Contact lens problems

Background

• Contact lens wearers are at increased risk of unique ocular complications. A thorough ophthalmic exam should be performed in patients presenting with ocular complaints.
• Mechanisms of complications include:
  • Direct trauma
  • Decreased corneal oxygenation
  • Reduced corneal/conjunctival wetting
  • Allergic/inflammatory responses
  • Infection

Clinical Features

• Presentation of various problems may be complicated by hypoesthesia in chronic contact lense wearers
  • Pain, photophobia, foreign body sensation, decreased visual acuity, discharge, and burning are common.

Differential Diagnosis

Contact lens wearers are at increased risk of:

• Infectious corneal infiltrate or ulceration
  • bacterial(pseudomonas in particular), fungal, and acanthamoeba
• Keratoconjunctivitis
• Hypersensitivity to contact lens solution
  • often secondary to a new solution or inadequate lens rinsing
• Contact lens induced Giant Papillary Conjunctivitis
• Allergic conjunctivitis
• Corneal edema, distortion
• Sterile infiltrates
• Neovascularization
• Displaced contact lens
  • if displaced it is usually in the superior fornix

Evaluation

• History
  • type of contacts, duration of wear, quality of symptoms, associated vision loss, prior contact lens complications, prior ocular surgeries
• Exam
  • Visual acuity with visual fields as indicated
  • if photophobia is it direct or consensual?
    • Iritis/uveitis are present with consensual photobia
  • Ocular Pressure
  • Remove lens and perform slit lamp exam with fluorescein
    • Atraumatic epithelial defect with fluorescein uptake should raise concern for ulceration
    • Pseudodendrites could indicate HSV or Acanthamoeba- consult ophtho
  • Invert lids
    • retained Foreign body or contact lens could be present.
  • Evaluate anterior chamber
    • Any infectious/inflammatory cause could produce anterior cells and flare.

Management

• Corneal Ulceration- Infiltrate + epithelial defect + Anterior chamber reaction + Pain
  • < 24 hour ophtho followup
  • Intensive topical Antibiotics- differing opinions but a safe option is 1-2 drops into the affected eye every 15 minutes for the first two hours and then hourly until seen by ophthalmology.
  • NEVER patch a contact lens wearer for comfort as this can accelerate infection
    • The provider must stress the importance of strict adherence to the dosing protocol
• Corneal Abrasion or keratitis
  • urgent ophtho followup
  • treat aggressively as above if ulcer cannot be excluded.
  • fluroquinolones (4-8 times daily) and lens removal are reasonable if uncomplicated abrasion expected.
• hypersensitivity
  • discontinue contact lens wear and prescribe preservative free drops
  • routine ophtho followup
• Contact lens deposits, neovascularization, corneal warpage, Chronic epithelial changes, dry eye are all diagnoses of exclusion and should not be made definitively in the emergency department- refer to ophtho and treat aggressively if infection is suspected.

Disposition

• if the above conditions are uncomplicated( no corneal perforation, vision loss, endophthalmitis, or other permanent visual threat) these patients may be discharged with next day ophthalmology followup.