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Practice

PRACTICE

PRACTICE POINTER

Eye problems in contact lens wearers

1 2
Syed M Shahid specialist registrar in ophthalmology , Syed N Ahmed Foundation Year 2 , Yusra
3
Khan general practitioner
1
Moorfields Eye Hospital, London, UK; 2Eastbourne District General Hospital, Eastbourne, UK; 3Stoke Gifford Medical Centre, Bristol, UK

What you need to know Microbial keratitis

• Contact lens associated keratitis can cause blindness and requires Microbial keratitis (infection of the cornea) can be sight
same day assessment and management at an eye emergency
department
threatening if not treated early, so should be considered in any
contact lens wearer presenting with a red and painful eye.
• Overuse of contact lenses is a known risk factor for keratitis
Predisposing factors include contact lens wear, trauma, corneal
• Refer contact lens users with a painful red eye for same day eye
emergency assessment to avoid missing a sight threatening complication surgery, ocular surface disease, and immunosuppression.6 It
such as microbial keratitis rarely occurs in the normal eye because of the protective nature
of the human cornea against infections. The incidence of
More than 140 million people worldwide wear contact lenses.1 microbial keratitis is 2-4 per 10 000 for soft contact lens wearers,
Contact lens wearers are more prone to ocular surface problems, but is higher for extended or overnight contact lens wear7 8 (table
particularly those who use extended wear contact lenses.2 3 1). Other risk factors are listed in box 1.10 12 The most common
Patients may present to the general practitioner, pharmacist, or cause is Pseudomonas spp; however, Gram positive infection
optometrist in approximately 42% of cases.4 Clinicians in acute with Staphylococci and Streptococcus, and fungal and parasitic
care need to be able to identify sight threatening conditions such infections can also occur.10
as microbial keratitis, and advise on more common problems
Box 1: Risk factors for microbial keratitis with contact lens
such as a retained contact lens or contact lens discomfort. This use9 12
article outlines the common eye conditions associated with
• Poor hand hygiene
contact lens wear and an approach that non-specialists can use
• Soft contact lens wear
to identify and manage them.
• Extended/overnight wear
Approach in primary care • Male gender

Accurate diagnosis and treatment of contact lens related • Smoking

problems in the non-specialist setting is challenging. Firstly, in • Poor contact lens storage (eg, use of tap water, lack of cleansing/regular
replacement of case)
the case of someone presenting with a red eye, the wide
• Poor ocular surface (eg, dry eyes, blepharitis)
differential diagnosis of the red eye has to be considered in
addition to the specific contact lens related complications
described in this article.5 Secondly, a slit lamp is required to Suspect microbial keratitis in a contact lens wearer with eye
confirm the diagnosis in most cases. As such, in primary care redness, pain, and photophobia concurrently. They may also
an assessment may be limited to identifying a likely cause, and have lid swelling, reduced vision, and epiphora (watery eye).
making a judgment about the risk of a serious or sight Examination will show a “white opacity” or infiltrate on the
threatening complications and need for urgent eye specialist corneal surface, which can be peripheral or central (fig 2). This
assessment. Forming this judgment is summarised in figure 1. is best seen on slit lamp examination, but it can sometimes be
We recommend that if a clinician is uncertain about the seen by looking at the cornea closely with the naked eye. An
diagnosis, they should seek further advice from an eye specialist. ophthalmoscope can be used as a magnifying lens by turning
Advise patients to abstain from using contact lenses while the dial to a high +lens (eg, +10 on the dial) to visualise the
awaiting specialist assessment and management. cornea better. This can be an important diagnostic tool for the
general practitioner.

Corresponding author SM Shahid ss4562@doctors.org.uk

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Intensive topical antibiotics along with a cycloplegic agent for are typically described as a mild pain or a foreign body
pain relief are the mainstay of management.3 In the general sensation. The abrasion can be stained with fluorescein eye
practice setting, if microbial keratitis is identified with the drops and seen with cobalt blue light, although the stain may
examination techniques described, it is reasonable to start the be visible even in the absence of a blue light (fig 6). This can
patient on an intensive regimen (box 2) with an urgent referral be managed with topical broad spectrum antibiotic such as a
to the on-call ophthalmologist or eye emergency department. fluoroquinolone (eg, ofloxacin or levofloxacin) four times a day
If microbial keratitis is suspected but not confirmed, the patient for seven days. It is important to exclude the presence of a
should see an ophthalmologist on the same day. corneal infection by checking for an infiltrate.

