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Contact Lens Induced Ulcer
Best Treatment Option
Giannie Castellanos
Introduction
Contact lenses provide patients with a good visual status, yet in some cases effect
ocular health. Approximately 1 out of every 20 contact lens wearers develops a contact
lens–related complication each year. Contact lens wear can induce a sterile keratitis,
which presents as a sudden onset of an anterior stromal or subepithelial PMNs leukocyte
and mononuclear cell infiltrates in the periphery of the cornea. The infiltrates usually are
small (0.1-2 mm) and may be single or in groups. The infiltrates may be round, oval, or
arcuate and may underlie either an intact epithelium or an epithelial defect. (1) These
infiltrates are believed to be an immune reaction to Staphylococcus found in patients lids
and ocular surface.
Contact lens ocular complications are most often due to hypoxia. The eye, while
open, receives 21% oxygen directly from the environment through the tear film. At night,
while the eye is closed, the oxygen is delivered to the cornea through the superior lid
plexus. Contact lens effect oxygen transmission, especially while the eye is closed. Soft
contact lenses reduce oxygen transmission more than rigid gas permeable. Also, contact
lenses with larger overall diameter or tighter fit can effect the tear fill exchange reducing
oxygen transport. The highest risk factor for patients is sleeping in contact lens. About
35% of patients sleep in their contact lenses. Low Dk lenses and certain lens material,
PMMA, may not provide the adequate oxygen supplies to the cornea. In 1999, minimum
oxygen requirements for safe Extended wear was 25 barrers. The FDA approved new
silicone hydrogel lenses for use as 30-day Continuous wear. These lenses consisted of the
CIBA Vision's Focus Night & Day (lotrafilcon A) and Bausch & Lomb's PureVision
(balafilcon A). Focus night and days Dk/t is 175 barrers and Bausch & Lomb's
PureVision is Dk/t of 110. (2) High Dk lenses were designed to minimize these hypoxic
effects, yet do not eliminate all contact lens related complications.
Other causes of contact lens complication are due to the patients wearing schedule,
replacement and cleaning regimen. The preservative, thimerosal, which is now rarely
used, produced a keratoconjunctivitis in as many as 10% of contact lens wearers who
used thimerosal-preserved products. (1)
Contact lens overwear complications can manifest differently effecting the lid,
conjunctiva, or cornea. The patients’ symptoms can range from extreme pain, contact
lens intolerance or some even being asymptomatic. Differentiating between the different
conditions is important for managing the patient. Careful evaluation of history, vision,
staining pattern and layer of involvement will allow for proper diagnosis and treatment.
Patient Data
February 9, 2009: Office Visit
History
A 39 year old Hispanic male, complains of sudden redness OU and mild pain OS
starting last night. Patient denies sleeping in contact lens. Patient ran out of Proclear
dailies contact lens and began wearing Ciba Focus night and days that he had remaining.
Current contact lens pair is a Ciba Focus night and day that is one month old. Patient
replaces case monthly and denies topping off; cleans contact lenses regularly with
Optifree Replenish.
Patient reports this as being the third occurrence. In September 9, 2009 patient was
wearing O2 Optix of unknown parameters and presented with Infiltrative Keratitis OU.
When the condition resolved, the patient was refitted with Focus night and days. In
November 11, 2009, the patient presented once again with Infiltrative Keratitis OD.
When the condition resolved patient refitted with Proclear dailies -3.00. Patient wears
contact lens three days of the week for 12-14 hours daily.
Patient denies discharge, photophobia, trauma, or history of URTI in the last year.
Patient’s medical history is unremarkable.
Preliminary Exams
Visual Acuity with current glasses:
OD: 20/20+
OU: 20/20
OS: 20/20Pupils, EOMs, CVF were within normal limits
Anterior Segment:
- Eyelids:
OD: Normal OS: mild swollen lid
- Conjunctiva: OD: W/Q
OS: +3 injection sup
- Cornea:
OD: old scars
OS: 3 (0.5mm) infiltrate, peripheral ulcer with positive staining
diffuse pek (+) staining
- A/C: D/Q OU no cells or flares
- Iris: F/I OU
Diagnosis/Treatment
The patient was found to have a Peripheral Corneal Ulcer with Intraepithelial
Infiltrates secondary to Contact lens wear. The patient was advised to use Vigamox 0.5%
igt qh first day, q2h 2nd day, then q4h 3rd day and artificial tears with no preservatives.
