A Review of Contact Lens Complications

By Randy McLaughlin, O.D., M.S
DECEMBER 1999

Find out what to look for and what steps to take to manage contact lens associated complications.

The complications associated with contact lens wear have greatly decreased over the past few years. This fact is primarily due to the advent of more disposable hydrogel contact lenses that have made lens wear not only safer, but more convenient and less costly for the patient. Unfortunately, contact lens complications have not been altogether eliminated. Therefore, it's important for you to know what symptoms to look for and how to manage them.

Corneal Erosions

A contact lens is a foreign body worn on the cornea that has the possibility of abrading the eye, infecting the eye or inducing inflammation. Corneal abrasions may occur with both rigid gas permeable (RGP) or soft contact lenses. A patient presenting with acute ocular pain, photophobia or an injected conjunctiva, should be evaluated as soon as possible. Visual acuity and biomicroscopic evaluation with fluorescein are mandatory. You should usually treat patients with erosions with antibiotic drops, such as Ocuflox (Allergan) or Ciloxin (Alcon), four times a day in the affected eye and examine them the next day. Many practitioners reserve these drops until absolutely necessary in hopes of decreasing the chance of resistance. However, when I have a patient with a centralized abrasion, I use a strong antibiotic drop, and follow-up with the patient until I no longer observe fluorescein staining.

Contact lens patients are not usually patched for the contact lens erosion because it may have harbored microorganisms that could incubate under the pressure patch, resulting in a severe corneal infection. Steroids are also not recommended until the epithelium is healed.

Solution Reactions

An overall staining of the cornea may signify the existence of a lens related solution sensitivity. Patients experiencing a solution reaction present with a mildly photophobic eye, overall bilateral punctate staining, and report decreased wearing time. Lens wear cessation, a review of current solutions and ocular lubricants are initially prescribed. If the cornea clears, begin fresh lens wear with another solution regimen. I tend to prescribe a hydrogen peroxide based system for confirmed solution-sensitive patients. Patients wearing RGPs may experience lens adhesion when a solution sensitivity is suspected. A thorough lens cleaning (especially of the posterior surface) and an alternate RGP solution regimen usually rectifies this problem. New liquid enzyme cleaners may also be helpful for RGP wearers.

RGP Complications

RGP lens wearers may display a unique corneal irritation or erosion in the 3 and 9 o'clock area of the cornea. This mechanical irritation and resulting vascularized limbal keratitis is due to a non-wetting adjacent corneal surface in the 3 and 9 o'clock area next to the lens. Usually observed in higher prescriptions, this condition is intensified by incomplete lid closure. If this problem is not addressed, scarring and vessel ingrowth will result. Treat patients by increasing the diameter of the RGP lens, increasing edge lift or thinning the overall design, and encourage them to use plenty of ocular lubricants, even at bedtime, such as Refresh P.M. (Allergan) or Duolube (Bausch & Lomb). Many RGP laboratories now offer new thin lens designs, such as the Thinsite Lens (Art Optical), which may be helpful for patients who experience mechanical abrasions.

Over Wear

Many patients push their cornea's physiological limits by maintaining extended wearing times without cleaning, disinfecting or changing their lenses. Unfortunately, in some cases, what is known as a "contact lens induced red eye" will result. These patients, usually soft contact lens wearers, will present with photophobia, pain, intense red eye and decreased visual acuity. They grudgingly report that they have worn their lenses "longer than they should have." On slit lamp examination, they may show limbal irritation, swelling, limbal vessel engorgement, and even, corneal infiltration. Instruct patients to cease lens wear and in certain cases, only give them ocular lubricants. Of course, many of these patients who do not have spectacles and refraction under these conditions are difficult to treat due to corneal edema. They should be followed the next day to monitor their symptoms as well as their corneas. It may be necessary for patients to cease lens wear for up to three to four weeks and be refitted after their symptoms digress.

Infectious Keratitis

The most serious contact lens induced complication is corneal ulceration. If the patient's corneal epithelium is penetrated and infected with microorganisms, an ulceration occurs, resulting in a painful, photophobic, red eye.

Slit lamp examination will show the stained, infiltrated area. If the ulcer is centrally located, then permanent vision loss is possible and you must take a culture before initiating therapy. If you are unable to culture a central or paracentral ulceration, refer the patient to someone who can culture the infection. Usually, fluoroquinolones, such as Ocuflox (Allergan) or Ciloxan (Alcon), are started every half hour. Unfortunately, I have had the unpleasant experience of treating resistant microorganisms many times. In a few cases, the patient may have to be hospitalized to ensure necessary therapy. These patients must be seen the next day, and need to be examined each day until the defect is epithelialized and the infiltration is completely eliminated. Microbiology and sensitivity reports will assist in the ongoing therapy. Many cases result in an apparent corneal scar.

Once lens wear is allowed (if at all), refit the patient and review their wearing schedule, lens disposal and maintenance solutions.

Corneal Neovascularization

Corneal neovascularization is a complication of hypoxia due to long-term lens wear often observed in extended wear patients, aphakic patients and even in daily wear patients. It's imperative that these patients be made aware of this potential complication. If left untreated, the vessels may continue to grow into the visual axis, resulting in permanent decreased vision. Refit patients with a highly oxygen-permeable lens with a reduced wearing time and follow-up with them every three months. New high-Dk silicone-hydrogel lenses may help these patients combat their neovascularization.

GPC -- Diagnosis and Management

Before the commercialization of disposable soft contact lenses, the most common contact lens complication I saw in my practice was contact lens induced giant papillary conjunctivitis (GPC). Patients would present with soiled or coated soft contact lenses, which would cause a delayed hypersensitivity of the tarsal plates of the eyelid, and concurrently cause extreme lens awareness and itching. Some patients were lackadaisical in cleaning their lenses, while others were extremely diligent. Fortunately today, there are many options for treating GPC. If a patient presents with GPC symptoms, perform a biomicroscopic examination of the tarsal plate to confirm the diagnosis. Patient history, including lens type, care regimen and disposable modality, is important in determining the necessary treatment. Even patients who wear disposable lenses can develop GPC.

Lens cessation is the first step in treating GPC. If the patient is symptomatic without lens wear, I prescribe a mild steroid, such as Flarex (Alcon), three times a day for the first week, tapering to twice a day for the next week, followed by one drop a day for the third week. Patanol (Alcon) used twice daily in conjunction with the steroid is helpful. In most cases, lens wear may resume after three weeks. Almost all soft lens parameters are available in at least one quarterly lens replacement modality. These lenses are usually competitively priced for the patient, promoting prescribed disposal. Furthermore, the cost of a daily disposable spherical lens is now approaching a dollar per day for the patient.

The only way to eliminate contact lens complications is to utilize spectacles or to consider refractive surgery, which are undesirable options for me because I have a contact lens only practice. Since these options have their drawbacks for a conventional contact lens practice, managing successful contact lens patients is of the utmost importance and very rewarding.

FIG. 1: GPC in soft extended wear contact lens patient.	FIG. 2: Contact lens peripheral ulcer.38
FIG. 3: Severe infectious keratitis.