Clinical challenge: contact lens wearer has pain, discharge, photophobia

Issue: July 2005

Right eye: Multiple, scattered, limbal-based infiltrates are evident.

Case report: A 21-year-old college student came in with a red, painful right eye of 2 days' duration. There is a slight discharge and photophobia. The left eye is slightly symptomatic. Though his contact lenses were initially prescribed for daily wear, he frequently wears them overnight. He admits noncompliance with respect to contact lens replacement frequency and lens care. He is currently using a private-label saline for lens care. He reports good health, taking no medications and having no known allergies.

Entering visual acuity is 20/25+ in each eye. Biomicroscopy reveals a soiled soft contact lens in each eye. Multiple, scattered, limbal-based infiltrates can be seen in the right eye (see photo). The left eye manifests conjunctival injection, but no infiltrates.

What do you think is the primary etiology? What is your first-line (acute) therapy? What is your contact lens management plan?

Choose antibiotic-steroid combo

Chris Snyder, OD, MS, FAAO: The patient evaluation and management does not include culturing of the eyes, adnexa, lenses or lens case, so diagnosis of the infectious nature of the event is made based on clinical features. (It is not customary to perform cultures in these cases). The key features of infiltrates that are multiple, peripheral and not more severe in appearance after 2 days coupled with only slight discharge and minimal involvement of the contralateral eye lead me to make the clinical diagnosis of infiltrative keratitis with conjunctivitis (keratoconjunctivitis).

There is a good likelihood that the infiltrates in this case are sterile in nature, perhaps occurring secondary to bacterial exotoxins from microbes on the lenses or lid margins. The dense and deep appearance of the primary infiltrate in the photo and the report of pain are worrisome, prompting me to believe that the degree of inflammation, if left unchecked, may lead to peripheral corneal ulceration.

One treatment option is a fluoroquinolone such as Zymar (gatifloxacin 0.3% solution, Allergan) or Vigamox (moxifloxacin HCl 0.5% solution, Alcon). However, in many of these contact lens wear-related cases, the cornea is primarily challenged by the cascade of inflammatory events ("sterile" infiltrative keratitis) and not by infection.

Chris Snyder [photo]
Chris Snyder

Pain management is best achieved by control of the inflammation and, because of this patient's pain, I would instead choose a treatment option that included an anti-inflammatory component. Accordingly, I would prescribe a topical antibiotic-steroid combination ophthalmic suspension, such as TobraDex (tobramycin 0.3% and dexamethasone 0.1%, Alcon) or Zylet (tobramycin 0.3% and loteprednol etabonate 0.5%, Bausch & Lomb), to treat the inflammation as well as any infection that may be present.

I would prescribe one drop in both eyes every 2 hours for the first day, then four times daily for 7 days. I would see him in 3 days to evaluate his response to treatment, and the treatment plan may be changed depending on his progress at that visit. Other follow-up visits would be scheduled as necessary until complete resolution of this episode is achieved.

This young man has stacked the odds against himself for safe and problem-free lens wear: noncompliance with lens wear and care; slow to seek eye care while continuing to wear his soiled lenses. Current lenses would be discarded immediately along with any of his lens cases and care product supplies. No lens wear would be allowed until the current inflammation/infection has resolved.

Upon complete resolution of this episode, a heavy dose of patient education would be given. He would be instructed to wear his new lenses only on a daily-wear basis, to replace the lenses at the regular, prescribed interval (yes, even when they still seem fine to wear longer), to use only a prescribed multipurpose disinfecting solution according to the package insert (and not the least expensive solution on the retail shelf) and to act promptly in ceasing lens wear and seeking eye care should he ever again develop any of the signs or symptoms that he experienced with this episode.

Chris Snyder, OD, MS, FAAO (Dipl), is professor of optometry and chief, Contact Lens Patient Care at the University of Alabama at Birmingham. He can be reached at UAB Optometry, 1716 University Blvd., HBP 112, Birmingham, AL 35294; (205) 934-6768; fax: (205) 934-6758; e-mail: csnyder@uab.edu. Dr. Snyder has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Choose antibiotic, cycloplegia

Joseph P. Shovlin, OD: This clinical presentation of indeterminate etiology represents an infiltrative response likely related to contact lens wear. The key differential is between a sterile or inflammatory event and a microbial etiology. Unfortunately, this presentation falls somewhere in between the two. Although it is unlikely that this patient is experiencing an infection, this situation must be managed judiciously because of presenting symptoms (pain and discharge). Aggregates of inflammatory cells in the cornea are a harbinger of serious tissue damage.

Joseph P. Shovlin [photo]
Joseph P. Shovlin

An infiltrative keratitis with an indeterminate etiology is accompanied by signs and symptoms not clearly meeting criteria for sterile or microbial groups. Signal data that might suggest infection in this patient include pain, discharge (not clear as to whether this was mucoid or purulent) and failing to use a continuous system of disinfection.

Factors suggesting that this is likely an acute red eye response with infiltrates (sterile) include size, location and number of infiltrates with apparent lack of staining (but this is not certain from the clinical picture). A number of causes of sterile infiltrative conditions have been determined. Often, the etiology is multifactorial and will affect treatment and management plans, especially in contact lens wearers.

Causes include toxin release from colonizing bacteria (lens and lid), mechanical insult, hypoxia, trapped debris beneath the lens and resultant decreased nutrition to that area of the cornea. A soiled lens worn overnight without proper disinfection is certainly an added risk factor for this type of corneal response.

Appropriate initial management would include cessation of lens wear until the infiltrates and red eye response have resolved, topical antibiotic prophylaxis and mild cycloplegia if there is an accompanying anterior chamber reaction. Initial dosing is dependent upon other diagnostic criteria such as anterior chamber reaction, epithelial integrity and nature of the discharge. Several of these factors are not well defined in this case presentation. Practitioners may choose to use a mild topical steroid but could never be faulted for withholding steroid treatment initially.

Patient instruction should include a discussion of potential morbidity, expected outcomes and alternatives, including other contact lenses, spectacle use or refractive surgery. A close follow-up, especially if the condition initally worsens, is essential.

Following an appropriate hiatus from lens wear, contact lens practitioners should educate patients about proper methods of disinfection, lens wearing schedule and replacement cycle. Refitting the patient into a higher oxygen flux material such as a disposable silicone hydrogel and using a Food and Drug Administration-approved disinfection system often is beneficial for minimizing the chance of recurrence.

It is important to check the lens for proper centration and movement. Before allowing the patient to resume lens wear, it is critical to carefully assess lid position and health of the lid. If lid status is not satisfactory, instructing the patient in effective lid hygiene may be necessary.

Joseph P. Shovlin, OD, FAAO, is a Primary Care Optometry News Editorial Board member. He can be reached at Northeastern Eye Institute, 200 Mifflin Ave., Scranton, PA 18503; (570) 342-3145; fax: (570) 344-1309; e-mail: jshovlin@aol.com. Dr. Shovlin has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.