contact lens complications

Part II: Redness and Swelling and Pain (oh, my)

The risk factors, symptoms, signs and treatment of contact lens-related sterile inflammatory complications.

Susan Kovacich, O.D., F.A.A.O. Bloomington, Ind.

Fortunately, contact lens-related sterile inflammatory complications are not of the serious nature of microbial keratitis (MK). That said, they are still disruptive to our patient's lives and, therefore, can prompt contact lens dropout. As a result, it's imperative we correctly identify and appropriately manage these inflammatory conditions.

Here, in part two of this three-part series on contact lens complications, I discuss these contact lens-related sterile inflammatory events: contact lens peripheral ulcer (CLPU), contact lens acute red eye (CLARE) and infiltrative keratitis (IK).

The five cardinal signs of inflammation (in Latin) are: rubor (redness), tumor (swelling), dolor (pain), calor (heat) and functio laesa (loss of function). One or more of these signs are apparent in these events.

As with MK, when taking a red eye history it is important to note the affected eye(s), red eye duration, +/− presence of pain, quality of the eye pain, +/− photophobia, redness and discharge type. In addition, on your patient history form be sure to ask about wear time, lens replacement schedule and disinfection method, as noncompliance with these items is associated with an increase in contact lens complications.(See “Getting the Honest Answer,” below.) All this information will facilitate diagnosis, management and patient education regarding future prevention.

Misery in the periphery

A CLPU is an infiltrate located in the peripheral cornea, which can cause pain, photophobia and tearing.¹ This infiltrate occurs in soft contact lens wearers and is primarily associated with sleeping in lenses and/or lid disease (blepharitis) and staphylococcal (gram positive) bacteria.² An extended/continuous wear (EW/CW) schedule may retard the flushing of toxins from underneath the lens. Exotoxins produced by staph bacteria associated with blepharitis can promote an inflammatory reaction in the cornea.³ The annualized rate of incidence of CLPU in the United States is less than 1% in silicone hydrogel EW.⁴

► Symptoms. In general, CLPU patients present with similar, but less intense symptoms as MK. Although some sensitive patients can complain of debilitating, severe pain (9/10 level), most complain of pain in the 6,7,8/10 level of pain or less (painful but bearable). Occasionally, a patient may be asymptomatic. While these patients often complain of photophobia, again it is at a reduced level at which they can function in lighted conditions. Also, these patients will report ocular redness and a watery discharge.
► Signs. The infiltrate is peripheral and focal. It tends to be 1mm to 2mm (but can besmaller), round or oval with well-circumscribed borders and surrounded by mild-to-moderate corneal edema swelling). Its off-axis location makes patient complaints of a decrease in vision uncommon. Conjunctival injection in CLPU patients tends to be sectorial and localized to the infiltrate. Also, you may note trace to +1 cell(s) in the anterior chamber (more common with larger infiltrates axis location makes patient complaints of a decrease in vision uncommon. Conjunctival injection in CLPU patients tends to be sectorial and localized to the infiltrate. Also, you may note trace to +1 cell(s) in the anterior chamber (more common with larger infiltrates; those closer to 2mm) but no hypopyon. In addition, although the corneal epithelium is disrupted over a white blood cell infiltration, the fluorescein staining pattern does not closely match the size of the infiltrate, usually only staining the central portion. Further, the infiltrate tends to be unilateral, although corneal scarring in either eye may show evidence of previous CLPU events. (See Image 1.) Finally, a lid reaction (upper lid swelling) may be present in the affected eye.

Image 1: This CLPU patient had previous corneal scarring, indicating evidence of a previous CLPU event

► Treatment. If you suspect the infiltrate is infectious (e.g. located toward the visual axis, large [2+ mm], etc.), treat it with a topical fourth-generation fluoroquinolone, a broad-spectrum antibiotic ointment and a cycloplegic agent, and follow the patient every 24 hours until the condition starts to resolve. (See “Part 1: Corneal Breach” www.optometric.com/articleViewer.aspx?articleID=106627 for specific information regarding time frame and dosing.)

If you are convinced the lesion is a CLPU, have the patient discontinue contact lens wear until the lesion resolves. There is a method of ramping up the treatment to correspond with the severity of the condition. This is a “step-up” approach, or adjusting the treatment as necessary to manage the inflammation. The step-up approach is comprised of the following:

1. No treatment. Since CLPUs and all the other sterile inflammatory events discussed here are self-limiting, you can elect to let the condition resolve on its own. This works best if the patient has a small CLPU and very mild symptoms.
2. Artificial tears. The use of these drops, as needed, will provide some relief. Personally, I am usually more aggressive in my management of this condition.
3. Topical medication. If the patient is symptomatic, particularly if he reports pain or photophobia, manage the condition with medication, unless he is adamantly against using medication (this is often the case with a pregnant patient). Topical medications, such as topical corticosteroids, help the condition resolve fast, which most patients appreciate, especially if they are symptomatic and/or they want to return to contact lens wear fast. Specifically, for a CLPU that has minimal/no corneal staining, prescribe a soft corticosteroid q.i.d. to be used five-to-seven days. Most CLPUs, however, present with some corneal staining, which warrant a topical antibiotic/steroid combination, again on a q.i.d. basis for five-to-seven days.⁵ After resolution, CLPUs will result in round/oval scars that resemble a bulls-eye.

