Managing Contact Lens
Complications Today

KATHY OSBORN, O.D., AND JOSEPH T. BARR, O.D., M.S.
FEB. 1997

We surveyed some prominent contact lens practitioners who identified the most common contact lens complications they see today and discussed their recommendations for diagnosis and treatment.

Like everything else in this rapidly changing society, contact lens technology has changed remarkably over the past few years. Disposable lenses have greatly decreased the amount of GPC seen in optometric practices, yet it still exists in those 'wear them till they hurt' situations. Contact lens care systems rarely contain thimerosal as a preservative, which led to many hypersensitivity responses in the past, and solution toxicity is rare today. Higher and higher Dk lenses are being made, resulting in healthier corneas and far fewer cases of corneal edema. However, these advances in technology have not completely erased complications associated with contact lens wear, especially in extended wear, where infection is the most feared complication.

Recently, we surveyed some members of the Cornea and Contact Lens Section of the American Academy of Optometry and other prominent contact lens care practitioners, asking them what some of the most common contact lens complications are and how they diagnose and manage them. Among the most prevalent answers were contact lens induced dry eye, superficial punctate keratitis, allergic conjunctivitis and extended wear induced hypoxic sequelae, including infiltrative keratitis.

CONTACT LENS INDUCED INFILTRATIVE KERATITIS

At the 1996 American Academy of Optometry meeting, Gary Cutter, Ph.D., a biostatistician from the American Cancer Institute who has participated in various contact lens epidemiology studies, reported that infiltrative keratitis is prevalent in about 1.6 percent of contact lens patients. Certainly, infiltrative keratitis and corneal ulcers are more common (at least five to six times more) in extended wear patients than in daily wear patients (Figs. 1 & 2).

FIG. 1: PERIPHERAL CORNEAL INFILTRATE.

FIG. 2: PARACENTRAL 1MM DIAMETER INFECTIOUS KERATITIS.

For mild peripheral corneal infiltrates less than two millimeters in diameter with minimal injection, no anterior chamber response, little or no staining over the infiltrate and little irritation, some practitioners simply discontinue contact lens wear. Others prefer to prescribe a prophylactic antibiotic (i.e., Polytrim) every four hours while awake for one week. The aggressiveness of treatment depends upon whether or not the symptoms and signs are diminishing.

More aggressive treatment is necessary if pain and photophobia, anterior chamber reaction and bulbar injection are approaching grade 4+, and if the lesion is two millimeters or more with more epithelial and stromal excavation. One optometrist who has vast experience in treating corneal infiltrates prescribes Ciloxan every 15 minutes for six hours, then every 30 minutes for 18 hours, combined with Homatropine 2%, Polysporin ointment and Motrin 400mg.

Also at the AAO meeting, Brien Holden, Ph.D., reported on a study from India that found contact lens induced peripheral ulcers in up to 12 percent of extended wear patients in one year. Cultures of these lenses often had gram positive organisms associated with them. Biopsies of the lesions themselves revealed PMNs and Bowman's layer (anterior limiting membrane of the stroma) intact, but there were no organisms within the lesions themselves.

These data and recent literature suggest antibiotic coverage for contact lens peripheral ulcers with both gram positive and gram negative organisms. All of the practitioners surveyed reported treating corneal ulcers, and all reported their treatment protocol includes a fluoroquinolone (Fig. 3). All stated also that they would quickly refer all central (6mm) corneal ulcers.

FIG. 3: THE FLUOROQUINOLONES. CILOXAN AND OCUFLOX ARE PREFERRED.

If you use fluoroquinolones, keep in mind that there are organisms resistant to fluoroquinolones and you may need to prescribe fortified antibiotics, especially with greater inflammatory response and more central lesions.

Most practitioners we surveyed said they do not culture all corneal ulcers, and all said that they have access to a microbiology lab. Experts agree that pressure patching a contact lens abrasion/ulcer is not desirable and that steroids are rarely warranted.

