Patient Experiences with Therapeutic Contact Lenses and Dry Eye Disease

Abstract

Objectives:

To report patient-reported experiences with dry eye disease and therapeutic contact lenses.

Methods:

A survey was distributed to patients with dry eye disease. Demographics, Ocular Surface Disease Index (OSDI), systemic disease, contact lens history, and burden of care information were collected. Descriptive statistics are presented and categorized by non-lens, soft lens, and scleral lens (SL) wearers.

Results:

Of 639 respondents, 15% (94/639) were currently using therapeutic soft or SLs (47 soft, 69 SL). Mid-day fogging or clouding of vision was reported by SL (75%, 50/67) and soft (62%, 29/47) wearers. Seventy-two percent of SL wearers spent over 20 minutes daily on dry eye treatment while 43% of soft lens wearers spent more than 20 minutes. Median annual expenditure was higher for SL ($1,500, n=63) than non-lens ($500, n=371) or soft lens wearers ($700, n=43). Mean OSDI scores in all groups were in the severe category (51 ± 22, n= 401 non-lens wearers; mean age; 45 ± 22, n=47 soft lens wearers; 60 ± 24, n=69 SL wearers).

Conclusions:

Mid-day fogging and blurring of vision was reported by the majority of individuals using therapeutic lenses for dry eye disease. SL wearers allocate the most resources for dry eye care.

Dry eye is a multifactorial disease affecting the ocular surface characterized by a loss of tear film homeostasis.¹ The disease is common in the general population with prevalence increasing with age affecting women more frequently than men.^2,3 Severe ocular surface disease is associated with a number of systemic diseases including Sjogren’s syndrome, systemic lupus erythematosus, rheumatoid arthritis, Stevens-Johnson syndrome and ocular graft-versus-host disease.^4–9 Individuals with dry eye disease can experience a varying range of symptom severity including foreign body sensation, dryness, irritation, itching, burning, and blurry vision.²

Therapeutic contact lenses can be prescribed for the management of severe dry eye.¹⁰ These lenses decrease the risk of epithelial compromise by providing a physical barrier between the corneal surface and the friction imposed by eyelid structures.¹¹ Reducing interaction with the eyelid and maintaining corneal hydration can also alleviate ocular pain.¹² Therapeutic contact lenses are typically prescribed only after less invasive treatments such as artificial tears, prescription eye drops, punctal occlusion, topical biologic agents, and in-office meibomian gland procedures fail to provide sufficient ocular surface protection or symptomatic relief.^13–15 The DEWS II report recommends therapeutic contact lenses including soft bandage and scleral lenses (SL) be considered after lid hygiene, topical lubrication, in office meibomian gland expression and prescription topical medications have been prescribed.¹⁵ Bandage lenses can protect the ocular surface from exposure and shearing effects of blinking.¹⁶ Use of soft bandage contact lenses for patients with ocular graft-versus-host disease have shown improvement in OSDI score, improvement in visual acuity, and decrease in corneal staining without complications of ocular infection or corneal ulceration.^17,18 SLs are another option for patients with severe ocular surface disease. The therapeutic benefits of SLs have been reported for patients with severe dry eye including Stevens-Johnson syndrome, graft-versus-host disease and Sjogren’s syndrome. ^19–22

Management of dry eye has associated time and economic burdens for patients. To better access the unfiltered experiences of patients who have dry eye and also wear therapeutic contact lenses, an online survey was administered to individuals who accessed educational materials, online support services, or social media forums dedicated to patients with various forms of dry eye disease. The purpose of this study is to describe patient experiences with dry eye disease and therapeutic contact lenses.

Methods:

This study was reviewed and approved by the University of Illinois at Chicago IRB and adhered to the tenets of the Declaration of Helsinki. An electronic survey was created and distributed using a REDCap (Research Electronic Data Capture) database housed at the same institution.^23,24 A link to the survey was distributed by the Dry Eye Foundation (www.dryeyefoundation.org, Kitsap County, WA) and shared by administrators of support groups and foundations for patients with conditions associated with severe dry eye disease, including Sjogren’s syndrome, Stevens-Johnson Syndrome, dysautonomia, and graft-versus-host Disease. A list is available in Supplemental Appendix 1. The survey was active between March 2018 and October 2018.

Participants with self-reported dry eye

Respondents indicating a positive diagnosis of dry eye disease were included. Demographic data collected included age, sex, and the year during which respondents first noticed dry eye issues. Respondents were asked to report diagnoses of additional systemic diseases using yes or no questions for conditions commonly associated with ocular surface disease and were able to use a fill in the blank option for other conditions. The 12-item Ocular Surface Disease Index (OSDI) was completed.²⁵ An overall score of 33 or greater is classified as severe dry eye disease.

