Soft CL Complications

Question 1

What are the 5 categories of Soft CL complications?

Answer 1

• Physical
• Visual
• Physiological
• Wearer-related
• Pathological
  –> OR combo of these

Question 2

Describe physical complications in soft CLs?

Answer 2

• The CL
  o Fit
  o Condition
  o Design
• Blinking
  o Completeness – partial blinking leads to dryness
  o Lid tonus – ptosis? Proptosis (lids are retracted)?

Question 3

Describe visual complications in soft CLs?

Answer 3

• Correct Rx
• Presbyopia (CL options?)
• Binocular vision

Question 4

Describe physiological complications in soft CLs?

Answer 4

• Dk – oxygen permeability
• Water content
• Environment – e.g. px takes up high altitude mountaineering, will need different lenses – e.g. px recently got new job as flight attendant etc
• Blinking – if blinks are not full, spread of tears will not be sufficient – get O2 from tears

Question 5

Describe wearer-related complications in soft CLs?

Answer 5

• Non-compliance:
  o Misunderstanding
  o Deviating from instructions
• FTA (failure to attend) appts
• Poor personal hygiene – anything that can give a microbe a way into the eye will cause issues
  CL compliance – if px does everything they are told to do

Question 6

Describe pathological complications in soft CLs?

Answer 6

• Micro-organisms
• Condition of CL/case – needs kept clean & changed regularly
• Immunological issues – px may have reduced immune system
• Chemical – something toxic
• Environment – depending on where px works, they may be exposed to microorganisms
• Pre-existing ocular pathology – particularly dry-eye disease – staining of cornea, means epithelium is compromised – easy route in for bug on CL to get in eye through compromised cornea

Question 7

What are the preventions for all complications with soft CLs?

Answer 7

• Px selection
• Lens selection
• Px education
• After care & intervention
• PREVENTION IS BETTER THAN CURE – need to make sure not risking px’s vision

Question 8

Describe corneal oedema including symptoms, striae, folds, Efron grading, management and prognosis?

Answer 8

• Swelling of cornea
• SCL-induced corneal oedema involves whole of cornea & is diffuse in nature
• Mild oedema  natural consequence of sleep
• Usually greater centrally than peripherally
• Occurs in an anterior-posterior direction
• Symptoms:
  o Generally asymptomatic unless corneal swelling is significant  means you need to look for it at aftercare rather than px coming in with it as a complaint
  o ↓ vision:
   ‘spectacle’ blur
   Haziness, haloes, coloured haloes
   Little or no change in Rx
• Striae:
  o Posterior stroma
  o Believed to be due to hypoxia (lack of oxygen)
  o (Usually) vertical white lines 1-3mm in length – sometimes at angle
  o Indicates at least 5% swelling
  o Caused by separation of stromal lamellae
  o SL  medium-high mag
  o Striae can develop into folds
• Folds:
  o As swelling increases (7-12%) then striae can develop into folds in the stroma and through to endothelium
  o More serious problem
  o Progresses to overall haze at about 15% oedema
• Diffuse Hazing:
  o Involves all layers
  o Signs can be subtle (or very obvious)
• Pachymetry can be used to measure subtle changes
• Efron Corneal Oedema Grading:
  o Grade 0 – what cornea should look like – nothing to see
  o Grade 1 – single vertical striae in posterior cornea – indicates 5% oedema
  o Grade 2 – 3 vertical striae in posterior cornea
  o Grade 3 – multiple striae but also see folds in endothelium – indicates at 7-12% oedema
  o Grade 4 – numerous folds, numerous striae, have multiple bullae – blistering or water within epithelium (will see haze) – insult to cornea means endothelium cannot pump all the water out & now have severe corneal oedema
• Management:
  o Maximise CL Dk/t (priority) – may mean a break from CL wear
  o Fit SiHy CLs (most effective)
  o ↓CL thickness – cornea may dry up though due to CLs being thinner
  o ↓CL wear
  o Consider RGP lenses – especially in cases of endothelial folding
• Prognosis:
  o Chronic oedema takes time – px needs to be patient(!)
  o Couple of weeks w/ no lenses (may take longer in older pxs)
  o Then make changes – see ‘Management’
  o Monitor px closely in case oedema starts up again – shorter recall

Question 9

Describe epithelial microcysts including signs and symptoms, Efron grading and management?

