Contact lens problems

Background

  • Contact lens wearers are at increased risk of unique ocular complications. A thorough ophthalmic exam should be performed in patients presenting with ocular complaints. [1]
  • Mechanisms of complications include[2]:
    • Direct trauma
    • Decreased corneal oxygenation
    • Reduced corneal/conjunctival wetting
    • Allergic/inflammatory responses
    • Infection

Clinical Features

  • 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.

Differential Diagnosis

Contact lens wearers are at increased risk of:

  • Infectious corneal infiltrate or ulceration
    • bacterial(pseudomonas in particular), fungal, and acanthamoeba
  • Keratoconjunctivitis
  • 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
  • Neovascularization
  • Displaced contact lens
    • if displaced it is usually in the superior fornix

Evaluation

  • History
    • type of contacts, duration of wear, quality of symptoms, associated vision loss, prior contact lens complications, prior ocular surgeries
  • Exam
    • 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.

Management

  • 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.
  • hypersensitivity
    • 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.

Disposition

  • 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.

See Also

External Links

References

  1. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia: Lippincott, 1994.
  2. https://eyewiki.aao.org/Contact_lens_complications