Help! I Can’t Wear My Contacts!!!

By Sam Winnegrad, ABOM, NCLEC

Learning Objectives

Upon completion of this course you should understand:

Describe the variety of reasons behind patients feeling they can’t wear their contacts.
List the culprits to be investigated in determining the causes of contact lens discomfort.
Explain how one addresses contact lens discomfort in each of its forms.

Course Description

Have you ever encountered a patient who was disgruntled due to lens discomfort? Of course, you have! Few things are as irritating as a contact lens that makes itself known in situ. When a patient exclaims, “I can’t wear my contacts!” we must put on our detective caps and begin to diagnose the source of discomfort. There is a myriad of reasons that one’s lenses can irritate. Some examples include allergies, the fit of the lens itself, lens deposition, edge design… there are a plethora of potential obstacles to comfortable lens wear. As a contact lens technician, you communicate with your patients and employ active listening techniques. We need to search for objective and subjective clues that will lead us toward the defining issue. The fitter and the wearer have a shared responsibility in the health care consumer relationship. As the eyecare professional, we must identify and correct any potential obstacles that may impede comfortable lens wear, and the patient must employ responsibility in heeding instructions and following care guidelines. Next, we will survey some common reasons patients may exclaim, “I can’t wear my contacts!”

Faculty/Editorial Board

Sam Winnegrad is a master optician who has instructed anatomy and physiology of the eye as well as other various ophthalmic courses for Roane State Community College in Harriman, Tennessee. He has also taught for Highline College's online optician program out of Des Moines, Washington. Sam is a technical speaker for the American Board of Opticianry and National Contact Lens Examiners. Sam holds a master's degree in business administration and a bachelor's in science, but above all, he treasures his license to practice opticianry.

Credit Statement

This course is approved for one (1) hour of CE credit by the National Contact Lens Examiners - NCLE, Ophthalmic Level 2. Course number: CTWJHI117-2 Ophthalmic Level II Course

Keratitis sicca, or dry eyes, is an all-too-common inflammatory condition characterized by inadequate cornea tear film protection. Patients suffering from this condition will constantly battle contact lens comfort issues. Two primary tests determine the tear film’s quantity and quality. Schirmer’s test is used to determine whether the eyes are producing enough tears for the eyes to maintain an appropriately moist environment. The break-up-time test, or (BUT), is used to determine the quality of the tear film. This test is performed by instilling fluorescein dye in the eyes and instructing the patient to blink. The patient is then told not to blink. The practitioner then counts how long until the first dry spot appears on the cornea. This is referred to as the break-up time. Tear films that “break up” in less than 10 seconds are considered abnormal and contra-indicative of contact lens wear. Patients who suffer from keratitis sicca have options, including artificial tears (formulated for contact lens wearers), punctual plugs and even blinking therapies. Interestingly, patients with dry eyes may experience excessive tearing. This is entirely counterintuitive; however, the body sometimes responds by over-lacrimation. Keratitis sicca can be a confusing diagnosis for a patient whose eyes are constantly tearing. Dry eyes may make contact lens wear difficult, but not always impossible.

Allergies can be quite a nuisance, and this is especially true for the contact lens wearer. Many contact lens patients will opt out of their lenses during allergy seasons, such as when the pollen count is high. Seasonal allergies can have a dramatic effect on wearer comfort. Allergies can be defined as hypersensitivity of the immune system to typically harmless environmental substances. Allergens such as pollen and dust can adhere to contact lenses and cause long-lasting irritation. One of the best ways to combat contact lens allergies is to use rewetting drops specifically formulated for contact lens wear so that the precorneal tear film is aided in maintaining a hydrated state. Using one-day daily disposable lenses is another excellent way to thwart allergens. If daily disposable lenses are not an option, it is paramount that patients properly clean, disinfect and store their contacts, as allergens will embed themselves into the lens matrix. Allergic conjunctivitis is a common disorder where the conjunctive, the tissue that lines the inside of the eyelids and the anterior of the sclera, becomes inflamed. Wearing contact lenses while suffering from conjunctivitis will only serve to exacerbate the condition. For conditions such as allergic conjunctivitis, it is imperative that patients wear spectacles until the condition clears up.

