What is the recommended treatment for a contact lens wearer with conjunctivitis?

Treatment of Conjunctivitis in Contact Lens Wearers

Immediately discontinue contact lens wear and do not resume until the cornea completely returns to normal—this is the single most critical intervention for any contact lens wearer presenting with conjunctivitis. 1

Immediate Management

Remove contact lenses immediately upon presentation and instruct the patient not to wear them until complete resolution occurs. 1 This applies to all forms of conjunctivitis in contact lens wearers, regardless of suspected etiology. 2

Critical Red Flags Requiring Urgent Evaluation

• Moderate to severe pain suggests possible bacterial keratitis or Acanthamoeba keratitis, particularly if the patient has a history of swimming, showering, or hot tub use while wearing contacts. 1 These patients require immediate ophthalmologic evaluation and should not be managed as simple conjunctivitis. 2

• Purulent discharge with corneal involvement warrants immediate evaluation for bacterial keratitis, which can threaten vision. 1 Contact lens wearers with bacterial conjunctivitis should always be treated with antibiotics and referred for evaluation of potential corneal ulcers. 3, 4

• Unilateral presentation with pain is more concerning for infectious keratitis than bilateral allergic or viral conjunctivitis. 2

Treatment Based on Severity

Mild Contact Lens-Related Conjunctivitis

For mild cases presenting with conjunctival injection, punctate epithelial keratopathy, and minimal symptoms:

• Prescribe a brief 1-2 week course of topical corticosteroids to reduce inflammation. 1, 5 This addresses the mechanical irritation and chronic hypoxia that characterize contact lens-related keratoconjunctivitis. 2

• Consider topical cyclosporine 0.05% for longer-term management if inflammation persists beyond the initial corticosteroid course. 1, 5

• Preservative-free artificial tears should be used liberally to soothe the ocular surface. 6

Bacterial Conjunctivitis in Contact Lens Wearers

All contact lens wearers with bacterial conjunctivitis require topical antibiotic therapy, unlike non-contact lens wearers where observation may be appropriate. 3, 4 This is because contact lens wear significantly increases the risk of bacterial keratitis, which can cause permanent vision loss. 2

• Prescribe broad-spectrum topical antibiotics (fluoroquinolones preferred for contact lens wearers due to Pseudomonas coverage). 3

• Refer to ophthalmology to evaluate for corneal ulceration, as contact lens wearers are at substantially higher risk. 4

Viral Conjunctivitis

• Treatment is supportive only with preservative-free artificial tears and cool compresses. 3, 7

• Do not prescribe antibiotics as they provide no benefit and increase resistance. 3

• Counsel on contagion prevention: frequent handwashing, separate towels and pillows, avoid close contact for 10-14 days from onset. 5

Allergic Conjunctivitis

If itching is the predominant symptom with bilateral watery discharge:

• Topical antihistamines and mast cell stabilizers are first-line treatment. 3, 7

• Preservative-free formulations are preferred to avoid additional irritation. 5

Follow-Up Management

At the follow-up visit after resolution:

Comprehensively review contact lens practices including: 1, 5

• Lens type, fit, and wearing schedule
• Cleaning and disinfection regimen
• Water exposure habits

Recommend specific modifications: 1, 5

• Switch to daily disposable lenses (eliminates cleaning-related issues)
• Use preservative-free lens care systems (hydrogen peroxide systems are superior for pathogen reduction but require careful patient education on proper neutralization) 2
• Select high DK/T ratio materials to improve oxygen transmission
• Reduce wearing time or eliminate overnight wear entirely

Strongly discourage overnight wear, as it increases corneal infection risk fivefold compared to daily wear, even with lenses approved for extended wear. 2, 1 Even occasional overnight wear carries significant risk. 2

Educate on water avoidance: Never swim, shower, use hot tubs, or wash hair while wearing contact lenses due to Acanthamoeba risk. 2, 1

Instruct on proper lens care: 2

• Never rinse lenses or cases with tap water, bottled water, or homemade saline
• Replace solution completely each time (never "top off")
• Replace lens cases every 3 months minimum
• Rub and rinse lenses with fresh solution even if using "no-rub" solutions

Consider permanent alternatives such as eyeglasses or refractive surgery if recurrent episodes occur. 1, 5

Common Pitfalls to Avoid

• Failing to discontinue contact lens wear during treatment leads to prolonged infection and potential corneal complications. 1

• Resuming contact lens wear before complete resolution causes recurrence and chronic inflammation. 1

• Treating all contact lens-related conjunctivitis as simple bacterial infection without considering keratitis—always examine the cornea carefully with fluorescein staining. 2

• Missing Acanthamoeba keratitis in patients with pain and water exposure history—this requires specialized treatment and can cause permanent vision loss. 2, 1

• Prescribing preserved topical medications when preservative-free alternatives exist, as preservatives worsen ocular surface inflammation. 5

• Not addressing underlying contact lens hygiene issues at follow-up, leading to recurrence. 1, 5