A 41-year-old patient attended for an eye examination and wanted to try contact lenses for the first time. On slit-lamp examination, each eye showed several discrete white opacities spread randomly across the cornea. They varied from around 0.25mm to 1mm in diameter and did not stain. A section suggested they were actually stromal. What are they likely to be and is this patient suitable for contact lenses?
The clinical editor replies: A useful question to ask the patient with this sort of presentation is 'did you have a severe bout of conjunctivitis some weeks ago?' These anterior stromal lesions are most likely residual infiltrates from adenoviral keratoconjunctivitis. Every eye care practitioner needs to know the signs of an adenoviral keratoconjunctivitis, as the condition is best managed with careful hygiene and avoidance of cross-contamination. For this reason, anyone presenting with signs of viral conjunctivitis (watery discharge, follicles on the tarsal plate, bilateral diffuse hyperaemia and perhaps swollen glands or flu-like symptoms) should have their corneas closely examined. Depending on the virus, there may well be corneal involvement.
Viral conjunctivitis is self-limiting and referral may end with a hospital clinician berating you for spreading the virus among their waiting patients with more serious illnesses. The main action should be one of limiting infection. Advise patients to avoid sharing towels, bed linen and so on. They should also wash hands and avoid any direct contact. The slit lamp and consulting room should be cleaned thoroughly after patient contact too, ideally with alcohol swabs.
If you are happy that the corneal involvement is not herpetic or anything more significant, then advise and monitor yourself. In the initial stages (within seven to 10 days of the initial infection) there may be a diffuse punctate epithelial response which, in most cases resolves. Many patients are grateful for a topical lubricant. Occasionally, however, there may be an anterior stromal infiltrative response underneath the epithelial lesions and it is these which may remain for many weeks or months after the initial contagion. If there are no signs of infection, as with your patient, especially if it is established the original infection was some weeks before, there should be no problem in proceeding with contact lenses. However, it would be a good idea to think carefully about patient hygiene and compliance in this case. ?