SCL conditions Flashcards
Bulbar staining
Aetiology
- Mechanical trauma of the conjunctival epithelium due to lens fit/design; tight fitting, lens edge or decentred.
- Poor blinking
- Solution toxicity
Symptoms
- Px usually asymptomatic
- Does not affect clinical performance of the lens
- May occasionally present with dryness, itching, CL intolerance
Signs
- Staining of the bulbar conjunctiva with NaFl
- Staining area often consists with edge of hydrogel lens
Management
- Only requires management if graded 2 or above
- Flatter lens design – increase BOZR
- Change material of lens i.e. SiHi
- Change care systems if solution toxicity
- Blinking exercises
contact lens periphery conjucntivitis
Aetiology
- Mainly caused by soft contact lens wear and is a bilateral condition
- The front surface of the lens caused mechanical irritation and immune response
- Appear as localised swellings (papillae) on the tarsal conjunctiva – usually superior
Symptoms
- Asymptomatic in early stages
- In moderate/advanced
o Increased lens awareness or intolerance
o Increased mucus causes: drying of lens surface, deposits, fluctuating vision
o Itching/fb sensation
Signs
- Enlarged papillae – raised cobblestone appearance with blood vessel core
- Roughness appearance of tarsal conj
- Palpebral redness
- Tissue oedema
Management
- Cease CL wear until resolved if moderate/severe
- Reduce wear time
- More frequent lens replacement
- RGPs – better tear exchange and less mechanical irritation
- Pharmacological therapy with optichrom (2%)
Limbal hyperaemia
Aetiology
- More common in hydrogels
- Short term manifestation of hypoxia
- Inflammation due to tight lens or mechanical irritation from lens
- Allergic reactions
Symptoms
- Usually asymptomatic, mild discomfort may be felt
Signs
- Engorged BVs at limbus
- May be localised or full coverage
Management
- Cease CL wear till resolution
- Fit lens with higher Dk/t
- Optimise lens fit – flatten lens
- Remove allergen
- Change care system
Neovascularisation
Aetiology
- Uncommon nowadays due to improved lens materials
- New vessels grow at a deep stromal level in response to corneal stress caused by hypoxia, limbal compression, tissue damage, acute infection and solution toxicity
- Hypoxia causes stromal oedema and softening which releases vaso-stimulatory agents within growth of new vessels
- If growth of new vessels is allowed to continue and encroach within the pupil area, vision may be reduced as surrounding tissue is changed
Symptoms
- Asymptomatic
- Neovasc can accompany a painful anterior segment disease
Signs
- Early signs are vessel spikes
- Branching capillaries from limbal arcade
- Anterior or deep vessels
- Ghost vessels can remain as blood is drained from the new vessels
Management
- Increase dk/t to as high as possible
- Reduce wearing time
- Patient advice and follow up
- Change in care system if caused by solution toxicity
Punctate staining
Aetiology
- Mechanical, exposure, metabolic, solution induced, allergic, infections
Symptoms
- Asymptomatic if less than grade 3
- May induce CL intolerance
- Reduce WT
- Dryness, itching and lacrimation
Signs
- SPK
- Staining may be intense or diffuse
- Bulbar conjunctival hyperaemia
Management
- If grade 2 or less remove lenses for 24 hours
- If grade 3 or more – lubrication, material, wearing schedule
SMILE staining
Aetiology
- Inferior epithelial arcuate lesion
- Localised disruption of the corneal surface due to desiccation
- Worse in thin and high water content lenses
- Lens hydration leads to elimination of post lens tear film and ultimately epithelial desiccation
- May be caused by sleeping with eyes slightly open
Signs
- Desiccated area stains with NaFl
- Punctate staining in inferior quadrant
- Staining may coalesce
- Stained areas are isolated from the limbus
- Area of staining may be small, to almost semi-circular
Symptoms
- Most asymptomatic
- May include: dryness, itchiness, lens awareness
Management
- Determine cause
- Increase centre thickness of lens
- Lower water content lens – SiHi?
