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Review Article

Contact Lens Wear and Dry Eye: Beyond the Known

Koh, Shizuka MD, PhD∗,†

Author Information
Asia-Pacific Journal of Ophthalmology: November-December 2020 - Volume 9 - Issue 6 - p 498-504
doi: 10.1097/APO.0000000000000329
  • Open


Contact lenses are widely used to correct refractive errors. According to the annual overviews of contact lens prescription trends, which surveyed contact lens fits from >20,000 cases from 25 countries in 2019,1 soft contact lenses (SCLs) were prescribed in 87% of the cases, whereas gas-permeable lenses are supplied in 13% of fits (conventional lenses, 10%; orthokeratology lenses, 3%).

This review primarily summarizes information from the latest topics related to contact lens and dry eye that would be useful for clinicians and contact lens practitioners, along with a concise review of what is known. Pitfalls that may be encountered in clinical practice and other associated topics are also described. Since most contact lenses prescribed today are SCLs, the contact lenses discussed in this review refer to SCLs.


Contact lens wear is one of the relevant risk factors for dry eye.2,3 Symptoms of discomfort and dryness are more frequent and intense in SCL wearers and exhibit a greater increase in intensity during lens usage than in nonwearers.4,5 Since the publication of the Contact Lens Discomfort (CLD) report by the 2013 Tear Film and Ocular Surface Society (TFOS) Workshop, its importance has continued to grow. The CLD report defines CLD as “a condition characterized by episodic or persistent adverse ocular sensations related to lens wear, either with or without visual disturbance, resulting from reduced compatibility between the contact lens and the ocular environment, which can lead to decreased wearing time and discontinuation of contact lens wear.”6 However, contact lens practitioners have used a variety of terms to describe this condition, and there is no standard definition. The CLD report describes some specific and relevant terminology that should be considered for such cases.6 CLD occurs while contact lenses are worn, and their removal mitigates the condition (especially the adverse ocular sensations). The terms “contact lens dry eye,” “contact lens-related dry eye,” or “contact lens-induced dry eye” should be reserved for cases with a preexisting dry eye condition that may be exaggerated by contact lens wear and should not be used when talking about CLD. “Contact lens dropout” refers to discontinuation of contact lens wear for a sustained period of time. In keeping with the definition proposed by the CLD report, CLD will be used throughout the review rather than “contact lens dry eye.”


Uneven or insufficient tear distribution and increased friction are the 2 main factors underlying CLD.7 A simplified scheme is shown in Figure 1. Once a contact lens is placed on the eye, the tear film is divided into the pre-lens tear film (PLTF) and post-lens tear film (PoLTF). Although the PLTF is less stable and thinner than the tear film over the cornea,8 it plays an important role in providing a smooth optical surface; it also provides comfort and lubrication to the palpebral conjunctiva, reducing the friction between the lens and palpebral conjunctiva. The PoLTF may be involved in interactions with the ocular surface and affect ocular comfort during contact lens wear.9 In addition, through tear exchange, the PoLTF removes the cellular and inflammatory debris contained within the lens itself. Tear evaporation rates associated with SCL use are high, even if SCL wearers are asymptomatic.10 Therefore, patients who previously did not experience symptoms may develop symptoms of discomfort and dryness.11 For successful contact lens wear, both the PLTF and PoLTF are important in maintaining ocular health. Multiple biophysical changes associated with this compartmentalization can occur in the tear film during SCL wear, which will be discussed later.9 Moreover, a possible increase in friction between the lens and lid wiper, or between the lens edge and bulbar conjunctiva, should be considered.

Simplified scheme for the mechanism of contact lens discomfort (CLD). Uneven or insufficient tear distribution and increased friction are the two main factors underlying CLD development.

A recent review suggested clinical and subclinical inflammation associated with contact lens wear,12,13 and summarized the evidence of inflammation during uncomplicated contact lens wear for both hydrogel and silicone hydrogel lenses.13