Contact lens history was queried. Respondents were asked if they are currently using bandage soft or SLs as part of their dry eye therapy. Current contact lens wearers were asked to report the type of contact lenses used, average hours of daily wear, and whether they experience mid-day lens fogging or clouding of vision with lens wear (including need for mid-day removal and the number of times the lenses needed to be removed during the day).

Respondents were asked to estimate their annual out-of-pocket costs for the treatment of their dry eye condition including all related expenses (office visits, testing, contact lenses, and medications). Individuals who reported currently using bandage soft or SLs as part of their dry eye therapy were additionally asked to estimate costs specifically related to their contact lenses and contact lens solutions each year.

All respondents were asked to estimate the amount of time spent daily on management of their dry eye condition (none, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50 minutes, 1 hour, 1.5 hours, 2 hours, 2.5 hours, or 3 hours or more).

Respondents provided their opinion about the accessibility of providers whose clinical focus is the management of ocular surface disease. Respondents were also asked whether their eye care provider was able to provide education about advances in dry eye treatment and management. The number of medical visits specifically for the management of dry eye disease was also estimated.

Statistical analysis

Responses were categorized into groups according to whether they used contact lenses. Comparative statistics were not completed due to the size differences in the groups of therapeutic lens wearers and those who did not wear lenses. Descriptive statistics are presented. Those wearing soft bandage contact lenses or SLs were separated into two groups. Not all respondents completed each survey item; the number of responses for each item is indicated along with results.

Results:

Demographics

A total of 639 individuals who reported they had been diagnosed with dry eye disease (90 males, 533 females, 16 preferred not to answer) completed the survey. Most respondents were from the United States (526/625) with 22 individuals each from Canada and the United Kingdom; and an additional 32 countries were represented. Demographics of respondents are shown in Table 1.

Table 1:

Demographics of individuals with self-reported dry eye categorized by contact lens wear. Age and years with dry eye disease are similar between non-contact lenses wearers, soft lens wearers and scleral lens wearers.

	Non-Contact Lens Wearers, n=401	Soft Contact Lens Wearers, n=47	Scleral Lens Wearers, n=69
Age, years; Mean ± SD (range)	55 ± 14 (18 – 89)	49 ± 12 (29 – 73)	55 ± 14 (18 – 76)
n	383	44	65
Male/Female	46/347	5/42	19/48
Years with dry eye symptoms; Mean ± SD (range)	11 ± 10 (0 – 63)	9 ± 8 (1 –36)	12 ± 11 (0 – 53)
n	394	46	69

Current contact lens use was denied by 401 individuals (mean age 55 ± 14 years, range: 18–89 years; 46 males). There were 126 individuals (mean age 52 ± 13 years, range: 18–76 years, n=117; 24 males) who reported current contact lens use. Among respondents currently using soft bandage or SLs as part of the dry eye management, 47 were using soft contact lenses and 69 were using SLs. The mean age of soft lens wearers was 6 years younger than non-contact lens wearers or SL wearers. The duration of dry eye disease from time of diagnosis was similar between non-contact lens wearers, soft contact lens and SL wearers.

A high prevalence of systemic disease was reported by participants. Supplemental Appendix 2 provides a full representation of reported systemic diseases categorized by all respondents, non-contact lens wearers, soft contact lens wearers, and SL wearers. Respondents could report more than one systemic disease. In this study, prevalence of systemic conditions associated with dry eye disease were as follows: Sjogren’s syndrome (38%), thyroid disease (20%), chronic graft-versus-host disease (12%), rosacea (9%), rheumatoid arthritis (7%), scleroderma (7%), Stevens-Johnson syndrome (6%) and systemic lupus erythematous (4%). The highest reported use of soft bandage lenses for the management of dry eye was reported by 36% (17/47) of individuals with Sjogren’s syndrome. The highest reported use of SL wear was by individuals with chronic graft-versus-host disease (33%; 23/69).

OSDI scores

The majority of respondents (76%, 473/620) had an OSDI score of 33 or greater indicative of severe dry eye disease. Mean OSDI scores of both therapeutic soft and SL wearers was greater than 33 (Figure 1). Mean OSDI scores were 15 points higher in individuals using SLs compared to soft lens wearers. OSDI scores of non-lens wearers were 6 points higher than soft lens wearers and 9 points lower than SL wearers.

Figure 1:

Mean Ocular Surface Disease Index (OSDI) scores by group. Each group’s mean is in the severe dry eye category. Scleral lens wearers reported the highest mean score.

