Contact lens–induced keratoconjunctivitis
Contact lens–induced keratoconjunctivitis (CLIK) can be ascribed to allergy, dry eye, infection, and deposits on lenses. Patients with ocular prostheses and exposed monofilament sutures have similar reactions. Findings suggest a combined mechanical and immune-mediated pathophysiology.
Preservative chemicals can produce a type IV delayed hypersensitivity response, resulting in conjunctivitis, keratitis, coarse epithelial and subepithelial opacities, and superior limbic keratoconjunctivitis. This condition has become less common, probably because of the replacement of thimerosal by other preservatives in contact lens solutions and the introduction of disposable contact lenses.
Figure 5-17 Three-o’clock and 9-o’clock corneal staining. A, Inferior corneal desiccation of the tear film. B, Peripheral corneal desiccation.
(Part B courtesy of Perry Rosenthal, MD.)
Giant papillary conjunctivitis
Giant papillary conjunctivitis (GPC) (Fig 5-16C) tends to develop more frequently with extended-wear soft contact lenses, dry eye, and meibomian gland dysfunction. It may also be induced by other irritants, such as loose sutures or prosthetics. Symptoms include contact lens intolerance, itching, excessive mucus discharge, and blurred vision with mucus coating the contact lens, contact lens decentration, and conjunctival redness. Sometimes, there may be bloody tears and ptosis secondary to inflammation of the superior tarsal conjunctiva.
The signs of GPC consist of hyperemia, thickening, and abnormally large papillae (diameter >0.3 mm) of the superior tarsal conjunctiva due to disruption of the anchoring septae. In some cases, the giant papillae cover the entire central tarsus from the posterior eyelid margin to the upper border of the tarsal plate; involvement in other cases may be less extensive. Long-standing or involuted giant papillae on the superior tarsus may resemble follicles. The symptoms of GPC generally resolve when contact lens wear is discontinued. The tarsal conjunctival hyperemia and thickening may resolve in several weeks, but papillae or dome-shaped scars on the superior tarsus can persist for years.
If GPC persists, the clinician should consider changing the lens to a different polymer or to daily-wear disposable lenses. Some patients prefer low-water-content lenses. In persistent cases, consider fitting the patient with RGP contact lenses, which are associated with a lower incidence of GPC, or discontinuing contact lens wear.
Many practitioners recommend discontinuing lens wear for 2–3 weeks while treatment is initiated. Mast-cell stabilizer/antihistamine topical medications are used for mild GPC. Topical corticosteroids may be used for several weeks for these or more advanced cases, with appropriate monitoring of the increased long-term risks of infection, elevated intraocular pressure, and cataract formation. Topical cyclosporine and tacrolimus may be helpful in some cases. In the most severe cases, it may be necessary to discontinue contact lens wear.
Typically, sterile infiltrates are observed in the peripheral cornea. They occur more often in younger patients. Often there is more than one spot, the epithelium over the spots is intact, and they are relatively small (Fig 5-16D). Discontinuing lens use can usually solve the problem quickly, but clinicians often prescribe an antibiotic, even though cultures tend to show no growth. Increased bacterial bioburden has been found on these lenses.
Excerpted from BCSC 2020-2021 series : Section 3 - Clinical Optics. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.