- Alter lens design
- Ask px about sleeping with eyes slightly open
Seal staining
Aetiology
- Superior epithelial arcuate lesion
- More common in higher modulus lenses
- Mechanical – sheer forces from higher modulus lens on cornea
- May also be caused by hypoxia, dehydration and physiology
Symptoms
- Typically asymptomatic
- Some may report irritation, discomfort, scratchiness
Signs
- Split-like arcuate lesion
- Parallel to limbus
- 1-3mm in inside the limbus
- 10 and 2 o’clock location
- 0.5mm wide and 2.5mm long
Management
- Remove lenses until healed, 2-4 days
- Ocular lubricants to relieve symptoms
- If problem occurs refit may be needed
- If hypoxia is cause – lens with higher dk/t
- If mechanical the cause – lens with lower modulus
- Sign that px isn’t suitable for EW
Contact lens periphery ulcer
Aetiology
- Mainly unilateral and more common in EW
- Considered to be an inflammatory response of the peripheral cornea
- Corneal scrapes are culture-negative, so no causative organism is found
- Due to interaction between the lens and epithelial surfaces
- Scarring due to post inflammatory cicatrisation
Symptoms
- Mild pain, may be described as FB
- Photophobia
- Decreased corneal sensitivity
Signs
- Small single circular focal infiltrate with halo or diffuse infiltration, usually less than 1-2mm in diameter
- The infiltrate is white with demarcated edges
- Usually peripheral and located in the anterior stroma
- The overlying epithelium is breached and rapidly takes up NaFl
- May be focal or general redness
- Lacrimation
Management
- Immediately discontinue lens wear
- Monitor carefully for first 24 hours
- Prophylaxis
- Chloramphenicol for 1-3 days
- Ulcer will resolve with scarring
CLARE
- Acute inflammatory response usually occurring with soft EW CLs upon waking
- Most common in first 3 months of lens wear
- There may be lens binding overnight, causing entrapment of debris/deposits
- Gram-negative bacteria
- Sensitivity to lens care products
- Debilitated GH i.e. upper respiratory tract infection
Symptoms
- Painful eye upon waking
- Photophobia
- Lacrimation
- Ocular irritation
Signs
- Gross unilateral hyperaemia of the bulbar conjunctiva and limbus
- Diffuse infiltrates (2-3mm from limbus), or focal zone of infiltrates
- Minimal or no staining
- Profuse lacrimation
Management
- Temporary discontinue lens wear
- Regular lens replacement, possibly no EW (if repeats)
- Palliative therapy – saline rinse and lubrication
- Low toxicity lens care products
Infilterative Keratitis
- Discrete collections of inflammatory cells
Signs
- Peripheral to mid-peripheral
- Mild or moderate diffuse infiltration or small focal infiltrate(s)
- Located in the sup-epithelial or anterior stroma
- Slight-moderate staining
- Moderate limbal redness
- No AC reaction or mild
Symptoms
- Red, watery eye
- Mild FB sensation
- Mild photophobia
Management
- Dictated by signs/symptoms, cause, risk of infection
- If staining – discontinue, monitor, prophylaxis with antibiotic
- Resolution before lens wear
- Infiltrates will take around 2-3 weeks to clear
- Advise against EW, warn about recurrence, switch to dailies if recurrence
Microbial keratitis
- Rare but most serious CL complication
- More common in extended wear due to CLs being worn when eyes are closed
- Bacterial adherence especially aeruginosa
- May also be viral, fungal, protozoa
Symptoms
- Mild irritation to severe pain
- Photophobia
- Reduced corneal sensitivity
- Redness
- Excessive tears/discharge
Signs
- Epithelial defect, ulceration, uveitis, lid oedema
Management
- Cease CL and emergency referral
- Culture/swabs of eye, lens case, solution
- Treatment dictated by causal organism
- Consider if lens wear is a future option
