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Issue: May 2008 Treating Contact Lens Wearers Who Have Ocular Allergies

Treating Contact Lens Wearers Who Have Ocular Allergies

Consider these approaches to minimize symptoms and keep patients in their lenses.

Dr. Karpecki: It's very common for a contact lens patient to have seasonal allergic conjunctivitis (SAC). How does such a patient differ from one who doesn't wear contact lenses?

Allergic reactions

Dr. Gaddie: Because of how the body's immune system responds to a contact lens, the incidence of allergies appears to be higher among contact lens wearers.1 The lens becomes coated with protein and allergens, inciting inflammation of the eyelids. Many patients stop wearing their contact lenses without recognizing they have allergies.

Dr. Devries: Contact lens wearers, especially those with significant myopia, will try to wear their lenses as long as possible. So we have to find treatments that will keep them in their lenses, even if it means reducing daily wearing time.

Silicone factor

Dr. Nichols: Silicone hydrogel lenses have reduced but not eliminated the incidence of giant papillary conjunctivitis (GPC). It's still important to invert the eyelid of a patient in these lenses if he complains of irritation and itching. We conducted a study2 and found that patients who used epinastine HCl ophthalmic solution 0.05% (Elestat, Inspire Pharmaceuticals) before and after lens wear for 5 to 7 days increased their wearing time by 1.33 hours compared with patients who used only a wetting agent.

Red eyes, puffiness, watering and mucus discharge are classic symptoms of seasonal allergic conjunctivitis.

Dr. Gaddie: In some patients, silicone actually can cause GPC and dryness, more so than traditional hydrogel material. Because silicone lenses are lipophilic and hydrophobic, they can be more abrasive on GPC nodules.

Dr. Nichols: Silicone materials act differently, depending on their lipophilic, protein-binding and mechanical properties. Differential protein and lipid deposits on lenses during allergy season could cause lens discomfort.

Removing the lenses

Dr. Karpecki: If contact lenses appear to be contributing to GPC or seasonal allergy, do you suggest the patient stop wearing her lenses?

Dr. Nichols: If the patient has SAC, I leave her in the lenses and prescribe epinastine. Many practitioners are reluctant to go the therapeutic route with contact lens patients. I take the GPC cases on an individual basis, looking at the eyelid and assessing the whole clinical picture — including the type of lens and solution they use — before deciding whether to remove the lenses.

Dr. Gaddie: When we lose contact lens wearers because of dry eye or allergy symptoms, they're less likely to maintain annual eye examinations and may seek refractive surgery because they believe contact lenses are causing all of their eye problems. Meanwhile, the patient goes to the surgery center, where coexisting dry eye and allergic symptoms must be treated before the surgeon can perform the procedure.

Dr. Devries: When I see patients, I have them complete a short tear function survey, asking them eight common dry eye and allergy questions — including those related to itching — and several questions about over-the-counter medications they may use. Patients are asked to describe the frequency of symptoms as "never, mild, moderate or severe."

Collecting this information in advance can help you offer the best options to your patients, even when their allergy or dry eye symptoms may not be present at the time of their visit. Their answers also could help give you the insight you need to keep patients in their lenses

"Silicone hydrogel lenses have reduced but not eliminated the incidence of giant papillary conjunctivitis. It's still important to invert the eyelid of a patient in these lenses if he complains of irritation and itching."

— Kelly K. Nichols, O.D., M.P.H., Ph.D

Managing the environment

Dr. Devries: I've discovered that managing the environment of the contact lens patient extends wearing time. Unfortunately, by the time I see patients at our laser center, many have discontinued wearing their contact lenses because of GPC and other irritating symptoms.

Dr. Gaddie: I recommend patients stop wearing their contact lenses for a short time to undergo treatment when they have significant chemosis or a bulbous conjunctiva, and when the lens is exacerbating the problem. I treat these patients with both an antihistamine/mast cell stabilizer and a corticosteroid.

I'm also concerned about allergy patients and continuous-wear contact lenses. If their allergies and dryness are moderate to severe, they probably shouldn't wear 24-hour lenses.

Dr. Karpecki: If you invert the eyelid and you see a normal pink tarsus without papillae, chemosis or hyperemia, you probably don't have much of a concern related to the contact lens itself other than it potentially could trap allergens.

Modifying lens frequency

Dr. Nichols: When 24-hour continuous wear is a concern, do you switch to daily wear?

Dr. Gaddie: Yes. I think daily lenses are by far the healthiest option for dry eye and allergy sufferers. By the time the lens becomes coated with protein and lipid deposits, the patient is discarding it, thus avoiding the chronic cycle of the allergic response. Daily lenses also allow patients to administer topical allergy medication.

Dr. Karpecki: Are there any other recommended contact lens modifications?

Dr. Gaddie: In general, frequently replacing contact lenses is best.3 Discontinuing overnight wear, especially during peak allergy season, also is good advice for patients and doctors.

Changing replacement schedules

Dr. Nichols: To avoid excessive protein buildup on silicone hydrogel materials, you can switch from a 2- to 1-week replacement schedule during allergy season. It's helpful to look at the lens when symptoms peak during the day. An improvement in daily hygiene also may help significantly, depending on the type of lens and degree of patient compliance.

Dr. Gaddie: Contact lens care is important, too. Some hydrogen peroxide systems are very effective for cleaning lenses that become heavily coated with protein and lipid deposits during allergy season. I switch patients who use multipurpose solutions to a hydrogen peroxide system, and most of them stick with it. The cleaning is that good.

Dr. Nichols: Using hydrogen peroxide systems or chemical disinfection systems may help because many patients aren't mechanically rubbing their lenses to eliminate some of the lipids and allergens.

Patient buy-in

Dr. Devries: Another important aspect of treating and managing ocular allergy is getting patients on your side. Communicate clearly to patients that you want them to remain in their contact lenses. Make sure they understand that they have a chronic condition, and they'll need to comply with your instructions to successfully wear their lenses long term. They need to be willing to compromise.

Dr. Nichols: That's correct. The literature has shown that the top reasons patients discontinue contact lens wear are discomfort and dryness. If they've been recently refitted for lenses, they're on the brink of dropping out permanently.

Dr. Gaddie: The attrition rate of contact lens wear due to discomfort associated with allergy or dryness is probably equal to the number of people entering contact lens wear. The need for special care presents a tremendous opportunity for optometrists, especially those who've not ventured into therapeutic practice. There's no better way to do this and also significantly help patients.

Whole package

Dr. Karpecki: I agree. Entering into a therapeutic practice is the best way to significantly help these patients. In our next discussion, we'll focus on building a therapeutic practice for the benefit of our patients. OM

References
  1. Friedlaender MH. Conjunctivitis of allergic origin: clinical presentation and differential diagnosis. Surv Ophthalmol. 1993;38:105-114.
  2. Nichols K, Morris S, Tian W. An evaluation of the effects of epinastine HCl ophthalmic solution 0.05% (Elestat) on contact lens comfort in subjects with contact lens intolerance during allergy season. Optometry — Journal of the American Optometric Association. 2007;78:277.
  3. Donshik PC, Porazinski AD. Giant papillary conjunctivitis in frequent-replacement contact lens wearers: a retrospective study. Trans Am Ophthalmol Soc. 1999;97:205-216.
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