Pain, photophobia, foreign body sensation, decreased vision, red eye, itching, discharge, burning, and contact lens intolerance.
Pain, photophobia, foreign body sensation, decreased vision, red eye, itching, discharge, burning, and contact lens intolerance.
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 4.12, Bacterial Keratitis, 4.13, Fungal Keratitis, and 4.14, Acanthamoeba Keratitis.
Giant papillary conjunctivitis: Itching, mucous discharge, and lens intolerance in a patient with large superior tarsal conjunctival papillae. See 4.22, 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 3.3, Corneal Abrasion), poor lens fit, damaged contact lens, and change in refractive error.
History: Main complaint (mild-to-severe pain, discomfort, itching)? Type of contact lens (soft, hard, gas permeable, extended wear, frequent replacement, or single-use daily disposable)? Age of lens? When was the lens last worn? Continuous time the lens was worn? Sleeping in lenses? How are the lenses cleaned and disinfected? Are enzyme tablets used? Preservative-free products? Recent changes in contact lens habits or solutions? How is the pain related to wearing time? Is pain relieved by removal of the lens?
In noninfectious conditions, while the contact lens is still in the eye, evaluate its fit and examine its surface for deposits, irregularities, and defects at the slit lamp.
Remove lens and examine the eye with fluorescein. Evert the upper eyelids of both eyes and inspect the superior tarsal conjunctiva for papillae.
Smears and cultures are taken when an infectious corneal ulcer is suspected with infiltrate >1 mm, involvement of visual axis, or when an unusual organism is suspected (e.g., Acanthamoeba or fungus). See 4.12, Bacterial Keratitis, 4.13, Fungal Keratitis, 4.14, Acanthamoeba keratitis, and Appendix 8, Corneal Culture Procedure.
The contact lenses and lens case are also cultured occasionally.
When the diagnosis of infection is suspected:
Possible Corneal Ulcer (Corneal Infiltrate, Epithelial Defect, Anterior Chamber Reaction, Pain)
Obtain appropriate smears and cultures. See Appendix 8, Corneal Culture Procedure.
Start intensive topical antibiotics, See 4.12, Bacterial Keratitis.
Small Subepithelial Infiltrates, Corneal Abrasion, or Diffuse SPK
Topical antibiotic (e.g., fluoroquinolone) drops four to eight times per day and a cycloplegic drop.
Can also add fluoroquinolone or bacitracin/polymyxin B ointment q.h.s. Beware of toxicity with long-term use.
See 3.3, Corneal Abrasion or 4.1, Superficial Punctate Keratopathy for specific details.
 NOTENever 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:
Giant Papillary Conjunctivitis
(See 4.22, Contact Lens–Induced Giant Papillary Conjunctivitis)
Hypersensitivity/Toxicity Reaction
Preservative-free artificial tears four to six times per day.
On resolution of the condition, the patient may return to new contact lenses, preferably daily-disposable lenses. If the patient desires frequent-replacement or conventional lenses, hydrogen peroxide–based systems are recommended, and appropriate lens hygiene is reviewed.
Replace with a new contact lens once the symptoms resolve. Consider changing the brand of contact lens, or changing to daily-disposable or frequent-replacement lenses.
Teach proper contact lens care, stressing weekly enzyme treatments for lenses replaced less frequently than every 2 weeks.
Consider a topical cycloplegic drop (e.g., cyclopentolate 1% t.i.d.) in the presence of an anterior chamber reaction.
Once resolved, refit patients with a flatter and more oxygen-permeable contact lens. Discontinue extended-wear contact lenses.
| 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). |
Discontinue contact lens wear. Explain to patients that vision may be poor for the following 2 to 6 weeks, and they may require a change in spectacle prescription. May need to discontinue lenses one eye at a time so patient can function.
A gas-permeable hard contact lens should be refitted when the refraction and keratometric readings have stabilized.
Consider a topical steroid (e.g., prednisolone 1% q.i.d. or loteprednol 0.5% q.i.d.) for extensive deep neovascularization (rarely necessary).
Refit carefully with a highly oxygen-transmissible, daily-wear disposable contact lens that moves adequately over the cornea.
Use preservative-free artificial tears and lubricating ointment.
Consider a short course of topical steroids (e.g., loteprednol 0.5%, fluorometholone 0.1%, or fluorometholone acetate 0.1%).
Consider autologous serum drops (e.g., 20%) or protein-rich plasma drops q.i.d.
In more advanced cases surgical considerations including selective epithelial debridement for partial limbal stem cell deficiency or limbal stem cell grafting in complete limbal stem cell deficiency may be indicated.
Pseudo-Superior Limbic Keratoconjunctivitis
Treat as described for hypersensitivity/toxicity reactions. Use preservative-free artificial tears. When a large subepithelial opacity extends toward the visual axis, topical steroids may be added cautiously (e.g., loteprednol 0.5% q.i.d.), but they are often ineffective. Steroid use in contact lens–related problems should have concomitant antibiotic coverage.
Inspect lens carefully for damage. If lens is undamaged, clean and disinfect it; if damaged, discard and replace. Recheck fit when symptoms have resolved.
Next day if infection cannot be ruled out. Treatment is maintained until the condition clears.
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.
The following regimen for contact lens care is one we recommend if single-use daily-disposable lenses are not possible:
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.
RGP lenses: Cleaning/soaking/rinsing all in one solution. Lenses can be reinserted soon after the removal from disinfecting solution.