Diagnosis: Contact Lens-Related Keratoconjunctivitis (Likely Bacterial Keratitis Until Proven Otherwise)
This contact lens user with intense conjunctival injection and eye redness requires immediate discontinuation of contact lens wear and urgent ophthalmology evaluation to rule out bacterial keratitis, which is the most serious sight-threatening complication in this clinical scenario. 1, 2
Immediate Management
Remove contact lenses immediately and do not resume wear until cleared by ophthalmology. 3
The crisp light reflection off the cornea suggests the corneal epithelium may still be intact, which is reassuring, but intense conjunctival injection in a contact lens wearer is a red flag that demands urgent evaluation. 1
Critical Warning Signs to Assess
- Moderate to severe pain - if present, strongly suggests bacterial or Acanthamoeba keratitis 1
- Photophobia - indicates corneal involvement requiring urgent care 1
- Decreased vision - suggests more serious pathology 1, 2
- Purulent discharge - indicates bacterial infection 1
Differential Diagnosis Priority
Most Serious (Rule Out First):
Bacterial keratitis - Pseudomonas aeruginosa is the most commonly isolated organism in contact lens-associated infections and adheres readily to contact lens deposits. 2, 4 This is a sight-threatening emergency.
Other Likely Diagnoses:
- Contact lens-related keratoconjunctivitis from chronic hypoxia, limbal stem cell failure, or mechanical irritation 3, 4
- Giant papillary conjunctivitis - common hypersensitivity reaction in long-term wearers 3, 2
- Superficial keratitis from chronic ocular surface irritation 2
- Corneal neovascularization from chronic hypoxia 2
Risk Factor Assessment (Critical for Prevention)
Evaluate the following hygiene practices, as 99% of contact lens wearers report at least one hygiene risk behavior: 2
- Water exposure - showering, swimming, or hot tub use with lenses increases Acanthamoeba risk 3-fold 2, 5
- Overnight wear - increases bacterial keratitis risk 5-fold (21 vs. 4 per 10,000 persons annually) 2
- Lens case care - failure to replace cases every 3 months creates contaminated reservoirs 2
- Water contact with lenses or cases - tap water, bottled water, or homemade saline introduces pathogens 2
- Lens reuse (if using daily disposables) - increases AK risk 5-fold 5
Treatment Algorithm
If No Corneal Infiltrate or Ulcer (Simple Keratoconjunctivitis):
- Discontinue contact lens wear until cornea returns to normal 3
- Short course of topical corticosteroids (1-2 weeks) may be prescribed 3
- Longer-term topical cyclosporine 0.05% for chronic cases 3
- Review and modify contact lens practices: 3
If Corneal Infiltrate, Ulcer, or Severe Pain Present:
Urgent ophthalmology referral for culture and antimicrobial therapy. 1, 2 This is bacterial or Acanthamoeba keratitis until proven otherwise.
Follow-Up and Prevention
- Do not resume contact lens wear until cleared by ophthalmology after complete resolution 3
- Reinforce water avoidance: never store lenses in water, remove before showering/swimming/hot tubs 3, 1
- Proper hand hygiene: wash with soap and water, dry with lint-free method before every lens handling 3, 1
- Case replacement every 3 months 3, 1
- Never sleep in lenses unless specifically approved for extended wear 3, 1
- Consider alternatives to contact lenses (eyeglasses or refractive surgery) if recurrent problems 3
Common Pitfalls
- Underestimating patient non-compliance: up to 69% of contact lens wearers are non-compliant with prescribed schedules, and one-third report previous red or painful eye conditions requiring doctor visits 2, 6
- Assuming patient-reported compliance is accurate: 86% of patients believe they are compliant, but only 34% actually exhibit good lens care practices 3
- Failing to report adverse events: contact lens-related complications should be reported to FDA MedWatch 3, 1
- Resuming lens wear too early: limbal stem cell failure symptoms may be prolonged but will clear with contact lens abstinence 3