This article is more than 5 years old. Information may no longer be current.
Unusual fluorescein staining in contact lens wearer
Click Here to Manage Email Alerts
A 62-year-old woman has been my contact lens patient for about 40 years. In February 2013 she reported that “something wasn’t right” with the vision in her left eye. Over the years I have been seeing her, she would often complain about her vision, especially up close. As she was wearing soft multifocal lenses and required an add in excess of 2 D, I was not overly concerned about her complaint that day.
The patient’s medical history was positive for having breast cancer about 10 years prior and taking warfarin daily to prevent a blood clot, as a stent was implanted due to complications of chemotherapy performed postoperatively. The remainder of the ocular history was noncontributory. She has no known allergies and takes no other medications.
Her visual acuity was 20/25, 20/40 for distance (unimproved with pinhole), and 20/40, 20/40- for near. Her external appearance was normal, and she reported no complaints of discomfort, redness or decrease in her full day wearing time. Upon slit lamp examination, the right cornea was clear; the left exhibited slight haze in the shape of a drop of dew. The widest part extended from the superior nasal limbus, dropping temporally and ending up in a point in her pupil.
Upon contact lens removal, fluorescein staining revealed an intact cornea in the right eye. See the accompanying figure for the appearance of the left eye.
The patient’s left cornea showed slight haze in the shape of a dew drop.
Images: Geula RH
Fluorescein stain after contact lens removal in the left eye.
In my 40 years of contact lens practice I had never encountered this type of staining pattern before. As my patient’s only complaint was her decreased visual acuity, and after ruling out any other source of her vision loss, I advised her to start preservative-free rewetting drops three times daily and to return to my office in 10 to 14 days.
Upon her return, I found her staining to be unchanged and advised her to try to decrease her wearing time and return to me in 7 days. At her return visit she reported no new symptoms and volunteered that she was unable to reduce her wearing time, as she never got used to wearing progressive eyeglasses and needed to wear her multifocal contact lenses for her work and her appearance. She was, however, compliant with her use of the preservative-free rewetting drops.
At this point I decided to seek the advice of a corneal specialist. After performing corneal topography, he diagnosed corneal stem cell deficiency resulting from contact lens wear. Another corneal specialist confirmed this diagnosis and recommended that corneal impression cytology be performed and interpreted by a specialist in Florida.
While awaiting the results from Florida, we sought the opinion of a third corneal specialist in New York City, where I practice. This doctor was not convinced of the stem cell deficiency diagnosis and thought it might be herpetic. All of the doctors we consulted recommended discontinuing contact lens wear and continuing the use of preservative-free drops. They postulated that the left cornea would probably heal itself in about 12 months, with no other treatment advised.
The results of the corneal impression cytology were inconclusive. The patient has been out of her lenses for 11 months as of this writing, and her left cornea has indeed improved. She reports not using any drops for months now. Her acuity has improved to 20/25- OS, although she is very despondent about not being able to wear her contact lenses and having to switch between two pairs of glasses constantly.
Her prognosis is good for a complete resolution of her corneal issues. This has reinforced my belief in removing lenses in the office and staining every contact lens patient who comes in.
This patient was wearing 8.8 +2 D high soft multifocals (38.6% water) in both eyes. Her keratometry readings were 40.25/41.50 OU, and her horizontal iris diameters were 12 mm. Although theoretically I would have preferred a flatter lens-to-cornea relationship, she never exhibited any signs of a tight contact lens fit, as evidenced by her continued clear cornea in the right eye. Over the years we had tried to improve her acuity with numerous custom soft and gas-permeable multifocals, but she always reverted to her original lenses for overall wearability and comfort.
I have prescribed single-use daily soft multifocal lenses for limited use, several hours at a time, two to three times per month, at the patient’s request.
All photos were taken with an iPhone 4 attached to a Keeler adapter on our Topcon SL3D slit lamp.
Corneal topography maps for both eyes.
One corneal specialist was not convinced of the stem cell deficiency diagnosis and thought it
might be herpetic.
The left cornea after 11 months of no contact lens wear.