23 June 2023
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?
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.Contact lens associated infiltrates tend to cause a foreign body sensation rather than pain
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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Comments (2)
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Dave C26 June 2023
Never sure what this segment is trying to achieve.
Scenario I’d always incredibly vague, and answers seem to be littered with inaccuracies & non-evidence-based assumptions.
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Nicholas Rumney25 June 2023
1. In one respect not enough information. The location is important, you may still have good VA with a near-central lesion. So where on the cornea is it ? Peripheral and 1-2mm is likely infiltrate but staining so possible infective.
1-2mm central and story could be different.
2. In my opinion one of the key diagnostic questions is "did the discomfort improve or worsen on lens removal".
If the former and its peripheral then it's very safe to manage and my choice would be keep lens out and use a combination such as Tobradex qds and review 48 hours.
If the latter I would Rx Exocin and review 24hours, unless pain level is high and there is any irregularity of shape. If very painful and irregular in a CL wearer I would refer to Eye Cas (assuming you have rapid access to ophthalmology that can be escalated up from ST level). Concern is MK or Acanthamoeba. Again in my experience pain ++ at this stage is more likely MK (no AB so they can swab), Acanth main usually comes later. If your cat unit is non-ophthalmic you are risking an inexperienced nurse or medic failing to manage correctly and patient is worse off.
Hospital and Medical does not always equal better.
As the guru of optometry primary care says "hit that sucker with a therapeutic in cat sit gets better on its own" and "never be the last to see an eye that goes blind". Somewhere in between those statements is the sweet spot.
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