Contact lens discomfort is an ever-present and frustrating part of fitting contact lenses. Earlier this year, I wrote about contact lens dropout and how to prevent it.1 Because contact lens discomfort is the leading cause of dropout,2 understanding strategies to minimize discomfort is crucial to maintaining long-term wear.
Despite our best efforts, however, contact lens discomfort persists in many wearers.3 Even with continued advancement in material technologies, optical designs, and lubrication systems, most patients will experience contact lens discomfort at some point during their wearing journey.4
When you have performed a thoughtful fitting, but the patient still complains of discomfort, how do you address those complaints in a meaningful way? When everything seems “fine” on initial glance, it can be daunting to determine what the best first step is to reduce discomfort and prevent dropout.
Read below for a stepwise approach to eliminate persistent discomfort.
Communicate about compliance
When your patient complains of discomfort, before putting them behind a phoropter or slit lamp, have open communication about how they are handling their lenses. Contact lens non-compliance is incredibly common.5-9
There are many points where compliance can go awry. Lens replacement, overnight wear, solution use, case hygiene, and hand hygiene are just a few of the areas of contact lens wear that a patient can be non-compliant with.
Non-compliance with lens replacement—whether in a daily, 2-week, or monthly replacement modality—leads to discomfort.10-11 Patients are often unknowingly non-compliant with replacement.
It has been reported that eyecare providers (ECPs) are good at providing thorough information and instruction at the initial contact lens fitting about contact lens handling and compliance, but clear instruction about lens replacement schedule is often poorly communicated.12
Leading with open-ended questions
Fortunately, it has also been reported that improved communication regarding replacement schedules leads to better compliance with replacement frequency.13 So, when the patient complains of discomfort, one of the first questions an ECP should ask is, “How often do you replace your lenses?” This simple, open-ended question allows the patient to describe their lens replacement habits without judgment.
Similar open-ended questions can be asked about overnight wear, solution use, cleaning practices, and case hygiene. This will allow a full understanding of how the patient handles their lenses and an opportunity to remind and educate on proper lens hygiene practices. Improving compliance alone can improve comfort.
Consider vision
Vision has a big impact on comfort,14 but it is an underacknowledged source of perceived discomfort in contact lens wearers. After taking a thorough compliance history, visual data is the easiest to collect next, but make sure to go beyond just checking visual acuity.
Even when objective visual acuity is “good,” visual issues could exist that are causing eye strain or fatigue. Over-/undercorrection, uncorrected astigmatism, and/or unaddressed presbyopia could all contribute to a patient’s perception of comfort when wearing contact lenses.15,16
After assessing vision, perform a careful over-refraction. If the patient is accepting cylinder over their contact lenses or accepts spherical power at any distance, this mis-correction could be influencing their visual comfort.
Following over-refraction, remove the lenses and perform a fresh refraction. If some time has passed since the initial exam, it is possible that the manifest refraction data is different, and updated powers could provide clearer and more comfortable vision. Consider how the over-refraction data relates to the updated manifest refraction data and update the contact lens powers if there is a meaningful difference.
Small amounts of power and toricity can greatly impact a patient’s subjective comfort experience, so implement power changes, regardless of how minimal they may seem.
Return to the ocular surface
While ocular surface health may have been acceptable upon initial fitting or during previous prescription updates, it is possible that the lens and ocular surface are not experiencing the same symbiotic relationship that they did at the initial assessment. At the first complaint of discomfort, perform a thorough evaluation of lens fit and ocular surface health.
Carefully examine the fit of the lens. Consider how factors like minimal or excessive movement and/or suboptimal centration or coverage might be affecting comfort. After removing the lenses, examine the ocular surface and adnexa. Check for signs of conjunctival and/or corneal disruption with sodium fluorescein and/or lissamine green.
Additionally, examine meibomian gland appearance and function and consider how gland function could be contributing to comfort and tear stability. Even if no major signs of ocular surface disruption are evident, complaints of discomfort warrant educating patients on best practices for maintaining optimal ocular surface health.
Discussion and instructions regarding proactive lubrication with artificial tears and how to maintain good lid and meibomian gland hygiene can help promote improved long-term comfort.
Consider the data and make a plan
Once you understand the patient’s contact lens compliance and have carefully assessed vision and the ocular surface, consider how abnormal findings in any of those categories are contributing to others. For many patients experiencing discomfort, the cause of their symptoms is multifactorial.
While making one change at a time would be the best way to determine what individual issue is causing most of the discomfort, it’s not realistic to slow down the process of eliminating discomfort by only addressing one problem at a time. Instead, consider pairing changes.
For instance, if you discover your patient is sleeping a couple of nights a week in their daily disposable lenses and they accepted a full diopter of astigmatic over-refraction, educate on daily replacement compliance and update to a toric lens. If you see signs of solution intolerance on the cornea of a monthly replacement wearer, educate on proactive lubrication and switch to a daily disposable modality.
Pairing common sense health and hygiene habit improvements with bigger changes like switching lens brands and power updates can expedite the process and also give wearers a chance to improve their habits and compliance in the long term.
Conclusion
Managing contact lens discomfort requires different considerations for each unique patient. With every patient, however, consider compliance, vision, and ocular surface health together to determine the best path back to comfortable contact lens wear.
