When Fitting the Mature Contact Lens Patient

By Christopher Miller, ABOC, NCLEC

They say 50 is the new 40, and 60 is the new 50. Current numbers indicate that a third of the U.S. population was between 40 to 59 years of age at the end of 2010 with 14.5 million turning 40 within the next four years. These aging baby boomers are more active, more style-conscious, have access to knowledge never before possible, and have the highest amount of disposable income than any previous generation. Many currently care for one or more parent, and the mix has made healthcare the number one issue in America. That's because no matter how well we take care of ourselves, with age and all its wisdom also come health issues; some are avoidable, some not. The mature eye has a wider range of conditions to consider that suggests different spectacle and contact lens modalities.

COMMON ADULT EYE COMPLAINTS AND THE CONTACT LENS FITTER

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 multifocal 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 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.

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, which can both be treated.

Eyelid Problems: Comes from a variety of different diseases or conditions. Common eyelid complaints include pain, itching, tearing or being sensitive to light. Giant Papillary Conjunctivitis (GPC) is a fairly common one. GPC is not an infection, but an inflammation of the inside surface of the lid, caused by constant rubbing 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.

Conjunctivitis (also called pink eye) occurs when the conjunctiva lining 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 an infection. Infectious pink eye can easily spread from one eye to the other and to other people. Advise the patient to remove their lenses until it clears up. Depending upon the severity, they should either see their doctor for further evaluation and treatment immediately or after a few days if conditions don't change.

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 ointment. 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.
• Blinking more often.
• Periodically rest the eyes, looking away at more distant objects, especially while reading, watching television or using the computer.

Meibomian Gland Dysfunction: 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, prevents tear spillage onto the cheek, makes the closed lids airtight and acts 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, 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 this condition 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
• Omega 3 supplementation

Corneal diseases and conditions can cause redness, watery eyes, pain, reduced vision or a halo effect. The cornea is the clear, dome-shaped “window” at the front of the eye. It helps to focus light that goes into 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).

Glaucoma is one of the leading causes of blindness. Glaucoma is a disease caused by the collapse of the trabecular meshwork and/or the Canal of Schlemm, resulting in increased eye pressure within the eyeball. This results in the death of capillaries that nourish the peripheral retina leading to a reduced visual field and eventually blindness if untreated. In early glaucoma, patients may not have any symptoms. Therefore the condition is often neglected. Early diagnosis and treatment will prevent blindness.

Age-related macular degeneration (AMD) is a medical condition, which usually affects older adults resulting in a loss of vision in the center of the visual field (the macula) because of damage to the retina. It is a major cause of visual impairment in older adults. Macular degeneration can make it difficult or impossible to read or recognize faces, although enough peripheral vision remains to allow other activities of daily life.

The inner retinal layer of the eye contains nerves that communicate sight. Behind the retina is the choroid, which contains the blood supply to the macula (the central part of the retina). In the dry (non-exudative) form, cellular debris called drusen accumulate between the retina and the choroid, reducing the regeneration of the chemistry required to send signals or the retina can become detached. In the wet (exudative) form, which is more severe, blood vessels grow up from the choroid behind the retina, and the retina can also become detached. It can be treated with laser coagulation, and with medication that stops and sometimes reverses the growth of blood vessels.

Although some macular problems affecting younger individuals are sometimes referred to as macular degeneration, the term generally refers to seniors or age-related macular degeneration (AMD or ARMD).

Diabetic retinopathy: Diabetes mellitus (DM) can cause diabetic retinopathy, leading to retinal hemorrhage, vitreous hemorrhage and retinal detachment. In the diabetic, cell walls may not have all the factors necessary to retain their wall strength and tonicity. This results in vessel walls that leak or burst. Depending on the duration and the age of onset of diabetes, the incidence of diabetic retinopathy varies from 20 to 55 percent in diabetic patients. 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.

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, five 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 composition 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 like diabetes. Such diseases can cause eye problems if not treated.
• Recommend a complete dilated eye exam with an eyecare professional every one to two years. This is the only way to find some 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 too much sunlight, which can raise the risk of getting cataracts. Also advise eyewear protection whenever needed.

CONCLUSION

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 a variety of trial lenses on hand; as we well know, eyes come in all sizes and all ages.