In terms of follow-up, follow the symptomatic patient who has a large (2mm) CLPU one-day post initiating corticosteroid treatment. This is to make sure symptoms are improving, and that the lesion looks like it is beginning to resolve. Then, follow the patient every two-to-three days until the condition resolves completely. Follow patients who have smaller, less symptomatic CLPUs less closely than what is described above. Most CLPUs resolve in seven-to-10 days. Always instruct these patients to cease contact lens wear during the healing process, and to return to the clinic fast if symptoms worsen.

If you don't adjust the patient's contact lens wear time or method of lens disinfection, he is likely to develop another CLPU. Therefore, recommend the patient switch from EW/CW lens wear to a daily wear modality. Daily disposables are often well received by patients previously in EW/CW, since they value convenience. Should the patient decide to switch from EW/CW to daily wear, recommend he use hydrogen peroxide disinfection instead of a multipurpose solution, as this appears to result in less inflammatory contact lens complications. Finally, prescribe warm compresses, lid scrubs and oral or topical antibiotics, if indicated, for CLPU-associated lid disease.

Widespread red

CLARE presents as a very red eye with or without pain, which results from EW/CW soft contact lens wear. Researchers believe the condition of the cornea and conjunctiva occurs when the eye develops a hypersensitivity to toxins produced by gram-negative bacteria. Specifically, with the absence of blinking, the flushing of toxins under the lens during closed eye hours is reduced, and a “pro-inflammatory state” develops, especially with a tight-fitting lens.¹

► Symptoms. As the condition's name reveals, redness tends to be the chief complaint of the CLARE patient. Specifically, these patients report that it presented upon waking with EW/CW lens wear. Of interest: Many of my CLARE patients have said they didn't even realize a problem existed until they looked in the mirror or another person asked about the health of their eye(s). Other CLARE patients, however, have presented with complaints of foreign body sensation and mild ocular discomfort, which actually woke them. Symptomatic patients can also report photophobia and a decrease in vision.

► Signs. The hallmark of CLARE is marked conjunctival injection, which tends to be bright red, circumferential and appears upon waking. This distinguishes it from IK. The cornea may be clear, or ultiple, small infiltrates may be present and surrounded by mild corneal edema, which may or may not stain with fluorescein. Patients who have corneal infiltrates tend to complain of foreign body sensation, mild discomfort, photophobia and a decrease in vision, the latter of which occurs if the infiltrates are present on the visual axis. Finally, no anterior chamber reaction tends to be present. (See image 2).

Image 2: Patients who have CLARE tend not to have any anterior chamber reaction.

► Treatment. If infiltrates are not present or the infiltrates do not stain, prescribe a soft topical corticosteroid drop q.i.d. for five-to-seven days, and have the patient return in a week or so to see whether he can resume contact lens wear. If the infiltrates stain, however, prescribe a topical antibiotic/steroid combination drop q.i.d. for five-to-seven days.⁵ Then, have the patient return for follow-up to ensure the condition has resolved before allowing him/her to resume contact lens wear.

Because CLARE is associated with sleeping in lenses, educate all your CLARE patients that it is probable the condition will recur with EW/CW wear, so they should wear their lenses on a daily wear basis only. For patients who want the convenience of EW/CW wear, daily disposable lenses may be an acceptable alternative. If the patient does not elect to go with daily disposables, again I recommend these patients switch to daily wear lenses and use hydrogen peroxide for the same reason mentioned regarding CLPU.

Too tight, too toxic

IK presents as a red, irritated eye(s) with soft contact lens wear. It is associated with lenses that don't move well on the eye (tight lenses), lid disease (blepharitis) and solution/lens interaction. Tight lenses can trap metabolic waste and exotoxins under a lens. IK is associated with grampositive microorganisms/resultant exotoxins, which are associated with blepharitis. An increased incidence in sterile inflammatory events with silicone hydrogel lens material and multipurpose solution has been noted and may indicate a material/solution interaction.⁶ During a one-year U.S. study, roughly 5% of 1,300 eyes in extended wear lenses experienced infiltrative keratitis.⁷

► Symptoms. The IK patient usually presents with complaints of ocular redness and problems with contact lens wear, such as corneal irritation, foreign body sensation and reduced contact lens wearing time. Also, these patients may complain of mild photophobia, watery discharge and a decrease in vision. Usually, no anterior chamber reaction is present. Many IK patients report a recurrent red eye with or without irritation, which comes and goes, affecting contact lens wear. These patients may report self-treatment by removing the contact lens(es) for a few minutes, hours, or days, then restarting contact lens wear with the problem often recurring sometimes weeks later. Also, IK patients may report self-treatment by inserting fresh contact lenses, switching contact lens disinfection solutions and/or using old medications prescribed for past ocular conditions.