Box 2: An example of a treatment regimen for microbial keratitis Retained contact lens
(secondary to bacterial infection)13 14
• Stop using contact lenses until symptoms have fully resolved
A retained contact lens—or a fragment of a torn contact
lens—may present with a foreign body sensation and history
• Topical fluoroquinolone
o G. Levofloxacin 0.5% hourly (intensive treatment for the first week is of either not seeing the lens when trying to remove it or only
recommended, eg, hourly drops for 7 days, four times a day for 7 days) obtaining part of the lens.17 18 The retained contact lens is usually
• Topical cycloplegic agent stuck in the superior fornix. Everting the upper lid usually
o G. Cyclopentolate 1% three times daily for 5 to 7 days encourages the lens to present itself, although in some cases a
“superior forniceal sweep” may be needed (box 4). We advise
further examination once the lens is removed, using fluorescein
2% to stain the corneal surface, to exclude a corneal abrasion.
Acanthamoeba keratitis
An important causative organism of microbial keratitis in contact Box 4: How to perform a sweep of the superior fornix (fig 7)
lens wearers is the parasite Acanthamoeba, which accounts for 1.Instil a topical anaesthetic in the inferior fornix, eg, proxymetacaine
approximately 5% of microbial keratitis cases.13 Consider 0.5%
acanthamoeba keratitis in contact lens wearers with eye exposure 2.Wet the tip of a sterile cotton bud with proxymetacaine 0.5%
to soil or contaminated water.15 Its incidence is on the rise, 3.Ask the patient to look down and gently lift the upper lid away from the
probably as a result of people swimming and showering with eye using the eyelashes

contact lenses. The typical clinical finding is that of a “ring 4.Insert the cotton tip into the superior fornix and gently sweep across
from the medial to lateral aspect of the inner lid surface and the
infiltrate” (fig 3). Patients suspected to have acanthamoeba conjunctiva
infection require a prolonged course of treatment with 5.Gently remove the cotton tip while the patient is still looking down, taking
antimicrobials for several months.3 care not to cause trauma to the corneal surface

Contact lens discomfort

Contact lens wearers commonly experience discomfort from Education into practice
prolonged contact between the lens and ocular surface. This is What approach would you take with a patient who presents to their GP
particularly true if the lens is tight fitting on the corneal surface, with a contact lens related red eye?
if lenses are worn for extended periods of time (in excess of How will you tailor your referral to eye emergency for a suspected microbial
keratitis based on the information and diagnostic pathway described in
eight hours a day), or if there is pre-existing ocular surface this article?
disease, such as dry eyes and blepharitis. It is often described If you suspect a patient to have a retained contact lens, will you now be
as a foreign body sensation, which is relieved by discontinuing able to perform an examination and diagnostic sweep of the fornix after
lens wear. This fluctuation is a helpful way of distinguishing reading this article?

contact lens discomfort from more serious conditions. There

may be accompanying conjunctival redness and superficial
punctate staining of the corneal epithelium with fluorescein (fig How patients were involved in the creation of this article
4) as seen on slit lamp examination. We decided to write this article after receiving feedback from patients attending
the eye emergency department (via their general practitioner) with contact
Giant papillary conjunctivitis lens related problems. These patients reported receiving too little information
in primary care about the possible cause of their symptoms, often because
Giant papillary conjunctivitis is commonly associated with ophthalmology equipment was unavailable. This encouraged us to write an
article to help primary care physicians to manage patients better who present
silicone hydrogen lens use and is thought to be caused by with contact lens related eye issues.
mechanical trauma of the lens against the conjunctival surface
of the eyelids. One study in the 1990s reported an incidence of
15%, but it is a lot less common now due to advances in contact
Acknowledgments Scott Hau, senior optometrist, Moorfields Eye Hospital, London,
lens material and design.3
UK (for supplying some of the images used in this article).
Typical symptoms of giant papillary conjunctivitis are epiphora Competing interests The BMJ has judged that there are no disqualifying financial
(watery eyes), red eye, and a mucoid discharge with itching and ties to commercial companies. The authors declare the following other interests:
discomfort. Giant papillae on everting the upper lid is a key none.
diagnostic feature (fig 5). Management includes discontinuing
Further details of The BMJ policy on financial interests are here: https://www.bmj.
lens use until symptoms subside and topical treatment with mast
com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-
cell stabilisers such as sodium cromoglycate 2%. If symptoms
competing-interests
do not settle or are severe, refer to an ophthalmologist who may
consider the use of topical steroids.3 16 Provenance and peer review: commissioned, based on an idea from the author;
externally peer reviewed.

Corneal abrasion
1 Lim CHL, Stapleton F, Mehta JS. Review of contact lens-related complications. Eye
Corneal abrasions commonly occur when removing a contact Contact Lens 2018;44(Suppl 2):S1-10. PubMed 10.1097/ICL.0000000000000481
2 Turturro MA, Paris PM, Arffa R, Wilcox D. Contact lens complications. Am J Emerg Med
lens, particularly if the contact lens has a tight fit. Symptoms 1990;8:228-33. PubMed 10.1016/0735-6757(90)90328-W

