Design of a questionnaire for detecting contact lens discomfort: the Contact Lens Discomfort Index

Complications and compliance in professionally-managed and self-managed contact lenses compared with non-contact lens wearers

PURPOSE

To test the impact of professional management of soft contact lens wear on symptoms and ocular complications.

METHODS

Subjective symptoms and ocular complications of soft CL users who did not seek professional follow-up care (self-managed, SM), were compared to users who were prescribed CLs and their care professionally managed in optometry practices (PM), and to a control group of non-CL wearers. Habitual visual acuity, subjective dry-eye symptoms, and corneal abnormalities were assessed in all participants. CL wearers filled-out a usage habits questionnaire, and their CL fit was assessed. Outcomes were compared using Kruskal-Wallis and Chi Squared tests.

RESULTS

The SM, PM, and non-CL wearers cohorts included 127 (mean age:24.3±5.1, median:23, range:16-45 years,104 female), 132 (mean age:25.5±6.2, median:23, range:18-43 years,103 female), and 56 (mean age:22.3±3.5, median:21, range:18-39 years,36 female) participants, respectively. Meibomian gland dysfunction grade (p = 0.004, p<0.0001), limbal redness (both p = 0.04), corneal neovascularization (both p = 0.003), and papillary conjunctivitis (p<0.0001,p = 0.005) were significantly worse in SM CL wearers compared with both the non-CL wearers and PM CL wearers, respectively. Conjunctival staining was significantly worse in the SM cohort compared with the PM cohort (p = 0.01). 38.6% of the SM compared with 22.8% of the PM CL wearers, had an inappropriate refractive correction (p = 0.006). SM CL wearers wore CLs significantly more years (mean and median 1 year,p = 0.008), for more daily hours (mean and median of 2 hours,p<0.00001), and tended to nap or sleep with their CLs compared with the PM CL wearers (47 vs. 29,p = 0.02). The cohorts did not differ in their subjective symptoms.

CONCLUSIONS

Complications are significantly more prevalent in SM CL wearers compared with PM CL wearers, and SM CL wearers tend to wear CLs with incorrect powers, and are less compliant with napping or sleeping with the CLs compared with PM CL wearers. These findings emphasize the importance of fitting, patient education and follow-ups in CL wearers.

Reliability of Tear Meniscus Height Measurements in Contact Lens Wearers and Its Relationship With Discomfort Symptoms

OBJECTIVES

To evaluate the reliability and agreement of tear meniscus height (TMH) measurements performed with a corneal analyzer and optical coherence tomography (OCT) technology in contact lens (CL) wearers and its correlation with contact lens discomfort symptoms.

METHODS

Asymptomatic and symptomatic CL wearers classified through the Contact Lens Dry Eye Questionnaire-8 were evaluated with the Corneal Analyzer (Topcon CA-800) and OCT technology (Topcon 3D OCT-2000). The repeatability and intraclass correlation coefficient (ICC) were calculated. The agreement between devices was calculated using the Bland-Altman method. The relationship between TMH measurements and the Contact Lens Dry Eye Questionnaire-8 and Contact Lens Discomfort Index scores was assessed through the Spearman correlation coefficient.

RESULTS

Seventy-nine asymptomatic and 42 symptomatic CL wearers aged 34.24±12.50 years were enrolled. The repeatability values obtained for the CA-800 were 0.07 mm in all cases, and the ICC was 0.93 for the whole sample. The CA-800 provided significantly ( P <0.01) higher TMH values than the OCT for the whole sample (0.22±0.08 vs. 0.17±0.06 mm). A weak indirect correlation (ρ=-0.22) between the OCT TMH measurement and Contact Lens Discomfort Index scores was found ( P ≤0.04).

CONCLUSION

The CA-800 provides reliable TMH measurements during CL wear; however, they might not be interchangeable with OCT ones. Tear meniscus height measurements might be useful as a complementary sign to detect CL discomfort, but it cannot be used alone as a diagnostic tool.

Corneal neuropathic pain: a review to inform clinical practice

Corneal neuropathic pain (CNP) is a poorly defined disease entity characterised by an aberrant pain response to normally non-painful stimuli and categorised into having peripheral and central mechanisms, with the former responding to instillation of topical anaesthetic. CNP is a challenging condition to diagnose due to numerous aetiologies, an absence of clinical signs and ancillary tests (in vivo confocal microscopy and esthesiometry), lacking the ability to confirm the diagnosis and having limited availability. Symptomatology maybe mirrored by severe and chronic forms of dry eye disease (DED), often leading to misdiagnosis and inadequate treatment. In practice, patients with suspected CNP can be assessed with questionnaires to elicit symptoms. A thorough ocular assessment is also performed to exclude any co-existent ocular conditions. A medical and mental health history should be sought due to associations with autoimmune disease, chronic pain syndromes, anxiety and depression. Management begins with communicating to the patient the nature of their condition. Ophthalmologists can prescribe topical therapies such as autologous serum eyedrops to optimise the ocular surface and promote neural regeneration. However, a multi-disciplinary treatment approach is often required, including mental health support, particularly when there are central mechanisms. General practitioners, pain specialists, neurologists and psychologists may be needed to assist with oral and behavioural therapies. Less data is available to support the safety and efficacy of adjuvant and surgical therapies and the long-term natural history remains to be determined. Hence clinical trials and registry studies are urgently needed to fill these data gaps with the aim to improve patient care.

