What is the diagnosis and treatment for contact lens irritation?

Contact Lens Irritation: Diagnosis and Treatment

Remove contact lenses immediately and consult an eye care provider urgently if experiencing redness, pain, tearing, photophobia, blurry vision, discharge, or swelling, as these symptoms may indicate serious complications requiring prompt evaluation and treatment. 1

Differential Diagnosis

Contact lens irritation encompasses a spectrum of conditions that must be systematically differentiated:

Infectious Complications

• Bacterial keratitis is the most serious complication, with Pseudomonas aeruginosa being the most commonly isolated organism in contact lens-associated infections 2
• Acanthamoeba keratitis is strongly associated with tap water exposure and improper lens hygiene 3
• Overnight wear increases bacterial keratitis risk 5-fold compared to daily wear (21 vs. 4 per 10,000 persons annually) 2
• Microbial keratitis occurs in approximately 2-5 cases per 10,000 contact lens wearers annually 4

Non-Infectious Inflammatory Conditions

• Giant papillary conjunctivitis is a common hypersensitivity reaction in long-term wearers 2
• Sterile corneal infiltrates account for approximately 10% of contact lens-related presentations 5
• Superficial keratitis from chronic ocular surface irritation 2
• Contact lens-related red eye (CLARE) represents approximately 8% of presentations 5

Metabolic and Mechanical Complications

• Corneal epitheliopathy is the most common diagnosis, representing 68% of contact lens-related presentations 5
• Corneal neovascularization from chronic hypoxia 2
• Transient stromal edema and corneal thinning from prolonged wear 2
• Contact lens discomfort affects 13-75% of contact lens wearers 6

Pre-existing Ocular Surface Disease

• Keratoconjunctivitis sicca (dry eye) may be unmasked or worsened by contact lens wear 2
• Blepharoconjunctivitis 2
• Limbal stem cell deficiency from chronic wear 2

Clinical Evaluation

Before determining treatment, perform a comprehensive medical eye evaluation with particular attention to: 1

• Eyelid function and margins to assess for blepharitis or meibomian gland dysfunction
• Tear film quality to evaluate for dry eye
• Conjunctival surface for hyperemia, papillae, or follicles
• Corneal surface using fluorescein staining to identify epithelial defects, infiltrates, or ulceration
• Contact lens hygiene practices including water exposure, case care, and solution use

Immediate Management

Critical Warning Signs Requiring Urgent Ophthalmology Referral

Patients must discontinue contact lens wear immediately and seek urgent ophthalmology evaluation if they experience: 1

• Moderate to severe pain
• Decreased vision
• Photophobia
• Purulent discharge
• Corneal infiltrate or ulceration

Initial Treatment Based on Diagnosis

For suspected bacterial keratitis:

• Discontinue contact lens wear immediately 1
• Initiate broad-spectrum topical antibiotic coverage (moxifloxacin 0.5% is FDA-approved for bacterial conjunctivitis, instill one drop three times daily for 7 days) 7
• Urgent ophthalmology referral for corneal culture and intensive fortified antibiotic therapy if keratitis is confirmed 1

For non-infectious irritation (epitheliopathy, mild hyperemia without infiltrate):

• Discontinue contact lens wear until symptoms resolve 1
• Lubricating drops may reduce contact lens discomfort, though evidence is limited 6
• Address underlying risk factors (see prevention below) 1

For giant papillary conjunctivitis:

• Discontinue contact lens wear temporarily 2
• Consider switching to daily disposable lenses when resuming wear 1
• May require topical mast cell stabilizers or antihistamines 8

Prevention and Risk Factor Modification

99% of contact lens wearers report at least one hygiene risk behavior that increases complication risk. 2 The following evidence-based recommendations from the American Academy of Ophthalmology, FDA, and CDC must be emphasized: 1

Hand Hygiene

• Wash hands with soap and water and dry with a lint-free method before handling contact lenses every time 1

Water Avoidance (Critical for Preventing Acanthamoeba Keratitis)

• Never store contact lenses in water 1
• Keep tap water away from contact lenses—remove before showering, swimming, or using hot tubs 1, 3
• Never rinse lenses or cases with tap water, bottled water, or homemade saline 1, 3
• Use only sterile, commercially prepared contact lens care products 1

Lens Care (For Non-Daily Disposables)

• Rub and rinse contact lenses in disinfecting solution each time you remove them 1
• Do not "top off" solution—use only fresh disinfecting solution, never mix old and new 1
• Hydrogen peroxide systems may be superior to preserved multipurpose solutions in reducing pathogen binding and providing cysticidal disinfection, but require more complex care regimens 1

Case Care

• Rub and rinse the case with contact lens solution, dry with a clean tissue, and store upside down with caps off after each use 1
• Replace contact lens cases every 3 months 1
• Cases become contaminated reservoirs and are a major source of infection 2

Wearing Schedule

• Do not sleep in contact lenses unless specifically approved by your eye doctor 1
• Overnight wear is the overriding risk factor for complications, not lens type 2
• Wear and replace contact lenses according to the prescribed schedule 1
• Daily disposable lenses have the lowest risk of complications due to elimination of cleaning and storage requirements 1

Common Pitfalls

• One-third of all contact lens wearers report previous red or painful eye conditions requiring a doctor visit, indicating high recurrence rates when risk factors are not addressed 2
• Approximately 42% of patients initially present to healthcare practitioners other than ophthalmologists, with mean duration from symptom onset to presentation of 6.3 days—this delay can worsen outcomes, particularly for infectious keratitis 5
• Patients should be advised not to wear contact lenses if they have any signs or symptoms of bacterial conjunctivitis 7
• All contact lenses, including decorative and costume lenses, are medical devices requiring a physician's prescription and supervision 1
• Adverse events related to contact lens wear should be reported to FDA MedWatch 1