IP and me

Contact lens and corneal infiltrate

OT  presents a clinical scenario to three of its resident IP optometrists. Here, we consider a contact lens wearer with a photophobic and painful eye and corneal infiltrate


The question:

‘A daily contact lens wearer presents with a photophobic and painful right eye. She last wore her contact lenses yesterday morning and removed them due to discomfort. Slit lamp examination reveals a 1-2mm round corneal infiltrate with indistinct edges, which does not stain with fluorescein. The anterior chamber is quiet and the visual acuity remains good. How would you manage this patient?’ 

OT’s panel says...

Kevin Wallace (KW): The most important thing in a case of a contact lens wearer presenting with a sore eye is to rule out microbial keratitis. If the lesion is small, not central and there is no anterior chamber reaction, then it is likely that it is a sterile infiltrate, but in the early stages the signs and symptoms can be similar.

It is very important to monitor the patient closely, particularly over the next few days, and you should have a low threshold for seeking advice if the condition worsens.

This patient has already done the most important thing, which is removing the contact lens. She should be instructed not to wear them again until the eye has fully healed. It can be useful to keep the contact lens (and case if they are reusable) in case they need to be cultured.

Ceri Smith-Jaynes (CSJ): I agree. My management on this would depend on how bad the symptoms are and whether I’m around for the next 48 hours to keep in touch with the patient. Contact lens associated infiltrates tend to cause a foreign body sensation rather than pain, so I’m already a bit twitchy about this one.

I would always keep Acanthamoeba, bacterial keratitis and fungal keratitis in mind in these cases. Size matters too: this one is a bit big for an infiltrate, but then it doesn’t stain and there is no anterior chamber activity, which is a good thing.

If there was any lid swelling or discharge, that would tip me over into immediate referral. I would have to see it and talk to the patient myself, but I think this one is just an infiltrate, which is inflammatory rather than infective. Lubricant drops can help with comfort and, if I am right in the diagnosis, it should be getting better over the next 24 hours, not worse.

I would leave the chat about contact lens hygiene and blepharitis management for the follow up appointment. We would need to consider the fit of the lens too – is it too tight?

Contact lens associated infiltrates tend to cause a foreign body sensation rather than pain

Ceri Smith-Jaynes, OT clinical multimedia editor
Farah Topia (FT): I am in agreement too. In all likelihood, this is a sterile ulcer, but as the differential diagnosis is microbial keratitis, we would need to watch very closely.

I would ideally review the patient at 24 hours and then again at 48 hours to ensure that there is no further pain, redness, discharge or anterior chamber activity. If it is a sterile ulcer, most signs and symptoms would have resolved by 48 hours. It is also more likely to be a sterile infiltrate if this has happened before, so an awareness of the history is useful.

This could also be marginal keratitis, and I would have a good look for any signs of blepharitis as a potential underlying cause. I might also suggest a lubricant to help with the symptom of discomfort in the short term. The key message is to keep a close watch with this one.

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