Contact Lens Mishaps
Title: Contact Lens Mishaps
Authors: Trey Winter, 4th Year Medical Student, University of Utah; Cori Jones, OD, George E Wahlen VAMC
Keywords: contact lenses, keratitis, corneal ulcer, dry eye syndrome, pseudomonas keratitis, corneal abrasion
Introduction: Contacts lenses are worn by millions of people worldwide. Depending on the type, contact lenses may cover the entire cornea or only a small part. When fit correctly, contact lenses allow for clear, comfortable vision, but if fit incorrectly, they can lead to significant complications. A correctly fit contact lens should allow for adequate tear exchange and oxygen permeability. Similarly, it is important that patients appropriately clean their contact lenses and follow compliance guidelines, including recommended wear time and replacement schedule.
Problems stemming from the use of contacts can be divided into two main categories: non-infectious and infectious. Non-infectious conditions typically arise from poor lens fit or irritants trapped on the cornea. Infectious complications most often occur after contamination of the contact lens, inadequate cleaning, or inappropriate wear schedules. Some of the more common contact lens complications are discussed below.
Non-Infectious Contact Lens Complications
Non-infectious complications arising from contact lens wear are usually a result of improper use or poor fit. An ill-fitting lens can lead to trapped debris, decreased oxygen availability at the cornea, and physical damage of the epithelial layers, among other issues. Even well-fitting contact lenses can cause focal damage of the corneal epithelium, leading to irritation and discomfort.
Insertion and removal of contact lenses can be difficult, especially for new wearers. Excessive pressure, long or jagged fingernails, and poor dexterity all have the potential to cause damage to the ocular surface, creating problems like conjunctival hemorrhage, excess tearing, redness, and pain.
Poor physical condition of contact lenses is another cause of corneal injury. Cracks in rigid lenses, tears in soft lenses, and trapped foreign bodies in any lens can lead to focal destruction of the corneal epithelium. These mechanical issues are usually not threatening to vision, but they can be painful and provide sites for bacterial infections. This type of complication most often leads to epithelial erosions and corneal abrasions, see Figure 1a.
Buildup of debris is another example of poor physical condition of contact lenses. It is common in those with poor wear time compliance and cleaning regimens. This can cause inflammation and irritation to the conjunctiva lining the inside of the eyelids, ultimately leading to papillary conjunctivitis. Symptoms are often worse after contact lens removal as the inflamed eyelids contact the cornea. Temporary discontinuation of contact lens wear and use of topical steroids are used to treat this finding.
Contact lens use can also be associated with hypoxia of the cornea. Oxygen enters the cornea through direct diffusion at the epithelium. Older contact lenses are not gas permeable and can cause hypoxia by blocking this diffusion. Additionally, most contact lenses sit directly on the cornea, and depending on wear schedule and patient compliance, they may remain on the eye for days at a time. The longer a lens remains on the eye, the less oxygen available at the corneal surface, creating a hypoxic environment. This can lead to cellular stress and corneal neovascularization, see Figure 1b. Hypoxia is more often observed in overnight contact lens wearers. The best treatment option is to decrease wear time or change the lens material.
Figure 1. Common non-infectious contact lens complications: a. large, central corneal abrasion highlighted by sodium fluorescein, likely from poor lens handling technique, b. superior corneal neovascularization, indicated by black arrows, c. a peripheral corneal infiltrate, and d. clustered central epithelial erosions are highlighted with sodium fluorescein in a patient. Photos a. and c. courtesy of Sergio Cruz, OD; photos b. and d. courtesy of Cori Jones, OD.
Corneal infiltrates are common complications observed in contact lens wearers. These infiltrates consist of inflammatory cell accumulation in the corneal stroma. They appear as fluffy, white stromal opacities with distinct borders and are typically found in the peripheral cornea, see Figure 1c. Infiltrates have been linked to overuse of lenses, more years of lens use, and younger patient age. Though corneal infiltrates do not typically present with symptoms, patients may experience sensitivity to light, pain, or discomfort with contact lens use. To treat, contact lens use should be discontinued for a few days while a topical steroid is used to calm the inflammation.
