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Contact Lens Monthly

Two-minute guide to ● High coefficient of friction between


lid and lens surface may then aggravate
the lack of lubrication available.

lid wiper epitheliopathy Management


Initial management is to improve

L
comfort to allow the wearer to enjoy
id wiper epitheliopathy
(LWE) is a relatively recently
The two-minute guide series is a better quality lens wear. This may
reduce the signs of LWE but may not
described clinical entity quick reference guide to commonly address the root of the problem.
associated with symptoms ● Regular, daily use of lubricant drops
of discomfort and dryness
encountered conditions, their reduces symptoms and friction between
both in contact lens wearers symptoms, signs, cause and lid and lens, allowing the conjunctiva
and dry eye. Contact lens wearers with to recover normal function
dry eye symptoms are twice as likely to management by ● If the wearer has a poor quality tear
display LWE as asymptomatic wearers, Andrew Elder Smith film (meibomian gland dysfunction,
although there does not appear to be a aqueous deficiency etc) then this must
link between LWE and clinical tear film be managed, otherwise the following
tests (tear break-up time, Schirmer’s). recommendations will be of limited
In non-contact lens wearing dry eye benefit
patients 88 per cent have LWE (66 per ● Refit with more lubricious (slippery)
cent at grade 2 and above) as opposed to lens surface
only 16 per cent (14 per cent grade 1, 2 ● Maintain good lens cleaning (rub
per cent grade 2) of those without dry and rinse) or daily disposables
eye. LWE is correlated with an increased ● Refit from silicone hydrogel to
number of lid parallel conjunctival hydrogel
folds (LIPCOF). The condition is ● Replace RGP regularly three to
revealed by lissamine green staining. It six monthly to ensure good surface
is more common in RGP and silicone quality
hydrogel lens wearers. LWE explains ● Refit from RGP to silicone hydrogel
contact lens intolerance in wearers that Lid wiper epitheliopathy shown with lissamine green or hydrogel
show no other signs. staining (courtesy of The Vision Care Institute) ● If severe or does not resolve with
above, discontinue CL wear until
How do I see it? rose bengal) staining near lid margin clear then refit with a lens with good
Instil a generous amount of lissamine ● Can be associated with poor quality biocompatibility, deposit-resistant
green (Figure 1), wait two to three tear film and lenses with high coefficient material and naturally slippery
minutes and evert the upper lid. With of friction (rigid gas-permeables, some surface.
the slit lamp, diffuse illumination, silicone hydrogels)
white light and low to medium ● Do not confuse with Marx line – Prognosis
mag (6-10X) examine the palpebral on lid margin near meibomian gland LWE causes loss of tolerance to
conjunctiva adjacent to the lid margin. orifices. It is normal for this to stain contact lenses if it is not managed.
LWE will show up as a band of green with lissamine green as a fine line of Once the wearer has been refitted
staining extending from the lid margin stain on the lid margin itself rather with an appropriate lens and is using a
across the palpebral conjunctiva with than on the margin of the palpebral suitable care system, good comfortable
a ‘feathered’ edge. Lissamine green conjunctiva. lens wear can be achieved. However,
staining can be made more visible by if related to poor quality tear film
using a red filter in the observation Causes then it may recur. Careful selection of
pathway of the slit lamp. Although it It is suspected that when the upper contact lenses, solutions, replacement
does not stain well with fluorescein, lid palpebral conjunctiva is subject to schedules and lubricating drops, lid
instilling several applications of higher than normal frictional forces hygiene etc may allow reasonable,
fluorescein and then observing the lid it undergoes structural changes. The comfortable wearing times.
margin through a yellow filter may compromised cells, which then stain
reveal uptake of the dye. with lissamine green, traumatise the Differential diagnosis
cornea and lead to increased corneal The staining pattern is very distinctive.
Symptoms sensitivity. The increased frictional The only time I have seen anything
● Increased lens awareness forces may be either intrinsic (tear similar is from mechanical trauma to
● Scratchiness especially on blinking related) or extrinsic (lens related): the lid margin from a foreign body
● Reduced wearing time ● Lack of lubrication as the lid passes (MDF fibres). ●
● In severe/advanced cases symptoms over the ocular surface/contact
may persist on lens removal. lens surface. This is supported by ● Optometrist Andrew Elder Smith runs
evidence of reduced mucin activity Contact Solutions Consultants which
Signs in wearers with LWE. It explains the offers in-practice training to all team
Lid wiper is the leading zone (1 to correlation with LIPCOF, which also members from optometrists to front of
1.5mm) of the palpebral conjunctiva has a frictional aetiology. Contact house. Training is tailored to individual
and normally does not stain. lens wear decreases conjunctival requirements and encompasses clinical
In LWE: goblet cell numbers, so less mucin is and non-clinical aspects of patient and
● Characteristic lissamine green (or produced customer care

32 | Optician | 02.07.10 opticianonline.net

32TwominMGD 32 2/7/10 12:57:40