THE MATURE CONTACT LENS PATIENT
Understanding Age-related Changes to Our Eyes
By Christopher Miller, ABOC, NCLEC
Release Date: June 1, 2020
Expiration Date: October 24, 2022
Upon completion of this program, the participant should be able to:
- Understand leading eye complaints and diseases for the older patient.
- Be familiar with common tests performed by the eyecare practitioner.
- Know the five steps to safeguarding eyesight.
This course has been approved for one (1) hour of Continuing Education credit by the NCLE Ophthalmic Level II. CTWJHI332-2.
To earn NCLE credit, please review the questions and take the test at 2020mag.com/ce. Note: As of January 2020, no tests will be graded manually. Please call (800) 825-4696 for more information.
They say 50 is the new 40, and 60 is the new 50, and why stop there—I say that 70 is the new 59 and holding! As of July 2018, the number of Americans between ages 40 and 69 is 120,700,000. Both Gen X and Baby Boomers are active, style-conscious and informed. Moreover, they have the highest disposable income compared to other generations. While enjoying better general health than prior generations, age-related changes increase health issues including eye health issues. Some of the age-related eye health changes can affect contact lens wear. The mature eye has a wider range of conditions to consider that suggests different spectacle and contact lens modalities.
CAVEAT: Contact lens fitters should be familiar with eye conditions to be well informed. If the patient has any questions concerning results of tests taken, always advise the patient to speak with their doctor directly. It is not within the scope of practice of the contact lens fitter to diagnose, treat or interpret any findings except what pertains to the filling of contact lens prescriptions.
COMMON ADULT EYE COMPLAINTS
The following common eye complaints are age related. Treatment can be easy. Sometimes they signal a more serious problem.
Presbyopia is a gradual loss of ability to see close objects or small print. It is part of the normal aging process. The lens itself stiffens making it increasingly harder to change shape, get more convex and accommodate near vision. Signs of presbyopia include holding reading materials at arm’s length, difficulty reading in dim light, headaches or tired eyes when reading or doing other close work. For contact lens wearers, there are several options such as the newer multi-focal lenses, a monocular fit or reading glasses worn over distance contact lenses.
Presbyopia at 60, 70 and 80: In the advanced stages of presbyopia, the patient often needs higher reading adds. These higher adds make it more difficult to see intermediate distances starting at computer length, and a patient may notice it more when cooking, shopping, doing craftwork or while in their yard. There may be other problems as well, making driving or reading at night difficult. Adequate lighting and low vision aids may be needed as well. Many of these patients may have been fit previously as a monocular fit, i.e., one eye for distance and one eye for near. The decision is yours and the prescribing doctor’s, whether they would be a good candidate for a multifocal contact lens. Patient interest and a willingness to try something different may open a whole new vista for them.
Floaters are small shadows of spots or filaments that patients describe as floating across their field of vision. They vary in size and shape, and are located in the vitreous humour. They may be of embryonic origin or acquired due to age-related degenerative changes of the vitreous humour or retina. They’re typically noticeable in a well-lit room, outdoors on a bright day or when reading a page with lots of light and a bright white background.
Floaters at 60, 70 and 80: Floaters are typically normal. However, they can be a sign of a more serious eye problem, like retinal detachment. A retinal detachment is often accompanied by flashes of light. If a patient notices a sudden change in the type or number of spots or flashes, advise them to see an ophthalmologist right away. Floaters are also common after cataract operations or after trauma. Contact lens wear does not affect floaters although they may become more apparent with visual correction from CL wear making them easier to see.
Excess tearing: Excess tears may be from sensitivity to light, wind or temperature changes. Protecting the eyes by wearing sunglasses is a simple solution to the problem. Sometimes excess tearing may mean a more serious eye problem, such as an infection or a blocked tear duct, both of which can be treated. Epiphora or watery eye is typically caused by infection or inflammation creating blocked tear ducts. Treatment is available. Excess tearing will result in discomfort when wearing contact lenses. Yet another reason that everyone who wears contacts should also have a fabulous pair of glasses on hand.
Eyelid problems: This comes from a variety of different diseases or conditions. Common eyelid complaints include pain, swelling, itching, tearing or being photophobia (sensitive to light). Giant Papillary Conjunctivitis (GPC) can be caused by a chemical reaction or an immune reaction, but it can also be brought on by physical irritation such as the eyelid rubbing against a contact.
