11/12/2014
Red = Inflammation
Practical Problem-Solving
of Red Eye
in the Contact Lens Patient
Thomas G. Quinn, OD, MS, FAAO, Dipl
Disclosure Statement:
* Alcon
* Allergan
* AMO
* Bausch & Lomb
*
*
*
*
Rubor
(redness)
Tumor
(swelling)
Calore
(heat)
Dolore
(pain)
CooperVision
J&J Vision Care
Paragon Vision Science
Polymer Technology
Courtesy of Bart Pemberton, OD
Please silence all mobile devices.
Unauthorized recording of this
session is prohibited.
Red = Inflammation
Red = Inflammation
A
A
protective response
If
persists, can contribute to disease
A
red flag that something is amiss!
protective response
Red Eye:Potential Causes
Contact
lens wear
Non-CL
related conjunctivitis
o Bacterial
o Viral
o Allergic
Dryness
Other
irritants
o Smoke
o Dust
o Pool Chlorine
First Step: A Good History
While modern medical technology has
greatly enhanced our ability to diagnose
and treat disease, it has also promoted
laziness—especially mental laziness—
among many physicians. Habitual reliance
on sophisticated medical gadgetry for
diagnosis prevents physicians from using
the most sophisticated, intricate machine
they'll ever and always have—the brain.
Herbert L. Fred, MD
Professor, Department of Internal Med.
The University of Texas
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A Good History
442
A Good History
consecutive patients
Compared
experience: Correct Dx
o Senior Resident
80.1%
• (4 yrs)
o Experience Clinician
84.4%
• (>20 yrs)
Paley L, et al. Utility of Clinical Examination in the Diagnosis of
Emergency Department Patients Admitted to the Department
of Medicine of an Academic Hospital Arch Intern Med. 2011;171(15):1393-1400
HPI
Most valuable tools?
o
o
o
o
o
o
o
History alone
Physical examination alone
Basic tests (BT) alone
Hx + Physical examination
Hx + BT
Hx + Physical exam +BT
Imaging studies
Res. Physn
19.8
0.8
1.1
39.5
14.7
16.9
6.5
19.3%
0.5%
1.3%
38.6%
14.7%
18.5%
6.1%
Paley L, et al. Utility of Clinical Examination in the Diagnosis of
Emergency Department Patients Admitted to the Department
of Medicine of an Academic Hospital Arch Intern Med. 2011;171(15):1393-1400
Location
Where’s
the red?
o One or both eyes?
o Overall?
o Paralimbal?
“My eye is red”
“My eye is red”
• 22 year old college student
• SCL wearer/DW/Reusable
• MPS
• corneal infiltrates OD
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“My eye is red”
“My eye is red”
OS:
What
o minimal injection
o 1+ infiltrates superior cornea
we did…
o Switched her to Hydrogen Peroxide-based
care system
o Asked to return in 2 weeks
What To Do?
“My eye is red”
Location
Where’s
the red?
o One or both eyes?
o Paralimbal?
o Sectoral?
o Overall?
o In the aperture? Dryness
o At the eyelid margin? Blepharitis/MGD
Before
After
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11/12/2014
HPI
Quality
How
do your eyes feel?
o Itch
Allergy?
o Burn
Dryness?
Quality: Itch
Quality: Itch
Where?
Where?
o Both eyes? Allergy
o Nasal canthus? Allergy
o Eyelid margins? Blepharitis
o Both eyes? Allergy
o Nasal canthus? Allergy
o Eyelid margins? Blepharitis
When?
o Seasonal? Allergy
o After computer use? Dryness
Modifying
factors?
o Rubbing? Does it help?
Quality: Burn
Worse Allergy
Better Dryness
HPI
Where?
o Both eyes? Dryness
o One eye? Host of possibilities
When?
o After reading/computer use? Dryness
o After CL application? Soln/Hands?/Lotion
Modifying
factors?
o Rubbing? Dryness: helps comfort and vision
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Associated symptoms
Produce
matter?
o Stringy vs globular Allergy vs Infection
o White vs green Allergy vs Infection
o Matted shut in am? Conj or Bleph?
Watery?
Viral? Dryness?
Photophobia? Uveitis/Cornea?
Red Eye: Potential Causes
Contact
lens wear
Treat Non-CL related
conjunctivitis
o Bacterial
o Viral
o Allergic
Treat Dryness
Remove Other
irritants
o Smoke
o Dust
o Pool Chlorine
HPI
Is redness associated with CL wear?
Modifying
factors (What helps?)
o Removing CL’s!!!
Is redness associated with CL wear?
Do
symptoms get worse when you wear your
CL’s?
Causes of CL Red Eye
Hypoxia
Do
symptoms get better when you remove
your CL’s?
Do
you wake up with red eyes?
o DW?
o EW?