Ocular surface symptoms are a feature of CLD. A contact lens dry eye questionnaire is the most likely candidate for large-scale CLD assessment, and the Contact Lens Dry Eye Questionnaire-8 (CLDEQ-8)14,15 is reported to represent the most validated measure of these symptoms.16 The CLDEQ-8 is an 8-item self-administered questionnaire that queries the frequency and late-day intensity of discomfort, dryness, blurry vision; the frequency of closing eyes for relief while wearing contact lenses; and the removal of lenses earlier than planned for relief of symptoms. It also reflects the wearers’ overall opinion of contact lenses, eye dryness, and eye sensitivity. The CLDEQ-8 (originally in English) was recently translated into different languages, and validation studies of the versions translated in Spanish, Japanese, and Turkish have been reported.17–19 Although both the Japanese18 and Turkish19 versions were valid and reliable, elaboration was required for the Spanish17 version. Interestingly, eye dryness, but not eye sensitivity, was useful to capture the symptoms in the Japanese populations.18 A study20 to develop and validate a Chinese version of the ocular comfort index21 reported that “grittiness” and “stinging” were difficult to interpret in Chinese. These studies17–20 imply that linguistic features and cultural differences should be carefully interpreted and considered during the development of questionnaires translated from a different language.

The prevalence of CLD and dryness symptoms in SCL wearers is reported to be approximately 50%.22 In a recent study from Japan, >70% of SCL wearers reported eye dryness.18 Digital device usage for both social and professional purposes has recently shown a remarkable increase across all age groups. Moreover, the current coronavirus disease 2019 (COVID-19) pandemic has accelerated the increased use of digital devices and screen time for both work and recreation around the world, which may lead to an increase in eye strain. Digital eye strain includes a range of ocular and visual symptoms, and its prevalence is reported to be ≥50% among computer users.23 Digital eye strain symptoms can be mainly classified into those associated with dry eye or those related to accommodation.23–25 With ≥6 hours of computer use, contact lens wearers were more likely to be affected than nonwearers, with prevalences of 65% and 50%, respectively.23


In accordance with the protocols suggested by both the Dry Eye Workshop (DEWS) II report and Asia Dry Eye Society (ADES) consensus report,3,26 proper assessment of the ocular surface, tear film, and symptom questionnaire are essential. Note the difference in the diagnostic criteria for dry eye between DEWS II and ADES. The recommended criteria for dry eye diagnosis by DEWS II are presence of symptoms and at least one positive result for homeostasis markers (decreased noninvasive tear breakup time, increased osmolarity, or a certain amount of ocular surface damage).26 In contrast, on the basis of ADES, dry eye can be diagnosed by a combination of symptoms and an unstable tear film (decreased tear breakup time). Actually, it is highly dependent on tear film stability.3 Several biophysical tear film changes associated with SCL wear are known, including increased evaporation, decreased tear film stability, reduced pre-lens lipid layer thickness, decreased tear volume, and changes in the tear composition.11 However, their influence on comfort remains unproven and inconclusive, and further investigation is needed.

Geographical and/or ethnicity-related differences in the susceptibility to dry eye have been reported, and Asian ethnicity is a risk factor for dry eye.27 Similarly, Asian ethnicity is associated with discomfort and dryness with contact lens wear.27 Interestingly, among non-Asians, dryness symptoms were more severe in the presence of corneal staining, whereas dryness severity did not appear to be related to corneal staining among Asians.28

The lack of in-depth investigations into the subtypes, causes, and contributing factors of the presenting dry eye results in relation to patient dissatisfaction has been addressed. According to a recent study, both asymptomatic and symptomatic SCL wearers who are asymptomatic without lenses exhibit similar clinical signs.29


Evaluation of the ocular surface and tear film of all contact lens wearers is essential, even when these individuals are asymptomatic. Makeup particles floating in the tear film and makeup residue in the eyelid margin are sometimes observed in female SCL wearers, which may be trapped by SCLs and may disturb vision. The migration of cosmetic products across the eyelid margin has been reported,30 and is thought to exacerbate tear film instability and symptoms of dry eye.31 Since eye cosmetics are frequently applied among female populations, who also constitute the majority of contact lens wearers, educational guidance regarding eye cosmetic usage with SCL wear should be appropriately provided.

To evaluate corneal or conjunctival epithelium damage, vital staining procedures are simple and useful. Fluorescein staining can be applied without special tools or devices. With fluorescein staining, a cobalt blue filter is typically used during slit-lamp examination; these filters transmit blue light, which activates the fluorescein dye. To enhance the visualization of the fluorescent tear film and staining, a yellow filter or a blue-free barrier filter can be used.32–34 This filter is especially useful in detecting conjunctival epithelial damage. Manufacturers have incorporated such yellow filters into their slit-lamps. The smile pattern of corneal staining in the inferior cornea is reported to be a characteristic corneal staining pattern in SCL wearers,35 whereas 3 to 9 o’clock staining is a characteristic pattern in rigid gas-permeable contact lens wearers36–38 (Fig. 2). Some SCL wearers are asymptomatic even with more than moderate corneal staining and state that they feel better with SCL wear. This can be attributed to the masking effect of SCLs.

