What is the recommended treatment for a patient of any age with a history of eye problems or allergies experiencing contact lens related eye irritation?

Management of Contact Lens-Related Eye Irritation

Immediately discontinue contact lens wear and do not resume until complete corneal healing is confirmed by slit-lamp examination, regardless of symptom severity. 1, 2

Immediate Actions

Remove contact lenses immediately upon presentation and instruct the patient not to wear them until ophthalmologic evaluation confirms complete resolution. 2, 3 This applies to all forms of contact lens-related irritation, regardless of suspected etiology. 2

Critical Red Flags Requiring Urgent Evaluation

• Moderate to severe pain suggests possible bacterial keratitis or Acanthamoeba keratitis, particularly with history of water exposure (swimming, showering, hot tubs) while wearing contacts. 2, 4
• Unilateral presentation with pain is more concerning for infectious keratitis than bilateral allergic or viral conjunctivitis. 2
• Purulent discharge or photophobia warrants urgent ophthalmology evaluation. 3
• Pseudomonas aeruginosa is the most commonly isolated organism in contact lens-associated bacterial keratitis. 3, 4

Diagnostic Evaluation

Perform slit-lamp biomicroscopy with fluorescein staining to evaluate for:

• Punctate epithelial keratitis, pannus, neovascularization, inflammation, and edema (contact lens-related keratoconjunctivitis from limbal stem cell hypoxia). 1, 2, 4
• Papillary hypertrophy of superior tarsal conjunctiva with mucoid discharge (giant papillary conjunctivitis). 1, 4
• Corneal infiltrates or ulceration (bacterial or Acanthamoeba keratitis). 2, 4

Assess eyelid function, margins, meibomian glands, tear film, and conjunctival surface. 1, 3

Treatment Based on Severity

Mild Contact Lens-Related Keratoconjunctivitis

• Prescribe a brief 1-2 week course of topical corticosteroids to reduce inflammation. 2, 4
• Consider topical cyclosporine 0.05% for longer-term management of persistent inflammation. 2, 4
• Provide lubricating drops to support corneal healing. 4

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, due to increased risk of bacterial keratitis. 2 However, patients should not wear contact lenses if they have signs or symptoms of bacterial conjunctivitis. 5

Giant Papillary Conjunctivitis

Discontinue contact lens wear for months or longer until resolution occurs. 1 May require topical corticosteroids and mast cell stabilizers. 1

Common Pitfalls to Avoid

• Failing to examine the cornea carefully with fluorescein staining can lead to missing keratitis. 2
• Missing Acanthamoeba keratitis in patients with pain and water exposure history—this requires specialized treatment and can cause permanent vision loss. 2
• Resuming contact lens wear too early before complete resolution can lead to recurrence and chronic issues. 2
• Treating all contact lens-related conjunctivitis as simple bacterial infection without considering keratitis. 2

Follow-Up and Prevention Strategy

Before Resuming Contact Lens Wear

Perform slit-lamp biomicroscopy to confirm:

• Complete epithelial healing
• Absence of infiltrate
• Resolution of inflammation 4

Lens resumption should not be permitted until ophthalmologic confirmation of complete healing. 4

Comprehensive Review of Contact Lens Practices

Hygiene modifications:

• Wash hands with soap and water, dry with lint-free method before every contact lens handling. 1, 3
• Never rinse lenses or cases with tap water, bottled water, or homemade saline—this dramatically increases infection risk, particularly for Acanthamoeba. 1, 2, 4
• Rub and rinse contact lenses in disinfecting solution each time removed, even with "no-rub" solutions. 1, 2
• Replace solution completely each time—never "top off" old solution with new. 1
• Replace contact lens cases every 3 months minimum. 1, 3, 4

Water avoidance (critical for preventing Acanthamoeba):

• Remove lenses before showering, swimming, or hot tub use. 1, 2, 4
• Never store contact lenses in water. 1, 3

Wearing schedule modifications:

• Do not sleep in contact lenses unless specifically approved—overnight wear increases corneal infection risk fivefold compared to daily wear. 1, 2
• Wear and replace lenses according to prescribed schedule. 1

Lens Type Modifications

Switch to true daily disposable lenses, which eliminate compliance issues with disinfection, storage, and replacement. 4 This is the preferred long-term strategy for recurrent irritation. 4

If daily disposables are not feasible:

• Refit with high DK/T ratio silicone hydrogel materials to improve oxygen transmission. 4
• Increase replacement frequency (e.g., switch from monthly to weekly disposables). 4
• Reduce total wearing time per day. 2, 4

Consider hydrogen peroxide systems over preserved disinfecting solutions for superior pathogen reduction, though they require more complex care regimens. 1, 3

Long-Term Considerations

Consider alternatives to contact lenses (eyeglasses or refractive surgery) once keratoconjunctivitis has resolved, particularly for patients with recurrent complications. 2

Schedule regular eye examinations to monitor lens fit, ocular health, and reinforce proper lens care and hygiene. 1, 2

Report adverse events related to contact lens wear to FDA MedWatch. 1, 3