What is the appropriate management of conjunctivitis in a contact‑lens wearer?

Management of Conjunctivitis in Contact Lens Wearers

Immediately remove contact lenses and discontinue wear until complete corneal healing is confirmed by slit-lamp examination, and treat all contact lens wearers with bacterial conjunctivitis with topical antibiotics due to increased risk of bacterial keratitis. 1

Immediate Actions

• Remove contact lenses immediately upon presentation and instruct the patient not to wear them until ophthalmologic evaluation confirms complete resolution. 1, 2
• Contact lens wearers with conjunctivitis require different management than non-contact lens wearers because they have significantly higher risk of bacterial keratitis and cannot be managed with observation alone. 1, 3, 4

Critical Red Flag Assessment

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

• Moderate to severe pain suggests bacterial keratitis or Acanthamoeba keratitis, particularly with history of water exposure (swimming, showering, hot tubs) while wearing contacts. 1
• Unilateral presentation with pain is more concerning for infectious keratitis than bilateral allergic or viral conjunctivitis. 1
• Punctate epithelial keratitis, pannus, neovascularization, inflammation, and edema indicate contact lens-related keratoconjunctivitis from limbal stem cell hypoxia. 5, 1, 2

Antibiotic Treatment

• All contact lens wearers with bacterial conjunctivitis require topical antibiotic therapy, unlike non-contact lens wearers where observation may be appropriate. 1
• Moxifloxacin 0.5% ophthalmic solution: instill one drop in the affected eye 3 times daily for 7 days. 6
• Patients should be advised not to wear contact lenses if they have signs or symptoms of bacterial conjunctivitis. 6

Anti-Inflammatory Treatment for Contact Lens-Related Keratoconjunctivitis

If examination reveals contact lens-related keratoconjunctivitis (hypoxia-induced changes):

• For mild cases: prescribe a brief 1-2 week course of topical corticosteroids to reduce inflammation. 5, 1, 2
• For longer-term management: consider topical cyclosporine 0.05% for persistent inflammation. 5, 1, 2
• If corticosteroids are used, perform baseline and periodic measurement of intraocular pressure and pupillary dilation to evaluate for glaucoma and cataract. 5

Follow-Up Evaluation and Contact Lens Modifications

At follow-up visit after complete resolution, comprehensively review and modify contact lens practices:

Lens Type Changes:

• Switch to daily disposable lenses to eliminate compliance issues with disinfection, storage, and replacement. 1, 2
• If daily disposables are not feasible, refit with high DK/T ratio silicone hydrogel materials. 5, 1, 2
• Increase replacement frequency or reduce total wearing time per day. 5, 2

Wearing Schedule:

• Strongly discourage overnight wear, as it increases corneal infection risk fivefold compared to daily wear, even with lenses approved for extended wear. 1
• Reduce contact lens wearing time. 5, 1

Hygiene Education:

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

Water Avoidance:

• Never swim, shower, use hot tubs, or wash hair while wearing contact lenses due to Acanthamoeba risk. 1, 2
• Never store contact lenses in water. 2

Alternative Options:

• Consider alternatives to contact lenses (eyeglasses or refractive surgery) once the keratoconjunctivitis has resolved. 5, 1

Common Pitfalls to Avoid

• Failing to examine the cornea carefully with fluorescein staining can lead to missing keratitis and treating all contact lens-related conjunctivitis as simple bacterial infection without considering keratitis. 1
• Missing Acanthamoeba keratitis in patients with pain and water exposure history requires specialized treatment and can cause permanent vision loss. 1
• Failing to discontinue contact lens wear during treatment can lead to prolonged infection and complications. 1
• Resuming contact lens wear too early before complete resolution can lead to recurrence and chronic issues. 1
• Contact lens abstinence can be challenging for some patients because the punctate keratopathy may lead to reduced vision correction in glasses. 5