Published in Refractive Surgery

What Does Refractive Surgery Have to Do With Contact Lens Intolerance?

This post is sponsored by Carl Zeiss Meditec

Is contact lens intolerance leading to drop-out rates in your practice? Learn more about the ZEISS SMILE procedure and how it can correct refractive error in your patients.

What Does Refractive Surgery Have to Do With Contact Lens Intolerance?

What is contact lens intolerance?

Contact lens intolerance (CLI) can hold a different meaning to each patient who experiences its spectrum of uncomfortable symptoms, including irritation, pain, dryness, discomfort, and poor vision. The two main factors that drive contact lens intolerance are increased friction and uneven or insufficient tear distribution due to contact lenses.

Intolerance can be an immediate reaction to a poor fit or the lens material itself. Conversely, it can also impact patients who have been comfortably wearing lenses for months or years. Causes of intolerance are often multifactorial in nature and can be related to the patient’s environment or the lens itself, including mechanical and physical reactions to lens packaging solutions, improper care or wearing regimen, lens materials, poor fit, contact lens-induced papillary conjunctivitis or corneal neovascularization, and new medications, to name a few.1

Contact lens intolerance increases drop-out rates

Understandably, CLI is a source of frustration for both optometrists and patients, and can lead to an increased contact lens dropout rate. However, working closely with patients to solve their problems can be a great opportunity for your practice and lead to stronger doctor-patient relationships and a greater sense of trust—especially when the intolerance is solved, the patient’s discomfort is relieved, and clear comfortable vision is restored.

What happens when optometrists don’t discuss refractive surgery?

“By the time a patient makes an appointment to address their discomfort, they’ve already self-selected themselves for having a problem,” said Sonny Goel, MD and founder of Goel Vision. “They’ve most likely already tried different brands of contact lenses and different types of cleaning solutions, because these are the logical first steps an eyecare provider would recommend. As an OD, if you haven't presented laser refractive surgery as an option, oftentimes a patient will bypass the optometrist and go directly to an  ophthalmologist.”

Because contact lens intolerance involves both discomfort as well as lifestyle disadvantages (if patients must switch to glasses), patients tend to be highly motivated to find a solution that goes beyond palliative measures. Additionally, laser vision correction procedures are experiencing a boom in popularity. The Refractive Surgery Council reported that the laser vision correction procedure volume for the fourth quarter of 2021 was 190,509, which is a year-to-date increase of 32% over 2020.2 As a result, most patients are familiar with the benefits of refractive surgery and will likely be open to a conversation with you, as their primary optometrist.

When you address a patient’s issues head on as their trusted doctor, they will appreciate your honesty, expertise, and guidance, resulting in a stronger doctor-patient relationship, which remains a keystone of care. On the flip side, if your patients don’t feel like you are providing significant treatment options, it’s easy for them to call or walk in for a consultation in one of many surgical centers in their communities—but you may also be missing an opportunity to deepen your bond by guiding them through the process.

How do you know if your patient has contact lens intolerance?

It can be challenging to solve a multifactorial condition like contact lens intolerance. Many optometrists begin with a detailed case history and follow with specific questions to glean insight into pre-existing conditions and gain more information about how long patients wear their lenses each day, how many hours they use digital devices, and what their symptoms are. “Often a patient will mention that they are using both artificial tears or prescription drops, supplements, daily disposable lenses, or other attempts to relieve discomfort,” said Sonny Goel, MD. “This can feel like a never-ending cycle.”

Next, Dr. Goel performs a clinical examination looking specifically for certain signs that can help elucidate if the intolerance is due to the contacts themselves, or from another condition, including dry eye disease, giant papillary conjunctivitis, or keratitis.

A sample exam to discern if a patient’s signs and symptoms are due to contact lens intolerance or dry eye disease may include:

  • Slit lamp examination to check tear production and examine meibomian gland function
  • Schirmer’s test to ascertain tear production
  • Tear break-up time to test how long the tear film layer remains stable after each blink

When is refractive surgery a viable alternative?