Lens deposition can be a particularly disruptive nuisance to the wearer. The two most common types of deposits are proteins and lipids. Any accumulation of debris on the lens surface can be quite irritating and if left uncorrected, could lead to troublesome conditions such as giant papillary conjunctivitis. Not only is comfort reduced with lens deposition, but also oxygen permeability suffers. Patients who wear contact lenses on an extended wear regimen are particularly vulnerable to increased lens deposits. Replacing contact lenses frequently and properly following all cleaning instructions are two ways patients can combat lens deposition. Some of the more common silicone hydrogel lenses are susceptible to protein deposits. Lens manufacturers use lens coating technologies to diminish this phenomenon. Suppose your patients are experiencing lens discomfort due to deposition, and they are properly cleaning their lenses. In that case, it may be time to talk with them about daily disposables or a change in their cleaning solution.

Eyeliner, eyeshadow and mascara may be a non-negotiable necessity for your patients. Still, they must understand the importance of proper application and hygiene to maintain a healthy environment for the eyes. The most important rule with contact lenses and makeup is to apply makeup after the contact lenses are already inserted. This is easy to remember because your patients appreciate being able to see as they apply their makeup! Also, eyeliner should only be applied to the outside of the eye. The use of eye makeup significantly increases infiltrates in the precorneal tear film. Trapping makeup deposits below the surface of a lens dramatically increases the risk of infection. Sharing eye makeup is also another great way to increase the risk of infection. Lastly, your patients must, unfortunately, remove their contact lenses before removing their makeup. If they complain about this instruction, just ask them if they would rather have their makeup applied before inserting their lenses.

In the simplest sense, a corneal abrasion is a scratched cornea. There are countless ways in which one could receive an abrasion. These can occur from a traumatic experience, such as getting poked in the eye with a branch, or a less innocuous occurrence, such as rubbing your eyes or having contact lens deposits. Corneal abrasions are quite painful. The cornea is a sensitive, living tissue. There is an increased risk of infection with abrasion and loss of sight. This is largely dependent on the depth of the scratch. The stromal layer of the cornea will scar and depending on where the scar is, could significantly reduce one’s quality of vision. Most corneal abrasions that only penetrate the epithelial layer of the cornea will heal and regenerate within 24 hours, but in the meantime, it can be quite discomforting. Eye doctors will often prescribe an antibiotic as a proactive measure to stave off infection. Bandage contact lenses are also often used with an antibiotic ointment, as wearing contacts can increase the risk of infection.

What is more uncomfortable than contact lenses that do not fit well? Nothing. There are so many variables that can go wrong in the fitting process. The base curve can be too steep, and the diameter can be too large… A lens that is too tight or loose can be incredibly uncomfortable. The steeper the base curve, the tighter the lens will fit. Likewise, as the diameter of a lens increases, the lens will fit tighter. Soft contact lenses have a draping effect and should be fit with a three-point touch technique. This is where the lens touches the eye at the center of the cornea and the two opposite edges of the sclera. Most manufacturers recommend that the lens move 1 millimeter with each blink. This also permits oxygen and tear exchange. The only way to determine if a lens is fitting poorly is through a thorough slit lamp evaluation. Other causes could be lens material rejection, inversion, edge design or other reasons.

Whether for 15 hours straight or a week past the wear schedule, wearing lenses longer than intended could have extreme consequences. Outside of being “uncomfortable,” lenses worn too long can lead to irreversible eye damage. Common conditions that result from lens overuse are neo-vascularization and corneal ulcers. Neo-vascularization is the growth of new blood vessels. As lenses are over-worn, they cannot transmit oxygen as well as they once did. This is due to deposits that attach to the lens matrix. As oxygen levels decrease, the cornea experiences hypoxia and starves for oxygen. The body responds by growing new vessels into the cornea. This can have dire con-

sequences as the cornea must remain transparent to allow for proper image formation. Corneal ulcers are open sores on the cornea. They are very painful. Many times, these are caused by an infection that can be related to contact lens abuse. The effects of an ulcer can be irreversible and steal one’s sight. Ensuring your patients understand the importance of following their prescribed wear schedule is paramount. For many visual maladies, wearing contact lenses is a luxury, as eyeglasses will provide sharp optics. Overwearing lenses is contraindicative to successful contact lens use.

Inflamed eyelids, or blepharitis, is a common condition that can wreak havoc on contact lens wear. Many times, blepharitis is associated with watery, gritty eyes. While blepharitis can usually be resolved with self-care, such as using warm compresses and washing around the eyelids with baby shampoo, there are times when prescribed medication may be necessary to control infection or reduce swelling. Blepharitis can take weeks or even years to resolve, becoming a recurring issue for the contact lens wearer. It is crucial that the patient who is suffering from inflamed eyelids take a break from wearing their contact lenses. Even the most advanced and biologically compatible lenses would exacerbate the symptoms of blepharitis and hinder the healing process. Commonly, patients with mild cases of blepharitis will mistake the condition for a passive issue, such as “their eyes being tired,” and continue as usual without receiving the care they desperately need.