(Left) Smile pattern of corneal staining is characteristic in soft contact lens wearers. (Right) 3–9 o’clock staining is characteristic in rigid gas-permeable contact lens wearers.

Lissamine green dye is widely used to stain the conjunctiva and assess its health. It provides information similar to the more traditional rose bengal dye, without discomfort for the patient. The conjunctiva responds in various ways to contact lens wear. Bulbar conjunctival staining with lissamine green is associated with CLD, particularly SCL edge-related staining. In addition, it has been reported that evaporation due to destabilization of the tear film by the SCL causes bulbar conjunctival staining.39–43 The palpebral conjunctiva is important in controlling the interaction between the ocular surface and lens. Identification of the presence of lid wiper epitheliopathy (LWE) linked to CLD is important, but is unfortunately easily overlooked (Fig. 3). Korb et al44 first introduced the term “lid wiper” to describe the area of the upper eyelid that spreads tear film over the cornea (or contact lens), and the term “lid wiper epitheliopathy” refers to the disruption of epithelial cell integrity in this area. Increased staining of the upper-lid margin has been reported in contact lens wearers with symptoms of dryness.44,45 Another study reported that LWE was found in 67% and 32% of symptomatic and asymptomatic SCL wearers, respectively.46 The pathophysiology of LWE is thought to involve increased friction between the lid wiper area and the surface of either the cornea or contact lens as a result of inadequate lubrication.47

Lid wiper epitheliopathy is identified with fluorescein staining. Courtesy to Dr. Hisayo Higashihara.


The following management strategies for CLD have been suggested by the CLD report48: change in the care solution and care system, adjustment of replacement schedule, change in lens design or material, tear supplementation (use of lubricating or wetting drops, and punctal plug insertion), dietary supplementation, and improvement of environment. Since then, several different contact lenses or contact lens care products and dry eye treatment eye drops have been introduced in the market. Dietary supplementation with oral omega-3 fatty acids was recommended by clinicians to relieve dry eye symptoms, with the assumption that they have antiinflammatory activity and are not associated with substantial side effects.49 However, the results of the 12-month Dry Eye Assessment and Management study revealed that dietary supplementation with oral omega-3 fatty acids is no better than placebo in relieving the signs and symptoms of dry eye.50 The results of their extension study were consistent with the primary trial.51 Therefore, updates to the current or latest strategy are essential.

Whether patients with CLD qualify for refractive surgery requires careful consideration and counseling of the individual patient. The surgical procedure itself is commonly associated with dry eye in the postsurgical period.52,53 According to a questionnaire survey, 23% of refractive surgery patients who were previous contact lens wearers cited dry eyes as the reason for their decision to receive refractive surgery.54 Moreover, visual performance during concentrated visual work and quality of life were reported to be worse with SCL wear than after laser in situ keratomileusis.55,56

The treatment strategy in our clinical practice can be classified into two approaches: pharmacological treatment (approach focused on the ocular surface) or selection of suitable contact lens (approach focused on the contact lens). In cases where discontinuation of contact lens wear is desirable, we ask the patient to stop contact lens wear. If contact lens wear is thought to be possible with concomitant eye drop usage for dry eye treatment, the possibility of discontinuation of contact lens wear should be thoroughly explained first. The transient enhancement of tear film stability by SCL lubricants is unlikely to provide a basis for prolonged symptomatic relief.57,58

Pharmacological Treatment

Based on the mechanism mentioned earlier in this review, treatment focuses on the management of uneven or insufficient tear distribution and increased friction. With the introduction of 3% diquafosol sodium ophthalmic solution (Diquas ophthalmic solution 3%; Santen Pharmaceutical Co., Osaka, Japan) and 2% rebamipide ophthalmic suspension (Mucosta Ophthalmic Suspension UD2%; Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan) both first in Japan, diagnosis and treatment of dry eye have advanced greatly. A new concept of layer-by-layer diagnosis and treatment for dry eye, termed “tear-film-oriented diagnosis” and “tear-film-oriented therapy” has been proposed.3,59 Currently (at the time of August 2020), diquafosol is approved and available in Japan, South Korea, China, Taiwan, Philippines, Thailand, Malaysia, Indonesia, and Vietnam. Rebamipide is available only in Japan.

