Dry eyes with contact lenses: why it happens and what to do

Dry, tired, scratchy eyes in contact lenses are so common that the field treats the problem as a condition in its own right rather than as ordinary dry eye that happens to occur in a lens wearer. In 2013 the Tear Film and Ocular Surface Society convened an international workshop specifically on contact lens discomfort, publishing a series of subcommittee reports on its definition, epidemiology, neurobiology, materials and management. That is how substantial the problem is.

The short version of what goes wrong: a lens sits in the middle of the tear film and splits it, it rubs the inside of your lids several thousand times a day, and over years of wear it is associated with measurable loss of the meibomian glands that keep the film stable. Most people can be made comfortable again, but usually by changing several things at once rather than by finding the one right lens.

Why a lens makes eyes feel dry

A lens divides a film that is only a few microns thick into a thin layer in front of the lens and a thinner one behind it. The pre-lens film breaks up faster than a normal tear film does, which is why vision often hazes over between blinks late in the day and clears when you blink. Meanwhile the lens edge moves against the conjunctiva of the upper lid with every blink.

The workshop's neurobiology subcommittee put the mechanism this way: the stimulus to the ocular surface from a contact lens is likely to be complex and multifactorial, including components of osmolarity, solution effects, desiccation, thermal effects, inflammation, friction and mechanical stimulation, with sensory input arising from the lid margin, the palpebral and bulbar conjunctiva and the cornea. They were also candid that there is limited evidence for the mechanisms involved in contact lens-related discomfort.

Hold on to that list, because it explains why single-factor fixes disappoint. If friction, solution chemistry, evaporation and lid inflammation are all contributing, changing your lens brand alone addresses one line of it. The TFOS DEWS II iatrogenic report makes the same point from the other direction, listing contact lens use among the interventions that induce or are associated with dry eye disease.

The meibomian gland finding

This is the finding lens wearers are least often told about, and it is the one that changes what you should do. Arita and colleagues imaged the meibomian glands of 121 contact lens wearers, mean age 31.8 years, and 137 healthy volunteers of similar mean age, using non-contact meibography. Gland loss in each eyelid was graded from 0, no loss, to 3, dropout of more than two-thirds of the gland area, and the upper and lower lid scores were summed.

The mean meiboscore was 1.72 in lens wearers against 0.96 in the control group, a highly significant difference. The comparison the authors drew is the arresting one: the average meiboscore of the contact lens wearers was similar to that of a 60 to 69 year old group from the normal population, in people whose average age was 31.8. There was also a significant positive correlation between how long someone had worn lenses and their meiboscore.

Their conclusion was that contact lens wear is associated with a decrease in the number of functional meibomian glands, and that this decrease is proportional to the duration of lens wear. Two qualifications are important. This was a cross-sectional study, so it shows association and not cause, and it cannot rule out that people with a tendency to gland problems are also more likely to end up in lenses. And "associated with" is not "will happen to you". But the finding is consistent with what the workshop described, and it means gland health deserves attention early in a lens-wearing life rather than after twenty years of it. The paper also noted, as background, that roughly 30% to 50% of contact lens wearers report dry eye symptoms.

Lens material, modality and wear time

There is no single best lens, and anyone who tells you otherwise is selling something. What is worth discussing with the person who fits your lenses is the combination of variables, because each one is adjustable.

Two more contributors sit outside the lens itself. Eye makeup applied inside the lash line sits directly over the gland openings, and in clinic we routinely see liner and mascara particles in the tear film and on the lens surface; applying makeup outside the lash line and removing it properly each night is a small change that often helps. And screen work multiplies everything, because it reduces both the rate and the completeness of blinking, which is covered in dry eyes from screen time.

What to actually do about it

In rough order of usefulness. See the person who fitted the lenses before changing anything yourself. A fitter can look at the lens on the eye, check the surface for staining, express the glands and see what the film is doing, and most of the variables in the table above are theirs to adjust.

Take a lens holiday. Glasses for a week is both a treatment and a diagnostic test. If the eyes settle completely, the lens or its care system is central; if they do not, you have an underlying dry eye that lens wear is unmasking, and swapping lenses will not fix it.

Treat the gland problem directly. Where an optometrist finds meibomian gland dysfunction, lid warming to soften stagnant oil is a first-line, guideline-recommended step, and unblocking the glands covers the practical routine.

Keep the lid margins clean. Crusting, redness and thickened margins make everything worse in a lens, and the options for cleaning them are compared in hypochlorous acid versus tea tree versus castor oil. Where a margin stays inflamed despite cleaning, Demodex mites are one of the things worth checking for, which we look at in Demodex and contact lenses.

Use lens-compatible rewetting drops during the day if your fitter recommends them, and keep any other drops for when the lenses are out unless you have been told otherwise.

On heat specifically, one rule matters: take your lenses out before any warm compress or heated mask, and leave them out until well after, as we explain in heated eye mask side effects. The Meibocare E-Heated Eye Mask runs three heat settings, each paired with its own timer: 20 minutes on Low, 15 on Medium and 10 on High. It is USB powered on a 2 m cord with a wall adaptor supplied, so it lives at a desk or a bedside rather than in a lens case. It addresses the gland side of the problem, not the lens fit, so treat it as one part of a plan your fitter is directing.

Talk to your optometrist or ophthalmologist before you start heat therapy, and while you continue it, if there is an infection in the eye, if you have had eye surgery recently, if you have glaucoma, or if your vision has changed at all. A red, painful eye with a lens in should be treated as urgent: remove the lens, keep it, and be seen the same day.

Frequently asked questions

Why do my contact lenses make my eyes dry?

A lens splits an already thin tear film and rubs the inside of the lids with every blink. The TFOS contact lens discomfort workshop described the stimulus as complex and multifactorial, including osmolarity, solution effects, desiccation, thermal effects, inflammation, friction and mechanical stimulation. That is why changing one thing, such as the lens brand, often only partly helps, and why several adjustments together usually work better.

Do contact lenses damage the meibomian glands?

They are associated with gland loss. In a study comparing 121 lens wearers with 137 non-wearers of similar age, the average meibomian gland dropout score was 1.72 against 0.96, and lens wearers averaging 31.8 years old scored similarly to a 60 to 69 year old group from the normal population. Longer wear correlated with greater loss. This was cross-sectional, so it shows association rather than proof of cause.

Should I stop wearing contact lenses if my eyes are dry?

Not necessarily, but a week in glasses is a useful test. If your eyes settle completely, the lens or its care solution is the main problem and your fitter can change the material, modality, fit or solution. If they do not settle, you have an underlying dry eye that lens wear is unmasking, and that needs treating in its own right. See the person who fitted your lenses before changing anything yourself.

Can I use a heated eye mask if I wear contact lenses?

Yes, but always remove your lenses first and leave them out until well after the session. Heat applied over a lens is uncomfortable and unnecessary, and a warm, closed eye is not the environment you want a lens sitting in. The most practical routine is to take lenses out in the evening, warm the lids, then leave the eyes lens-free overnight.

Educational information only, not medical advice. References: Arita R, et al. Ophthalmology. 2009;116:379–384; Stapleton F, et al. Invest Ophthalmol Vis Sci. 2013;54:TFOS71–TFOS97; Nichols JJ, et al. Invest Ophthalmol Vis Sci. 2013;54:TFOS7–TFOS13; Gomes JAP, et al. Ocul Surf. 2017;15:511–538.