Corneal Reaction towards Contact Lens Wear

Wearing of contact lenses causes alterations in corneal physiology, which in turn leads to : (i) (ii) Epithelial, stromal and endothelial damages Disorders of the ocular surface

(iii) Complications. a Complications range from practically harmless allergic conjunctivitis to the adverse microbial keratitis. Other associated disorders : Dry eye Sterile Infiltrates Causes All kinds of contact lenses affect the health of the eyes to some extent leading sometimes to complications. Rigid Gas-Permeable(RPG) lenses have less adverse complications compared to soft lenses used for daily wear or extended hydro gel lenses. Contact lenses(CL) are found to be the most significant cause in the development of the extremely serious and damaging microbial keratitis. These disorders are caused by: - Failure of contact lens maintenance systems - Patient related reasons like non-adherence to wearing schedules. Pre existing complications aggravate the problems but are not a cause of these. Corneal Epithelial ABRASION Corneal abrasions from CL wear need to be recognized and treated because they indicate chronic epithelial stress due to the contact lens. Epithelial defects can allow bacteria to penetrate the cornea, resulting in a stromal infection. Wrinkling- epithelial, corneal

 Chronic corneal epithelial trauma can stimulate sub epithelial fibrosis in the absence of an infection. The specific abrasion pattern often provides the necessary clues to indicate what problem can be corrected to improve the comfort and safety of the patient. Debris trapped under a CL or a tear in the edge of CL can produce dramatic curvilinear abrasions. Hypoxia Also known as corneal edema. Occurs when sufficient oxygen does not reach the cornea due to contact lens impermeability. Decrease in the levels of oxygen in the cornea mainly to the endothelium and the stromachange of metabolic activity and stromal swelling. Acute edema: -microcystic epithelial changes occur , with further advancement cell death & imbalance of traumatized epithelial cells. - symptoms: extreme pain, tearing, reduced vision, intolerance of contact lens wear, photophobia. Tight Lens (Red Eye) Syndrome A CL occasionally can become tightly adherent to the eye and produce marked, diffuse stromal inflammation and an anterior chamber reaction. The resultant pain, photophobia, injection, and tearing are typically acute and severe. The epithelium has punctate staining, diffuse or peripheral infiltrates in the anterior stroma. Symptoms can be resolve with removal of the CL, infiltrates may takes a few days to disappear. A short course of topical steroids will speed the resolution of the symptoms.

Opacity Also known as stromal scar. Corneal opacification may result from variety of inflammatory conditions affecting the stroma. Damage to the stroma will usually leave a residual scar. Opacity maybe of long standing and of no relevance to current wearing habits. Symptoms: - none, if opacity is small within the stroma. - decreased vision and photophobia for larger, more central opacities. Corneal endothelium CL also may compromise the corneal endothelium. Wearers have a greater variation in endothelial cell size (polymegethism) and an increased frequency of non-hexagonal cells (polymorphism) than do nonwearers. Along with the dramatic alteration in endothelial cell morphology, a small decrease in endothelial cell density also has been found in long-term contact lens wearers in soft and RGP lenses. Blebs Intracellular oedema of endothelial cells. Due to local decrease in pH, associated with hypoxia and carbon dioxide build up. Maximum response occurs 20-30 minutes after lens insertion. Always occurs in unadapted wearers. Reduction in response occurs over period of weeks. Maybe a precursor to polymegethism. Sign: black spot (holes) on endothelium in specular Others disorders of ocular surface reflection.

 There are few other disorders of the ocular surface, effect from contact lens wear: a) b) Dry eye Sterile infiltrates

c) Wrinkling- epithelial, corneal Dry eye Most common sensation reported by soft lens wearers. Various causes, but tear deficiency is implicated. Increased frequency with older lenses. Signs: - Varies from none, to tear deficiency and corneal & conjunctival desiccation in the interpalpebral aperture. - Poor prelens tear film. Symptoms : - Dryness - Most marked at end of wearing time. How contact lens wear can cause dry eye problems Contact lens will be place on the cornea and fully covered total surface of the cornea (for soft contact lens). The contact lens will disrupts the tear layer on the cornea which is responsible for moisture the cornea surface. The condition, where the eye will have poor exchange if the lens is not fitted well and also for extended wearer. It will interrupt the tear flow which consist the dissolve oxygen to the cornea. In order the eye to compensate this condition, the rate of blinking will be increase. Sterile infiltrates CL wear can induce a distinctive sterile keratitis.

 The etiology of these sterile infiltrates may involve an immune-mediated reaction to bacterial toxins from colonized contact lenses. Keratitis is a condition in which the eyes cornea, the front part of the eye, becomes inflamed. The condition is often marked by moderate to intense pain and usually involves impaired eyesight. Usually sterile infiltrates can be differentiated from infectious infiltrates on clinical signs and symptoms alone. Wrinkling-epithelial, corneal Altered corneal shape resulting from mechanical pressure of the lens or desiccation effects. Maybe more common in thin, high water content lenses. Signs: - Flourescein pooling in furrows - Distorted keratometry mires following lens removal. Symptoms : Decreased vision.

Complication Microbial Keratitis Ultimate corneal damaging complication associated with contact lens usage and is distinguished from other forms of harmless sterile infiltrates. Due to hypoxia and subsequent epithelial disruption. Microbial keratitis is serious to the extent that it can lead to permanent loss of vision due to scars and perforations in the cornea. Higher incidence in extended wear of hydrogel lenses. Sign: - Epithelial break, penetrating into the stroma, sorrounded by oedema and infiltrates. - Mucopurulent or watery discharge. - Aqueous flare often present. Symptoms: Acute pain, foreign body sensation, red eye and photophobia.

Hemorrhage Very rare but serious complications of vascularisation Haemorrhage maybe superficial or deep stromal. Area of opacification remains on resolution of haemorrhage. Most commonly occurs in aphakic soft lens wear. Sign : Haemorrhage located near vascularised area of cornea. Symptoms : - Patient may observe red spot on cornea. - May report hazy vision, or photophobia.