Keratitis is the condition in which the cornea becomes inflamed. There is a multiplicity of potential causes. One of the most common causes of keratitis is wearing contact lenses that have become contaminated with bacteria. Not following the proper wear schedule or cleaning regimen will increase the odds of keratitis. When patients over-wear lenses, it reduces tear distribution and can lead to hypoxia and keratitis sicca (dry eyes). These all make the eyes more susceptible to infection. To make matters worse, if your patients are abusing their lenses, not replacing them and cleaning them properly, they are undoubtedly inviting more infiltrates and bacteria to their ocular surface. It is much more difficult for damaged dry corneas to fight off an infection than healthy corneas. Treatment of keratitis depends on the cause. Contact lens discontinuation is almost always advised. If the inflammation does not stem from an infection, the doctor may not prescribe any medication. An antibiotic or antifungal is sometimes necessary to treat the condition.

It is often one of the last considerations but contact lens solution can be a common reason your patients may be experiencing discomfort from their lenses. Just as some patients are non-adapted to a lens brand, they can also reject a specific multi-purpose solution. This is mainly due to the differences in our tear chemistry. The tonicity of our tear film is 0.9 percent sodium chloride. Most solutions try to mimic this percentage and imitate the 7.6 pH of our tear film. If a cleaning and disinfection system veers too far from these benchmarks, the eyes would be less likely to welcome the solution as an acceptable tear alternative. Furthermore, solutions add various agents to improve lens-wearing dynamics, such as wettability and resilience to deposition. Some eyes are more sensitive than others to these added chemicals and may respond by staying irritated. If someone cannot wear their lenses, it is always advisable to see if they have recently made any changes in lens care solutions.

Maybe it’s not what your patients are cleaning their lenses with; it’s how they are cleaning them! Though there are many different types of cleaning solutions, there are some basics in lens care that the wearer often overlooks. Many people, with good intentions, do not correctly clean their lenses and end up wearing contacts that are rattled with protein and lipid deposits. Are your patients washing, rinsing and drying their hands before ever handling their lenses? One of the most common opportunities in lens care is for patients who do not rub their lenses before storing them in a disinfection solution. No matter how amazing the formula is, it is always advisable for your patients to gently rub the lenses for about 20 seconds before storing them. One analogy might be assuming that you do not need to scrub the floor with a mop just because you have a remarkable floor cleaner. There will be a huge difference in cleanliness with the scrubbed floor instead of a floor that was gently mopped. Instruct your patients to always follow lens care instructions from the manufacturer because dirty lenses are uncomfortable.

Have you ever had a contact lens patient swear that brand X is superior to brand Y? They may go as far as to say they cannot understand how anyone can even wear brand Y because they are so uncomfortable! Many times, this is due to the edge design of the lens. Patients’ eyes differ pretty dramatically from one another; thus, they have different “opinions” on what constitutes a comfortable lens fit. Some contact lens edges thin out to a knife point, while others have a chisel-type design. Most primary contact lens brands maintain a particular edge design through the evolution of the material technology. Interestingly, scleral lenses are often found to be very comfortable due to their larger diameter. This minimizes any lid interaction.

If your patient comes into your office screaming that they cannot wear their contact lenses, it may be time for you to visually inspect the lens’ periphery. The smallest micro-tear can cause gigantic discomfort. More often than not, patients can view these tiny tears without the benefit of magnification, but for those mature presbyopes, sometimes the best course of action may be to replace the lens and see if it restores comfort. When in doubt, your patients should always lean toward replacing their lenses. This is one of the reasons why daily disposables are such a great option. Your patients will not be as inclined to try and “save” a lens that must be replaced. The heightened sensitivity of the cornea makes wearing a lens with a tear in it almost unbearable. Visual inspection of uncomfortable contact lenses will usually offer explanations ranging from extreme deposition to lens warpage and tears.

New contact lens wearers almost always experience some level of discomfort. This is especially true with toric lenses that correct for astigmatism. After all, contact lenses are a foreign body that is introduced to the eye’s anterior surface. Though entirely beneficial and a wonderous technological advancement, contact lenses are still limited as an external medical device. Thankfully, our eyes can adapt to contact lenses with relative ease if the fit is appropriate. Once the lens is in situ, equilibration is the first step in the adaptation process. Equilibration is the time it takes for the lens to settle on the eye properly. This generally takes 5 to 10 minutes, as temperature, pH and osmolarity are all factors. Soft lenses offer rapid adaptability, while RGP and hard lenses take a more extended adjustment period. Either lens type requires a progressively increasing wear schedule until maximum tolerance is achieved. It is important to set realistic expectations with new wearers. If after a few weeks, the patient is still complaining of discomfort, switching brands may be the best option.