Answer 9

• Can occur in:
  o Corneal dystrophies
  o Anterior eye inflammations
  o Anterior eye infections
  o Chronic hypoxia
• Related to Dk/t of CL & wear modality
• Delayed onset (2-3 months)
• Common, especially in SCL EW – can take few months to appear, see px at a month then 3 months then 6 months
• Low cyst count regarded as ‘acceptable’ – can see low number of epithelial microcysts in healthy non-CL wearers
• Signs & Symptoms:
  o Small, usually round ‘dots’, relatively well-defined borders
  o Exhibit reversed illumination (highly refractive index of necrotic cells)
  o Vary in number from a few to >100
  o Fluorescein only discloses cysts when they are ‘breaking out’ from epithelium’s front surface
  o Usually asymptomatic unless numerous – must find them as they indicate chronic corneal hypoxia  these are usually a problem in EW so should find them as monitoring these pxs more closely & frequently
• NEED HIGH MAG TO SEE THIS
• Grading Scale:
  o Grade 0: none
  o Grade 1: have 1 microcyst
  o Grade 2: have ~16, some still quite faint as just newly formed
  o Grade 3: dozens, now through to epithelium & starting to stain
  o Grade 4: loads and loads with lots having broken through to surface
• Management:
  o Careful monitoring
  o If <10, no action needed  MUST STILL MONITOR THOUGH
  o ↑number warrants intervention
  o ↑CL Dk/t
  o ↓CL wearing time
  o Cease EW
  o Change to RGP
  o Rebound effect after CL discontinuation or lens changes – immediately after it will look like no. of microcysts is increasing but these are just the ones that were developing coming to the surface
  o Lengthy time to resolve – approx. 3 months for full resolution

Question 10

Describe corneal vascularisation including aetiology, investigations and management?

Answer 10

• Aetiology:
  o Hypoxia:
   Lack of oxygen
   Gas Permeable (GP) & SiHy CLs < affected than hydrogel CLs
   Excessive wearing time/ over-wear
   Chronic hypoxia can give slight softening of stroma – makes more vulnerable
  o Corneal oedema
  o Epithelial injury:
   Prolonged mechanical insult
   Poor/suboptimal fitting
   Chronically disturbed tear film
   Excessive wearing time/over-wear
  o Infection – if px had v nasty keratitis – will see vessel growth towards area of oxygen – not necessarily due to CL wear
• Asymptomatic unless v severe – if vessels growing over pupil – vision will then be affected
• Must be looked for at every aftercare – make sure to check superior cornea
• Investigations:
  o Supporting documentation/diagram(s)/photograph(s)
  o Extent of radial penetration – measure how far vessels have penetrated into cornea from limbus – length of vessels – use beam width
  o Location (o’clock)
  o Depth (relative to corneal anatomical layers)
  o Severity (grading scale)
  o Assessment by corneal quadrant
• Management:
  o ↑Corneal O2 supply
   ↑CL Dk/t
   Refit w/ SiHy CLs (if px on hydrogels) - (SiHy CLs  ↓↓CV)
   Refit w/ GP CLs – if px already on SiHy
  o Optimise CL fitting – make sure lens fitting well to ensure getting good tear exchange  helps with oxygen
  o ↓CL wearing time
   Change from EW to DW
   ↓hours of DW
  o Don’t need to do all this at once – need to monitor these pxs v closely
• Removal of stimulus leads to retreat of blood column from new BVs (can take months)  leaves a ghost vessel
• Early intervention is vital to prevent permanency of new vessels
• ‘Ghost’ vessels remain unless intervention was made early (1-2 weeks) i.e. soon after onset of vascular changes
• Close monitoring if lens wear is resumed  if hypoxia starts up again, the vessels refill & continue to grow
• Stopping CL wear for couple of months is best but not always practical

Question 11

Describe infiltrates including aetiology and appearance?

Answer 11

• Relatively common CL-induced condition
• Seen in 1% of non-CL wearers
• May be epithelial, sub-epithelial or stromal
• Usually overlying epithelium is intact
• Believed to be discrete collections of inflammatory cells
• May be ‘sterile’ or infected
• Aetiology:
  o Bacterial presence
  o Eye closure with CL – e.g. sleeping in CLs
  o Hypersensitivity
  o CL deposits
  o Inadequate disinfection/hygiene – poor compliance
  o Tight CL
  o Mechanical trauma
  o Hypoxia
• Appearance:
  o May be focal, arcuate or diffuse
  o Hazy, greyish white (0.5mm to 2mm)
  o Tiny & circular to a ‘wooly’ appearance
  o Location:
   Epithelial
   Subepithelial
   Stromal

Question 12

Describe infiltrative keratitis (IK) including symptoms, signs, immediate management and later management?

