Irritation and foreign body sensation in a contact lens patient

The question:

A teenage contact lens patient attends practice with their father, and reports irritation, a foreign body sensation, and general pain in their left eye. On inspection, you also notice a rough texture inside the eyelid and a small amount of mucus discharge. How would you diagnose?

OT’s panel says...

Ceri Smith Jaynes: I have a few questions...

Is the patient still wearing the contact lenses? I hope I have trained my patients well enough to know that the first thing to do, if the eye doesn’t feel right, is to stop wearing the lenses – the second being to come and see me.

How long has it been going on for? Have they used any treatment? Sometimes, patients manage to obtain chloramphenicol from the pharmacist, even if they are a contact lens wearer, and then they get conjunctivitis medicamentosa from the treatment.

Is the eye red? Probably, it is at least a bit red. But that doesn’t seem to be a significant concern in the scenario.

Is vision affected? How painful is painful, on a scale of one to 10? Is it intermittent or constant? With or without the lens in? Any photophobia?

I’m curious about this being just one eye; for that reason, I’m leaning away from contact lens-associated papillary conjunctivitis and allergy. It could be the start of viral conjunctivitis, a damaged contact lens, foreign body, injury, chlamydia, or Thygeson superficial punctate keratitis.

I’m going to need a slit lamp and fluorescein to get any further with this. Have I missed any other differentials?

I hope I have trained my patients well enough to know that the first thing to do, if the eye doesn’t feel right, is to stop wearing the lenses

Kevin Wallace: I agree with Ceri’s initial thoughts. On its P licence, Chloramphenicol is only for bacterial conjunctivitis – and this doesn’t appear to be that. It isn’t that a pharmacist cannot supply it to a contact lens wearer – but that it is not recommended because a red eye in a contact lens wearer obviously could be something much more significant, so they should have an assessment to rule that out. In my experience this is not something that is asked often by pharmacists though – although I had one recently tell me that they always ask so they can make sure the patient removes their contact lenses before instilling the drops – which is good practice, but not the point of the guidance.

Like Ceri I would hope that most of my patients remember the advice of either removing the lens, or not putting it in, and seeking help – rather than struggling on and asking a pharmacist. Thankfully, in this case it doesn’t sound serious.

I would definitely want to have a good look at the eye and the contact lens to see if I can find a cause of the monocular complaint. If I can’t find anything, and there is nothing that indicates something more significant (particularly a red eye with worse vision) I would review the patient in a few days after no contact lens wear, and in the meantime would provide some lubricating drops – not particularly to treat anything, but to make the eye more comfortable.

Ankur Trivedi: I concur with Kevin that the supply to a contact lens wearer is not explicitly against the P classification, but does not follow best practice.

I agree we all drum into our contact lens patients (and their parents, carers or guardians, in the case of minors) about what steps to take if there are any issues or concerns. I do not think we have information on the contact lens modality: is it a reusable, and if so, have the lenses been brought in for examination? This is also part of the explicit training for new wearers, which may need to be reiterated at every follow up to cement it.

Some modalities are more prone to palpebral conjunctival roughness, as per this case. However, it would be unusual for it to be a monocular presentation unless there was some obvious reason for this, for example, the contact lens only worn in symptomatic eye, and that lens being damaged or deposited, or uniocular exposure to an antigen. Asking about the patient’s general health and known allergies may also provide some further clues.

I would be erring toward conservative treatment in the first instance, as outlined by Ceri and Kevin, assuming there was no evidence of any corneal or anterior chamber involvement, or if red flags such as drop in visual acuity or severe or marked chemosis and/or hyperaemia is detected.

For advice in any situation where you are unsure how to manage a patient, contact the AOP’s clinical and regulatory team via email or phone on 0207 549 2020, extension 1.