Itching and discomfort in a contact lens patient

The question:

A 44-year-old contact lens patient presents at practice and reports itching and discomfort. They also say that they can feel their contact lens moving around in their eye. After examination, you identify an inflamed conjunctiva. How would you proceed?

OT’s panel says...

Ankur Trivedi: I am assuming this patient is new to the practice. If so, we need to ascertain more information about the contact lenses, including the modality, material, and replacement schedule. Are any solutions and/or eye drops used? If so, are drops used with or without the contact lenses in situ?

I would also find out whether the symptoms improve or resolve with lens removal. Do the symptoms wax/wane as the day goes on, or with the age of the lens, if reusable?

They also say that they can feel their contact lenses moving around in their eyes. Have they always moved, or has the issue become more pronounced recently? Is the timescale in line with the other issues? These questions could help us to ascertain whether it is a related or a separate issue.

We also need to ask about general health and history. If this is related to an allergy, which the mention of itching would suggest, there is likely to be relevant history. Have there been any changes to their environment that would fit into a similar timescale?

There are other potential issues at play, including non-allergic inflammation or infection, which also need to be considered. I am sure Ceri and Kevin will want to expand there.

Kevin Wallace: I agree with Ankur’s start. This is not a worrying presentation – bilateral symptoms of itch are likely to be an allergy. I would definitely want to investigate the contact lenses to consider contact lens-associated papillary conjunctivitis (CLAPC). If that was suspected, changing to daily disposables if possible is the best solution.

If it’s not linked to that, then it could just be allergic conjunctivitis making the contact lenses uncomfortable. That is something I’m seeing quite often at the time of writing – the grass pollen count is very high at the moment. It can be difficult to work out what the patient is reacting to, and investigating potential changes in their environment can be useful.

If the patient presents again next year with similar symptoms, that is helpful in confirming a diagnosis of seasonal allergic conjunctivitis. Appropriate treatment would be something like Opatanol – it usually gives prompt improvement in symptoms, which is popular with patients, and its twice daily dosing makes it suitable for use with contact lenses – they just need to ensure there is an appropriate gap between inserting the drop and inserting their contact lenses. These drops can only be used for a maximum of four months, but this is adequate in most cases – and if it’s not, something else can be used once the patient has been made more comfortable.

“The grass pollen count is very high at the moment. It can be difficult to work out what the patient is reacting to, and investigating potential changes in their environment can be useful”

Ceri Smith-Jaynes: Like Kevin, my first thought was CLAPC. Eyelid eversion will be revealing in this patent. I’m expecting to see lumpy palpebral conjunctivae, which would account for the itching and the lenses being dragged about by the rough surface.

If there are papillae, then Ankur already alluded to potential causes: a reaction to lens surface deposits, a thick edge design or stiff material, or an ingredient in drops or solution. If they are monthly disposables, I’d like to see the surface of the contact lenses at the end of their month, and I’ll be looking for solution induced corneal staining (SICS) with fluorescein.

CLAPC is more common in overnight wearers. As Kevin said, we are better addressing the cause than just treating the problem with drops. I can’t switch a scleral lens wearer to daily disposables, but I may be able to improve their cleaning regime or landing zone design.

Pharmacological options for treatment include olopatadine (Opatanol) or ketotifen (Ketofall comes in single dose, and is preservative free). Both of these are instilled only twice a day. However, it needs to be made clear to the patient that this is an off-licence use for CLAPC, unless we are treating seasonal or perennial allergic conjunctivitis as well. I’m not keen on reaching for the steroids for this because they would be a short-term treatment, unless all else fails.