By Dr Amira Howari
BOptom(Hons) MOptom GradCertOcTher
Systemic conditions can critically affect the successful wearing of contact lenses and should never be overlooked.
A 23-year-old Caucasian female presented to the clinic for a second opinion regarding her contact lenses. She had seen an optometrist three months earlier as she was keen to wear contact lenses for sports. The patient had had type 1 diabetes for 13 years and her HbA1c had been elevated for the past five years, ranging from 9.0 to 13.
The previous optometrist had attempted to teach insertion and removal but when this was unsuccessful, had recommended that the patient wear monthly extended wear lenses.
The plan was for the patient to visit the optometrist at the beginning of each month and have the lenses replaced with a fresh pair. The optometrist also suggested that a family member could assist with insertion and removal if required.
On examination, after the patient had worn the contact lenses for two weeks:
Best corrected visual acuity with contact lenses RE 6/7.5- LE 6/9
CL Rx RE -1.50 LE -1.75
Slitlamp examination revealed diffuse punctuate staining across both corneas and 360 degrees of limbal injection. Moderate dry eye was also noted, where tear break up time of seven seconds was recorded for both eyes. Contact lens assessment showed a tight fit with no movement on blinking.
On questioning, the patient reported ocular irritation but thought this was the expected norm with contact lens wear.
Management included ceasing contact lens wear, using preservative-free lubricating eye-drops every two hours and preservative-free eye gel at night. Review was booked for one week later.
Follow-up showed a marked improvement where the superficial punctuate staining had resolved, and tear break up time was now nine seconds in both eyes.
The patient was successfully fitted with a daily disposable water gradient material contact lens with a Dk/t 156 and water content that approached 100 per cent at the outer-most surface of the lens.
She was shown various techniques to insert and remove her contact lenses until she was comfortable and confident in doing this independently. Contact lens care education was initiated and diabetic health care was also discussed at length. Communication included the patient’s endocrinologist, GP and retinal ophthalmologist.
When selecting the appropriate contact lens for a patient, the effects of systemic conditions can play a critical role on whether the patient can successfully wear contact lenses and should never be underestimated or overlooked.
Diabetic patients with poor, fluctuating blood glucose levels will often experience fluctuating dehydration, which can also be evident across their fragile corneal layers.1,2 In such cases, opt for a contact lens with both higher oxygen transmissibility and water content, and minimise or avoid extended contact lens wear in such profiles by opting for daily disposables.2,3
Ocular anatomy can at times make fitting and teaching insertion and removal a little more challenging. Patiently trialling various techniques may be the key to set up a patient for success without potentially compromising their ocular health.
1. Kathryn Skarbez, Yos Priestley, Marcia Hoepf et al. Comprehensive review of the effects of diabetes on ocular health. Exp Review Ophthalmol 2010; 5: 4: 557-577.
2. Martin Göbbels, Manfred Spitznas, Joachim Oldendoerp. Impairment of corneal epithelial barrier function in diabetics. Graefe's Arch Clin Exp Ophthalmol 1989; 227: 2: 142-144.
3. Clare O'Donnell, Nathan Efron. Diabetes and contact Lens wear. Clin Exp Optometry 2012; 95: 3: 328-337. doi: 10.1111/j.1444-0938.2012.00738.x.
4. March W, Long B, Hofmann W et al. Safety of contact lenses in patients with diabetes. Diab Tech Therap 2004: 6: 1: 49-52. doi:10.1089/152091504322783404.