To treat uneven or insufficient tear distribution, diquafosol, which promotes aqueous and mucin secretion from the conjunctiva, is expected to be effective. It is reported to increase the tear meniscus height in SCL wearers.60 Using a rabbit model of SCL wear, both the PLTF and PoLTF thickness were reported to increase after diquafosol instillation.61 Moreover, 4-week treatment with diquafosol improved tear stability, ocular surface vital staining score, and subjective symptoms.62 Rebamipide, which increases the secretory mucin level, is reported to be effective in treating friction-related ocular surface disorders such as superior limbic keratoconjunctivitis and LWE,63,64 probably because of the gradual increase in goblet cells.65 Rebamipide is reported to be effective in improving discomfort associated with SCL wear.66,67 This effect is thought to involve a reduction of the increased friction associated with SCL wear. This strategy is based on the available treatment in Japan where the author is involved in clinical practice.

To date, there have been no published studies investigating the efficacy of topical steroid treatment for CLD.48 Except for dry eye associated with immune system diseases, the role of topical steroids is either unclear or contradictory for the treatment of dry eye and related conditions.68

Selection of Suitable Contact Lens

Daily disposable lenses with good lens wettability would be a great option for SCL wearers with dry eyes, partly because contact lenses are prone to developing surface deposits over time.69,70 The choice between silicone hydrogel and hydrogel has been a matter of constant debate and the subject of several comparative studies. However, the choice depends on the individual eye, and not all eyes are fitted with the latest or high-end model contact lens.

Silicone hydrogel was commercially introduced as a contact lens material in the late 1990 s.71–73 First-generation silicone hydrogels for extended wear were expected to address the issue of oxygen permeability during continuous wear; however, these lenses had lower water content and higher modulus than the hydrogel lenses, which made them stiffer and sometimes caused mechanical complications. Efforts to minimize the mechanical issues causing discomfort and the adverse events associated with silicone hydrogel have led to the development of silicone hydrogel daily disposable lenses, which combine the advantages of the silicone hydrogel material and the daily disposable modality. The prescription rate of silicone hydrogel lenses has been increasing worldwide. According to the international contact lens prescription trends in 2019, the proportion of silicone hydrogels used for daily disposable lenses continues to rise and is currently at 62%.1 The 1-Day Acuvue TruEye or 1-Day Acuvue Moist Brands Performance Overview (TEMPO) registry found low rates of adverse events associated with daily disposable lenses of both types and improved safety outcomes with daily disposable contact lenses.74 This supports the previous finding that overnight wear continues to be the major risk factor for microbial keratitis.75 According to a recent study comparing subjective, objective, and safety performance of silicone hydrogel daily disposable with hydrogel daily disposable contact lenses,76 there was no difference in discomfort, and the adverse event rates were low with both lenses. Limbal redness was more frequent in hydrogel lenses, whereas conjunctival staining and indentation were more frequently observed in silicone hydrogel lenses. Thus, the choice of material may be based on patient and practitioner preference.

Visual disturbances manifesting as blurring or fluctuating vision are common in CLD, and can affect visual performace.4 Quantitative objective measurements have suggested that the material and water content of the contact lens may affect surface lens wettability and its interactions with the ocular tear film, which can influence optical quality.77–81 Sequential measurements of higher-order aberrations have evaluated the effect of internal wetting agents and contact lens material on the on-eye optical quality.77,80,81 According to a series of studies, both daily disposable hydrogel or silicone hydrogel lenses with novel internal wetting agents yield a better and more stable optical quality compared to hydrogel lens without the added wetting agent.77,81 These findings also suggest that the choice of material may be based on patient and practitioner preference.76 Alternatively, SCL wearers with CLD could switch to using rigid gas-permeable contact lenses. However, to date, there have been no published evidence-based studies supporting this.48


Safety, comfort, and good visual performance should be prioritized for contact lens wear. Because of the enormous efforts by contact lens manufacturers, safety has been achieved. However, comfort is greatly dependent on the eye condition of the wearers. Visual performance is also related to comfort since visual symptoms are a part of CLD; these are the challenges associated with CLD. In dry eye, the weak association between clinical signs and symptoms has been a bottleneck in diagnosis and management.82–85 With the growing field of contact lens technology and pharmacological developments for dry eye, many possible improvements can be expected to manage CLD in the future.


The author thanks Hisayo Higashihara, MD, PhD (Higashihara Clinic, Kyoto, Japan) for providing clinical photo images.


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contact lens; contact lens discomfort; dry eye

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