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PRACTICE

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3 Alipour F, Khaheshi S, Soleimanzadeh M, Heidarzadeh S, Heydarzadeh S. Contact 12 Stapleton F, Edwards K, Keay L, etal Risk factors for moderate and severe microbial
lens-related complications: a review. J Ophthalmic Vis Res 2017;12:193-204.28540012 keratitis in daily wear contact lens users.Ophthalmology 2012;119:1516-21. PubMed
4 Fagan XJ, Jhanji V, Constantinou M, Amirul Islam FM, Taylor HR, Vajpayee RB. First 10.1016/j.ophtha.2012.01.052
contact diagnosis and management of contact lens-related complications. Int Ophthalmol 13 Tuft S, Burton M. Microbial keratitis—focus article. Royal Coll Ophthalmol 2013. https://
2012;32:321-7. PubMed 10.1007/s10792-012-9563-z www.rcophth.ac.uk/wp-content/uploads/2014/08/Focus-Autumn-2013.pdf
5 Pflipsen M, Massaquoi M, Wolf S. Evaluation of the painful eye. Am Fam Physician 14 Shah VM, Tandon R, Satpathy G, etal. Randomized clinical study for comparative
2016;93:991-8.27304768 evaluation of fourth-generation fluoroquinolones with the combination of fortified antibiotics
6 Lin A, Rhee MK, Akpek E. Bacterial keratitis preferred practice pattern.Am Acad in the treatment of bacterial corneal ulcers. Cornea 2010;29:751-7. PubMed
Ophthalmol 2019. https://www.aaojournal.org/article/S0161-6420(18)32644-7/pdf 10.1097/ICO.0b013e3181ca2ba3
7 Carnt N, Samarawickrama C, White A, Stapleton F. The diagnosis and management of 15 Lorenzo-Morales J, Khan NA, Walochnik J. An update on Acanthamoeba keratitis:
contact lens-related microbial keratitis.Clin Exp Optom 2017;100:482-93. PubMed diagnosis, pathogenesis and treatment.Parasite 2015;22:10. PubMed
10.1111/cxo.12581 10.1051/parasite/2015010
8 Cheung N, Nagra P, Hammersmith K. Emerging trends in contact lens-related infections. 16 Flattau PE. Treatment of giant papillary conjunctivitis—considerations in contact lens use
Curr Opin Ophthalmol 2016;27:327-32. PubMed 10.1097/ICU.0000000000000280 under adverse conditions. Nat Acad Press, 1991.
9 Dart JKG, Radford CF, Minassian D, Verma S, Stapleton F. Risk factors for microbial 17 Shorooq AA, Abdulrahman AF. Retained bandaged contact lens for more than two years
keratitis with contemporary contact lenses: a case-control study. Ophthalmology in one eyed patient: a case report. Egypt J Hosp Med 2017;69:2819-23. 10.12816/0042572.
2008;115:1647-54. 10.1016/j.ophtha.2008.05.003 18 Morjaria R, Crombie R, Patel A. Retained contact lenses. BMJ 2017;358:j2783.
10 Steele KR, Szczotka-Flynn L. Epidemiology of contact lens-induced infiltrates: an updated 10.1136/bmj.j2783.
review. Clin Exp Optom 2017;100:473-81. PubMed 10.1111/cxo.12598
Published by the BMJ Publishing Group Limited. For permission to use (where not already
11 Denniston AKO, Murray PI. Oxford Handbook of Ophthalmology. 4th ed. Oxford University
Press, 2018. granted under a licence) please go to http://group.bmj.com/group/rights-licensing/
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Table

4 9-11
Table 1| Key differences between soft lenses and rigid gas permeable (RGP) lenses

Contact lens type Soft contact lens RGP lens

Indication Refractive correction Refractive correction (particularly irregular astigmatism)
Therapeutic use
Lens material Hydroxthyl methylacrylate Silicone, fluorene, polymethyl methacrylate, etc.
Advantages Comfortable Excellent optical quality
Inexpensive Good oxygen permeability
Easy to fit Reduced risk of microbial keratitis
Disadvantages Less effective for astigmatic patients Discomfort (particularly at initial wear)
Need regular replacement Need experienced practitioner for initial fitting

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Figures

Fig 1 Flow chart for the assessment and management of patients presenting with symptoms related to contact lens use

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Fig 2 Microbial keratitis with a focal corneal infiltrate. The white opacity is characteristic of an infiltrate, which is absent with
a corneal abrasion alone

Fig 3 “Ring-infiltrate” seen in a patient with established acanthamoeba keratitis and corresponding confocal microscopy
showing multiple cystic lesions in the corneal stroma. The green colour following staining of the cornea with fluorescein
eye drops may suggest an epithelial defect overlying the infiltrate

Fig 4 Numerous punctate spots seen with cobalt blue light after instillation of fluorescein eye drops—these are microscopic
areas of epithelial cell loss that usually indicate dryness on the ocular surface

Fig 5 Giant papillae on the tarsal surface of the upper lid

Fig 6 Corneal abrasion with visible fluorescein stain (notice the lack of a corneal infiltrate as seen in figure 2, which is a
hallmark of microbial keratitis)

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Fig 7 Performing a sweep of the superior fornix

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