Practice owner Brian Tompkins is a former president of the British Contact Lens Association (BCLA), and divides his time between working in practice and speaking at education meetings around the world. Dr Keyur Patel holds qualifications in both the UK and US, along with Diplomas in Therapeutics, Glaucoma and Sports Vision.
Brian Tompkins and Dr Keyur Patel have over sixty years of contact lens fitting experience between them. At Brian’s UK-based independent practice, alongside fellow Optometrist Debra Grant, their approach has evolved over time to help drive higher levels of success with their contact lens patients, taking advantage not only of improved materials and lens designs, but also new instrumentation, and therapeutic options. In this article they provide clinical insight from the practice, explaining what they do with a new contact lens patient and why.
Brian: “The advent of single fit lenses, empirical fitting, corneal topography-guided fitting and now scleral topography-guided fitting allows practitioners to ‘put something on the eye’ or ‘order a trial’. With the majority of manufacturers having technical services to help you order and modify lenses, even the more ‘complicated’ lenses are getting relatively easier to fit.
So if contact lenses are getting easier to fit and the materials are getting better, why do we still hear about significant contact lens drop out? A study following the retention of new wearers showed that some of the reasons for early drop out are to do with handling difficulties or poor vision.1 We make sure we support patients that are new to contact lens handling and we ensure vision is fully corrected. To optimise comfort we try and select the most comfortable material, modality and lens design.”
Keyur: “This all helps maximise success in contact lenses, but what else can be done? This is where we turn our attention to the patient’s ocular surface, tear film and lid margins. You would not run a marathon without preparation. Likewise, without suitable assessment and preparation of the ocular surface, how can we expect to deliver optimal contact lens comfort?”
Brian: “Clear communication is critical of course, and we take time to help our patients understand what we are doing and why. We find that a patient who understands their eyes, lenses and any treatment that has been recommended is more likely to do well.”
Keyur: “All new contact lens patients undergo the following work up. We are seeking to understand the comfort of their eyes at baseline, the quality of their tear film, and the presence of any changes suggestive of dry eye, such as increased osmolarity or inflammatory markers. Finally, we conduct a very careful assessment of the lid margins. Here we are assessing the meibomian glands in detail, the quality of meibum, and expressibility of the glands, along with the general appearance and condition of the lid margin and signs of blepharitis or Demodex infestation.”
Brian: “Where possible, in our practice we make use of our skilled clinical technicians to perform a number of these preliminary assessments for us. We have the results to hand when reviewing the patient, and of course can add in any additional tests or imagining as we see fit.”
Ocular Surface Disease Index (OSDI)
- A validated standardised dry eye assessment tool which includes symptom and lifestyle-based questions.
- It is important to have baseline information before the tear film is disturbed with a contact lens. If the patient has dry eye symptoms, this will have to be managed to ensure successful wear. We may instigate some relevant treatment and management therapies, and we will also discuss contact lens comfort with the patient to help manage expectations.
- We routinely repeat OSDI at annual aftercare or if the patient presents with a contact lens-related concern
- We use a topographer to measure non-invasive tear break up time (NITBUT) and tear prism height. We find the cold light source and non-invasive nature of these measurements gives us a good impression of the patients tear quality and quantity at baseline.
- We use the TearLab® system (Innovasium Tearlab Corp, CA, USA), and we find these results gives us another valuable baseline marker to determine ocular status at presentation.
- As per advice from the instrument manufacturer, we pay attention to readings that are greater than 300 mOsm/L, or where the difference between eyes is greater than 8 mOsm/L.
- Osmolarity is one of the diagnostic tests recommended in the TFOS DEWS II report for diagnosis of dry eye disease (DED), with higher overall values, and inter-ocular differences, associated with mild-moderate (315 mOsm/L or difference of 11.7 mOsm/L), and severe DED (336 mOsm/L or difference of 26.5 mOsm/L).
- These measurements can be repeated after initiation of treatment to monitor progress.
- Inflammatory markers
- MMP-9 markers are measured using RPS InflammaDry ® (Quidel, CA, USA)
- Although there is ‘no scale’ to grade a positive result, we have seen in practice that patients with a very sore eye will show a ‘brighter pink’ response. With confirmed presence of an inflammatory marker we may consider initiating treatment. For a ‘mild response’ accompanied by mild symptoms, we recommend Optimel (see below). With a stronger response and/or increased symptoms, we prescribe a low penetrating steroid (eg: FML or Lotemax), occasionally moving to a stronger steroid if required.