Clinical characterisation of contact lens discomfort progression

PURPOSE

This study aimed to assess the subjective and objective differences among the steps of the contact lens discomfort (CLD) progression classification established by the Tear Film & Ocular Surface Society (TFOS) using questionnaires and clinical signs, and to propose a simplified classification.

METHODS

Contact lens (CL) wearers were evaluated in a single visit. The Contact Lens Dry Eye Questionnaire (CLDEQ)-8, the Contact Lens Discomfort Index, and Visual Analog Scales for discomfort and dryness were administered. The non-invasive break-up time, the tear film lipid layer thickness, conjunctival hyperaemia and papillae, lid-parallel conjunctival folds, the fluorescein tear film break-up time, corneal and conjunctival staining, lid wiper epitheliopathy, and the Schirmer test were assessed. Sign and symptom scores were compared among TFOS CLD progression steps using analysis of variance or the Kruskal-Wallis H test. Steps 1 and 2 (reduced comfort), and steps 3 and 4 (reduced wearing time) of the TFOS classification were combined to obtain a simplified classification, and the same comparison was performed. A p-value ≤ 0.05 was considered statistically significant.

RESULTS

One hundred-fifty CL wearers (97 women and 53 men) aged 34.4 ± 12.6 years were included. In the TFOS classification, there were significant differences between step 0 (no CLD) and the rest of the severity steps for the scores obtained in all questionnaires (p ≤ 0.015). All steps were differentiated (p ≤ 0.032) based on the simplified classification for all questionnaires, except steps 1 and 2 for the CLDEQ-8 and dryness VAS (p = 0.089 and p = 0.051, respectively). There were no differences (all p ≥ 0.06) between the sign scores among the steps of either classification.

CONCLUSION

CLD management is encouraged from its first appearance. Simplifying the phases of CLD severity may allow a more accurate classification and a better awareness of the problem by clinicians and CL wearers by using more straightforward simple messages.

Evaluation of ocular neuropathic pain

AIM

To identify and assess the quality of current validated questionnaires that could be used to evaluate ocular neuropathic pain and its associated aetiologies.

METHODS

A literature search was performed on MEDLINE, PubMed, EMBASE, PsycINFO and The Cochrane Library. Articles evaluating questionnaires for ocular neuropathic pain and its associated aetiologies were included. Data on psychometric properties, validity, and reliability of the questionnaires was extracted and analysed using a set of quality criteria. Clinical and demographical associations with ocular neuropathic pain were also reviewed.

RESULTS

The search generated 1738 results with 61 publications meeting the inclusion criteria. The 61 publications covered 28 questionnaires including 3 ocular pain, 12 dry eye disease, 2 blepharitis, 2 refractive surgery, 3 contact lens wear, 3 Sjogren's Syndrome, and 3 that were non-disease-specific. Only 57 publications provided enough data on psychometric properties and validity of the questionnaire to be included for quality assessment. The Contact Lens Discomfort Index (CLDI) had the highest rated psychometric properties, whereas the English version of the Ocular Comfort Index (OCI) provided the most data on psychometric properties (9 out of 10 criteria). Most ocular pain and disease-specific questionnaires contained appropriate items to assess ocular pain in specific populations. However, non-disease-specific ophthalmic questionnaires demonstrated poor reliability and validity when evaluating ocular pain.

CONCLUSION

Ocular pain questionnaires can potentially diagnose ocular neuropathic pain. Disease-specific questionnaires were limited to their target populations, and non-disease-specific ophthalmic questionnaires were unreliable. Further studies are required to determine the most appropriate questionnaire to evaluate ocular neuropathic pain.

TFOS Lifestyle: Impact of contact lenses on the ocular surface

Several lifestyle choices made by contact lens wearers can have adverse consequences on ocular health. These include being non-adherent to contact lens care, sleeping in lenses, ill-advised purchasing options, not seeing an eyecare professional for regular aftercare visits, wearing lenses when feeling unwell, wearing lenses too soon after various forms of ophthalmic surgery, and wearing lenses when engaged in risky behaviors (e.g., when using tobacco, alcohol or recreational drugs). Those with a pre-existing compromised ocular surface may find that contact lens wear exacerbates ocular disease morbidity. Conversely, contact lenses may have various therapeutic benefits. The coronavirus disease-2019 (COVID-19) pandemic impinged upon the lifestyle of contact lens wearers, introducing challenges such as mask-associated dry eye, contact lens discomfort with increased use of digital devices, inadvertent exposure to hand sanitizers, and reduced use of lenses. Wearing contact lenses in challenging environments, such as in the presence of dust and noxious chemicals, or where there is the possibility of ocular trauma (e.g., sport or working with tools) can be problematic, although in some instances lenses can be protective. Contact lenses can be worn for sport, theatre, at high altitude, driving at night, in the military and in space, and special considerations are required when prescribing in such situations to ensure successful outcomes. A systematic review and meta-analysis, incorporated within the review, identified that the influence of lifestyle factors on soft contact lens dropout remains poorly understood, and is an area in need of further research. Overall, this report investigated lifestyle-related choices made by clinicians and contact lens wearers and discovered that when appropriate lifestyle choices are made, contact lens wear can enhance the quality of life of wearers.