Finally, dry eye syndrome and solution sensitivity can lead to discomfort and pain in contact lens wearers, see Figure 1d. Individuals with a poor tear film most often complain of lens irritation and end-of-day dryness. Hypersensitivity reactions to contact lens solution often present with diffuse punctate epithelial erosions. These patients report red, irritated eyes and stinging upon contact lens insertion. In both cases, switching lens brand and solution may lead to symptom resolution. In recalcitrant or severe cases, cessation of contact lens use may be necessary.
Infectious Contact Lens Complications
Contact lenses and contact lens cases provide a perfect environment for bacteria to grow. Poor contact lens compliance increases the risk for infection of the cornea, called infectious keratitis or corneal ulcer. Classic examples of poor compliance include extended use of contact lenses, wetting lenses with saliva, poor cleaning and overuse of storage cases, reusing or “topping off” contact lens solution, storing lenses in tap water, or swimming in the lenses.
In most cases, a form of non-infectious keratitis, or corneal inflammation, is a pre-requisite to an infectious ulcer. Non-infectious keratitis includes damage to the corneal epithelium like epithelial erosions and corneal abrasions. As previously discussed, contact lenses may physically erode the corneal epithelium, creating sites for potential bacterial infection.
The most common infectious agent in contact lens-related corneal ulcers is the Gram-negative Pseudomonas organism. Gram-positive Staphylococcus and Streptococcus species are also commonly found in contact lens-related ulcers.
Patients with an infectious corneal ulcer may complain of pain, redness, discharge, blurry vision, and light sensitivity. On slit lamp exam, an ulcer will have an infiltrate with an overlying epithelial defect of approximately equal size, see Figure 2; this finding may be central or peripheral. Without appropriate, timely treatment, central corneal ulcers can result in permanent vision loss.
Figure 2. Infectious corneal ulcers: a. large, central ulcer with scarring and neovascularization and b. the epithelial defect of a small peripheral ulcer is highlighted by sodium fluorescein stain. Photos courtesy of Cori Jones, OD.
Diagnosis and Management of Contact Lens Complications
Differential diagnoses of contact lens complications can be extensive. Common presenting signs and symptoms of contact lens issues are similar to many other ocular conditions that result in a red, irritated eye. Differential diagnoses include, but are not limited to, dry eye, subconjunctival hemorrhage, herpes keratitis, allergic conjunctivitis, episcleritis, scleritis, uveitis, hyphema, and angle closure glaucoma.
It is important to conduct a thorough slit lamp examination on any patient with suspected contact lens complications. If the patient presents wearing the lenses, it may be helpful to assess the fit. However, a careful examination of the ocular surface should be performed without the lenses in place for all contact lens patients, even those without complaints, as some complications arise without symptoms. Fluorescein dye can be used to highlight areas of damage by staining dead and devitalized epithelial cells.
Generally, non-infectious complications can be resolved with discontinuation of contact lens wear, copious artificial tears, and a mild topical steroid.
Infectious complications require topical antibiotics in addition to discontinued lens wear and artificial tears. Cycloplegic agents may be indicated for pain. After the epithelial defects are healed, a topical steroid can be added to lessen stromal scarring. A bacterial culture from a corneal scraping should be considered in cases of large, central ulcers, and especially in recalcitrant cases.
If any contact lens complication is noted on exam, regardless of etiology, the patient should discontinue contact lens use until the cornea heals. After resolution of the problem, it is safe for the patient to resume lens wear; a re-fit should be considered if the complication may have been caused by an ill-fitting lens. Changing lens modality or wear schedule may be necessary if the complication is due to poor lens compliance. Patients with recurrent contact lens complications may need to discontinue contact lens use indefinitely.
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Faculty Approval by: Griffin Jardine, MD