The patient was educated on importance of discontinuing contact lens wear. Scheduled
for a follow-up in three days.
February 12, 2009: Follow up
Patient Data
Patient returning for CLUP follow-up. Patient presents with no current ocular or
visual complaints. Patient has discontinued contact lens wear for four days and is
currently using Vigamox QID OS. Patient denies pain, discharge, photophobia, or any
change in VA OS.
Preliminary Exams
Visual Acuity with current glasses:
OD: 20/20+
OU: 20/20
OS: 20/20Pupils, EOMs, CVF were within normal limits
Anterior Segment:
- Eyelids:
OD: Normal OS: mild swollen lid
- Conjunctiva: OD: W/Q
OS: +3 injection sup
- Cornea:
OD: old corneal scars/opacities
OS: 3 (0.5mm) infiltrate, peripheral ulcer resolved ( no staining present)
diffuse pek
- A/C: D/Q OU, no cells and flares
- Iris: F/I OU
Diagnosis/Treatment
Resolved CLUP OS. Patient currently has Subepithelial infiltrates OS secondary to
Contact lens wear. Patient was advised to discontinue Vigamox and begin using
Tobradex q4h OS. Patient was asked to discontinue contact lens wear. Scheduled to
return to clinic in one week.
February 14, 2009: Follow up
Patient Data
Patient returning for SEI OS follow-up. Patient presents with no current ocular or
visual complaints. Patient has discontinued contact lens wear and is currently using
Tobradex q4h OS and artificial tears OU. Patient denies pain, discharge, photophobia, or
any change in VA OS. Patient denies any systemic history of immunocompromised.
Patient is interested in lasik options.
Preliminary Exams
Visual Acuity with current glasses:
OD: 20/20+
OU: 20/20
OS: 20/20Pupils, EOMs, CVF were within normal limits
Anterior Segment:
- Eyelids:
OD: Normal OS: mild swollen lid
- Conjunctiva: OD: W/Q
OS: +3 injection sup
- Cornea:
OD: old corneal scars/opacities
OS: 3 (0.5mm) infiltrate, diffuse pek, no staining present
- A/C: D/Q OU, no cells and flares
- Iris: F/I OU
Diagnosis/Treatment
Corneal opacities secondary to Subepithelial infiltrates OS>OD from contact lens
wear, not visually significant. Patient was advised to taper Tobradex TID OS for four
days and discontinue on February 18, 2009. Patient was asked to discontinue contact lens
wear until until condition resolves. Patient scheduled to return to clinic in one week for
follow-up and refit of Proclear dailies. The patient was educated on the importance of
using Proclear dailies versus Focus Night and Days.
Discussion
Contact lens overwear occurs in many patients. Contact lenses can cause many
different ocular conditions or condition may mimic contact lens overwear. Identifying
patients’ condition is the most important step in properly managing these patients.
History is the most important tool to differentiate amongst conditions such as contact
lens, infectious, or mechanical related problems. Asking patients about contact lens wear,
replacement and cleaning regimen allows practitioners to find the etiology of the existing
condition. This vital information provides the practitioner with refitting options.
Careful examination of the anterior segment and staining pattern clarifies underlining
cause. Diffuse staining patterns are usually due to dryness. Band staining patterns are due
to mechanical interruption of the tear film. Peripheral staining patterns are most like
sterile in nature. Also determining the localization of infiltrates assists in the
differentiation amongst the etiologies that may exist. Intraepithelial are almost always
sterile and appear small; may or may not cause staining. Subepithelial infiltrates are
commonly associated with epidemic conjunctivitis and result due to an immune reaction;
present when host is no longer contagious. Stromal infiltrates occur in viral infections.