Secondary GPC is not an infection, but an inflammation of the inside surface of the lid, caused by constant rubbing of the lid across a contact lens or other foreign body. Normally, the undersurface of the upper eyelid is completely smooth. In patients with GPC, the undersurface of the eyelid becomes roughened and inflamed, and the entire eye becomes irritated. In addition to mechanical irritation, contact lenses also trap deposits on their surface, which add to the inflammation. The condition is so named because large bumps (papillae) appear on the underside of the eyelid. GPC occurs both in patients who use soft and rigid gas permeable contact lenses, though it occurs much more frequently in soft contact lens wearers. Contact lens wear should be discontinued until the condition abates. Recommend that patients give their eyes regular breaks from long-term wear of contacts and wear eyeglasses for periods of time to prevent CL induced papillary conjunctivitis. Since CL over wear is a primary contributor to developing GPC, consider switching the patient to a more frequent replacement schedule. (A 4.5 to 36 percent decreased incidence of GPC was seen with more frequent replacement.)
Blepharitis: Another eyelid condition that will affect CL wear is blepharitis, an inflammation infection of the lids. Symptoms can be caused by the following conditions: bacterial eyelid infection, Meibomian Gland Dysfunction (MGD), dry eyes, fungal eyelid infection and Demodex, a parasitic eyelash mite.
Blepharitis is often concurrent with dry eyes and result in a condition called dry eye blepharitis syndrome (DEBS). Dry eye may be a late expression of blepharitis, making it important to treat blepharitis to reduce the chance of dry eye. Bacterial overgrowth on the eyelid margins and at the base of the eyelashes can multiply and form a toxic biofilm similar to the plaque that forms on teeth. The biofilm is a food source for a type of parasitic mite on the eyelashes called Demodex. These mites can grow in numbers and contribute to blepharitis and dry eye symptoms. Another lid complication that can lead to meibomian gland dysfunction is the production of exotoxins, a type of bacteria that cause meibomian gland inflammation. Skin conditions often associated with blepharitis are ocular rosacea, dandruff, psoriasis and eczema. Common symptoms can be intermittent or chronic and consists of burning, stinging, crusting at the eyelash base, sensation of a foreign body, itchy, irritated and watery eyes. A loss of eyelashes is another possible symptom.
Blepharitis makes contact lenses very uncomfortable as it leaves the eye unlubricated and dry. This can cause problems for contact lens wearers. Contact lens wear should be stopped until the condition is cleared up.
Conjunctivitis (also called pink eye) occurs when the conjunctiva lining on the inside of the eyelids (and also is the top layer of the cornea) becomes inflamed. It can cause itching, burning, tearing or a feeling that something is in your eye. Conjunctivitis can be due to allergies or a bacterial or viral infection. Infectious pink eye is highly contagious and can easily spread from one eye to the other and to other people. Advise the patient to remove their lenses until it clears up. Advise them that they should either see their doctor for further evaluation and treatment immediately, and no later than a few days if conditions don’t improve.
Dry eye syndrome: Dry eyes are caused by a lack of tears. Tears are necessary for the normal lubrication of our eyes and to wash away particles and foreign bodies. Most patients who experience dry eyes may describe a burning, scratching or stinging sensation. They may also have strained or tired eyes after reading, even for short periods of time. Reading reduces the blink rate by more than half. If these patients wear contact lenses full time, they will likely feel uncomfortable, especially later in the day. Having dry eyes can lead to tiny abrasions on the surface of their eyes, which will show during fluorescein staining.
Common causes of dry eyes include: aging, dry environment or workplace (wind, air conditioning), excessive time on the computer, sun exposure, smoking or secondhand smoke exposure, cold or allergy medicines, an eye injury or problem with the eyes or eyelids (drooping eyelid or bulging eyes, exophthalmos), Sjogren’s syndrome (includes dry eyes, mouth and mucus membranes, and often rheumatoid arthritis or other joint disorder) and previous eye surgery such as Lasik.
The following steps may help:
- Artificial tears, available as either drops or ointments. Ointments last longer, but are thicker and can cause blurry vision especially with contact lenses.
- Reduce or eliminate smoking. Avoid secondhand smoke, direct wind and air conditioning.
- Use of a humidifier, especially in the winter.
- Blink more often.
- Periodically rest the eyes, looking away at more distant objects, especially while reading, watching television or using the computer.
Meibomian Gland Dysfunction (MGD): The Meibomian glands (or tarsal glands) are a special kind of sebaceous glands at the rim of the eyelids inside the tarsal plate. They are responsible for the supply of meibum, an oily substance that prevents evaporation of the eye’s tear film; prevent tear spillage onto the cheek, make the closed lids air-tight and act as a blockade for tear fluid, trapping tears between the oiled edge and eyeball. There are approximately 50 glands on the upper eyelid and 25 glands on the lower.
Dysfunctional meibomian glands often cause dry eyes, one of the more common eye conditions. They may also cause blepharitis, an inflammation of the eyelids, as the dry eyeball rubs off small pieces of skin from the eyelid, which may get infected. Inflammation of the meibomian glands (also known as meibomitis, meibomian gland dysfunction or posterior blepharitis) causes the glands to be obstructed by thick secretions; the resulting swelling is termed a chalazion. Besides leading to dry eyes, the obstructions can be degraded by bacterial lipases (water insoluble lipids or fats), resulting in the formation of free fatty acids, which irritate the eyes and sometimes cause punctate keratopathy.