Answer 12

• Symptoms:
  o Range from asymptomatic to painful – depends on px pain threshold
  o CLs can ‘mask’ the problem – bandage effect
  o Typically:
   FB sensation – irritated
   Photophobia
   Lacrimation – watery eye, not sticky or mucousy
• Signs:
  o Located peripherally to mid-peripherally (central is rare)
  o Mild to moderate diffuse infiltration &/or small, infiltrate, possible multiple
  o In anterior stroma (sub-epithelial)
  o Usually, no observable corneal oedema
  o Slight to moderate staining
  o No anterior chamber reaction
  o Moderate limbal redness
  o Can be bilateral
• Immediate Management:
  o CL wear must be stopped – until corneal infiltrate(s) cleared – in mild cases this is a week or 2  if there a lot of infiltrates in a lot of locations it can take months
  o Monitoring
  o Specific advice to pxs – if there is any pain, reduced vision, mucousy discharge (indicating microbial rather than infiltrative keratitis) then they MUST see you
  o Artificial tears – for comfort
  o Antibiotics – could be used prophylactically if epithelium broken through
  o Resolution (clear cornea) necessary before CL wear resumed, can take days – weeks – months
• Later Management:
  o Risk of recurrence
  o Need to ↓ risk
  o Isolate cause – may need to refit px w/ daily disposable
  o CLs, solutions, CL care routine
  o CL wear schedule
  o Px re-education – px may have developed bad habits
  o Consider their CL wear schedule – could reduce
  o Refit w/ daily disposable, SiHy, or GP CLs
  o Use preservative-free products
• When px wants to start CLs again  SiHy daily disposable – takes care of hypoxia issue, takes care of problems w/ CL care, w/ deposits, w/ preservatives
• DON’T CHANGE EVERYTHING AT ONCE AS THEN WON’T KNOW CAUSE

Question 13

Describe asymptomatic infiltrative keratitis (AIK)?

Answer 13

• Infiltration of cornea w/ no symptoms
• Small infiltrates (<0.5mm)
• Usually peripheral
• Appearance similar to IK, they just appear as smaller infiltrates
• Need to really look at cornea of all CL pxs, even those w/ no symptoms
• Similar management to symptomatic IK
• Advice to pxs w/ IK & AIK regarding signs of infection – pain, discharge, reduced vision

Question 14

Describe corneal staining - general punctate -> including symptoms, signs and management?

Answer 14

• Common in CL wearers (approx. 60%) – could be couple of dots or entire cornea
• Due to drying of cornea
• Can occur in no-CL wearers – particularly dry-eye pxs
• Symptoms:
  o FB sensation
  o Irritation/grittiness
  o Excessive lacrimation – reflex tearing
  o Reduced CL wear time – px self-managed and reduced wear time as uncomfortable
• Signs:
  o Tends to be on inferior half of cornea – this tends to be area which is drying up more
• Manage:
  o CL re-wetting drops – make sure drop is suitable for CL use – either preservative-free or it’s been license for CL use – needs to be used regularly (4 times a day)
  o Reduced wear time – a few days w/o lenses
  o Re-fit (if soft consider silicone hydrogel or daily disposable)
  o Treat underlying conditions i.e. MGD, anterior bleph

Question 15

Describe corneal staining - epithelial abrasion/epithelial erosion –> including symptoms, signs, investigations & management?

