Clinic: CL complications and aftercare Flashcards by B H

List 7 possible causes of CL discomfort

CL properties
Patient factors (hygiene)
Medications
Compliance
Ocular surface condition
External environment
Occupational factors

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List 6 management options for CL discomfort

CL exchange
CL modality change (change wearing schedule)
Patient education (e.g. hygiene)
Lubrication
Tx of any ocular or systemic disease
Environment modification

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List 6 risk factors for post CL corneal neovascularisation

High myopia
High astigmatism
Improper contact
lens alignment
HSV
Post-keratoplasty

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List 4 management options for CL corneal neovascularisation

CL exchange (re fit to higher dk/t lens if hydrogel EW)
CL modality change
Anti-angiogenic therapy
Laser photocoagulation

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What are SEALs?

Superior Epithelial Arcuate Lesions - full thickness lesions with split/jagged edges appearing usually around 1mm from superior limbus

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In what contact lens modality can SEALS typically occur? Why?

EW Si-Hy - usually due to stiff nature of Si-Hy material.

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List 7 risk factors for SEALs

CL properties
Male gender
Presbyopia
Tight upper lid
Steep cornea
Corneal abrasion
EW Si-Hy lenses

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List 2 management options for SEALs

CL exchange
CL removal

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What is CLPU?

Contact Lens Peripheral Ulcer - variant of infiltrative keratitis specifically associated with lens wear

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Describe the clinical features of a CLPU

Circular, well-circumscribed focal infiltrate (anterior stroma) <2mm, involving loss of overlying epithelium

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How likely are recurrences of CLPU?

likely

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List 2 risk factors for CLPU

EW Si-Hy lenses
Corneal abrasion

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List 2 management options for CLPU

Discontinuation of CL
Consider replacing EW CL with DD (daily disposable)
NSAIDs

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List 4 risk factors for bacterial keratitis in CL wearers

Hypoxia
Microtrauma
Contamination (poor hygiene? etc)
Extended Wear

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How do you manage CL associated bacterial keratitis? (3)

Empirical monotherapy with fluoroquinolones (e.g. ciprofloxacin)
CL removal
swab and culture

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List 2 risk factors for Acanthamoeba in CL patients

Multi-purpose solution poor compliance
Tap water use

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How do you manage CL associated acanthamoeba keratitis?

Initially treat as bacterial/normal CL keratitis
2 day review? (1-2 days if central) if no improvement:
Same day referral to opthalm/emergency centre
Telephone hospital to tell them what you have done

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How do you manage HSV keratitis (5)

Acyclovir ung 5 x a day
Debridement and patching acyclovir also potential treatment
Do NOT use topical steroids in active HSV epithelial keratitis (However DO use it in stromal keratitis etc)
Manage IOP as needed
Comfort: (lubricants, cycloplegia)

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Name one oral medication regime for HSV keratitis and HZV keratitis

HSV: Acylovir 400mg tablets 5/day for 1 week
HZV: Acylovir 800mg tablets 5/day for 1 week

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Describe the clinical features of GPC

Hyperaemia and papillary reaction of upper tarsal conjunctiva in CL wearers

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List 4 risk factors for GPC

Si-Hy lenses
EW lenses
Mechanical trauma
Allergy and atopy

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List 3 management options for GPC (5)

Transient removal of CLs
CL exchange (once healed)
Consider changing modality to DDs
Topical AH/MCS: Patanol BiD or Zatiden BiD for several months
if that doesn’t work:
FML iBD-iQD in short term for more severe cases

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List 4 risk factors for dry eye in CL patients

Hydrogel lens
Lower refractive index
Female
Increased daily wearing time

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List 3 management options for dry eye in CL patients

CL exchange (to Si-Hy lenses if not already. Or just exchange between current Si-Hys for another Si-Hy)
Lubricants/Artificial tears

Define ptosis. Does it occur more often with RGPs or Soft CLs?

MRD1 =1.5mm. Occurs more often with RGPs.

