treatment plan

Solution Interaction in a Successful GP Lens Wearer

BY LEO SEMES, OD, FAAO

A 45-year-old female who had been a successful GP lens wearer for at least a decade presented with acute complaints of reduced wearing time and ocular irritation that had begun no more than a week earlier. She did not complain of reduced visual acuity.

Visual acuity was correctable to 20/20 in each eye, and she had a proper lens fit with lid attachment and lens movement with the blink. There was no evidence or complaint of discharge other than mild watering that was associated with lens wear. The anterior chamber was quiet and clear, absent cells and flare. Pupillary responses were normal. Fluorescein pattern evaluation showed central alignment with peripheral standoff. There was a considerable amount of punctate staining that involved the entire cornea but didn't affect the conjunctiva.

The patient denied allergies to medications as well as to seasonal situations. She had not been in contact with anyone who was infectious. She had not initiated any new medications or topical products and was using no ophthalmic preparations.

Treating Signs and Symptoms

We agreed to discontinue contact lens wear for one week while using Tobradex drops (tobramycin 0.3% and dexamethasone 0.1% sterile ophthalmic suspension, Alcon Laboratories) four times daily and to re-evaluate her condition in one week. I chose the antibiotic-steroid combination for its prophylactic and anti-inflammatory effects.

At the follow-up visit, the corneal epithelium was completely clear, visual acuity was still 20/20 in each eye and the remainder of the anterior segment remained uninvolved. We decided to resume contact lens wear on a daily basis.

The patient returned in two weeks time complaining of reduced wearing time and ocular irritation identical to her initial presentation. The clinical picture was also similar to the initial presentation. I decided to treat the situation in the same way because the symptoms and signs were the same. The course over one week produced resolution with Tobradex drops and discontinuation of contact lens wear.

The Root of the Problem

At this point, we reviewed the patient's lens care regimen. She had purchased an alternative contact-lens storage and wetting solution that was a generic "equivalent" to the Boston (Bausch & Lomb) lens care system that we had previously prescribed. Her use of this generic product coincided with the onset of her symptoms. We agreed to resume lens care with the Boston system and to discard the generic product. At a followup visit two weeks later, she was symptom and sign free.

Lessons Learned

The lesson that I gained from this case is that acute contact lens incidents may manifest as more than an irritative or allergic response. This patient had no complaint of itch, which put allergy low on the list. There was no appreciable discharge or conjunctival injection, which helped to eliminate infection. We had little reason to suspect a physical lens problem in this acute presentation because of the long-standing adequate lens fit and the absence of conjunctival injection. Once we reviewed the lens care regimen, it became the focus of the suspected etiology.

With continued comfortable lens wear and the absence of symptoms for over six months, it appears that we were correct in diagnosing that the circumstantial evidence pointed to the generic solution as the culprit.

Engaging this patient in her own care was a key to solving this problem. As with all lens patients, making consistent recommendations for care is critical. CLS

Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.