- Assessment of lid position, laxity and orbit depth (deep set eyes may have difficulty inserting lenses).
- Assessment of lid margin condition: signs of notching, thickening, loss of lashes, blepharitis, cylindrical dandruff/collarettes (sign of Demodex), telangiectasia.
- Meibomian glands: assessment of gland openings, ease of expression and quality of meibum expressed.
- Meibography of upper and lower lids to assess gland drop out and tortuosity.
- Lid eversion: assessment of tarsal conjunctiva and lid wiper area, following staining with Lissamine Green and Sodium Fluorescein.
- Imaging when necessary, either with our digital slit lamp or mobile phone through the eyepieces (Figure 1).
Brian: “Any digital images we capture of course serve as an important part of our clinical records, but they are also invaluable when used to help explain to a patient what you are seeing and why they may need to address a particular issue. That patient may not have heard of blepharitis, but they will understand why their lid margins need attention after we have shown them a magnified view of their Demodex!”
Keyur: “We find digital images are particularly useful for asymptomatic patients. When only the clinician can see the issue, but the patient cannot feel it themselves, it makes an enormous difference to be able to share with them what we have found. It is a fantastic way to educate the patient and have them fully motivated to undertake treatment, some of which can be long-term management of chronic conditions such as blepharitis, Meibomian gland dysfunction and dry eye.”
Brian: “A further advantage of capturing good digital images is that it allows us, along with clinical grading and having patients assign ‘numbers’ to their symptoms, to monitor the patient’s progress over time.”
Our treatment plans
Keyur: “Once a baseline issue has been noted, and the patient educated on what we have found, we move to instigating treatment and management. Some therapies are conducted in practice, and others are given for ongoing use at home.”
The majority of these treatments are well known and long standing, but one is more recently available in practice. Optimel® (Melcare, Aus), is a Manuka honey-based eye drop. Manuka honey has been shown to have antibacterial properties, and be well tolerated by the ocular surface in vivo.2,3 In a clinical trial of patients with evaporative dry eye and meibomian gland dysfunction, Optimel produced significant improvements in meibum quality and significantly reduced the amount of bacteria on the eyelid margin compared to conventional therapy.4 Optimel has been available in Australia and New Zealand for some time, and in the past year we have had access to it in the United Kingdom. We have had positive responses from our patients that have used it.
Brian: “Although this may seem like a lot of detail to cover with a new contact lens fit, especially if that patient is just looking for simple daily disposable soft lens use, we absolutely believe it is worth the effort. Our dropout rate in practice, last year, was minimal, just 13%, with none of the reasons for drop out attributable to comfort issues. Taking the time to understand, and improve where needed, the condition of the ocular surface, tear film and lid margins, can make the difference between a successful happy contact lens wearers and a failure.”
Keyur: “Thinking back to the analogy of running a marathon, there is no point at all in having the best running shoes in the world if you do not prepare your body for the race ahead. We recommend the most appropriate contact lens designs and materials in practice, but preparation of the environment they are worn in can make an enormous difference to the ability of the patient to wear that lens comfortably.”
- Sulley A, Young G, Hunt C, McCready S, Targett MT, Craven R. Retention Rates in New Contact Lens Wearers. Eye Contact Lens 2017;44 Suppl 1:S273-S282.
- Craig JP, Rupenthal ID, Seyfoddin A, et al. Preclinical development of MGO Manuka Honey microemulsion for blepharitis management. BMJ Open Ophthalmol 2017;1(1):e000065.
- Craig JP, Wang MTM, Ganesalingam K, et al. Randomised masked trial of the clinical safety and tolerability of MGO Manuka Honey eye cream for the management of blepharitis. BMJ Open Ophthalmol 2017;1(1):e000066.
- Albietz JM, Schmid KL. Randomised controlled trial of topical antibacterial Manuka (Leptospermum species) honey for evaporative dry eye due to meibomian gland dysfunction. Clin Exp Optom 2017;100(6):603-615.