With the advent of daily disposables, solution sensitivity reactions are less frequent. However, many patients do need to reuse and disinfect their lenses. The toric, aspheric or bifocal design they need may not be available in daily disposables. Your patient may require a thicker lens with lower water content for his or her marginally dry eyes. For these patients, the evidence has been accumulating that using a preservative free care system and preservative-free lubrication will minimize complications and chronic dry eye symptoms.
I was skeptical when ClearCare, CIBA’s one-step reworking of AOSept, hit the market. I really liked the Quick Care system, especially the surfactant cleaner, for my patients who coated their lenses or had preservative sensitivities to other multi-purpose solutions. But Quick Care was a two-step system, and the cleaner required adequate rinsing to avoid stinging the eyes. ClearCare has been a wonderful alternative for patients who wear two-week or monthly replacement lenses. It is a truly a one-step system. The cleaning and disinfection results are impressive. Most important, it leaves no residual preservative in the lenses.
New information tells us that certain preservatives bind very effectively to the new silicone hydrogels, thus increasing superficial punctate staining and dry eye symptoms. Research from Pacific University has confirmed that some preservatives found in multi-purpose solutions can also be responsible for vague, chronic dry eye symptoms or for signs of corneal desiccation. All patients who reuse soft lenses may be candidates for toxicity and hypersensitivity reactions over the long term from solutions containing preservatives. When such patients say, “But I have used this solution years!” I respond, “That is why they call it delayed hypersensitivity!”
Lubricating drops should also be suspects in cases of red eyes, dry eye symptoms, reduced contact lens tolerance or signs of conjunctival and corneal staining. Ask your contact lens patients if they use any eye drops-they usually won’t tell you that they do unless you ask-and you will be surprised at how many patients use inappropriate drops with their contact lenses, especially vasoconstrictors. Over time, the preservativefree options or the lubricants with approved pro-preservatives (for example, Allergan’s Refresh Contacts) work the best. Viscosity can also be important. Some patients prefer low viscosity such as CIBA’s Focus Lens drops and Allergan’s Lens Plus Drops; others prefer higher viscosity alternatives such as Allergan’s Refresh Plus. The gels also are a great addendum for use after lens removal for the marginally dry eye (for example, TheraTears by Advanced Vision Research).
Become a bit of a detective and find out what environmental factors affect your patient’s contact lens comfort. When I see coated lenses, and the patient seems to be complying with the care system, other factors need to be ruled out. For some female patients, makeup removal technique is always something to ask about. Baby oil, Vaseline and other oily makeup removal products do not work well with soft lenses. Suggest water-soluble makeup removers, or suggest that the patient dilute baby shampoo in water-a solution we use for lid scrubs in blepharitis patients. Application of any greasy skin creams, especially sunscreens, should occur after contact lenses are applied, to avoid contamination.
Once our patients are on a preservative-free and contaminant-free track, complications become more scarce. Going preservative-free has immediate benefits for the patient in increased comfort and wearing time. It is worth the effort to find out what your patient is actually using and get him or her oriented to using preservative-free products.
Dr. Keech (firstname.lastname@example.org) is in private practice in Shoreline, Wash.
Contributor: Patricia Keech