Full thickness suggest viral, sterile or may be associated with a systemic condition. The
deeper that the infiltrates are located, the greater the risk factor (3)
Contact lens overwear can cause peripheral corneal infiltrates and is most common
in patients wearing extended wear soft contact lenses. While often considered "sterile" in
the literature, a significant number have been shown to be culture-positive. (4) Patients
have staphylococcus normally in their lids. Over worn CLs have an increase in protein
build up, causing a papillary reaction, hyperemia and increase risk of infiltrative
occurrence.
Contact lens overwear can manifest differently depending on the patients. Most
patients will express severe pain causing them to awaken, photophobia, FB sensation,
watering, and blurred vision. On examination, the cornea may exhibit a degree of
epithelium defect ranging from a small superficial punctate keratitis to a corneal ulcer.
Most patients will also have cornea edema due to the hypoxia created due to contact lens
overwear. With time patients may develop neovascularization, epithelial microcysts,
corneal thinning (stromal), reduced corneal sensitivity, or/and contact lens intolerance.
Contact lens overwear can cause mainly six different conditions: Asymptomatic
Infiltrates, CLARE (Contact lens acute red eye), CLPU (Contact lens-induced peripheral
ulcer), IK (Infiltrative keratitis)/ AIK, MK (Microbial keratitis), CL-SLK. Asymptomatic
infiltrates is the most benign of the conditions. Infiltrates are present anywhere in the
cornea. AI may exists in patients who wear or do not wear contact lens. Since patients are
asymptomatic, treatment is optional. Contact lens acute red eye is a non-ulcerative sterile
keratitis associated with gram negative organisms. Patient awakens with extreme pain,
red eye and tearing. Vision is typically not affected. Mid-periphery SEI are associated
with CLARE. CLARE is highly associated with tight lens fits. CLARE may also present
as an immune reaction to the lens. Contact lens-induced peripheral ulcer are caused by
gram positive bacteria. These toxins caused by the bacteria result in corneal infiltrate.
Infiltrates typically appear in the superior peripheral cornea due to lid interaction with
contact lens reducing oxygen exchange. These ulcers may or may not affect vision
depending on the location. Staining will be present due to the full thickness epithelial
defect. Treatment options consist of a prophylactic antibiotic and artificial tears. Once
staining is no longer present a steroid may be introduced. Infiltrative keratitis has a later
onset and is due to mechanical disruption, foreign body, microbial organisms, contact
lens overwear, solution hypersensitivity. Infiltrates present in the epithelium with staining
or stroma without staining. Depending on the severity an anterior chamber reaction may
be present. Treatment depends on severity and patients symptoms. Contact lens–induced
superior limbic keratoconjunctivitis (CL-SLK) is an immunologic reaction in the
peripheral conjunctiva produced by contact lens wear. It is characterized by conjunctival
thickening, erythema, and a variable amount of fluorescein staining of the superior bulbar
conjunctiva.(1) Patient complains of photophobia, burning and decrease in vision. It’s
caused by excessive lens movement. Microbial keratitis is the most severe complication
that may occur with contact lenses. MK mainly occurs with hydrogel lenses and rarely
with rigid gas permeables. Patients will complain of pain, discharge, and a decrease in
vision. Upon examination papillae, follicles, infiltrates, ulcer or an anterior chamber
reaction may be present. These patients must receive treatment with an appropriate
antibiotic or antifungal, carefully monitor.
Contact lens wear complications are due mainly to improper contact lens
characteristics or patient incompliance. Some risk factors for developing these
complications are materials such as PMMA or low Dk lens that do not provide adequate
oxygen supplies to the cornea. The eye normally receives 21% O2 daily the environment
through the tear film. At night the superior plexus located in the superior lid provides
oxygen to the cornea. If a contact lens is present the oxygen exchange is reduced. Two
new silicone hydrogel lenses for use as 30-day CW, the CIBA Vision's Focus Night &
Day and Bausch & Lomb's PureVision can eliminate this hypoxic corneal state by
reducing overnight corneal swelling (2)
There has been found an inverse relationship between the contact lens modulus and
water content; low water content increase oxygen permeability. (Graph 1) Amongst
hydrogel lenses, Dk values and water content do not range greatly. (Graph 2) While
silicone hydrogels show difference amongst brand. High Dk silicone hydrogels have low
water content, thus providing more oxygen permeability. Silicone hydrogels do provide
more oxygen to the cornea, yet are stiffer effecting patients ocular comfort. (8)
Graph 1
Graph 2: The green dots represent hydrogels.
