It’s bright and early on a Monday morning, and you’re just walking into your practice, ready to tackle a brand new week.

Before you have the opportunity to get settled in, your receptionist informs you that an emergency appointment is coming in this morning. The patient—a contact lens wearer you’ve seen for several years—has a red eye that developed over the past few days.

The first thing that comes to mind is the suspicion of contact lens abuse, but it’s important to proceed cautiously before assuming poor compliance is the culprit.

First Considerations
At the forefront of every successful contact lens-centric practice is the goal of maintaining proper health in our lens wearers. As such, we seek to avoid complications by prescribing lenses and recommending care systems that best match the patient’s specific lifestyles and visual needs.

But of course we still encounter patients with acute red eyes.

Among contact lens wearers, such presentations are thought to derive from lens wear. Oftentimes, contact lens abuse is at the top of this list. Patients who sleep in their contact lenses have a higher rate of infiltrative keratitis than those who do not.^1-3

Patients who do not properly wash their hands prior to lens handling tend to have an increased risk of developing microbial keratitis.³ The incidence of microbial keratitis tends to be higher in patients who reported poor storage case hygiene, as well as in smokers.²

The importance of multipurpose disinfecting solutions was apparent in 2006 and 2007, when two contact lens solutions were globally recalled due to associations with Fusarium keratitis and Acanthameoba keratitis.^4,5,6

In light of these recalls, we always recommend patients bring in to their appointment their contact lens solution, case and any other products they’re using, so that we can determine whether non-compliance may be contributing to any complications they’re experiencing.

Before we assume that poor compliance is the culprit of these cases of acute red eye, we must first rule out some common etiologies of the condition, such as those described below.

Rule These Out
• Mucus fishing syndrome, an interesting condition where a patient will actually “fish” mucus out of the lower fornix. The irritation actually causes the eye to then produce more mucus.^7,8 These patients tend to become so accustomed to this that they consider it “normal” and may not report the behavior.

Patients with this condition will often present with exacerbations of a red eye. Temporary resolution can occur with use of a topical corticosteroid.

Only upon careful questioning will you uncover this unique condition, allowing you to properly direct patients to break this cycle.

• Floppy eyelid syndrome. This condition is caused by an abnormality in the collagenous tissue in the tarsus, which causes the upper eyelid to become easily everted. It is often associated with a papillary conjunctivitis.^9-11 Patients presenting with floppy eyelid syndrome tend to be overweight males.¹²

Floppy eyelid syndrome can also present as an acute red eye. Treatment options for mild cases include additional lubricants during the day and an eye cover in the evening.

In more severe cases, horizontal shortening of the lateral upper eyelid is ultimately required to tighten the lid apposition to the globe.¹³

• Adult inclusion conjunctivitis. An ocular manifestation of a systemic condition caused by Chlamydia, this also commonly presents with a red eye. Patients respond relatively well to topical antibiotics or a combination of antibiotics and steroids. Unfortunately, the red eye will often return.

Ultimately, these patients will need a systemic antibiotic for resolution, typically either 100mg of doxycycline BID PO or a single dose of 1g of oral azithromycin.^14,15

What typically distinguishes the clinical appearance in these patients is a relatively prominent follicular response on the palpebral conjunctiva, along with the bulbar hyperemia.¹⁶

• Bacterial conjunctivitis. This complication is often passed from one individual to another. Patients presenting with the condition as a result of contact lens overwear are typically not considered contagious, though. Patients often report a history of contact with someone who has also had a “red eye.”

Bacterial conjunctivitis will typically respond well to topical antibiotic therapy.

• Viral conjunctivitis. This manifestation can be difficult to distinguish from a bacterial conjunctivitis. In fact, clinicians only correctly diagnose these conditions about 50% of the time.¹⁷

The AdenoPlus test allows for rapid identification of adenovirus, the most common pathogen associated with viral conjunctivitis. We now perform this test on every patient who presents with an acute red eye of unclear etiology.

• Allergic conjuncitivitis. This condition is often associated with seasonal changes; most patients will report that their ocular allergies have returned. Be aware that there are perennial allergies that can manifest more in the winter months as a result of patients spending more time indoors with their heaters turned on.

The signs and symptoms of allergic conjunctivitis respond well to topical antihistamine/mast cell stabilizer combinations.¹⁸

There are more chronic forms of the disease as well. Giant papillary conjunctivitis displays the classic sign of large papillae on the superior tarsal plate, which makes it important to evert the upper eyelid of every patient presenting with acute red eye.

This condition is usually associated with contact lens abuse, as lid irritation from lens deposits is thought to be a trigger.¹⁹ Temporary suspension of contact lens wear along with topical corticosteroids is usually an effective strategy to employ when treating these conditions.

When a contact lens wearer presents with an acute red eye, it may indeed be true that lens wear is responsible. But it is important that we look for and rule out other possible etiologies before making decisions that might deprive the patient of continued contact lens wear.

Ultimately, diagnosing and treating these conditions quickly and appropriately will be the key to getting patients back into their lenses and preventing dropouts.

The Case of the Wrongfully Accused Contact Lens

A 60-year-old Caucasian female presented with a red and irritated left eye. She was wearing a two-week disposable silicone hydrogel toric lens and using a generic store-brand solution. She wore her lenses during the visit. At the time of presentation, she was replacing her lenses every month. Her current lenses were three weeks old. She wasn’t sure why her left eye was causing so much discomfort, and she was worried that something might be wrong with her lens. She also reported that, several weeks prior, her grandson also had a red eye that improved with drops. Entering visual acuity with her current prescription was 20/20 OS. Anterior segment examination was remarkable for a diffuse conjunctival hyperemia. The lens was removed and the cornea was remarkable for mild punctate epitheliopathy inferiorly. The palpebral conjunctiva showed a mild papillary response as well. An AdenoPlus test was positive for the presence of adenovirus in the affected eye. The patient’s lenses were disposed of, along with her current contact lens case. She was treated with topical ganciclovir gel 1gt QID OS based on evidence of its activity against adenovirus.20 At follow up five days later, there was complete clinical resolution of signs and symptoms. The drops were then used 1gt TID OS for the next three days. Contact lens wear was successfully resumed at that time.

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