On February 18th we were privileged to have a very comprehensive, contemporary presentation on common contact lens complications and their management. Although the presentation was primarily for optometry students and residents, the information provided – including very good graphics – benefits everyone in contact lens practice. It is archived under the “Residents & Students” tab on www.gpli.info. The following includes a summary of the topics presented in this webinar:
I. HYPOXIA
=====a. Corneal Neovascularization
i. Causes
ii. Management
=====b. Corneal Edema
i. Causes
ii. Management
=====c. Corneal Infiltrates
i. Causes
ii. Management
=====d. Important Factors
i. Often present with low Dk lens materials; ===============increase Dk (for GPs you can go to the ===============material list on www.gpli.info)
ii. Be sure to stain to evaluate for the results of a ===============tight lens (imprint), and staining associated ===============with infiltrates; can change to a flatter BCR or ===============smaller diameter
II. INFLAMMATION
=====A. Giant Papillary Conjunctivitis (GPC)
==========a. Diagnosis
==========b. Causes
==========c. Patient symptoms
==========d. Risk factors:
i. Infrequent lens replacement, longer wear ====================time, poor lens hygiene, atopy
ii. High water contact hydrogel material
iii. Lipid deposits on high modulus Si-HY ====================material
==========e. Management
i. Stop CL wear x 4 – 6 weeks
ii. Artificial tears in mild cases
iii. Topical mast cell stabilizer/anti-histamine ====================or combination
iv. Short term topical steroid
v. Switch CL modality (daily disposable) or ====================material
vi. Change solutions (H2O2); enzymatic ====================cleaner (GP)
=====B. Solution Toxicity
==========a. Clinical Signs
==========b. Symptoms
==========c. Causes
i. Preservative reaction in MPS system
ii. H2O2 used improperly
==========d. Management:
i. Remove offending agent
ii. Temporarily d/c CL wear (copious AT use)
iii. Switch solutions
iv. Review proper care instructions
III. CORNEAL INFILTRATIVE EVENTS
=====A. Contact Lens Acute Red Eye
==========a. Symptoms
==========b. Clinical Signs
==========c. Management
i. D/c CL wear
ii. Artificial tears
iii. Steroid or steroid/Ab combination
iv. Change CL modality once resolved
=====B. Infiltrative Keratitis
==========a. Symptoms
==========b. Clinical Signs
==========c. Management
i. D/c CL wear
ii. Lid hygiene
iii. Artificial tears
iv. Steroid or steroid/Ab combination
v. Change CL modality once resolved
=====C. Contact Lens Peripheral Ulcer (CLPU)
==========a. Inflammatory response: “sterile ulcer”
==========b. Symptoms
==========c. Clinical Signs
==========d. Associations (Gram + bacteria {staph}), extended ===============wear
==========e. Management
i. Differentiate from infectious etiology
ii. D/c CL wear
iii. Prophylactic antibiotic
iv. Steroid/antibiotic combination
v. Daily follow-up
vi. Change CL modality once resolved
=====D. Infectious Chronic Infiltrative Events
==========a. Microbial Keratitis (Corneal Ulcer)
i. Defined as a lesion “caused by superficial ====================loss of tissue, usually with inflammation”
ii. Risk Factors (and questions to ask to ====================determine cause)
====================1. Eyelid disorders
====================2. Ocular surface disease
====================3. Systemic disease/medications
====================4. Trauma/Surgery
====================5. Contact Lenses:
=========================a. Extended wear
=========================b. Poor personal hygiene
=========================c. Surface deposits
=========================d. Non-compliance with ==============================disinfection
=========================e. Corneal hypoxia with ==============================extended wear
iii. Common Pathogens
iv. Clinical Signs
v. Symptoms
vi. Management:
====================1. Cultures
====================2. Antibiotic selection (initial broad-=========================spectrum until culture comes =========================back; 1 drop every minute x 5 =========================min.; then every 5 minutes for 15 =========================min; then 1 drop every hour x 24 =========================– 48 hrs. or dual therapy with 2 =========================fortified antibiotics =========================(aminoglycoside, cephalosporin; =========================1 drop q 30 min for first 24 – 48 =========================hrs.)
====================3. Cycloplegic agent
====================4. Follow-up within 24 hours
=====E. Ulcer Versus Infiltrate
==========a. Pneumonic “PEDAL” (Pain, Epithelial defect, ===============Discharge, Anterior chamber reaction, ===============Location); More pain, bigger epithelial defect, ===============mucopurulent discharge, AC reaction, central ===============location with MK)
==========b. Very good chart of ulcer versus infiltrate
IV. MECHANICAL CONTACT LENS COMPLICATIONS
=====a. Conjunctival Impression/Staining
i. Soft or GP lens edge in tight fit
ii. Management:
===============1. D/c CL
===============2. Flatter BCR
===============3. ATs if due to lens drying of tightening ====================syndrome
===============4. Refit with different edge design
===============5. Change CL modality
=====b. Superior Epithelial Arcuate Lesion (SEAL)
i. Associated with lens material (stiffer modulus), ===============design, lid force
ii. Clinical Signs
iii. Symptoms
iv. Management
===============1. D/c CL wear until healed
===============2. ATs
===============3. Antibiotic treatment
===============4. Refit lens
===============5. Increase frequency of replacement
===============6. Typically resolves within 24 hours to 1 week
=====c. Desiccation (smile staining)
i. Aka Inferior Epithelial Arcuate Lesion
ii. Associations
iii. Clinical Symptoms (bilateral, asymmetric ===============arcuate staining 4 & 8 o’clock)
iv. Symptoms
v. Management
===============1. D/c CL wear
===============2. Lubrication
===============3. Reduce wear time
===============4. Refit to a lower water content material
=====d. 3 & 9 o’clock Staining
i. GP lenses (poor edge, poor tear film, improper ===============blinking, inferior decentration)
ii. Clinical Signs
iii. Symptoms
iv. Management
===============1. Ocular lubricants
===============2. Refit GP: Improve centration, change ====================diameter, thinner edge/ultrathin, ====================Lenticular, toric design for higher ====================cylinders
===============3. Change material: improve wettability
=====e. Dimple Veiling
i. Not true staining but indentations in epithelial ===============due to trapped bubbles
ii. Often excessive clearance of a GP lens ===============resulting in “bubble-like” pattern
iii. Management
===============1. Refit into a more alignment fitting lens ====================typically flattening the BCR or ====================decreasing OZD
===============2. For soft lenses select lens with a lower ====================modulus
=====f. Foreign-Body Tracking
i. Track mark superficial staining of cornea due to ===============trapped debris
ii. Management: may simply be an airborne ===============particle and sensation goes away quickly; if ===============recurrent evaluate edge and ensure lens is not ===============damaged
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