The contact lens fit may also cause ocular complications. If the contact lens is
fitted to tight, oxygen transport is decreased. It is very important to assess movement.
Proper movement of the contact lens will allow good oxygen exchange and patient
comfort. Due take into account that while in office lens may have adequate movement,
yet as the day progress contact lens dehydration may occur.
Patient incompliance is one the greatest risk factors. Extended wear are more at risk
for developing complications. Patients should be educated on proper lens wear and
replacement. If the patient’s lifestyle requires them to sleep in lenses than fit this patient
with continuous wear lenses. It has been found that wearing variation can cause these
effects. Patient should be advised not to vary their wearing schedule by more than two
hours from one day to the next. Patients with poor hygiene are prone to contamination of
lens products and should be fitted with dailies. It is important to stress proper cleaning
regimen. If patient is still incompliant after re-education, consider placing patient in daily
wear lenses. Daily wear lenses eliminate contact lens case that can be contaminated and
improper cleaning consequences. An increase oxygen supply to the cornea is important,
yet if the patient does not use the contact lens properly and infection begins to occur,
daily contact lenses are the best option.
Conclusion
Many patients wear contact lens and maybe at risk of developing ocular
complications due to contact lens overwear. These complications can be minimized by
eliminating risk factors. The most common risk factors deal with contact lens care and
sleeping in contact lenses. Educating patients is an important step in prevention of ocular
complications occurring secondary to contact lens wear. Refitting the patient with the
best contact lens that suit that patient’s lifestyle is important. High Dk lens, like silicone
hydrogels Ciba focus night & days and RGPs Menicon Z provide adequate oxygen
supplies for patients with a history of these conditions. Yet for some patients Daily
contact lenses provide better comfort and hygiene. With Dailies contact lenses like
Proclear dailies, contact incompliance in no longer an issue. Ocular complications, like
CLUP and MK, can be significantly reduced if patients were more often fitted with a
daily contact lens.
References
1. Contact Lens Complications. Mark Ventocilla, OD, FAAO, Clinical Professor,
Michigan College of Optometry; Editor, American Optometric Association Contact
Lens and Cornea Section Newsletter; September 2006.
2. Corneal Infiltrative Complications Associated With Contact Lens Wear. Joel A.
Silbert, O.D., F.A.A.O. Review of Optometry. Issue April 2004.
3. Keratitis: A Quick and Accurate Diagnosis. Louis J. Catania, OD. Optometric Review
of Optometry. Issue November, 2001.
4. Peripheral corneal infiltrates associated with contact lens wear. P C Donshik, J K
Suchecki, and W H EhlersUniversity of Connecticut Health Center. Trans Am
Ophthalmol Soc. 1995; 93: 49–64.
5. Predictive factors for corneal infiltrates with continuous wear of silicone hydrogel
contact lenses. Szczotka-Flynn L, Debanne SM, Cheruvu VK, Long B, Dillehay S,
Barr J, Bergenske P, Donshik P, Secor G, Yoakum J. Arch Ophthalmol. 2007
Apr;125(4):488-92.
6. Swabrick, HA, Holden, BA (1994) Complications of Hydrogel Extended Wear
Lenses. In: Silbert, JA, Anterior Segment Complications of Contact Lens Wear.
Churchill Livingstone, New York, 289-316.
7. Baush and Lomb Image Library
http://www.bausch.com/en_US/ecp/resources/image_library/Epithelium.aspx
8. Graphs
http://www.clspectrum.com/article.aspx?article=13130