Evaluation of Celligent® Biomimetic Water Gradient Contact Lens Effects on Ocular Surface and Subjective Symptoms

This study aimed to evaluate the non-invasive and subjective symptoms associated with Lehfilcon A water gradient silicone hydrogel contact lenses with bacterial and lipid resistance technology. A prospective, longitudinal, single-centre, self-controlled study was conducted among silicone hydrogel contact lens wearers. Non-invasive analysis of the pre-lens tear film was performed using the Integrated Clinical Platform (ICP) Ocular Surface Analyzer (OSA), and the meibomian glands were evaluated with the Cobra® HD infrared meibographer. After 30 days of contact lens wear, the subjects were re-evaluated to determine the changes in conjunctival redness, subjective dry eye disease, tear meniscus height, lipid pattern, and non-invasive break-up time. Results showed that the lipid layer thickness decreased significantly from 2.05 ± 1.53 to 0.92 ± 1.09 Guillon patterns, and the tear meniscus height decreased from 0.21 ± 0.04 to 0.14 ± 0.03. The mean pre-lens non-invasive break-up time (NIBUT) significantly increased from 15.19 ± 9.54 to 25.31 ± 15.81 s. The standard Patient Evaluation of Eye Disease (SPEED) score also decreased from 7.39 ± 4.39 to 5.53 ± 4.83. The results suggest that Lehfilcon A significantly reduced lipid and aqueous tear film volume but improved break-up time and subjective dry eye symptoms.

What Are the Dry Eye Questionnaires Available in the Scientific Literature Used for? A Scoping Review

PURPOSE

Dry eye disease (DED) is a frequent chronic ophthalmic condition. Its diagnosis includes tests and patient reported outcomes (PRO) questionnaires. Although many PRO dry eye questionnaires (PRO-DEQs) are available, they differ greatly from each other and not all have been validated. The purpose of this study was to retrieve the PRO-DEQs present in the scientific literature by performing a descriptive analysis of them and identifying those with known validity and reliability characteristics and to perform a descriptive analysis of the geographic area, year of publication, and characteristics of the target population of the clinical studies that have used validated PRO-DEQs.

DESIGN

Scoping review of the literature.

METHODS

Searches were conducted in PubMed to retrieve PRO-DEQs published up to July 2018 and written in English, French, Italian or Spanish.

RESULTS

One thousand six hundred two records were identified and 973 were included in the final analysis. Of these, 56 provided information on the design and validation of PRO-DEQs and 49 PRO-DEQs were identified. Twenty-two PRO-DEQs were validated (17 original and 5 modified) and 27 had no associated design, validity, and reliability studies. Most of the validated PRO-DEQs were designed in English, the number of items varies from 1 to 57, the dimensions are generally not specified, and they are self-administered. The greatest use of validated PRO-DEQs in clinical studies has been in Asia since 2010, with the Ocular Surface Disease Index being the most used. These questionnaires have been used mostly in adults, retired professionals, and people with visual diseases to diagnose DED.

CONCLUSIONS

This study aims to encourage the use of validated PRO-DEQs to guarantee the quality of the results obtained and the comparability and replicability among studies.

OSDI Questions on Daily Life Activities Allow to Detect Subclinical Dry Eye in Young Contact Lens Users

Dry eye disease (DED) is difficult to detect in young contact lens (CL) wearers, who usually have no signs, mild symptoms and an ocular surface disease index (OSDI) below the DED diagnosis values (OSDI ≥ 13). We investigate if some of the 12 OSDI questions (OSDI A—ocular symptoms; OSDI B—vision-related functionality; OSDI C—environmental triggers) contribute the most to classify young CL as symptomatic. TBUT and tear volume are also measured. Age, gender and refraction error-matched eye glasses (EG) wearers participated as the control. CL and EG data were compared with t-test and z-test. Confusion matrices and logistic correlation analyses were performed to define the contribution of each OSDI question to classify symptomatic subjects. OSDI classified symptomatic CL better than the tear volume or TBUT values. In CL, only OSDI B and C values were significantly higher in symptomatic vs. asymptomatic subjects (p < 0.001), while values of all twelve OSDI questions were significantly higher in symptomatic vs. asymptomatic EG (p < 0.05−0.001). All OSDI questions contribute equally to identify symptomatic EG, while only OSDI B questions on daily life visual functions are significant to classify symptomatic CL wearers at risk to develop DED or at a subclinical stage. CL wearers scoring ≥ 2 on the OSDI B questions should be considered for preventive treatments, even if their clinical sings are scarce or absent.