For patients whose ocular surfaces don’t do well with contact lenses despite trying new materials and supplies, refractive surgery may be a solution that can result in both enhanced visual acuity as well as lifestyle advantages and comfort. Over the past two decades, refractive surgery has emerged as a viable alternative to contact lenses and glasses to correct refractive error, including myopia, astigmatism, and hyperopia. Current estimates suggest that roughly 2.1 million patients suffering from contact lens intolerance are ideal candidates for refractive surgery.3

What is SMILE and how does it address refractive error?

In 2016, the U.S. Food and Drug Administration (FDA) approved the VisuMax Femtosecond Laser for small incision lenticule extraction (SMILE) procedure to reduce or eliminate myopia in certain patients. In 2018, the FDA expanded the guidelines and issued approval for SMILE to treat myopia with astigmatism.

During the SMILE procedure, a surgeon uses a femtosecond laser to cut at precise and predefined positions and depths within the cornea. The laser’s high peak intensity over a short pulse duration (within a few femtoseconds of time) allows it to harmlessly pass through the upper layer of the cornea while creating micro-precision single holes that form minute cuts in the underlying corneal stroma. The surrounding tissue remains unaffected, and in less than 30 seconds, the laser creates a small, lens-shaped piece of corneal tissue (called the lenticule) inside the cornea. The surgeon then removes the lenticule through a 4 to 6 mm small incision in the outer area of the cornea. This reshapes the cornea and corrects the refractive error.

In the initial clinical trials for approval of SMILE for spherical myopia, 99.7% of eyes achieved 20/40 or better UCVA at 6 months postoperative, and 87.5% had 20/20 or better UCVA.4 Similarly, in data supporting FDA premarket approval, which included both spherical and astigmatic corrections (NCT02430428), 98.6% of eyes achieved a UCVA of 20/40 or better, and 84.2% had 20/20 or better UCVA at 6 months.5

SMILE only requires a small incision rather than a flap and visual recovery is quick. While dependent on a surgeon's recommendation, most patients can resume swimming, contact sports, and daily activities the next day——and even apply makeup. Currently, more than 7 million eyes have been treated by SMILE globally, and to date, the procedure has been featured in more than 700 peer-reviewed articles.6

What are the advantages of the SMILE procedure?*

  • Flapless procedure—SMILE laser surgery is a flapless and minimally invasive refractive surgery. In fact, the laser is used for approximately 30 seconds, and the opening created is about 4-6mm. The entire procedure only takes about 10-20 minutes from start to finish, including the removal of the lenticule.
  • Fewer dry eye symptoms—SMILE could lead to a potentially lower incidence of dry eye syndrome.7 Fewer corneal nerves are disrupted with SMILE, which may lead to fewer postoperative dry eye symptoms.
  • Faster recovery—Due in part to the flapless procedure, patients can expect a quick return to daily activities. Depending upon surgeon recommendations, patients may be able to resume swimming, contact sports, and daily activities the next day—and can even apply makeup. SMILE patients often report better vision just hours after the procedure with acuity sharpening over the next week.
  • Extensive research—Over 7 million SMILE procedures have been performed globally, and more than 700 peer-reviewed papers about SMILE have been published.

* ZEISS: Data on file.

Want to make it easier for your staff to talk to patients? Download the cheat sheet!

How to get your patients talking about contact lens intolerance

1. Encourage your staff to engage patients at check-in. A sample script could be as simple as, “You’re here to discuss your contact lenses? This must be frustrating, but I know the doctor is eager to get to the bottom of this for you.”

2. During the exam, a few quick questions may help differentiate dry eye disease from a patient’s contact lens related issues:

  • Does removing contact lenses from the equation alleviate their dry eye?
  • How many hours a day do patients use screens, which can reduce blink rate and exacerbate symptoms of contact lens intolerance?
  • Does contact lens irritation worsen at or near the end of the day?
  • Are their symptoms caused by meibomian gland dysfunction, persistently unstable and/or deficient tear film causing discomfort and/or visual impairment, accompanied by variable degrees of ocular surface epitheliopathy, inflammation and neurosensory abnormalities?8

3. Decide if your patient is a potential candidate for refractive surgery.
“It’s important to balance the characteristics of the patient’s visual acuity as well as the structure and function of their eyes in order to make a sound clinical recommendation,” said Jeffrey Augustine, OD, ClearChoice LASIK Eye. “I first consister the parameters of refractive error and then take into account the condition, thickness, and shape of the cornea. Sharing this information with the patient helps them feel invested and is key to building trust.”

