Week 11- SCL complications 2

Question 1

What is Smile corneal staining?

Answer 1

• Staining in the inferior cornea
• Pattern similar to ‘smiling face’
• Severity subject to individual variation
• Worst with high water, ultra thin SCLs
Caused by:
• Mechanical/physical damage
• Evaporation

Question 2

What are Smile corneal staining symptoms?

Answer 2

• Most are asymptomatic
Symptoms reported include:
• Dryness
• Itchiness
• Grittiness
• CL awareness
Usually pain is NOT reported

Question 3

What are Smile corneal staining signs?

Answer 3

• Punctate staining in the inferior quadrant
• Staining may coalesce
• Stained area isolated from the limbus
• Severe cases may also have lighter staining superiorly

Question 4

How is Smile corneal staining managed?

Answer 4

• Increased CL centre thickness (tc)
• Decreased water content
- or a combination of both
• If standard lens, try another CL type and/or a different manufacturer
• Any drops? Discontinue CL wear?

Question 5

What is SEAL, found in corneal staining and its aetiology?

Answer 5

• Superior Epithelial Arcuate Lesion (SEAL)
AKA
• Tight lens syndrome
• Superior arcuate keratopathy
• Soft CL arcuate keratopathy (SLAK)
Aetiology - unknown. Possibilities include hypoxia, mechanical, decentration, a combination of factors

Question 6

What are SEAL, found in corneal staining symptoms?

Answer 6

• Most are asymptomatic
Symptoms reported include:
• Dryness
• Itchiness
• Grittiness
• CL awareness
• Burning
Usually, pain is not reported

Question 7

What are SEAL Signs?

Answer 7

• 1-3 mm inside limbus, 10 o’clock to 2 o’clock location, 0.5 mm wide, 2-5 mm long
• Usually, in corneal area covered by upper lid
• Can involve full epithelial thickness
• Usually, unilateral
• Lesion often has irregular edges
• Little or no local injection or inflammation
• ‘Tight’ eyelids a common factor
• Stains with fluorescein but not rose bengal

Question 8

What is the SEAL management plan?

Answer 8

• Stop CL wear immediately (risk of neovasc, infections and/or scarring)
• Wait for about 1 week (check for complete healing)
• Continue with:
- same CLs (?)
- new CLs, same specifications (?)
- new CLs, different specifications (looser fit)
- prescribe GP CLs

Question 9

What is CLPU?

Answer 9

Contact Lens Peripheral Ulcer
• CLs are the most ‘important’ risk factor
• Defined as: ‘ulceration of the corneal epithelium with underlying inflammation of the corneal stroma
• Corneal scrapes are negative
• Condition is inflammatory
• Ulcer usually located peripherally

Question 10

What is the CLPU Aetiology?

Answer 10

• Bacterial Toxins
• Staphylococcus sp.
• Corynebacterium sp.
• Interaction of CL & epithelial surfaces
• Seasonal factor may apply

Question 11

What are CLPU symptoms?

Answer 11

• Asymptomatic to severe pain
• FB sensation
• Photophobia
• Decreased corneal sensation

Question 12

What are CLPU signs?

Answer 12

• Small, single, circular, focal infiltrate
• Halo of diffuse infiltration
• Usually peripheral, not central
• Located in anterior stroma
• Overlying epithelium breached
• Redness (local & general)
• Tearing

Question 13

How is CLPU managed?

Answer 13

• Discontinue CL wear immediately
• Generally, healing is rapid
• Monitor carefully for first 24 hrs
• Drops?
• Resolves with scarring
• Treat any underlying blepharitis
• Can resume CL wear but consider stopping EW

Question 14

What is CLARE?

Answer 14

Contact lens acute red eye
• An acute inflammatory response usually associated with SCL
EW
• Sudden onset, usually early AM
• Presentation is dramatic
• More likely in first 3/12 of lens wear
•F>M

Question 15

What is CLARE- aetiology?

Answer 15

• EW (closed-eye hypoxia)
• CL binding overnight
• Entrapped debris & deposits
• Gram-negative bacteria
• Sensitivity to CL care products
• Debilitated general health
• Some seasonal variation

Question 16

CLARE - Symptoms

Answer 16

• Patient woken (often early AM) by a painful eye
-a.k.a. ‘3 AM Syndrome’
• Photophobia
• Lacrimation
• Ocular irritation

Question 17

What are CLARE - Signs?

Answer 17

• Moderate to severe ocular redness
• May have 360° conjunctival redness
• Diffuse infiltrates (2-3 mm from limbus)
• May also have focal zones of infiltrates
• Minimal or no staining
• Lacrimation, often profuse

Question 18

How is CLARE managed?