Rigid gas-permeable contact lenses have some fantastic qualities. For starters, correcting up to 3 diopters of corneal astigmatism with a well-fit spherical gas permeable is possible. They are also very durable and provide excellent vision. Gas-permeable lenses are generally less susceptible to protein and lipid deposits. One of the most significant disadvantages of rigid gas-permeable lenses is their lack of initial comfort. Unlike soft lenses, gaspermeable lenses do not offer a fast adaptation and acceptance. On average, it takes anywhere from three to five weeks for patients to fully adapt to their lenses. Furthermore, suppose a patient stops wearing their gas-permeable lenses for even a short period of time. In that case, they will have to re-adapt to the lenses and go through the uncomfortable adaptation period all over again. This is one of the main reasons that soft lenses are so popular—they can easily be worn for special occasions and on a less consistent basis. Maybe your patients can’t wear their contacts because they just can’t tolerate the discomfort associated with the initial adaptation period.

If your patient’s lenses are not permitting adequate oxygen to feed the corneal tissue, there will be many adverse effects—some that could even lead to permanent vision loss. When a tissue such as the cornea is deprived of oxygen, it is referred to as hypoxia. The oxygen permeability of contact lenses is referred to as the Dk value. There are three main factors that go into a lens’ Dk value (oxygen permeability): water content, center thickness and surface deposits. If a patient is suffering from hypoxia, they are also susceptible to corneal edema and neovascularization. Some symptoms of hypoxia may include redness, swelling, discomfort and even double vision. As the cornea swells, its refractive state is likely to change. If your patients’ lenses allow for inadequate oxygen exchange, they will undoubtedly experience some level of discomfort.

Contact lens wettability is perilous to overall lens comfort. Lenses with poor wetting surfaces are uncomfortable for various reasons. As we blink, our eyelids expect to encounter an even tear film. The lenses that we wear should seek to mimic this experience. Lenses with sub-standard wettability may present spots of dehydration and an uneven surface, creating a dry, uncomfortable sensation with every blink. One measurement that was often used to determine the wettability of rigid gas-permeable lens materials is called the wetting angle. The wetting angle measures the ability of water to spread over the surface of the lens. Wettability is directly linked to comfort and acceptance of the ocular surface environment.

Water content shows the proportion of water in contact lenses. As a generality, lenses with higher water content are softer and allow more oxygen to pass through the material and reach the cornea. Though higher water content lenses may allow more oxygen to pass through, it does not automatically mean they are more comfortable than their lower water content counterparts. One of the reasons why a high-water content lens may be less comfortable is that it can warp and deform more easily because its matrix is weaker. Contact lenses are designed to a specific base curve, and they are fit to drape the cornea evenly. Sometimes, these higher water content lenses will misshape from handling. Another reason that a high-water content lens may be less comfortable is that it requires more tear film absorption. As such, these lenses do not perform well for patients who are suffering from keratitis sicca. They only exacerbate the issue and make it more difficult for the tear film to protect the cornea.

Is there anything more irritating than an inverted contact lens placed on the cornea? This is usually so bothersome that the wearer will remove the lens immediately after placing it in situ. The good news is that there are easier ways to know if a lens is inside-out other than placing it on the eye and waiting to see if you will feel excruciating “irritation.” The taco test is a great way to tell if a lens is inverted. To complete this test, one places a soft lens in the crease of the outside palm of the hand. When closing the hand, if the lens is oriented correctly, the edges of the lens will curve inward and look like a taco. If the lens is insideout, the edges will flair. While visually inspecting lenses, they should appear bowl-shaped, and if the edges flair out, the contact is inverted. Many lenses also have manufacturer engravings on them, which can be read only when the lens is in proper orientation and will appear backward when the lens is inverted.

CONCLUSION

Sometimes, it is necessary for the contact lens technician to be a detective—that is, to consider the preponderance of evidence and decide what is needed to improve patient comfort and satisfaction. Are their lenses the correct parameters? Is there heavy lens deposition? Do they need to change their cleaning solution? Though the options are almost endless, sometimes being observant and using active listening skills can help the eyecare professional define the issue. There is much joy and benefit in contact lens wear. It is our role as health care professionals to enable individuals to experience the maximum benefit of these wonderful devices. Not only do we want contact lenses to provide crisp, sharp vision, but we also want to ensure that our patients wear their lenses without discomfort.