Pain, photophobia, foreign body sensation, decreased vision, red eye, itching, discharge, burning, and contact lens intolerance.

NOTE:

Any contact lens wearer with pain or redness should remove the lens immediately and have a thorough ophthalmic examination as soon as possible if symptoms persist or worsen.

See the distinguishing characteristics of each etiology.

• Infectious corneal infiltrate/ulcer (bacterial, fungal, Acanthamoeba): White corneal lesion that may stain with fluorescein. Must always be ruled out in contact lens patients with eye pain. See 4.11, BACTERIAL KERATITIS, 4.12, FUNGAL KERATITIS, and 4.13, ACANTHAMOEBA KERATITIS.
• Giant papillary conjunctivitis: Itching, mucous discharge, and lens intolerance in a patient with large superior tarsal conjunctival papillae. See 4.21, CONTACT LENS–INDUCED GIANT PAPILLARY CONJUNCTIVITIS.
• Hypersensitivity/toxicity reactions to preservatives in solutions: Conjunctival injection and ocular irritation typically develop shortly after lens cleaning and insertion, but can be present chronically. A recent change from one type or brand of solution is common. It not only occurs more often in patients using older preserved solutions (e.g., thimerosal or chlorhexidine as a component) but also is seen with newer “all-purpose” solutions. May be due to inadequate rinsing of lenses after enzyme use. Signs include SPK, conjunctival injection, bulbar conjunctival follicles, subepithelial or stromal corneal infiltrates, superior epithelial irregularities, and superficial scarring.
• Contact lens deposits: Multiple small deposits on the contact lens, leading to corneal and conjunctival irritation. The contact lens is often old and may not have been cleaned or enzyme-treated properly in the past.
• Tight lens syndrome: Symptoms may be severe and often develop within 1 or 2 days of contact lens fitting (usually a soft lens), especially if patient sleeps overnight with daily-wear lenses. No lens movement with blinking and lens appears “sucked-on” to the cornea (this can occur after rewearing a soft lens that has dried out and then been rehydrated). An imprint in the conjunctiva is often observed after the lens is removed. Central corneal edema, SPK, anterior chamber reaction, and sometimes a sterile hypopyon may develop.
• Contact lens–associated red eye (CLARE): Red eye, corneal edema, iritis with or without hypopyon, hypoxic subepithelial, or stromal infiltrates (often multiple) may be present.
• Corneal warpage: Seen predominantly in long-term polymethylmethacrylate hard contact lens wearers. Initially, the vision becomes blurred with glasses (“spectacle blur”) but remains good with contact lenses. Keratometry reveals distorted mires and corneal topography shows irregular astigmatism that usually eventually resolves after lens discontinuation.
• Corneal neovascularization: Patients are often asymptomatic until the visual axis is involved. Superficial corneal neovascularization for 1 mm is common and usually not a concern in aphakic contact lens wearers. With any sign of chronic hypoxia, the goal is to increase oxygen permeability, increase movement, and discontinue extended-wear lenses.
• Limbal stem cell deficiency: Early signs include punctate staining in a whorl-like pattern of the epithelium near the limbus, often superiorly. If untreated, the epitheliopathy can extend to involve the entire cornea. Neovascularization and haze can develop.
• Contact lens keratopathy (pseudo-SLK): Hyperemia and fluorescein staining of the superior bulbar conjunctiva, particularly at the limbus. SPK, subepithelial infiltrates, stromal haze, and irregularity may be found on the superior cornea. This may represent a hypersensitivity or toxicity reaction to preservatives in contact lens solutions (classically thimerosal, but newer preservatives as well). No corneal filaments, papillary reaction, or association with thyroid disease.
• Displaced contact lens: Most commonly the lens has actually fallen out of the eye and been lost. If retained, the lens is usually found in the superior fornix and may require double eversion of the upper eyelid to remove. Fluorescein will stain a soft lens to aid in finding it.
• Others: Contact lens inside out, corneal abrasion (see 3.2, CORNEAL ABRASION), poor lens fit, damaged contact lens, and change in refractive error.

When the diagnosis of infection is suspected:

1. Discontinue contact lens wear.
2. Antibiotic treatment regimen varies with diagnosis as follows:

Small Subepithelial Infiltrates, Corneal Abrasion, or Diffuse SPK

1. Topical antibiotic (e.g., fluoroquinolone) drops four to eight times per day and a cycloplegic drop.
2. Can also add fluoroquinolone or bacitracin/polymyxin B ointment q.h.s. Beware of toxicity with long-term use.
3. See 3.2, CORNEAL ABRASION or 4.1, SUPERFICIAL PUNCTATE KERATOPATHY for specific details.

NOTE:

Never pressure patch a contact lens wearer because of the risk of rapid development of infection.

When a specific contact lens problem is suspected, it may be treated as follows:

Tight Lens Syndrome and CLARE

1. Discontinue contact lens wear.
2. Consider a topical cycloplegic drop (e.g., cyclopentolate 1% t.i.d.) in the presence of an anterior chamber reaction.
3. Once resolved, refit patients with a flatter and more oxygen-permeable contact lens. Discontinue extended-wear contact lenses.
4. If a soft lens has dried out, discard and refit.

NOTE:

Patients with small hypopyon do not need to be cultured when tight lens syndrome is highly suspected (i.e., if epithelium intact, with edema but no infiltrate).

1. Next day if infection cannot be ruled out. Treatment is maintained until the condition clears.
2. In noninfectious conditions, reevaluate in 1 to 4 weeks, depending on the clinical situation. Contact lens wear is resumed when the condition resolves. Patients using topical steroids should be followed more closely with attention to IOP monitoring.
3. The following regimen for contact lens care is one we recommend if single-use daily disposable lenses are not possible:
   1. Daily cleaning and disinfection with removal of lenses while sleeping for all lens types, including those approved for “extended wear” and “overnight wear.” We prefer standard rather than hyperoxygen-transmissible lenses for frequent replacement, as the latter may allow greater adherence for organisms.
   2. Daily cleaning regimen for soft contact lenses:
      • Preservative-free daily cleaner.
      • Preservative-free saline.
      • Disinfectant, preferably hydrogen peroxide type.
      • Disinfection solutions must be used for recommended time (hours) prior to lens reinsertion.
      • Weekly treatment with enzyme tablets (not necessary in disposable lenses replaced every 2 to 4 weeks or less).
   3. RGP lenses: Cleaning/soaking/rinsing all in one solution. Lenses can be reinserted soon after the removal from disinfecting solution.