Answer 18

• Temporary discontinuation of CL wear
• Palliative therapy (unpreserved saline/lubricants)
• Complete resolution of infiltrates (1-3 weeks normally, can take up to 3 months)
•Regular CL replacement
• Re-start with DW initially (caution with EW)
• Optimise CL fitting
•Change CL type/care products
• Monitor for recurrence

Question 19

What is CL-Associated SLK and its aetiology?

Answer 19

• Contact lens associated superior limbal keratoconjunctivitis
Aetiology
• Solution preservative sensitivity
• Mechanical irritation by CL
• CL deposits
• SCL wearers mainly

Question 20

What are CL-Associated SLK symptoms?

Answer 20

• Increased CL awareness
• Burning, itching, photophobia
• Mild discharge
• Vision may be affected slightly

Question 21

What are CL-Associated SLK Signs?

Answer 21

• Typically bilateral but can be asymmetrical
• Superior bulber and limbal hyperaemia
• ‘Apron’ of redundant folds of bulber conjunctive at superior limbus
• Conjunctival chemosis
• Infitrates (grey)
• Sub-epithelial haze
• Comeal & conjunctival staining with fluorescein/Rose Bengal
• Signs remain well after cessation of CL wear

Question 22

How is CL-Associated SLK managed?

Answer 22

• Discontinue CL wear and monitor recovery
• Lubrication
• Change CL design/CL fit
• Fit GP CLs
• Use alternative care solutions:
- preservative-free
- different preservative(s)
• Steroid therapy

Question 23

What is Microbial Keratitis?

Answer 23

• Relatively uncommon but…..
• One of the most serious CL conditions
• CLs are the most likely cause of MK
• EW increases risk of MK
• Risk: EW: 2% DW: 0.07% (Fonn et al., 1997)
OCULAR EMERGENCY

Question 24

What are the 6 different types of microbial keratitis?

Answer 24

• Microbial infiltrative keratitis
• Infectious keratitis
• Corneal infection
• Corneal ulcer
• Bacterial keratitis
• Bacterial ulcer

Question 25

What is the aetiology for microbial keratitis?

Answer 25

• More common in EW (prolonged eye closure)
• Hypoxia
• Bacterial adherence esp. Gram-negative P. aeruginosa
• Can be viruses, fungi, or protozoa
• Organisms in stagnant tear film
•CL deposits
•Acquired resistance to CL care products
• Non-compliance
• No surfactant cleaner/ no rub and rinse

Question 26

What are symptoms of microbial keratitis?

Answer 26

• May be mild irritation to severe pain (usually acute, usually
• Excessive tearing/discharge
• Redness
• No improvement with lens removal

Question 27

What are Signs of microbial keratitis?

Answer 27

• Severe redness
• Discharge:
- watery
- muco-purulent
• Ulcer with oedema/infiltrates
• Central or paracentral (>1mm)
• Lid oedema
• May have anterior chamber reaction, hypopyon
• Infiltrate with feathery margins (fungus)

Question 28

How is Microbial Keratitis managed?

Answer 28

• Cease CL wear, dont throw away case+Cl
• REFER
• Experienced anterior eye professional required
• Take cultures of Eye (lesion,) Cl lens/case and solutions bottle
• Treatment indicated by casual organism and MK severity

Question 29

What is Acanthamoeba Keratitis?

Answer 29

• Protozoan MK
• Acanthamoeba are found in tap water, increased risk with CL wear
• Clinical signs are disproportionate to symptoms
• Patient will report pain and possibly lacrimation, blurred vision, photophobia
• Question them on CL compliance, travels etc

Question 30

What are Acanthamoeba Keratitis signs?

Answer 30

• 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.
• Can appear simply as a corneal haze
• A ring defect will appear in due course
• Diagnosis often delayed
- Be aware of this in a CL wearer, If you suspect then stop CL use and refer as an emergency with their lenses and case

Question 31

What is prognosis of acanthameba keratitis?

Answer 31

• Rare
• Sight threatening, it is a stubborn organism that is difficult to irradicate
• Must be treated by ophthalmology, corneal scraping required for diagnosis

Question 32

How do ophthalmologists treat acanthamoeba keratitis?

Answer 32

• What will the ophthalmologist do?
• This protozoan doesn’t respond to standard antibiotics
• Antiseptic drops with anti-amoebic effects
• eg propamidine and polyhexammethylene-biguanide (PHMB)
• May take weeks or months of treatment
• Topical steroid too for the inflammation
• Pain relief