Answer 15

• Mechanical aetiology is most common
• Fingernails/fingers
• Trapped FBs
• CL defect – more common in RGP
• Significant abrasion leads to disorganisation of epithelium’s regular cellular arrangement
  o If significant, may not fully heal within 48hrs – epithelium may not fully attach to its basement membrane then it can re-detach (this is when becomes erosion)  px wakes up in middle of night/early in morning in a lot of pain
  o Lubricate for few months to prevent abrasion forming
• Important to investigate in H&S as px will probs be able to tell you what happened
• Symptoms:
  o Mild to severe pain – cornea v sensitive
  o Photophobia
  o CL bandage effect can mask symptoms until CL removal and lids start rubbing over top of abrasion
• Signs:
  o Dense, localised staining with fluorescein – depends on what caused abrasion
   Clear, defined margins on staining – defect confined to epithelium
   Hazy margins on staining – defect may be stromal – more risk of infection
  o Bulbar redness
  o Lacrimation – pxs eye could be streaming
  o Stromal infiltrates possible – depend on severity of abrasion
  o Px NEEDS TO BE USING LUBRICATION FOR AT LEAST 3 MONTHS TO TRY TO PREVENT AN EROSION
   Takes about 3mths for epithelium to fully reattach basement
  Membrane if it has been severely disrupted
• Investigations/Management:
  o Check for FB – identify where they are – check if anything else still there – px look in all positions of gaze and MUST lid evert
  o Prophylactic antibiotics e.g. chloramphenicol – depends on what has caused abrasion
  o Monitor px closely – if large abrasion bring px back next day to check on it
  o If infiltrates detected – treat as Microbial Keratitis until proved otherwise
  o Avoid corticosteroids – these are immunosuppressant & will slow healing down
  o Bandage SCL – to improve comfort while cornea heals
• CMG Notes on Corneal Abrasion:
  o “In the case of CL wearers, antibiotic prophylaxis should be w/ a drug effective against Gram -ve organisms, e.g. a quinolone such as levofloxacin or moxifloxacin, or an aminoglycoside such as gentamicin. CLs should not be worn during tx period.”

Question 16

Describe CLPC (CL induced papillary conjunctivitis) - including cause, symptoms, signs and management?

Answer 16

• Contact lens induced papillary conjunctivitis AKA giant papillary conjunctivitis (GPC can be induced independently of CLs too)
• Mainly a result of SCL wear (less common in RGPs)
• Usually bilateral
• Caused by:
  o CL front surface deposits
  o Mechanical irritation of CL
  o Immune response – from body to lens on eye
  o Drying of CL surface
• Symptoms:
  o Most likely asymptomatic in early stages
  o In moderate/advanced stages:
   ↑CL awareness
   ↑CL movement
   ↑mucus affecting: drying of CL surface, CL deposits & reduced or fluctuating vision
   Itching – presents in similar to way as allergy – but doesn’t follow seasonal variation
   CL intolerance
  o NB itching/irritation symptoms can sometimes be worse w/o the CL as the lens can act as a bandage
• Signs:
  o Enlarged papillae
  o Roughened appearance
  o Palpebral hyperaemia
  o Tissue oedema
  o Ptosis if chronic, widespread papillae
• Management:
  o Modify CL wear – change to DW or daily disposable
   Can be caused by higher modulus lens (stiffer) – could be monthly SiHy causing this  change to daily disposable (thinner & lower modulus)
  o More frequent CL replacement
  o Optimise CL care & maintenance
  o Pharmacological therapy – mast-cell stabiliser such as sodium cromoglicate as allergic – can take couple weeks to kick in
  o Px education – on importance of good care and compliance
  o Can take a break from CLs
  o Gas Permeable CLs – good option if getting recurrent or severe CLPC
  o If px doesn’t respond to any of above, short course of topical steroids can be used to get inflammation under control -> would not jump straight to this – try other things 1st

Question 17

Describe how to differentiate papillae vs follicles?

Answer 17

• PAPILLAE:
  o Raised, cobblestone-like appearance
  o Occurs in allergic diseases (CLPC & vernal conjunctivitis)
  o Often CL treated
  o Tend to have a BV core
  o Vessels at base & a central vascular tuft
  o Often upper palpebral conjunctiva
  o 0.3-0.9mm diameter (larger) – can go larger in GPC
  o May be accompanied by strands of mucus
• FOLLICLES:
  o Pyramidal or rounded rice grain shape
  o Often in viral/chlamydial disease – watery discharge, acute in onset, may jump from eye to eye
  o Usually NOT CL-related
  o Pale, translucent (milky-white, greyish-white)
  o Most, but not all, are avascular
  o Usually inferior, palpebral conjunctiva
  o 0.2-0.4mm diameter (small)
  o Watery discharge

Question 18

Describe CL deposits?