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11/12/2014
Silicone Hydrogels
Benefits of Silicone Hydrogels
More
66%
Oxygen!
Fewer hypoxic changes
o Less limbal redness
of US market
• 31% (EW) - 35% (DW)
with hydrogels2
Papas EB, Vajdic CM, Austen R, Holden
BA: High oxygen transmissibility soft
contact lenses do not induce limbal
hyperaemia. Curr Eye Res 1997; 16:
942-948,
2. Chalmers RL, Dillehay S, Long B, et al. Impact of previous extended and
daily wear schedules on signs and symptoms with high Dk lotrafilcon A
lenses. Optom Vis Sci. 2005;82:549-554.
Nichols, J. Contact Lens Spectrum, Jan 2014
Causes of CL Red Eye
Corneal Oxygen Demand
Hypoxia
Quinn and Schoessler
o More likely if:
• Long hours of wear
• Higher prescription (lower Dk/t)
• High corneal oxygen demand?
3. Mueller N, Caroline P, Smythe J, Mai-Le K and Bergemske G. A comparison of overnight swelling response
with two high Dk silicone hydrogel contact lenses. Optom Vis Sci 2001; 78(suppl.):199.
2. Quinn TG, Schoessler JP, Human corneal epithelial oxygen demand- population characteristics.
Am J Optom Physiol Opt 1984; 61(6): 386-388.
1. Larke, JR, Parrish, ST and Wigham, CG. Apparent human corneal oxygen
uptake rate. Am J Optom Physiol Opt 1981; 58(10): 803-5.
Causes of CL Red Eye
Signs of Hypoxia
Hypoxia
Limbal redness
Neovascularization
o More likely if:
• Long hours of wear
• Higher prescription (thicker lens)
• High corneal oxygen demand?
o 18% with hydrogel EW
o Other signs to look for
Dumbleton KA, Chalmers RL, Richter DB,
Fonn D. Vascular response to extended
wear of hydrogel lenses with high and
low oxygen permeability.
Optom Vis Sci 2001, 78(3): 147-151.
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11/12/2014
Signs of Hypoxia
Signs of Hypoxia
Limbal redness
Limbal redness
Neovascularization
Neovascularization
Corneal microcysts
Corneal microcysts
Myopic creep
o 90-100% in hyd EW
Low Dk lens wearers switched
to high Dk lens
• 49% of EW Hyd wearers
Dumbleton KA, Chalmers RL, Richter DB,
Fonn D. Changes in myopic refractive error
with nine months` extended wear of
hydrogel lenses with high and low oxygen
permeability. Optom Vis Sci 1999;76:845-9 .
High Dk lens wearers
Keay L, Sweeney D, Jalbert, I et al,
Microcyst Response to High Dk/t
Silicone Hydrogel Contact Lenses,
Optom Vis Sci 2000; 77(11):582-585.
Causes of CL Red Eye
Silicone Hydrogels
Hypoxia
Mechanical issues
o SEALS
o Contact lens-induced
papillary conjunctivitis
(CLPC)
Mechanical/Allergic
• Higher rate of local
CLPC with SiHy lenses
(4.6%)
Skotnitsky C, et al. The incidence of local and general contact lens induced
papillary conjunctivitis in silicone hydrogel contact lenses.
Invest Ophthalmol Vis Sci 2005 46: E-Abstract 2064.
GPC (CLPC)
Symptoms:
o Itchy/ mucous
o Len decentration/
intolerance
Onset:
Treatment:
o Variable/ allergy season?
o D/C CL wear
o Steroids/antihistimine/
mast cell stablizer
o Refit DD
Silicone Hydrogels
Mechanical issues
o SEALS
o Contact lens-induced
papillary conjunctivitis
(CLPC)
• Higher rate of local
CLPC with SiHy lenses
(4.6%)
• DD SiHy: rate
significantly reduced
Skotnitsky C, et al. The incidence of local and general contact lens induced
papillary conjunctivitis in silicone hydrogel contact lenses.
Invest Ophthalmol Vis Sci 2005 46: E-Abstract 2064.
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11/12/2014
Causes of CL Red Eye
A
(Lid) Flip Should Be Part of Every CL Exam!
Hypoxia
Mechanical/Allergic
Corneal
Infection/ Inflammation
Gabby Douglas, US Olympian
Silicone Hydrogels
To the Rescue?
MK rates unchanged
with EW (~5xDW)
o 19891 (Hyd):
20.9/10,000
o 20052 (SiHy):
18.0/10,000
o 20083(SiHy):
25.4/10,000
Silicone Hydrogels
1. Poggio EC, Glynn RJ, Schein OD, et al
The incidence of ulcerative keratitis
among users of daily-wear and
extended-wear soft contact lenses
N Engl J Med 1989 Sep 21; 321(12) :779-83.