Contact lens experience of individuals prescribed soft and SLs for dry eye therapy

Patient-reported contact lens wearing experience is summarized in Table 2. Individuals using both soft bandage (n=40) and SLs (n=67) prescribed for dry eye management reported similar hours of daily lens wear (11 versus 12 hours, respectively). Mid-day fogging or clouding of vision during lens wear was reported by the majority of both soft (62%, 29/47) and SL (75%, 50/67) wearers. A higher percentage of SL wearers than soft lens wearers reported the need to remove lenses during the course of the day (60% compared to 28% of soft lens wearers). SL wearers reported lens removal an average of 3 times daily, compared to 2 times daily for soft lens wearers.

Table 2:

Soft lens wearers and scleral lens wearers reported similar daily lens wear time. More than half of each group reported mid-day fogging or clouding of vision. More scleral lens wearers reported they removal and reapply their lenses mid-day.

	Soft Contact Lens Wearers	Scleral Lens Wearers
	Hours of Daily Lens Wear
Mean ± SD (range)	11 ± 5 (0 – 18)	12 ± 4 (2 – 18)
n	40	67
	Mid-day Fogging
Percent	62% (29/47)	75% (50/67)
	Daily Mid-day Lens Removal and Reapplication
Percent	28% (13/47)	60% (40/67)
	Frequency of Lens Removal
Mean ± SD (range)	2 ± 1 (0 – 3)	3 ± 2 (1 – 10)
n	13	39

Time and financial burden

Sixty three percent of non-contact lens wearers (250/396) and 57% of soft lens wearers (27/47) spent 20 minutes .or less on dry eye management each day (Figure 2). Conversely, only 28% (19/69) of SL wearers reported spending 20 minutes or less on dry eye management with 46% (32/69) spending between 25 and 60 minutes, and 26% (18/69) spending 90 minutes or more.

Figure 2:

Estimated time spent daily on dry eye treatment by non-contact lens wearers, soft contact lens wearers and scleral lens wearers. The majority of non-contact lens wears and soft lens wearers spend 20 minutes or less per day on their dry eye treatment.

Expenses related to dry eye management were estimated by respondents and are presented in Table 3. Annual out-of-pocket cost was highest for SL wearers ($3,019 ± $4,843, n=63). The estimated expense of lenses and contact lens solutions were more than three times higher for SL wearers ($2,244 ± $5,012, n=65) compared to soft lens wearers ($709 ± $1,060, n=41).

Table 3:

Yearly reported out-of-pocket costs for dry eye patients. Respondents were categorized as non-contact lens wearers, soft contact lens wearers and scleral lens wearers. Contact lens wearers reported spending more than non-lens wearers, with scleral lens wearers spending more than soft lens wearers.

	Non-Contact Lens Wearers	Soft Contact Lens Wearers Only	Scleral Lens Wearers Only
	Estimated out-of-pocket cost per year
Mean ± SD (range)	$1,386 ± $4,743 ($0 – $65,000)	$1432 ± $2,151 ($0 – $12,000)	$3,019 ± $4,843 ($220– $35,000)
Median	$500	$700	$1,500
n	371	43	63
	Estimated yearly out-of-pocket cost for contact lenses and solutions
Mean ± SD (range)		$709 ± $1,060 ($0 - $6,000)	$2,244 ± $5,012 ($0 -$40,017)
Median		$400	$1,100
n		41	65

Individuals who did not wear contact lenses reported an average of 3 ± 3 (mean ± SD) office visits per year related to their dry eye disease (range 0–20, n=391). Individuals who were prescribed soft and SL as part of their dry eye management reported an average of one more office visit per year, with a mean of 4 ± 5 (range 1–20, n=46) for soft contact lens wearers and 4 ± 3 (range 1–20, n= 66) for SL wearers.

Only 29% of non-contact lens wearing respondents (n=392) felt it was easy to locate dry eye specialists, while 35% and 38% of lens wearing respondents (soft lens n= 46 and SL n=69 respectively) felt it was easy to find an expert in dry eye management. Most respondents in all groups felt their eye care provider kept them up to date on the most recent advances in dry eye management (63% non-contact lens wearers (n=393), 65% soft lens wearers (n=46) and 69% of SL wearers (n=68)).

Discussion:

Patient-reported outcomes are an essential component of health care²⁶. A prior study described patient satisfaction and care burden of contact lenses in patients with keratoconus²⁷; however, there is limited evidence regarding the burden of care and quality of life for patients with dry eye disease who are using therapeutic contact lenses. It is particularly important to consider patient impressions of their dry eye disease as management is often guided by patient-reported symptoms.²⁸ Utilizing an electronic survey distributed directly to individuals associated with dry eye support organizations made it possible to obtain information directly from a wide range of individuals with dry eye disease. A higher prevalence of systemic disease was reported among respondents than is found in the general dry eye population.² The survey purposefully targeted patients who were likely to have severe ocular surface disease associated with systemic diseases. The study design provided a unique opportunity to obtain unfiltered patient experiences and daily burden of care as it was not associated with or administered by a physician.