After healing is complete, all patients require: a re-evaluation of lens fit and design; a new lens case; a new care system; complete reinstruction on cleaning their hands, case and lenses and on rinsing and disinfection; and an explanation of why each step is important.

DRY EYE WITH CONTACT LENSES

The contact lens patient with dry eye has no edema, no obvious dry eye symptoms prior to lens wear, no obvious allergy, deposits or other problems, but reports dry eye symptoms and limited wear and may show reflex tearing after an hour or a few hours of lens wear. Other reasons for lens induced discomfort, including solution induced mild toxicity, are ruled out.

Currently, dry eye is classified as tear deficient or evaporative. Tear deficient can refer to Sjogren's Syndrome or non-Sjogren's (lacrimal gland disease, obstructional such as cicatrical, reflex such as neuroparalytic, or contact lens related). Evaporative refers to oil deficiency (including blepharitis or meibomian gland dysfunction), lid/blink-related, contact lens induced and surface changes (xerophthalmia).

We asked the practitioners which testing procedures they perform to diagnose dry eye, and the most common answers included case history, rose bengal staining and evaluation of the tear film and tear meniscus via biomicroscopy. Other answers included Schirmer test, tear break up time and phenol red thread test.

Most practitioners prescribe nonpreserved lubricants as their most common treatment regimen for dry eye. Warm compresses, lid scrubs and punctum plugs were also common treatment suggestions. The reported use of punctum plugs for dry eye conditions ranges in frequency from a few patients per week to a few patients per month.

Treatment regimens specifically for soft contact lens wearers with dry eye include administering lubricants, increasing lens thickness, decreasing water content, and performing meibomian gland expression, if indicated. Care protocol is similar for RGP wearers with dry eye, but may also include changing the design of the contact lens to increase lens movement.

Humidifying the air and avoiding dry, smoky environments, good nutrition (including multivitamin supplements), drinking plenty of fluids and avoiding diuretic agents are also important (Table 1).

STAINING

To manage 3 and 9 o'clock staining, as well as other common types of staining, it's wise to let the cornea heal completely first. Lubrication may be helpful, or you may consider modifying RGP lens diameter (for example, a larger diameter for lid attachment positioning if the lens has been riding low, or the use of lenticular designs in low minus and plus lenses), increasing the edge lift and teaching blinking. If these attempts fail, prescribe a soft contact lens.

The most common cause of staining or abrasion in a long-term, successful RGP wearer is central erosion from protein deposits on the posterior lens surface. This patient typically has worn lenses all day for years and now can't seem to get past a few hours of wear. A new lens, polishing the back surface or a few days of enzyme cleaning usually resolves the problem, and discontinuing lens wear for a few days heals the erosion.

Severe peripheral corneal staining, vascularized limbal keratitis and staining associated with bound RGP lenses can be resolved with the same treatment regimens (including dry eye treatment) plus using a more well-centered lens and instructing patients to take at least an hour pre- and post-wear break or rest after and prior to sleep (Figs. 4, 5 & 6).

FIG. 4: VASCULARIZED LIMBAL KERATITIS.

FIG. 5: BOUND RGP LENS. NOTE DEBRIS BEHIND LENS.

FIG. 6: STAINING FROM BOUND RGP LENS. NOTE THE DISTORTED CORNEA AND IMPRINT. THESE PATIENTS NEED A LENS DESIGN THAT WILL CAUSE LESS CORNEAL WARPAGE.

ALLERGIC CONJUNCTIVITIS

For significant giant papillary reactions, one suggestion we received was to prescribe one drop of Flarex, morning and night for two weeks, combined with replacement of the contact lenses (preferably into a planned replacement program, disposable lenses or RGP lenses), the use of a hydrogen peroxide disinfection system, and Crolom twice a day. Other practitioners prefer Alomide or Livostin. Most doctors reported prescribing these medications for use in the morning prior to contact lens wear and in the evening after the lenses have been removed.

