5.2.1. Manages the aftercare of patients wearing soft lenses. Flashcards
DO and Record 1 OK. Please provide a new APR for a patient with a problem which you have addressed.
CLPC
- Mainly caused by SCLs, mechanical irritation and immune response
- Appear as localised swelling on the superior tarsal conjunctiva
- Rough appearance, palpebral redness
- Precursor to GPC
- In more advanced cases, symptoms include
1. Increased lens awareness
1. Itching/fb sensation
1. Lens intolerance
Management
* Cease CL wear
* Mast cell stabiliser regularly for 2 weeks; sodium cromoglicate / opatanol
* Stop sleeping in lenses / increase frequency of replacement
* Refit with lower modulus – hydrogel
* Peroxide care system
*
Neovascularisation
- New vessels grow at a stromal level in response to corneal stress, generally due to hypoxia
- Branching capillaries visible from limbal arcade
- 1st sign @ superior cornea
- Asymptomatic in early stages
Management
* Refit with SiHy if wearing hydrogel to increase Dk/t
* Reduce WT
* Patient education
SMILE staining (dry)
- Inferior epithelial arcuate lesion
- Worse in higher WC lenses
- Can also be caused be sleeping with lids open / incomplete blinking
- Mostly asymptomatic, possibly slight dryness
- Punctate (SPK) staining visible at inferior cornea – isolated from limbus
Management
* Ocular lubricants
* Lower water content lens – SiHy
* Advice about blinking / ask about sleeping with eyes open
SEAL staining (mechanical issue)
- More common in lenses with higher modulus (rgps / sihys)
- Mechanical irritation – sheer force of lens on the cornea
- Superior arcuate lesion parallel to limbus (separated by clear margin)
- 10-2 oclock, 0.5mm wide 2.5mm long
- Patients generally asymptomatic, possibly some irritation / discomfort
Management
* Cease lens wear for 2-4 days, with ocular lubricants to relieve symptoms
* Refit with lower modulus lens – possibly hydrogel
* Sign that px is not suitable for EW
CLPU
- Inflammatory response of the peripheral cornea
- Generally, no causative organism
- Full thickness break in the epithelium, underlying infiltrate in the anterior stroma of the peripheral cornea
- Small <2mm, white, with demarcated edges – stains with nafl
- Mild pain, fb sensation, photophobia
Management
* Discontinue lens wear
* Monitor closely for 24 hours
* Prophylaxis with CPL
* Ocular lubricants
* Should fully resolve with some scarring
Microbial keratitis
- Most serious CL complication
- Most common in EW
- Epithelial break penetrating into stroma – with surrounding oedema & infiltrates
- Lid oedema, severe redness, AC reaction (hypopyon)
- Acanthamoeba infection = ring infiltrate
- May also be bacterial viral or fungal
- Pain, redness, photophobia, discharge
**Management **
* Cease wear immediately & emergency referral
* No treatment initiation – must find out cause
* Advise px to take lens case etc to hospital – swabs for organism
CLARE
- Acute inflammatory response; usually with soft EWs on waking
- Dramatic presentation
- Caused by overnight lens wear / bacterial toxins
- Most common 1st 3 months of lens wear
- Gross unilateral hyperaemia
- Diffuse infiltrates (2-3mm from limbus) – minimal staining
- Profuse lacrimation
- Wakes with painful eye; redness, pain, lacrimation, photophobia
**Management **
* Cease lens wear
* Change from EW to dailies
* Lubricants for symptoms
Corneal infiltrates
- Accumulation of inflammatory cells
- Produced by reaction to viral infection, chemical toxicity, denaturation, cellular debris, allergic response
- Overlying epithelium usually intact; no nafl staining
- Sub-epithelial/anterior stroma; small focal infiltrate(s) peripheral – mid peripheral
- Red eye – pain/redness/photophobia/lacrimation
**Management **
* Cease CL wear ~2 weeks
* Advise on lens care system
* May change to dailies
* Lubricants for symptoms
Oxygen deprivation (hypoxia)
- Neovascularisation
- Polymegathism (damage to endothelial cells)
- Striae (vertical lines in posterior stroma)
- Endothelial folds
- Corneal oedema
- Corneal microcysts (chronic corneal hypoxia, small translucent dots in mid periphery)
Vision Vs Comfort
- Vision
- Rx - OR, Diabetic change, Overminused due to o/a accomm
- Fit - Steep or flat, Toric rotation - papillae or pinguecs affecting it
- Condition - Deposits, Dryness, Dummy lens
- Comfort
- Person - dryness e.g. bleph
- Lens - incorrect way, tears
- Environment - occupation, dusty environment
Toric fit:
- LARS, rotational stability
- Example:
- Comfort - Good, 9/10, condition of lens good/no deposits or tears
- Vision - DV + NV good, 9/10, doesn’t fluctuate after blink
- Centration - 0.2mm inferiorly displaced
- Movement on blink - 0.2-0.3mm
- Coverage - full corneal coverage, good edge alignment/no conj indentation/vessel blanching
- Push up test - easily moved, fast, good recentering
Keratoconus
Thanks for sharing the details! Here’s a quick recap of the information:
Keratoconus
- Non-inflammatory condition causing the cornea to thin and bulge into a cone shape.
- Impairs the ability of the eye to focus, leading to poor vision.
Treatment Options
-
RGP Lenses (Rose K2)
- Help create a more regular refracting surface.
