanding how both contact lens wear and the ocular surface impact one another. From there, we can identify and address any ocular surface diseases, such as dry eye or blepharitis, that can negatively impact contact lens wear and then use our knowledge of lens materials, replacement schedules, and care systems to recommend the best lens choice for our patients.
So, remember, when it comes to the balance of fitting contact lenses and maintaining ocular surface health it is an “and” not an “or” proposition.
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Alan G. Kabat, OD, FAAO
About Alan G. Kabat, OD, FAAO

Alan G. Kabat, OD, FAAO, is the Associate Director of Medical Communications at Eyes On Eyecare and an Adjunct Professor at Salus University. He is an experienced academic clinician, educator, researcher, and administrator with more than 30 years of private and institutional practice. He is a subject matter expert on ocular disease diagnosis and management, with a specialization in anterior segment disease.

Dr. Kabat is an honors graduate of Rutgers University and received his Doctor of Optometry from the Pennsylvania College of Optometry. He completed a residency at John F. Kennedy Memorial Hospital in Philadelphia, PA, and then spent 20 years on faculty at Nova Southeastern University College of Optometry in Fort Lauderdale, FA. Subsequently, he rose from associate to tenured professor in his time teaching at Southern College of Optometry and Salus University.

In addition, Dr. Kabat has consulted for more than 25 companies in the ocular pharmaceutical and medical device space. He has also served as lead medical director in the areas of peer-reviewed scientific publications, continuing medical education, medical market access presentations, and promotional speaker training.

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Alan G. Kabat, OD, FAAO
Cory J. Lappin, OD, MS, FAAO
About Cory J. Lappin, OD, MS, FAAO

Dr. Cory J. Lappin is a native of New Philadelphia, Ohio and received his Bachelor of Science degree from Miami University, graduating Phi Beta Kappa with Honors with Distinction. He earned his Doctor of Optometry degree from The Ohio State University College of Optometry, where he concurrently completed his Master of Science degree in Vision Science. At the college he served as Class President and was a member of Beta Sigma Kappa Honor Society. Following graduation, Dr. Lappin continued his training by completing a residency in Ocular Disease at the renowned Cincinnati Eye Institute in Cincinnati, Ohio.

Dr. Lappin has been recognized for his clinical achievements, receiving the American Academy of Optometry Foundation Practice Excellence award. He has also been actively engaged in research, being selected to take part in the NIH/NEI T35 research training program and receiving the Vincent J. Ellerbrock Memorial Award in recognition of accomplishments in vision science research.

Dr. Lappin practices at Phoenix Eye Care and the Dry Eye Center of Arizona in Phoenix, Arizona, where he treats a wide variety of ocular diseases, with a particular interest in dry eye and ocular surface disease. He is a Fellow of the American Academy of Optometry, a member of the American Optometric Association, and serves on the Board of Directors for the Arizona Optometric Association. He is also a member of the Tear Film and Ocular Surface Society (TFOS) and volunteers with the Special Olympics Opening Eyes program.

More by Cory J. Lappin, OD, MS, FAAO
Cory J. Lappin, OD, MS, FAAO
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