List 2 risk factors for ptosis in CL wearers

Age Wearing time

List 1 management option for ptosis in CL wearers

Surgical

Describe the appearance of pingueculae

yellowish to brown nodules on the bulbar conjunctiva near the sclerocorneal junction

Describe the incidence of pingueculae in CL wearers vs non-CL wearers

20-33% in CL wearers vs 13-14% in non-CL wearers. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5423374/table/T1/?report=objectonly

List 1 management option for pingueculae

Surgical Or could just do nothing

List 2 risk factors for corneal staining in CL patients on fluorescein testing

CL fit/properties Increased daily wearing time

List 3 management options for corneal staining in CL patients

CL exchange Decrease wearing time

Describe corneal edema

Corneal swelling that blurs vision

List 2 risk factors for corneal edema in CL patients

EW schedule Atopy (i.e. contact allergic related)

List 2 risk factors for allergic response in CL patients

EW schedule Atopy (i.e. contact allergic related)

List 5 management options for allergic response in CL patients

CL exchange (to DDs?) Reduce wear time Preservative-free lubricants Allergen avoidance AH/MCS (e.g. patanol BID for several months re GPC) https://pubmed.ncbi.nlm.nih.gov/11057353/

What are mucin balls?

pearly transparent, spherical particles which are actually accumulation of post-lens debris: shearing of tear film rolling of debris into balls

What do mucin balls consist of? (2)

mucin and lipid

List 2 risk factors for mucin balls in CL patients

EW schedule Steeper corneas

What happens to mucin balls on removal of the contact lens?

They are rapidly blinked away, however they leave behind depressions within the epithelium, which can be seen with SL/fluorescein

How do we manage mucin balls in a CL patient?

There is no evidence currently that mucin balls are associated with long term deleterious effects, however you could consider a CL exchange for a better fit if needed Particularly would go with CL exchange if large number of mucin balls is having any effect on vision

How can you manage a herpes reactivation in a CL patient?

Mx as per herpes. And give patient a longer time on prophylactic treatment.

List 9 components to a CL aftercare

History General observation Vision (often both with and without CL) Spherocyl over-rx (SCO) Topography or keratometry over CL Assess fit and condition of lenses SL examination (with and without fluorescein) Subjective refraction (not always required. Only done if not sure why reduced VA) Management and advice

What feature of CL symptoms/discomfort might indicate to you that you have a tight fitting lens?

Symptoms later in the day

What should you consider in the history taking of a CL aftercare patient? (5)

Vision: quality + consistency and comfort Redness, Dryness, Itching, Tearing, Pain, Discomfort, Discharge, Photophobia, etc Usage: wear times, lens rep, mode of wear Lens maintenance Review medications and general health

How does CLARE occur?

Contact lens-induced acute red eye (CLARE) occurs in the presence of corneal hypoxia combined with noninvasive gram-negative bacteria that elicit an inflammatory reaction secondary to bacterial endotoxin. No actual corneal infection exists in this case.

List 5 management options for CLARE

Discontinue CL wear Comfort: lubricants, cycloplege Steroids for severe symptoms and significant infiltration Re-establish successful DW eventually Recurrence possible

What 9 aspects of CL discomfort should we investigate with the patient?

Onset Consistency Laterality Quality Severity Location Comparison (with and without CLs) Associations (pain, redness, photophobia, discharge, etc) Behaviours (e.g. changed working environment, changed CL care system, different ocular lubricants, etc.)

How should you discuss CL hygiene with a CL aftercare patient?

Get them to tell you how they do it.

Describe the 5 steps of the CL surface cleaning procedure

Wash hands Place lens in palm of hand Place 2-3 drops of solution on each lens surface Rub each side with forefinger for ~15 secs Rinse well

How often should the CL surface cleaning procedure be done?

Must be done every time lenses are removed and with all lenses to be used again

With what kind of solution is CL surface cleaning typically conducted with?

Multi purpose solution (but there are daily cleaners as well)

How long do manufacturers recommend disinfection with 3% H2O2 solution

6 hours (overnight)

How long do biguanides (PAPB/PHMB) take to achieve disinfection of CLs?

4-6 hours (overnight)

How long does polyquad take to achieve disinfection of CLs?

6 hours (overnight)

What is the benefit of Multi-purpose solutions?

They combine the actions of cleaning, rinsing, disinfection, storage/soaking and sometimes enzyme cleaning

List 4 Multi-purpose solutions for CLs

Opti-free Complete Renu Bio true

Ideally, how often should CL cases be replaced?

Every 3 months

How often should CL cases be cleaned? How is this achieved

Daily: use disinfecting solution/hot water/toothbrush/cotton bud Make sure you (air) dry them after