In part one of our series of articles summarising the key points of the BCLA CLEAR publications, Neil Retallic and Dr Debarun Datta discussed the findings of the BCLA CLEAR regarding the anatomy and physiology of the eye1 and its relevance to contact lenses practice.
In an interactive exercise relating to this paper, you were asked to consider the case of a 54-year-old male patient attends your practice for their first eye examination for a consultation regarding contact lens wear. The aim was to encourage discussion about what changes to the ocular surface might be expected with age. Here are some of your responses.
What changes to the ocular surface and adnexa might you expect to see in this patient that would not be seen when they were a teenager?
Not surprisingly, most responses included quite extensive lists of changes, including lower tear prism and shorter tear breakup time, desiccated corneal surface with possible conjunctiva redness, and arcus changes to the cornea. One, comprehensive response stated: ‘The tears film composition alters as the eyes mature. The lacrimal gland secretions diminishes and its composition changes. Gland inflammation and ductal fibrosis have been reported. Meibomian glands decrease in number and their ducts can keratinise causing blockages and delaying the delivery of secretions to the ocular surface. Lipid secretions can then change in character. Conjunctival wrinkles can develop and lid wiper epitheliopathy. The surfaces of the conjunctiva can also alter under influences of UV rays leading to pinguecula and pterygia. There may be lumps and bumps on the tarsal plates if concretions are present due to hygiene issues or reactive stresses to pollens/pets etc. The cornea may show some arcus as opposed to teenage life plus any possible scars this patient may have picked up from life. If hygiene has become an issue there may be associated blepharitis.’
In what way might these changes have implications upon your decision to fit, what type of lens design and material, the wearing schedule, and what future problems might be predicted, if any?
Nobody felt this patient to be unsuitable for a contact lens trial. Most, in fact, suggested management of any conditions mentioned in the first response (such as MGD) that might affect success, and then to try a multifocal option. For example: ‘Being proactive to CLs, our decisions would not be any different to any other strategy to fit multifocal contact lenses.’ Surprisingly, some of our respondents felt that a 52-year-old was likely to have limited manual dexterity.
In an ideal world, in which you could have access to any instrumentation or data gathering technique, what tests would you want to undertake on this patient beyond refraction, keratometry or slit-lamp?
Responses here ranged from the simple (most wanted an accurate way of measuring HVID) to the more advanced, such as meibography. The most wished for instrumentation, however, that respondents claimed they wanted but did not yet have access to, was a topographer. In addition, quite a few recognised the importance of a method of measuring tear osmolarity and also a way of imaging the tears to allow accurate and locational tear break up.
Neil Retallic says: ‘Ageing is a biological process that typically results in a decline of biological function; the ocular surface and optical system are no exceptions. Most components of the ocular surface experience age-related changes, which may include reductions in lacrimal and tear film quality and quantity, meibomian gland functionality changes, corneal structure and sensitivity changes. Interestingly, reports show women tend to have poorer quality ocular surfaces with higher tear evaporation rates. Such changes can lead to dry eye symptoms as well as optical performance challenges.
‘Examination should always include identification of any clinical signs of sub-optimal contact lens performance. A detailed slit lamp assessment of the ocular surface, lids and adnexa, along with careful questioning, the use of vital stains and observation of blinking is essential.
‘As a result, the optimal contact lens is likely to differ as the age of the eye advances. For presbyopes, multifocal contact lenses should be considered as first choice and the wearer may need separate management of any associated ocular pathology, both with and without lens wear. Any modifiable risk factors, including environment-originated, should be discussed.
‘Advances in technology can support clinical decision-making, such as topography, dry eye and gland assessment tools and anterior OCT. The art of good communication and expectation setting is important to keep wearers successful in a lifetime of contact lens wear.’
- Neil Retallic works for Menicon and the College of Optometrists. He has been involved with various organisations across the sector and is currently part of the GOC Education Committee, President of the BCLA and a Past Chair of the British and Irish University and College Contact Lens Educators. He has been awarded fellowships from the BCLA and IACLE.
Reference
- Downie, LE; Bandlitz, S; Bergmanson, JPG; Craig, JP; Dutta, D; Maldonado-Codina, C; Ngo, W; Siddireddy, JS; Wolffsohn, JS. CLEAR – Anatomy and physiology of the anterior eye. Contact Lens & Anterior Eye; 2021, 44, 132-156. Available for download at: doi:https://doi.org/10.1016/j.clae.2021.02.009