Despite well-documented benefits of both soft and SL use for management of severe dry eye disease, their use is not generally recommended as early therapy.^22,29,30 Fewer than 15% of all respondents were using contact lenses as part of their management of dry eye disease in this study. The mean age of individuals using SLs was older than those using therapeutic soft lenses. Individuals using SLs also had a longer mean duration of ocular symptoms and higher mean OSDI scores. This finding is consistent with previous studies which have reported that SLs tend to be reserved for patients with more severe disease.^13,14

Mid-day fogging has been reported to occur in 26% to 46% of patients using SLs.^31–35 In this study, 75% of SL wearers reported issues with lens fogging or clouding of vision necessitating mid-day lens removal in 60% of those reporting the phenomena. However, mid-day fogging or clouding of vision has not been formally investigated in soft lens wearers. The tear film dynamics over soft contact lenses are complicated and are influenced by lipids, proteins, mucins, electrolytes, and individual lens characteristic as well as cosmetics.³⁶ In patients with severe dry eye disease, the tear film may not be adequate to support soft lens use.³⁷ Notably, mid-day fogging and blurry vision was also reported by 62% of soft lens users, with nearly a third reporting they needed to remove and reapply their lenses during the day. Practitioners should evaluate patients with complaints of mid-day fogging and blurry vision for eyelid inflammatory conditions and meibomian gland dysfunction.³⁸ The presence of inflammatory cells and lipids have been investigated as contributors to mid-day fogging in SL wearers.^35,38 Mid-day fogging and clouding of vision in both soft and SL wearers can negatively affect visual function and significantly increase the burden of care associated with lens wear.^31,34 Patients for whom mid-day removal is required may find it difficult to maintain productivity at work and may even limit activities outside of their homes due to the need to have specific lens solutions and handling supplies available.

Individuals reported their perceived burden of dry eye disease. Time spent daily on dry eye management was less than twenty minutes for 63% of non-contact lens wearers and 57% of soft therapeutic lens users but only 28% of individuals using SLs spent less than twenty minutes. Despite more time and money spent on dry eye treatment, the SL group reported the highest mean OSDI scores. It is likely individuals using SLs have more severe ocular surface disease. The median expenditure of individuals wearing SL was three times higher than that of non-lens wearers and more than twice that of individuals using therapeutic soft lenses. Although some of the additional cost can be attributed to contact lens materials and supplies, individuals with more severe disease also likely require more frequent office visits with additional therapeutic costs. Because this study was based upon patient-reported outcomes, diagnosing severity of dry eye was not possible beyond the reported OSDI scores.

Limitations of this work include those associated with any survey-based research and to specific features in the design of this study. Survey research is subject to selection bias; it is not possible to determine whether respondents are truly representative of a larger population. The survey was only available online through dry eye foundations and support organizations, which excluded patients without internet access. Patients who seek information through these channels may be more likely to have experienced difficulties identifying eye care providers who can address their concerns compared to those whose eye care specialists can meet their needs. Purposeful distribution of the survey through organizations that address specific conditions associated with severe dry eye disease may have biased the participant pool towards more severe disease. Overall, this cohort was comprised primarily of middle-aged persons who are involved in dry eye support groups. Many more females than males responded to the survey which may reflect a bias towards female participation in these forums or may reflect the fact that females are more likely to suffer from dry eye disease.^2,3 Future quality of life studies would be strengthened by active recruitment of male participants and differentiation by disease etiology. Results are therefore not likely to be generalizable to the general population or individuals with mild to moderate dry eye disease but do provide unique insights to patients who have multiple systemic co-morbidities along with dry eye. Given that this survey was distributed directly to individuals outside the purview of their clinician, specific clinical data which could help to define disease severity was not available. While the method of distribution may have encouraged patients to honestly report their symptoms (neither over-stating nor downplaying symptoms during an encounter with an eye care provider), lack of clinical data which would allow for assessment of disease severity also limits the degree to which this data may be generalized.

The study provides unique perspectives directly from individuals living with the challenges associated with dry eye disease who wear therapeutic contact lenses and highlights areas for potential improvement in care. Therapeutic contact lenses can improve patient symptoms; however, individuals prescribed therapeutic contact lenses may experience intermittent fogging of vision and mid-day fogging requiring additional time spent on lens care and handling and lens care, particularly with SLs.³⁹ Eye care providers have an opportunity to improve care provided to their patients with dry eye disease by routinely assessing and monitoring patient-reported symptoms and quality of life using OSDI and other standardized questionnaires. Increased awareness of the burden of dry eye disease on patients and recognition of the importance of overall disease management can help eye care providers improve the care they offer to patients with dry eye disease. Patients that remain symptomatic can be referred to colleagues that specialize in dry eye management and specialty contact lenses in an attempt to offer further treatment and relief for patients living with chronic dry eye disease.