Answer 18

• Tiny spots all over CL – protein deposits – can be managed using protein removers in CL care regimen
• Stripes/oily appearance – due to lipids on surface – fingerprint on lens, would see this appearance if used moisturiser before putting CL in
• Small black dots – mucin – no reversed illumination – on the CL – when take lens out, won’t see them anymore – may see NaFl pooling due to indent, but it is not a true stain as not broken through epithelium
• Management:
  o Optimise care & maintenance
   Solutions/systems used – protein removing tablets
   Care regimen applied – ensure compliance – rub & rinse step when cleaning lenses
   CL replacement rate
  o Consider daily disposables (DD CLs)

Question 19

Describe cL wrinkling?

Answer 19

• Not seen as often now
• Aetiology:
  o High minus or plus BVP
  o Low water material
  o Lid forces on blinking – causing CL to wrinkle
• Symptoms:
  o Severe vision ↓ if wrinkling is over pupil zone, milder if not over pupil
  o Onset may be rapid (minutes) to months
  o Recovery: ‘prompt’ to ‘hours after’
• Signs:
  o Corrugated central or mid-peripheral CL zone
  o Does not change w/ a blink – shows it is not a lipid deposit
  o CL wrinkling can cause corneal wrinkling
  o Now a rare occurrence
• Management:
  o Change CL design
  o Higher water content
  o Thicker design
  o Consider a more rigid CL material SiHy CLs
  o Consider Gas Permeable CLs

Question 20

Describe corneal staining - Smile -> including symptoms, signs and management?

Answer 20

• Staining in inferior cornea
• Pattern similar to ‘smiling face’
• Severity subject to individual variation
• Worst w/ high water, ultra-thin SCLs (hydrogel)
• Caused by:
  o Mechanical/physical
  o Evaporation
• Symptoms:
  o Most are asymptomatic
  o Dryness
  o Itchiness
  o Grittiness
  o CL awareness
  o Usually, pain is not reported
  o Vision not usually effected as staining is inferior rather than over pupil
  o Not likely to get discharge
  o HAVE TO DO NaFl CHECK AT ALL AFTERCARES
• Signs:
  o Punctate staining in inferior quadrant
  o Staining may coalesce – looks more dense
  o Stained area isolated from limbus – bit of clear cornea with no staining just underneath the staining before reach limbus
  o Severe cases may also have lighter staining superiorly – will not be as dense
• Management:
   ↑CL centre thickness (tc)
   ↓water content
  o Some combo of above
  o If standard lens, try another CL type &/or a different manufacturer  more likely in hydrogel pxs so switch them to SiHys (thicker lens), if in SiHy px switch them to RGP
  o Lubricating drops
  o Discontinue CL wear for few days to get cornea healed – is epithelial so once remove lenses and use lubricants for few days it should heal quickly
  o If significant or decent amount of staining, give eye a chance to recover, resolve the staining then make the change in CL material/type/manufacturer

Question 21

Describe corneal staining - Superior Epithelial Arcuate Lesion (SEAL)?

Answer 21

• Always in superior part of cornea
• AKA
  o Tight lens syndrome
  o Superior arcuate keratopathy
  o Soft CL arcuate keratopathy (SLAK)
• More common in stiffer lenses – higher modulus - SiHys
• Aetiology – unknown
  o Possibilities include hypoxia (chronic lack of oxygen), mechanical (from presence of lens), decentration, a combo of factors
• Symptoms:
  o Most are asymptomatic
  o Dryness
  o Itchiness
  o Grittiness
  o CL awareness
  o Burning
  o FB sensation
  o Usually, pain is not reported
  o Vision will not be down because it is not in the visual axis
  o No discharge – maybe a little watering
• Signs:
  o 1-3mm inside limbus – clear zone of cornea between limbus & staining
  o 10 o’clock to 2 o’clock location
  o 0.5mm wide, 2-5mm long
  o Usually, in corneal area covered by upper lid – MUST lid evert & NaFl assessment
  o Can involve full epithelial thickness – NaFl will be bright
  o Usually, unilateral
  o Lesion often has irregular edges
  o Little or no local injection or inflammation – conj will look quite white
  o ‘Tight’ eyelids a common factor – means lens is more firmly in place
  o Stains w/ fluorescein but not Rose Bengal
• Management:
  o Stop CL wear immediately (risk of neovasc, infections &/or scarring)
  o Wait for about 1 week (check for complete healing)
  o Don’t continue w/ same CLs
  o Try new CLs w/ different specifications– try a lower modulus (thinner lens) & moves about more  try daily disposable, try hydrogels, could try SiHy w/ looser fit (increase base curve or reduce total diameter)
  o Could give px gas permeable lenses

Question 22

Describe contact lens peripheral ulcer (CLPU) including symptoms, signs and management?

