In the second in a series of articles summarising the key findings of the BCLA CLEAR publications, a major review of the published evidence relating to all aspects of contact lens practice, Pauline Bradford offered an overview of the BCLA CLEAR section relating to contact lens complications (Optician 06.05.2022).
This article was then the source material for an interactive CPD exercise focusing on two different cases. In each case, the patient was a contact lens wearer presenting with some degree of discomfort.
Cases for discussion
Case study 1
A 34 year old male patient presents for an unscheduled aftercare complaining of a sore right eye for the last few days. He has been unable to wear his lens but the eye still feels like it is getting worse without lens wear too. He is photophobic and has some noticeable oedema of the right eyelid. The left eye is asymptomatic.
Slit lamp examination reveals a 2mm circular lesion 3.5mm away from the limbus with fuzzy edges which stains with fluorescein (figure 1, below). He also has grade 2 MGD.
His lenses are monthly replacement and he is unsure exactly how old they are or how old the case is. He admits he only sometimes rubs and rinses and thinks he may have slept for a few hours in them at the weekend.
Questions to consider in your discussions:
Most respondents correctly suspected this to be a case of microbial keratitis. Key indicators are the continuation of discomfort after lens removal, photophobia, oedema and fuzziness of the edge of the lesion. Its more central location and evidence of epithelial damage as indicated by fluorescein also suggest an exogenous, microbial condition. The presence of photophobia led some of you to question the presence of anterior chamber activity, something that would certainly support a diagnosis of microbial keratitis (MK).
As with all good debates, there were some arguments among readers. The absence of discharge and lack of severity of pain made some consider other causes, including epithelial loss from lens binding. It is worth remembering that pain can vary greatly between patients, while significant discharge is not typical in early MK.
Having established possible MK as a cause, initial action would be an urgent referral (as appropriate to local protocol) is required, probably for an anti-bacterial agent such as fluoroquinolone to be prescribed. Note that chloramphenicol is not effective in such cases.
Longer term management would be to cease all contact lens wear and to manage his MGD. Once all evidence of active keratitis is resolved and the MGD treated, it might be appropriate to consider refitting with a daily disposable or daily wear rigid corneal CL and to re-educate the patient about compliance, including hand hygiene, avoidance of water, and no overnight wear.
Case study 2
A 25 year old woman presents for a routine aftercare appointment on her monthly disposable SiHy lenses, reporting occasional grittiness over the last few weeks in the left eye. It has not stopped her wearing the lenses.
She is a smoker and has a long-standing history of blepharitis, and generally adheres to contact lens related compliance well.
Slit lamp examination reveals a 1mm circular lesion. It is located 1mm in from the limbus between 4-5 o’clock with clearly defined edges and some fluorescein staining.
Questions to consider in your discussions:
Most respondents correctly identified this as a case of contact lens peripheral ulcer, a sterile corneal infiltrative event. Its position at the limbus and clear definition were important clues, as was the reduced discomfort as suggested by the patient still being able to wear the lens and reporting ‘grittiness’ only.
Table 1: Features of and factors associated with contact lens complications
Key: CLPC = Contact lens papillary conjunctivitis, CL = Contact lens, CWT = Comfortable lens wear time, LSCD = Limbal stem cell deficiency, DW = Daily Wear, DD = daily disposable; LIPCOF = Lid-parallel conjunctival folds, MGD = Meibomian gland dysfunction, LWE = Lid-wiper epitheliopathy, BUT = Break up time.
Management options might include:
The prognosis here should be good. The infiltrate will resolve over 2 to 3 weeks of no lens wear, perhaps more quickly with topical treatment. The patient would be expected to still be able to wear lenses again, though recurrence would be a possibility if steps aren’t taken to reduce risks.
A useful summary of the features and related factors of contact lens complications is to be found in the relevant BCLA CLEAR publication1 and is reproduced here as table 1.
- Neil Retallic is President of the BCLA
Reference
- Stapleton F et al. CLEAR - Contact lens complications. Contact Lens & Anterior Eye, 2021;44(2):330-67. https://doi.org/10.1016/j.clae.2021.02.010