4. Ask questions to better evaluate where the patient is on their contact lens journey, and whether they are willing to consider an alternative approach to both contacts and glasses. If they are, providing education on the cause of their discomfort is an easy way to ease into a discussion about surgery as a potential solution. Because most patients are familiar with refractive surgery, it’s best to be straightforward and lead with the benefits they will gain from the procedure.

Once a patient has a clear understanding of what may be causing the intolerance, they are typically eager to hear about possible solutions to their discomfort.

5. Talk to your patient about your best recommendations.
“I use illustrations to show a patient the basic techniques behind surgical techniques,” said Dr. Augustine. “Then, I suggest which procedure would be best for their particular refractive error, eye anatomy, corneal thickness, and so on. For example, if the surgeon believes the patient would be most successful with SMILE,9,10 I’ll let them know that we’ve seen fewer cases of transient dry eye after SMILE and there is less of a chance of needing a secondary procedure after SMILE, because it’s a closed system that facilitates rapid biological healing. I’ll also tell them what they can expect in terms of both pre- and post-op steps they will need to take.”

6. When the patient schedules their follow-up appointment, encourage your staff to ask a patient how they are feeling or how the appointment went.
You may also consider offering literature patients can take home with them to learn more and possibly discuss with their families.

Drs. Goel and Augustine have a contractual or paid relationship with Carl Zeiss Meditec, Inc. and may have received financial support.

Read more to discover if SMILE might be the right option for your patients.

1. Nichols JJ, Willcox MD, Bron AJ, et al. The TFOS International Workshop on Contact Lens Discomfort: executive summary. Invest Ophthalmol Vis Sci. 2013; 54: TFOS7–TFOS13.
3. Pucker AD, Tichenor AA. A Review of Contact Lens Dropout. Clin Optom (Auckl). 2020;12:85-94. Published 2020 Jun 25.
4. VisuMax Femtosecond Laser. Small incision lenticule extraction (SMILE) procedure for the correction of myopia. Professional use information. Carl Zeiss Meditec. 2016.
5. Premarket approval. US Food and Drug Administration. VisuMax Femtosecond Laser. Femtosecond laser system for refractive correction. October 25, 2018. Accessed May 2, 2019.
6. ZEISS: Data on file.
7. Yu EY, Leung A, Rao S, Lam DS. Effect of laser in situ keratomileusis on tear stability. Ophthalmology. 2000;107(12):2131-2135.
8. Tsubota K, Pflugfelder SC, Liu Z, Baudouin C, Kim HM, Messmer EM, Kruse F, Liang L, Carreno-Galeano JT, Rolando M, Yokoi N, Kinoshita S, Dana R. Defining Dry Eye from a Clinical Perspective. Int J Mol Sci. 2020 Dec con4;21(23):9271.
9. Moshirfar M, Shah TJ, Masud M, Linn SH, Ronquillo Y, Hoopes PC Sr. Surgical options for retreatment after small-incision lenticule extraction: Advantages and disadvantages. J Cataract Refract Surg. 2018;44(11):1384-1389.
10. Siedlecki J, Luft N, Priglinger SG, Dirisamer M. Enhancement Options After Myopic Small-Incision Lenticule Extraction (SMILE): A Review. Asia Pac J Ophthalmol (Phila). 2019;8(5):406-411.
Eyes On Eyecare Client Team
About Eyes On Eyecare Client Team

Led by our Director of Client Services Dr. Antonio Chirumbolo, OD, the Eyes On Eyecare Client Team leverages innovative content solutions and data-backed insights to create memorable educational content that resonates with eyecare providers worldwide.

Eyes On Eyecare Client Team
How would you rate the quality of this content?