Answer 22

• CLs are most ‘important’ risk factor
• Defined as: ‘ulceration of corneal epithelium w/ underlying inflammation of corneal stroma’
• Corneal scrapes are negative – no active infection, it is an inflammatory response to bacteria present (bacteria usually in lids or lashes)
• Condition is inflammatory
• Ulcer usually located peripherally
• Always double check under eyelid
• Smaller lesion ~1mm in size
• Symptoms:
  o Asymptomatic to severe pain
  o FB sensation
  o Photophobia
  o May get watering too
  o ↓corneal sensitivity
• Signs:
  o Small, single, circular, focal infiltrate – confined to one location
  o Halo of diffuse infiltration
  o Usually peripheral, not central
  o Located in anterior stroma – will see this on corneal section
  o Overlying epithelium breached — means it will fluoresce with NaFl
  o Redness (local & general) – may be more intense in area where ulcer is
  o Tearing
• Management:
  o Discontinue CL wear immediately
  o Generally, healing is rapid
  o Monitor carefully for 1st 24hrs – in case its microbial keratitis – looking for pain, reduced vision, pus discharge -> if don’t see the healing in 1st 24hrs then be on look out for MK
  o Lubricating drops – helps comfort and washes away any debris
  o Resolves w/ scarring
  o Treat any underlying blepharitis
  o Can resume CL wear but consider stopping EW – speak to px about compliance & lid hygiene

Question 23

Describe contact lens acute/associated red eye (CLARE) - including symptoms, signs and management?

Answer 23

• Acute inflammatory response usually associated with SCL EW
• Sudden onset, usually early AM
• Presentation is dramatic – but don’t need to panic about CLARE
• More likely in 1st 3/12 of lens wear
• F>M
• Aetiology:
  o EW (closed-eye hypoxia)
  o CL binding overnight
  o Entrapped debris & deposits
  o Gram-negative bacteria on CL
  o Sensitivity to CL care products
  o Debilitated general health – if immune system not up to scratch
  o Some seasonal variation
• Symptoms:
  o Px woken (often early AM) by a painful eye
   AKA ‘3am Syndrome’  find this out in H&S
  o Photophobia
  o Lacrimation
  o Ocular irritation
• Signs:
  o Moderate to severe ocular redness
  o May have 360° conjunctival redness – can be entire conj
  o Diffuse infiltrates (2-3mm from limbus – gap on cornea between the infiltrates & the limbus) – will be small infiltrates
  o May also have focal zones of infiltrates
  o Minimal or no staining
  o Lacrimation, often profuse
• Management:
  o Temporary discontinuation of CL wear
  o Palliative therapy (unpreserved saline/lubricants)
  o Redness & discomfort will go down within a few days
  o Complete resolution of infiltrates (1-3weeks normally, can take up to 3 months)
  o Regular CL replacement to stop this recurring
  o Re-start with DW initially (caution with EW)
  o Optimise CL fitting – make sure got movement – prevent it from binding on
  o Change CL type/care products – if px determined to go back to EW, a night off a week is a good idea to give the lens a proper clean & the eye a rest
  o Monitor for recurrence
  o Make sure have resolution of infiltrates and hyperaemia before considering going back to EW

Question 24

Describe CL - associated Superior Limbal Keratoconjunctivitis (SLK) - including symptoms, signs and management?

Answer 24

• Aetiology:
  o Solution preservative sensitivity
  o Mechanical irritation by CL
  o CL deposits
  o SCL wearer mainly
• Symptoms:
  o ↑CL awareness
  o Burning, itching, photophobia
  o Mild discharge
  o Vision may be affected slightly
• Signs:
  o Typically, bilateral but can be asymmetrical
  o Superior bulbar & limbal hyperaemia
  o ‘Apron’ of redundant folds of bulbar conjunctiva at superior limbus
  o Conjunctival chemosis – swelling of conj
  o Infiltrates (grey)
  o Sub-epithelial haze (stromal region)
  o Corneal & conjunctival staining with fluorescein/Rose Bengal
  o Signs remain well after cessation of CL wear – takes while to go away
• Management:
  o Discontinue CL wear and monitor recovery
  o Lubrication – for comfort
  o Change CL design/CL fit – go to daily disposable if deposit related/care related – or go to GPs as they don’t deposit as much
  o Fit GP CLs
  o Use alternative care solutions:
   preservative-free – e.g. hydrogen peroxide
   different preservative(s) – often linked to the preservative THIMEROSAL, this is not used as often anymore but check ingredients in case
  o Steroid therapy – only if v severe and not recovering quickly

Question 25

Describe marginal keratitis - including other names, aetiology, symptoms, signs and management?