However, the IK patient may also present for a routine exam and be asymptomatic (asymptomatic infiltrative keratitis/AIK). If you encounter a patient who reports several past red eye events on his patient history form but presents without signs or symptoms, encourage the patient to return to your practice at the next event, so you can determine the culprit (and not to wait, since the problems can resolve on their own). Patient education regarding your suspicion of a contact lens-related sterile inflammatory complication is important, since the extra visit will involve an extra fee, and the patient may not feel the problem is “bad enough.”

► Signs. IK is marked by multiple, small (>1mm) corneal infiltrates and conjunctival injection that develops as the day goes on.¹ (See Image 3.) A lid reaction (upper lid swelling) in the affected eye(s) may be present. (It is not unusual for this condition to present bilaterally.) The small, multiple infiltrates may or may not stain, or the stain may break up over the infiltrates negative staining.) The conjunctival injection tends be mild to moderate and localized to the infiltrates. Usually, no anterior chamber reaction is present.

Image 3: Multiple small, focal corneal infiltrates are signs of IK.

► Treatment. If the infiltrates don't stain, remove the contact lens(es), and prescribe a soft corticosteroid q.i.d. for seven-to-10 days. If the infiltrates stain, prescribe a combination antibiotic/steroid ophthalmic drop q.i.d. for seven–to-10 days.⁵ Keep in mind that multiple small staining lesions may also be an uncommon presentation of Herpes Simplex Keratitis, so follow these patients for the next day or two when prescribing a steroid, as steroids can exacerbate a herpes infection.

Patients who have severe cases of IK, in which dense infiltrates and increased corneal edema can result in a decrease in vision and great discomfort, are often more symptomatic. Therefore, you should follow these patients more closely (every two-to-three days) to assess the effectiveness of treatment. It may be weeks before these patients are ready to resume lens wear, and you should educate them on what needs to change to prevent IK from recurring. Prior to this follow-up appointment, instruct these patients to bring a fresh pair of lenses, so you can make sure the lenses move well on the eye. Since silicone hydrogel lens material and multipurpose disinfection solution may be associated with IK, recommend the patient switch to a hydrogen peroxide disinfection solution or to switch to a daily replacement modality. Research has shown that the lowest rates of toxic staining and corneal inflammation with silicone hydrogel materials occurs when using hydrogen peroxide disinfection.⁶

Asymptomatic patients may be difficult to manage because they don't know they have a problem, and you are asking them to cease contact lens wear for a period of time and possibly use a medication, which can be costly. If you encounter a skeptical patient, use an anterior segment image to educate the patient on his condition. This promotes compliance to your recommendations.

The real challenge

I've found that the real challenge with these complications is the return to lens wear. These patients are at risk for recurrences unless they make changes (e.g. contact lens material and/or modality, fit, wearing schedule, disinfection solution and lid disease management).⁸ Therefore, it's crucial you educate these patients on the benefits of adhering to your recommendations. Doing so can help keep these patients satisfied with lens wear. OM

1. Sweeney DF, Jalbert I, Covey M, et al. Clinical characterization of corneal infiltrative events observed with soft contact lens wear. Cornea 2003 Jul; 22(5):435-42.
2. Stapleton F, Keay L, Jalbert I, Cole N. The epidemiology of contact lens related infiltrates. Optom Vis Sci. 2007 Apr; 84(4):257-72.
3. Sankaridurg PR, Sharma S, Willcox M, et al. Bacterial colonization of disposable soft contact lenses is greater during corneal infiltrative events than during asymptomatic extended lens wear. J Clin Microbiol. 2000 Dec; 38(12):4420-4.
4. McNally JJ, McKenny C. A clinical look at a silicone hydrogel extended wear lens. Contact Lens Spectrum 2002 Jan.; 17:38-41
5. Thomas R, Melton R. 2010 Clinical Guide to Ophthalmic Drugs. Review of Optometry. www.revoptom.com/supplement_toc/s/129/(Accessed 12/20/11)
6. Carnt NA, Evans VE, Naduvilath TJ, et al. Contact lens-related adverse events and the silicone hydrogel lenses and daily wear care system used. Arch Ophthalmol 2009 Dec;127(12): 1616-23.
7. CIBA Vision: Shared Passion for Healthy Vision and Better Life. FAQs: Answers to some of our most frequently asked questions: http://procare.cibavision.com/faq.shtml (Accessed 1/23/12)
8. Bates AK, Morris RJ, Stapleton F., et al. “Sterile” infiltrates in contact lens wearers. Eye. 1989; 3:803-10.

In Part III — the final of this three-part series — I'll discuss Mechanical Complications.

Dr. Kovacich is the chief of the Cornea and Contact Lens Service at Indiana University School of Optometry, where she is an associate clinical professor. She is a consultant for Alcon and Allergan. E-mail her at skovach@indiana.edu, or send comments to optometricmanagement@gmail.com.