Typical treatments for MGD may include, depending on specifics of the condition: warm compresses (to liquefy any secretions that have solidified and are clogging the glands), lid scrubs, oral antibiotics (such as doxycycline) or topical antibiotic ointments, and Omega 3 supplementation. Contact lens wear should be stopped until these conditions/symptoms improve.
Corneal diseases and conditions can cause redness, watery eyes, pain, reduced vision or a halo effect. The cornea is the clear domeshaped “window” at the front of the eye. It helps to refract and focus light that enters the eye. Disease, infection, injury, toxic agents and other things can harm the cornea. Advise patients to always wear eye protection for any sport activities, when working with any equipment, when using caustic cleaning chemicals or when doing yard work.
Cataract is the clouding of the crystalline lens. Common symptoms include blurry vision, glare in sunlight, halos at night around streetlights or car lights, colored objects losing their original tone and an increase in myopia (nearsightedness from extreme flattening of the crystalline lens). Cataracts do not affect contact lens wear.
Glaucoma damages the optic nerve due to increased pressure within the eyeball due to inadequate drainage or overproduction of fluid inside the eye. The optic nerve relays electrochemical signals to the brain, without which we cannot see. It can result in blindness if untreated in the early stages of the disease. In early glaucoma, patients may not have any symptoms. Therefore, the condition is often neglected. Early diagnosis and treatment can help prevent blindness. Glaucoma is treatable but not curable. Many can continue to wear contacts with glaucoma depending on their eye doctor’s recommendation.
Age-related macular degeneration (AMD) is a major cause of visual impairment and legal blindness in older adults. Macular degeneration results in central vision loss, which can make it difficult or impossible to read, see faces, drive and even walking becomes more hazardous, all of which compromise one’s independence. Peripheral vision remains but is very limiting.
Behind the retina is the choroid, which contains the blood supply to the macula (the central retina and the area of highest resolution vision). In the dry (non-exudative) form, cellular debris called drusen accumulate between the retina and the choroid. This interferes with the blood supply to the retina cells and can ultimately cause cell death. These pockets of cellular debris separate the retina from normal blood supply inhibiting normal metabolism of waste removal as well as the delivery of nutrients to the photoreceptor cells that are essential for sight.
Blindness can occur rapidly with retinal detachment in the wet (exudative) form of AMD. Exudative AMD can result in neovascularization and is more severe, because the blood vessels grow up from the choroid into the retina and swell and leak. The retina can become scarred and may become detached. Exudative AMD can be treated with laser coagulation and with injections of medication that stops and sometimes reverses the growth of leaky unstable blood vessels.
Diabetic retinopathy: Diabetes mellitus (DM) can cause diabetic retinopathy (DR) and ultimately diabetic macula edema (DME), both of which can advance to severe vision loss and even blindness. Prevent Blindness lists the following stages:
Mild nonproliferative retinopathy: At this stage, micro aneurysms occur. They are small areas of balloon-like swelling in the retina’s tiny blood vessels.
Moderate nonproliferative retinopathy: This stage is when blood vessels that nourish the retina are blocked.
Severe nonproliferative retinopathy: In this stage, many more blood vessels are blocked, depriving several areas of the retina with their blood supply. These areas of the retina send signals to the body to grow new blood vessels for nourishment.
Advanced proliferative retinopathy: At this advanced stage, the signals sent by the retina for nourishment trigger the growth of new blood vessels. These new blood vessels are abnormal and fragile. They grow along the retina and along the surface of the clear, vitreous gel that fills the inside of the eye. By themselves, these blood vessels do not cause symptoms or vision loss. However, they have thin, fragile walls. If they leak blood, severe vision loss and even blindness can result. Early diabetic retinopathy is asymptomatic. Once diagnosed with diabetes, patients should consult an eye doctor to have a thorough baseline assessment of their eyes. Regular follow-up eye examinations are essential every six months to one year, depending on the severity of the diabetic eye disease.
Wireless powered smart contact lenses that can diagnose and treat diabetes by controlling drug delivery with electrical signals are under development. Counter to past recommendations, there is general agreement amongst doctors that diabetic patients can wear contact lenses if extra precautions are taken. Those patients presenting with A1C levels of 10 and up are prohibited from wearing contacts. With a more modest elevation of 7 to 8, patients can proceed with contact use but should proceed with caution. Daily wear contacts should be used, and they must be thoroughly cleaned with the proper solution daily. Proper cleaning is vital to avoid particles attached to the lens causing abrasions or damage to the cornea. The risk for diabetics with contact use are corneal erosions. All eye injuries take longer to heal for a diabetic and therefore should be rigorously avoided. Dry eye is a high risk for diabetic patients, and they should be on the lookout for burning, itchy, gritty feeling or the sensation of something being in the eye. Always seek expert medical advice before starting contact lens wear. New therapeutic contact lenses measure blood glucose levels.