ABRASION MANAGEMENT

An effective treatment regimen for corneal abrasions in both contact lens wearing and non-contact lens wearing patients starts with two to three drops of Voltaren in-office after an initial drop of topical anesthetic, then a prescription broad spectrum antibiotic (Polytrim or fluoroquinolone) every three to four hours, bedrest and sleep. A follow-up examination in 24 hours is necessary to determine what to do next. Most of the optometrists we talked to stated they may use bandage contact lenses in cases where they do not suspect infection.

Staining Pattern

What is the typical staining pattern of the dye? In mild keratoconjunctivitis sicca (KCS), you will find some blue staining on the nasal bulbar conjunctiva and possibly along the superior edge of the lower lid. In dryer eyes, the staining becomes more intense, and may involve the temporal bulbar conjunctiva and cornea as well. After you have used the dye for several patients, you will be able to quickly grade the severity of the KCS by the amount of blue staining.

The dye is also helpful in detecting recurrent corneal erosions and dendritic ulcers. In contact lens patients, the dye will pick up any punctate staining or central corneal staining from a poorly fitting lens.

Procedure

At what point in an eye examination should you use lissamine green? First, obtain the patient's ocular history, then perform an external eye examination and a refraction. After the refraction, instill one drop of the dye in each eye. If the eyes aren't dry and the patient is a contact lens candidate, proceed with the contact lens fitting.

If the eyes are dry, you may need to rethink when and what type of lenses you will prescribe for that patient. If the eyes are very dry, start the patient on artificial tears and do punctal occlusion before fitting the lenses. Once the KCS has been treated, fit the patient with either RGPs or daily wear, low water content soft contact lenses. Because patients with dry eyes are more susceptible to bacterial corneal ulcers, do not prescribe high water content soft contact lenses for extended wear.

If the dye shows the eyes are only slightly dry, then start the patient on artificial tears at the same time you prescribe the lenses. Instruct the patient to use saline or rewetting drops if he is wearing soft contact lenses.

If you use lissamine green on both your new and current patients, you'll be surprised at how common KCS and OSD are. This is particularly true for patients (especially women) who present with red, irritated or itching eyes, or who have a history of recurrent conjunctivitis. KCS is very often the underlying problem, and as part of their treatment, these patients will need artificial tears and probably punctal occlusion as well. The dye will also demonstrate that patients with pterygium, blepharitis and corneal ulcers are very likely to have KCS as well.

Even a normal appearing eye can have severe KCS and OSD. Using the dye will demonstrate this. If patients don't believe their eyes are dry then have them look in a mirror to see the staining.

Not every patient with KCS will stain with the dye. Some younger KCS patients with dry eye symptoms or patients with reflex tearing secondary to KCS may not stain, even though their eyes may be quite dry. These patients will still need artificial tears and punctal occlusion.

Lissamine green dye is available from Dakryon Pharmaceuticals (800) 658-2024.

- Peter W. Shenon, M.D.

Dr. Shenon has no financial interest, directly or indirectly, in Dakryon Pharmaceuticals.

HEALING AND PREVENTING

Recent studies reveal the need to use fluorescein after removing a soft contact lens for improved detection of staining. Yet, too often, it is probably not done. Accurate diagnosis, based on experience and careful interpretation of signs and symptoms, is necessary for selection of the appropriate treatment level. Proper use of topical antibiotic and anti-inflammatory agents, letting the eye and cornea heal, and accurate selection of lens design can resolve and prevent many further complications. Punctum plugs are helpful for many dry eye patients, although some practitioners question their long-term value.

Many of these treatment regimens require long-term compliance and close monitoring to assure compliance. Therefore, educating patients about the importance of proper lens care and providing them with ongoing follow-up care are especially important to prevent complications. CLS

We acknowledge the suggestions of Drs. Bobby Christensen, Barry Kissack, Barry Eiden, Douglas Benoit, Jan Bergmanson and Randy McLaughlin in preparing this article.

Dr. Osborn is a fellow in the Advanced Practice Contact Lens Graduate Program at The Ohio State University College of Optometry. Dr. Barr is the editor of Contact Lens Spectrum. He is an associate professor and chief of the Contact Lens Clinic at OSU.