Daniel Tillia is a research optometrist at the Brien Holden Vision Institute, a part-time clinical supervisor at the School of Optometry and Vision Science, University of New South Wales, Australia and occasionally works in private practice
The majority of lens care systems designed for soft contact lenses are multipurpose: they are used for cleaning, rinsing, disinfecting and storing lenses1. A multipurpose system (MPS) should achieve a balance between consumer convenience and comfort, disinfection efficacy and interactions between lens and solution2. The importance of lens care products has been highlighted recently with outbreaks of Fusarium keratitis3-6 and Acanthamoeba keratitis7, and the availability of data on corneal staining2, 8, 9 and incidence of adverse events10 with different lens-solution combinations. Whilst many eye care practitioners (ECPs) prescribe appropriate lens care systems, many patients purchase their products from sales outlets that do not require practitioner supervision. Confronted with a plethora of different products all claiming superiority, many will choose one not recommended by their ECP or simply purchase based on the lowest price.
Background
RA, a 23-year-old female patient, presented for a consultation due to a two-week long burning irritation in her left eye, bordering on being painful, with increased redness in the same eye. No symptoms or signs were noted in the right eye. She had been wearing contact lenses for about 12 months, and continued to wear the lenses despite her signs and symptoms. RA reported symptom-free wear for the first six months of lens wear. However, she noted several episodes of increased redness and irritation, occurring in both eyes, but not lasting more than one week. Her current concern was the length of time her signs and symptoms had persisted.
RA was wearing senofilcon A (ACUVUE® OASYS®, Johnson & Johnson) contact lenses. Her ECP had recommended that she replace her lenses twice a month, but she felt the lenses were still comfortable after two weeks of wear and so replaced them less frequently than advised, usually after a month. She was caring for the lenses with OPTI-FREE® RepleniSH® (Alcon) with rinse only. She could not remember which lens care system her ECP had originally recommended, and for the past three months had been using the cheapest care product available at her pharmacy. Her ocular and general history was unremarkable.
RA’s current lenses were about three weeks old, and she had been wearing contact lenses for about four hours prior to her consultation. Contact lens visual acuities were 6/6 (20/20) in each eye. The overall assessment of lens fitting for both eyes was acceptable. Specific details regarding lens parameters and fitting can be found in Table 1.
Table 1: Parameters and fitting details of RA’s contact lenses at first consultation
| Parameter | Right | Left |
| Base curve (mm) | 8.4 | 8.4 |
| Diameter (mm) | 14 | 14 |
| Power (D) | -3.50 | -4.25 |
| Centration (mm) | 0.1 superior | 0.2 superior |
| Primary gaze movement (mm) | 0.2 | 0.3 |
| Primary gaze lag (mm) | 0.2 | 0.2 |
| Tightness (%) | 48 | 48 |
Diagnosis
Slit lamp biomicroscopy revealed peripheral focal and diffuse corneal infiltrates in the left eye (Figure 1), with moderate bulbar and limbal hyperaemia and no anterior chamber reaction. The right eye was white and quiet. Diffuse, punctate staining was noted across the corneas of both eyes (Figures 2 and 3) following the instillation of sodium fluorescein, with both eyes exhibiting about the same level of staining. She was diagnosed with infiltrative keratitis in the left eye and bilateral solution-induced corneal staining (SICS). She was advised to interrupt lens wear and return within 24 hours to ensure her condition was non-progressive.
Figure 1: Peripheral focal and diffuse with increased bulbar and limbal hyperaemia noted in the left eye at RA’s first consultation.
Figure 2: Solution-induced corneal staining noted in the right eye at RA’s first consultation.
Figure 3: Solution-induced corneal staining noted in the left eye at RA’s first consultation.
Follow-up
At her follow-up the next day, RA reported no increase in her symptoms. The infiltrates were still present in the left eye while corneal staining in both eyes had completely resolved. She was prescribed a mild steroidal anti-inflammatory (fluorometholone 0.5%) t.i.d. left eye only for one week, with instructions to immediately report any worsening of her symptoms.
At the follow-up one week later, the infiltrates had resolved and both eyes were white and quiet. Contact lens wear was re-commenced with new OASYS lenses in the same parameters as previous, with instructions to replace lenses twice every month. A hydrogen peroxide system (AOSEPT® PLUS/ClearCare®, CIBA VISION) was prescribed for lens care. This patient has enjoyed symptom-free contact lens wear for the past 12 months.
Discussion
Whilst corneal infiltrates are generally not sight threatening10, 11, they may induce discomfort, inconvenience and be responsible for the discontinuation of contact lens wear10 SICS has been described as an asymptomatic condition12 but has been associated with discomfort during long term lens wear13. The lens-solution combination worn by RA at the time of diagnosis was in the higher categories for both staining and corneal infiltrative events2, 8, 10. Given the history, it seems likely RA had endured several bouts of corneal infiltrates. Following the re-commencement of contact lens wear, the use of a hydrogen peroxide-based lens care system was a logical choice given the reported low levels of staining and infiltrates. Consideration was given to prescribing a new type of lens; however, since this lens type was previously successful, it was left unchanged. Non-compliance with lens replacement was also addressed with the patient, as this might have contributed to the overall clinical presentation.
While it may be argued that peroxide-based lens care systems have advantages over MPS, MPS continue to be the most commonly used LCP, possibly due to lower costs and increased convenience.1 Manufacturers of lens care products understand the importance of an MPS that offers good disinfection and few complications. The past year has seen the release of three new dual-disinfection lens care systems: Bausch + Lomb’s Biotrue™, Alcon’s OPTI-FREE® EverMoist® and Abbott Medical Optics’ RevitaLens OcuTec™. Whilst all three products are promising, their benefits will be minimised unless patients are compliant with their directions for use. In the case presented here, conversion to and continued compliance with a prescribed care system was relatively easy given the symptoms experienced by the patient. The ECP is required to not only choose an appropriate LCP but to also ensure patient compliance through regular follow-up and continuing patient education.
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