Contact lens problems
- Contact lens wearers are at increased risk of unique ocular complications. A thorough ophthalmic exam should be performed in patients presenting with ocular complaints. 
- Mechanisms of complications include:
- Direct trauma
- Decreased corneal oxygenation
- Reduced corneal/conjunctival wetting
- Allergic/inflammatory responses
- Presentation of various problems may be complicated by hypoesthesia in chronic contact lense wearers
- Pain, photophobia, foreign body sensation, decreased visual acuity, discharge, and burning are common.
Contact lens wearers are at increased risk of:
- Infectious corneal infiltrate or ulceration
- bacterial(pseudomonas in particular), fungal, and acanthamoeba
- Hypersensitivity to contact lens solution
- often secondary to a new solution or inadequate lens rinsing
- Contact lens induced Giant Papillary Conjunctivitis
- Allergic conjunctivitis
- Corneal edema, distortion
- Sterile infiltrates
- Displaced contact lens
- if displaced it is usually in the superior fornix
- type of contacts, duration of wear, quality of symptoms, associated vision loss, prior contact lens complications, prior ocular surgeries
- Visual acuity with visual fields as indicated
- if photophobia is it direct or consensual?
- Iritis/uveitis are present with consensual photobia
- Ocular Pressure
- Remove lens and perform slit lamp exam with fluorescein
- Atraumatic epithelial defect with fluorescein uptake should raise concern for ulceration
- Pseudodendrites could indicate HSV or Acanthamoeba- consult ophtho
- Invert lids
- retained Foreign body or contact lens could be present.
- Evaluate anterior chamber
- Any infectious/inflammatory cause could produce anterior cells and flare.
- Corneal Ulceration- Infiltrate + epithelial defect + Anterior chamber reaction + Pain
- < 24 hour ophtho followup
- Intensive topical Antibiotics- differing opinions but a safe option is 1-2 drops into the affected eye every 15 minutes for the first two hours and then hourly until seen by ophthalmology.
- NEVER patch a contact lens wearer for comfort as this can accelerate infection
- The provider must stress the importance of strict adherence to the dosing protocol
- Corneal Abrasion or keratitis
- urgent ophtho followup
- treat aggressively as above if ulcer cannot be excluded.
- fluroquinolones (4-8 times daily) and lens removal are reasonable if uncomplicated abrasion expected.
- discontinue contact lens wear and prescribe preservative free drops
- routine ophtho followup
- Contact lens deposits, neovascularization, corneal warpage, Chronic epithelial changes, dry eye are all diagnoses of exclusion and should not be made definitively in the emergency department- refer to ophtho and treat aggressively if infection is suspected.
- Always instruct patients to remove contact lenses until cleared by an ophthalmologist.
- if the above conditions are uncomplicated( no corneal perforation, vision loss, endophthalmitis, or other permanent visual threat) these patients may be discharged with next day ophthalmology followup.
- The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia: Lippincott, 1994.