contact lens management

Weathering the Perfect Storm

Manage contact lens papillary conjunctivitis.

GREGORY W. DENAEYER, O.D.

Silicone hydrogel (SiHy) contact lenses have not only reduced the risk of hypoxic- related complications, such as hyperemia and neovascularization, but they have also improved comfort for many soft contact lens wearers. This, in turn, has prevented several patients from dropping out of contact lens wear, enabling many of us to maintain and, in some cases, even increase the revenue from our practice's contact lens portion. Yet, because SiHy lenses significantly deposit lipids, as compared with HEMA-based materials, and their relatively higher modulus may contribute to mechanical trauma of the palpebral conjunctiva, they can create the perfect storm for inducing contact lens papillary conjunctivitis (CLPC), a condition which can prompt contact lens dropout.^1,2

Although the literature doesn't provide a current statistic on the amount of patients who develop CLPC due to SiHy lens wear, you should know how to both diagnose and treat CLPC to ensure those patients who have the condition maintain both their ocular health and contact lens wear.

CLPC diagnosis

CLPC is characterized by papules that are 0.3mm or larger in size on the upper tarsal plate that may be diffuse or localized. Although usually bilateral, approximately 10% of patients have either unilateral or dramatically asymmetric CLPC.³

Clinical signs of CLPC (e.g. redness, mucous discharge associated with ocular irritation) can predate symptoms, which include irritation with contact lens wear, increased lens awareness, burning, itching and excessive lens movement.³ If you suspect a patient as having CLPC, evert their lids to check for the aforementioned papillary response. (It is important to note that routinely checking the upper tarsal plate on your contact lens patients allows you to proactively intervene on patients who have early CLPC signs, yet no symptoms.)

CLPC is characterized by papules that are 0.3mm or larger in size on the upper tarsal plate.

Treatment

Treatment of CLPC involves reducing the inflammatory and immune response as well as removing their triggers.

If the patient has mild or moderate irritation and redness, prescribe a mast cell stabilizer/antihistamine drop to be used q.d. to b.i.d. preand post-contact lens removal. If the patient's symptoms are severe (e.g. mucous discharge), have the patient discontinue contact lens use for four weeks, and prescribe a mast cell stabilizer/antihistamine drop to be used with a steroid drop at q.i.d. dosing, and taper the steroid down through a month. The papules on the upper tarsal plate may actually remain unchanged or slowly diminish in height or diameter as a result of the aforementioned treatment protocols.³

It stands to reason that the longer a SiHy lens is worn, the more it will become coated, which increases the overall antigenic load on the lens as well as its potential to cause mechanical trauma.⁴ As a result, studies suggest refitting these patients in lenses that require more frequent replacement than before.

For instance, in a retrospective study of 47 newly fit soft contact lens wearers, the incidence of CLPC was 4.5% in patients who replaced their lenses at less than four weeks vs. 36% of patients who replaced their lenses at four weeks or longer.⁴

In addition, a study on 221 soft (85.6%) and rigid (15.4%) contact lens wearers who developed CLPC and were refit after a period of discontinuation, revealed that 68% of patients refit in the same lens type (soft or GP lens), 82% refit into a GP lens, and 91% refit into a frequent replacement or disposable lens (defined as replaced every three months or less) achieved successful contact lens wear post- CLPC.⁵ Ideally, daily disposable lenses may be the best option for these patients, by virtue of their wear schedule. When a SiHy contact lens patient presents complaining of lens discomfort, be vigilant about keeping CLPC on your list of differential diagnoses, so you can immediately treat it and get the patient back in contact lens wear. OM

1. Sorbara L., Jones, L. Williams-lyn D. Contact lens induced papillary conjunctivitis with silicone hydrogel lenses. Cont Lens Anterior Eye. 2009 Apr;32(2):93-6.
2. Cheung SW, Cho P. Chan B., et al. A comparative study of biweekly disposable contact lenses: silicone hydrogel versus hydrogel. Clin Exp Optom. 2007 Mar; 90(2):124-31.
3. Donshik PC, Ehlers WH, Ballow M. Giant Papillary Conjunctivitis. Immunol Allergy Clin North Am. 2008 Feb;28(1):83-103, vi.
4. Donshik PC, Porazinski AD. Giant Papillary Conjunctivitis in Frequent- Replacement Contact Lens Wearers: A retrospective Study. TR. Am Ophth. Soc 1999;97:205-220.
5. Donshik PC. Giant Papillary Conjunctivitis. Trans Am Ophthalmol Soc. 1994;92:687-744.