Answer 25

• Relatively uncommon
• One of most serious CL conditions
• CLs are most likely cause
• EW ↑ risk of MK
• Risk: EW: 2%, DW: 0.07%
• Larger lesions >1mm
• OCULAR EMERGENCY
• AKA:
  o Microbial infiltrative keratitis
  o Infectious keratitis
  o Corneal infection
  o Corneal ulcer
  o Bacterial keratitis
  o Bacterial ulcer
• Aetiology:
  o More common in EW (prolonged eye closure)
  o Hypoxia – reduced oxygen
  o Bacterial adherence to CL esp. Gram-negative P. aeruginosa
  o Can be viruses, fungi, or protozoa
  o Organisms in stagnant tear film
  o CL deposits – allows microbes to grab on & stick to CL
  o Acquired resistance to CL care products
  o Non-compliance – wearing lenses too long, not cleaning them, sleeping in them when they aren’t suitable for that
  o No surfactant (like a soap) cleaner / no rub & rinse (essential step in cleaning)
• Symptoms:
  o May be mild irritation to severe pain (usually acute, usually pain)
  o Excessive tearing/discharge
  o Redness – all quadrants
  o No improvement with lens removal
• Signs:
  o Severe redness – intense conjunctival hyperaemia
  o Discharge:
   Watery
   Muco-purulent
  o Ulcer with oedema/infiltrates
   Central or paracentral (>1mm)
  o Large epithelial defect
  o Lid oedema
  o May have anterior chamber reaction, hypopyon (if v severe & not been dealt w/)
  o Infiltrate with feathery margins (fungus) – doesn’t change your management
• Management:
  o Cease CL wear immediately (important not to throw away contact lenses or case – px takes them to hospital to hospital to get cultured)
  o REFER – emergency, same day
  o Experienced anterior eye professional required
  o Cultures or swabs of:
   eye (lesion)
   CL lenses/case
   solutions bottle
  o Treatment dictated by causal organism & MK severity
  o Px will be monitored by HES until resolved
   Likely to resolve w/ scarring so can affect vision
  o Change CL type &/or wear mode
   Think about other eye and how it will now be the only one with good vision – risk to them putting a CL in this eye
   Could maybe do part time daily disposables for occasional sport or social occasions – give px CLEAR guidance about compliance & cleaning – be much more cautious with them
   If px still wants CLs  daily disposable & part time wear – especially if have reduced vision in eye that was affected

Question 26

Describe acanthamoeba keratitis?

Answer 26

• Protozoan MK
• Acanthamoeba are found in tap water, increased risk with CL wear
• Clinical signs are disproportionate to symptoms at beginning
• Patient will report pain and possibly lacrimation, blurred vision, photophobia – but may not see many signs
  o H&S v important – ask about compliance, any travelling recently? any spas/hot tubs?
• Question them on CL compliance, travels etc
• Signs are non-specific in the early stages
• Possibly infiltrates or a pseudo-dendrite appearance (similar to Herpes), be wary of suspect Herpes in a CL wearer
  o Can phone ophthalmology for advice
• Can appear simply as a corneal haze
• A ring defect will appear in due course
• Diagnosis often delayed
  o Be aware of this in a CL wearer
  o If you suspect, then stop CL use and refer as an emergency w/ their lenses & case
• Rare
• Sight threatening – stubborn organism that is difficult to irradicate
• Must be treated by ophthalmology, corneal scraping required by diagnosis
• Ophthalmologist tx:
  o This protozoan doesn’t respond to standard antibiotics
  o Antiseptic drops with anti-amoebic effects
  o E.g. propamidine and polyhexammethylene-biguanide (PHMB)
  o May take weeks or months of treatment
  o Topical steroid too for the inflammation – once know for sure it is acanthamoeba keratitis
  o Pain relief