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

Treatment of Conjunctivitis in Contact Lens Users

Contact lenses must be immediately removed and discontinued until the cornea completely returns to normal, and all contact lens wearers with bacterial conjunctivitis require topical antibiotic therapy due to increased risk of bacterial keratitis. 1, 2

Immediate Management

Remove contact lenses immediately upon presentation and instruct the patient not to wear them until complete resolution occurs, regardless of suspected etiology. 1, 2 This is critical because:

• Contact lens wear during active conjunctivitis can lead to contact lens-related keratoconjunctivitis with punctate epithelial keratitis, pannus, neovascularization, inflammation, and edema due to limbal stem cell hypoxia 3, 1
• Continuing lens wear can cause prolonged infection and permanent complications 1
• FDA labeling for topical fluoroquinolones explicitly warns against contact lens wear during bacterial conjunctivitis treatment 2

Critical Red Flags Requiring Urgent Evaluation

Examine the cornea carefully with fluorescein staining to rule out keratitis, as missing this can lead to permanent vision loss. 1 Specifically assess for:

• Moderate to severe pain: Suggests possible bacterial keratitis or Acanthamoeba keratitis, particularly with history of swimming, showering, or hot tub use while wearing contacts 3, 1
• Unilateral presentation with pain: More concerning for infectious keratitis than bilateral allergic or viral conjunctivitis 1
• Water exposure history: Acanthamoeba keratitis requires specialized treatment and can cause permanent vision loss 1

Antibiotic Treatment

All contact lens wearers with bacterial conjunctivitis require topical antibiotic therapy, unlike non-contact lens wearers where observation may be appropriate. 1, 4, 5 This is because contact lens wearers have significantly increased risk of bacterial keratitis. 1, 4

Recommended Antibiotic Regimen

For patients 1 year of age or older with bacterial conjunctivitis, use topical fluoroquinolone (e.g., gatifloxacin 0.5%): 2

• Day 1: Instill one drop every two hours while awake, up to 8 times 2
• Days 2-7: Instill one drop two to four times daily while awake 2

Topical antibiotics shorten the duration of bacterial conjunctivitis and allow earlier return to school or work. 4

Treatment for Contact Lens-Related Keratoconjunctivitis

If contact lens-related keratoconjunctivitis is present (hypoxia-induced limbal stem cell damage): 3, 1

• Mild cases: Brief 1-2 week course of topical corticosteroids 3, 1
• Add longer-term topical cyclosporine 0.05% to manage inflammation 3, 1
• Monitor intraocular pressure and pupils if corticosteroids are used, as baseline and periodic measurements are required to evaluate for glaucoma and cataract 3

Symptoms may be prolonged with limbal stem cell failure but will usually clear with contact lens abstinence. 3

Follow-Up and Contact Lens Modification

At follow-up evaluation, comprehensively review contact lens practices: 1

• Lens type and fit: Consider switching to daily disposable lenses or high DK/T ratio materials 3, 1
• Care regimen: Use non-preserved lens care systems 3, 1
• Wearing schedule: Reduce contact lens wear time 3, 1
• Strongly discourage overnight wear: Increases corneal infection risk fivefold compared to daily wear, even with lenses approved for extended wear 1

Water Avoidance Education

Educate patients to never: 1

• Swim, shower, use hot tubs, or wash hair while wearing contact lenses due to Acanthamoeba risk
• Rinse lenses or cases with tap water, bottled water, or homemade saline
• Use preserved disinfecting solutions if hydrogen peroxide systems are available

Proper Lens Care Instructions

Instruct patients to: 1

• Replace solution completely each time
• Replace lens cases every 3 months minimum
• Rub and rinse lenses with fresh solution even if using "no-rub" solutions

Alternative Options

Consider alternatives to contact lenses (eyeglasses or refractive surgery) once the keratoconjunctivitis has resolved, particularly for recurrent cases. 3, 1

Common Pitfalls to Avoid

• Failing to examine the cornea with fluorescein staining can lead to missing keratitis 1
• Treating all contact lens-related conjunctivitis as simple bacterial infection without considering keratitis 1
• Resuming contact lens wear too early before complete resolution leads to recurrence and chronic issues 1
• Missing Acanthamoeba keratitis in patients with pain and water exposure history 1