TESTS FOR THE ADULT EYE
A comprehensive examination by the doctor should include a dilated examination, screens for glaucoma, diabetic retinopathy, hypertensive retinopathy, macular degeneration and cataracts. It should also include taking visual fields, corneal topography (mapping), a scanner laser exam which aids in early glaucoma diagnosis, and digital photography to ensure there is a baseline image to aid in any further investigation of ocular disease. There are several additional tests, which might be done for contact lens wearers such as a Schirmer’s Test. This test measures tear production. Fluorescein staining analyzes the fit of a contact lens or can highlight a scratched cornea. For the older patient, many of these tests are done on a routine basis to ensure optimal optical health as some diseases have little or no symptoms, and early treatment is best to halt any advancement.
Pachymetry: A pachymeter measures corneal thickness and is a useful tool for the diagnosis of corneal disease, glaucoma risk and for assessment of potential Lasik patients.
Visual fields: Contributes to the diagnosis of optic nerve disease and retinal pathology. Digital photography: Captures a baseline retinal photograph for comparison at subsequent visits.
CURRENT OR POTENTIAL CONTACT LENS WEARERS
The following tests might also be added:
Topography: Corneal topography, also known as photokeratoscopy or videokeratography, is a non-invasive medical imaging technique for mapping the surface curvature of the cornea. Since the cornea is normally responsible for 70 percent of the eye’s refractive power, its topography is of critical importance in determining the quality of vision.
The three-dimensional map is therefore a valuable aid to the examining ophthalmologist or optometrist, and can assist in the diagnosis and treatment of a number of conditions; in planning refractive surgery such as Lasik and evaluation of its results; or in assessing the fit of specialty contact lenses. A development of keratoscopy, corneal topography extends the measurement range from the four points a few millimeters apart that is offered by keratometry to a grid of thousands of points covering the entire cornea. The procedure is carried out in seconds and is completely painless.
Tear breakup test: Sodium fluorescein dye is added to the eye, and the tear film is observed under the slit lamp while the patient avoids blinking until tiny dry spots develop. The longer it takes, the more stable the tear film. A short tear breakup time is a sign of a poor tear film. Generally, greater than 10 seconds is thought to be normal, 5 to 10 seconds, marginal and less than 5 seconds, low (with high likelihood of dry eye symptoms). An unstable tear film can explain dry eye symptoms in patients who have a normal quantity of tears. Unstable means the com-position of the tears is imbalanced, resulting in tears evaporating too quickly or not adhering properly to the surface of the eye.
A Schirmers Test measures aqueous tear production. A premeasured strip of test paper is placed in your lower eyelid and measures how much tears are soaked up in five minutes. A measurement less than 10 indicates inadequate tear production or dry eye syndrome.
Fluorescein staining: This test is very useful for detecting injuries or abnormalities on the surface of the cornea as well as the fit of a rigid contact lens.
A piece of blotting paper containing the dye is wetted with saline and touched to the surface of the eye. As the patient blinks, the dye is spread around and coats the surface of the cornea. A cobalt light is then directed at the eye. Any problems on the surface of the cornea will be stained by the dye and appear green under the blue light.
The health care provider can determine the location and likely cause of the cornea problem depending on the size, location and shape of the staining.
FIVE STEPS TO SAFEGUARD MATURE EYES
- Recommend regular physical exams with their primary doctor to check for diseases/conditions that affect eye health.
- Recommend a complete dilated eye exam every one to two years for the early detection of eye diseases such as glaucoma that have no early signs or symptoms.
- Take a thorough history. Does any family member have a history of diabetes or eye disease? If so, recommend a dilated eye exam every year.
- Advise the patient to see an eyecare professional at once if they have any loss or dimness of eyesight, eye pain, fluid coming from the eye, double vision, redness or swelling of the eye or eyelid.
- Advise them to always wear sunglasses and a hat with a wide brim when outside. This will protect their eyes from sun damage which can raise the risk of getting cataracts. Also advise eyewear protection whenever needed.
If any of your older patients wear contact lenses, chances are they have done so for a decade or more. This is a great time to upgrade them to the new breathable materials or perhaps to try a multifocal design. For some, it may be their first time trying contact lenses, and we should be aware of any dry eye issues as this is a common complaint in this age group. Reduced wearing times and a moisturizing eye drop may be part of every successful fit. Dailies may be especially appealing as cost may not always be the deciding factor. In any case, have varieties of trial lenses on hand—as we well know, eyes come in all sizes and all ages.