Clinic: CL complications and aftercare Flashcards
List 7 possible causes of CL discomfort
CL properties Patient factors (hygiene) Medications Compliance Ocular surface condition External environment Occupational factors
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
List 6 risk factors for post CL corneal neovascularisation
High myopia High astigmatism Improper contact lens alignment HSV Post-keratoplasty
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
What are SEALs?
Superior Epithelial Arcuate Lesions - full thickness lesions with split/jagged edges appearing usually around 1mm from superior limbus
In what contact lens modality can SEALS typically occur? Why?
EW Si-Hy - usually due to stiff nature of Si-Hy material.
List 7 risk factors for SEALs
CL properties Male gender Presbyopia Tight upper lid Steep cornea Corneal abrasion EW Si-Hy lenses
List 2 management options for SEALs
CL exchange
CL removal
What is CLPU?
Contact Lens Peripheral Ulcer - variant of infiltrative keratitis specifically associated with lens wear
Describe the clinical features of a CLPU
Circular, well-circumscribed focal infiltrate (anterior stroma) <2mm, involving loss of overlying epithelium
How likely are recurrences of CLPU?
likely
List 2 risk factors for CLPU
EW Si-Hy lenses
Corneal abrasion
List 2 management options for CLPU
Discontinuation of CL
Consider replacing EW CL with DD (daily disposable)
NSAIDs
List 4 risk factors for bacterial keratitis in CL wearers
Hypoxia
Microtrauma
Contamination (poor hygiene? etc)
Extended Wear
How do you manage CL associated bacterial keratitis? (3)
Empirical monotherapy with fluoroquinolones (e.g. ciprofloxacin)
CL removal
swab and culture
List 2 risk factors for Acanthamoeba in CL patients
Multi-purpose solution poor compliance
Tap water use
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
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)
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
Describe the clinical features of GPC
Hyperaemia and papillary reaction of upper tarsal conjunctiva in CL wearers
List 4 risk factors for GPC
Si-Hy lenses
EW lenses
Mechanical trauma
Allergy and atopy
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
List 4 risk factors for dry eye in CL patients
Hydrogel lens
Lower refractive index
Female
Increased daily wearing time
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