- Modify the front and back surfaces of the lens to improve light focus through the pupil zone, reducing ghosting images.
-
Collagen Cross-Linking
- Numbing drops and riboflavin drops are applied to the eyes.
- The drops soak for 30 minutes, then UV light is used to strengthen the cornea by tightening the collagen fibers.
- The procedure strengthens the cornea to prevent further progression of keratoconus.
- Takes 60-90 minutes to complete.
VLK (vascularised limbal keratitis)
Red area near limbus - stinging, FB sensation. Inflammation
Inadequate tear film and wetting results in epithelial keratopathy
EW RGP wear?
DD:
- Redder on conj than a pterygium would be + sxs would be there
- Corneal neovasc would not occur with RGP wear for the most part or have sxs or leave any corneal opacities
- Dellen won’t stain but has a pool of NaFl staining instead
Signs:
- Vascularised area (deep & superficial) at 3&9, enroaching cornea from conj
- Staining in this region, occassionally corneal infiltrates
Management:
- Might be easier to cease lens wear until resolved
- Fit RGP better
- Change to soft lenses, DD or SiHy
- Use lubricants
Dellen
Area of dryness, thinning & desiccation of epithelium at 3&9 normally next to elevated structure e.g. pterygium or tumour. Caused by tear film instability & dry eye in that area
Will stain and pool slightly with NaFL
Signs & Sxs:
- Redness, FB sensation
- Depressed region with clearly defined margins, 2-3mm
- Base of lesion looks hazy & dry
- Adjacent cornea normal
Causes:
- Ocular trauma, surgery e.g. cataract
- CL wear
- Secondary to paralimbal elevation from: Limbal tumour, pterygium or pingecula etc (mechanical)
DD:
- Pterigium - more vascularised - limbal opacities, extends further?
- Pingecula - more yellowish - no corneal involvement
Management:
If left untreated - corneal scarring & vascularisation - reduced vision
Eliminate cause of this e.g. pterygium, CL
Use lubricants every 3 hours for next week. Rereview after this period whilst ceasing CL wear
Infiltrates & Infiltrative keratitis
Accumulation of WBCs in cornea
Reaction to hypoxia, toxicity, allergy, trauma, exo or endo toxins from bacteria or viral
CL associated
Signs & Sxs:
- Discomfort, FB sensation, redness, tearing, photophobia (mild)
- Sxs REDUCE on lens removal
- Single or multiple circular infiltrates (dull, grainy, hazy appearance <1.0mm) in epithelium or anterior stroma - either unilateral or bilateral
- Overlying epithelium does not stain!
- Limbal or conj hyp
DD:
- MK
- Adenovirus
- CLPU
Management:
- Treat cause
- Cease lens wear until resolved - change to DW - rereview in 1 week!
- Use chloramphenicol if suspected bacterial issue
Endothelial Blebs
Signs & symptoms:
Black, non-reflecting areas within end. mosaic
Greater response soft vs. RGP, thicker lenses, lower Dk
Increase in number in late evening with EW
Px asymptomatic
Prevalence: 100% CL wearers. Observed within 10 minutes of CL insertion
Management: disappear within minutes of lens removal!
Fuch’s
Aetiology
- Slowly progressive dysfunction of the corneal endothelium that eventually results in corneal oedema and reduced vision; resultant stromal and epithelial oedema leads to epithelial bullae
- Sporadic disease onset
- “The cornea progressively loses its transparency, affecting BEs & is normally inherited”
Predisposing factors
- 4th decade +, rarely 1st decade
- Females
- Smoking
Symptoms
- Glare & Blur moreso on waking (overnight corneal oedema make sxs prominent)
- Diurnal Rx changes (myopic on waking)
- Sharp pain (epithelial bullae rupture)
- Reduced CS
Signs
- Bilateral (can be assymetrical)
- Central cornea (extends peripherally with time)
- Corneal guttata - creates beaten metal appearance
- Pigment dusting on endothelium
- Ground glass appearance (cystic epithelial oedema)
- CCT increase - stromal oedema can lead to descemet membrane folds
- Posterior stromal scarring
Management
Routine referral - confirms diagnosis. CCT measured & monitored.
- Posterior lamellar transplant may be needed - DSAEK/DSEK/DMEK
- Penetrating keratoplasty
- May be combined with cataract surgery
Polymegathism
Signs & symptoms:
Cell density & regularity decreases - cells are NOT the same size
- In 25 year old diameters 1:5
- In advanced case in CL wear 1:20
Connected with corneal exhaustion syndrome?
- Loss of endothelial pump function
Not really sxs but just an indicator of hypoxia mostly
Prevalence:
- Normal age-related change
- CL wear accelerates this change
Management:
- Unclear if management needed- however, indicator of metabolic stress
- Irreversible- therefore poor prognosis
Contact Lens Specific Issues:
Lipid deposits
Shimmering affect on the lens
Causes are:
- Lid margin disease i.e mgd
- Skin care products with oil used before handling lens
- SiH and group II hydrogels
Management:
- Px should insert lens before using skincare
- Better rub and rinse and surfactant solution (B&L Biotrue)
- Treat mgd
- DDs
Protein deposits
Uneven haziness on the lens
Causes:
- Fluorosilicone acrylates?
- Tears - made up of protein
- Some people more predisposed
Management:
- Rub and rinse
- Amiclair protein remover
- DDs
- Treat dry eye