2. Schein OD, McNally JJ, Katz J et al. The
Incidence of microbial keratitis among wearers
of a 30-day silicone hydrogel extended-wear
contact lens. Ophthalmology 2005 Dec; 112(12):
2172-9
3. Stapleton F et al. The incidence of contact lens-related
Microbial keratitis in Australia. Opththalmology 2008 Oct;
115(10):1655-62.
CLARE
(Contact Lens Associated Red Eye)
Symptoms
MK rates unchanged
Concern about corneal
inflammatory events (CIEs)
• (~5xDW)
o 26.7% incidence1
o 2x increase vs hydrogel
1,2
1. Szczotka-Flynn L, Diaz M, Optom & Vis Sci April 2007;84(4):247-256
2. Radford CF, et al.Ophthalmology 2009 Mar;116(3):385-92.
CLPU (Contact Lens Peripheral Ulcer)
CLPU
o Watery, painful eye
Onset
o On waking with EW
Etiology
o Gram neg bacteria
Treatment
o D/C CL Wear;Meds?
o 1/3 will recur1
1. Fonn, D and Sivak, A.
CL Spectrum,
Spectrum, Feb 2005.
(Courtesy: CCLRU/LVPEI Guide to Corneal Infiltrative Conditions)
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11/12/2014
Silicone Hydrogels
Risk factors for CIEs
MK rates unchanged
Bacteria bind in higher levels to SiHy lenses
– Related to increase in CIEs?
• (~5xDW)
Concern about corneal
inflammatory events (CIEs)
o 26.7% incidence1
o 2x increase vs hydrogel
1,2
• Material/wear sch/other?
Pseudomonas aeruginosa
Source: CDC
Subbaraman LN, et al. Influence of
protein deposition on bacterial
adhesion to contact lenses.
Optom Vis Sci Aug 2011;88(8):959-966
1. Szczotka-Flynn L, Diaz M, Optom & Vis Sci April 2007;84(4):247-256
2. Radford CF, et al.Ophthalmology 2009 Mar;116(3):385-92.
Contact Lens Safety
Chalmers et al. March 2012
– Incidence of CIEs:
• 12.5 X less likely with
Daily Disposable
Daily Disposables: Usage in USA
2009: 11%
2010: 13%
2011: 14%
2012: 17%
2013: 20%
vs reusable lenses
Chalmers, Robin L. et al, Multicenter Case-Control Study of the
Role of Lens Materials and Care Products on the Development
of Corneal Infiltrates, Optometry & Vision Science. 89(3):316-325,
March 2012.
Why Not DD?
Limited Parameter Availability?
–
–
–
–
Spheres
Tinted Spheres
Torics
Multifocals
Nichols, J. Contact Lens Spectrum, Jan 2014
Why Not DD?
Limited Parameter Availability?
Concerns about Overwear?
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11/12/2014
Lens Over-Wear
Compliance with replacement is higher than
2wk or 1 mo: Why?
– Easy
• Lead cause of non-compliance:
– Forgot which day due to replace
– Not an issue with DD!
– No change in behavior required
Confronting Cost-Perspective
Why Not DD?
Limited Parameter Availability?
Concerns about Overwear?
Cost?
Confronting Cost: The Facts
Up-front cost vs Long-term benefits
CL-induced infiltrates in USA in 2010:
– Severe:
• 17,248 cases
• $1500/episode
– Non-Severe:
• 32,031 cases
• $1000/episode
Cost (1 yr supply)
Solution Costs
Rebates
1-Day
2-wk
$value
$value
-0-
$value
$value
$value
Difference(2 wk)*: $0.26 more per day
Difference (Monthly)*: $0.10 more per day
– Total Cost: $58 million overall
Smith AF, Orsborn G. Estimating the Annual Economic Burden of Illness
Caused by Contact Lens-Associated Corenal Infiltrative Events in the
United States. Eye Contact Lens. 2012 Apr 10.
Confronting Cost-Fee Setting
Material price competitive with on-line
– Profit: 2 x more than 2wk or Monthly
Additional incentive
Total Profit
For Part-Time Wearers: cheaper than reusable!
* Drs. Quinn, Foster & Associates
Daily Disposables- Benefits
It’s what’s best for the patient
– “Dirty lenses create most contact lens complications”
– Reduced fitting fee
– 30% higher than 2 wk
– 23% higher than Monthly
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11/12/2014
Handwashing
Sources of Microbial Contamination
Contact Lens Case
Solution Bottle
Hands
Environment – soil, water
Old, deposited contacts
Hands as a vector, even with DD
– Lipid Deposits1
– Bioburden2
• Discomfort
• CIEs
• MK
1. Campbell D, Mann A, Hunt O, Santos LJ. The significance of hand wash compliance on the transfer of dermal lipids in
contact lens wear. Cont Lens Ant Eye. 2012 Apr;35(2):71-6; quiz 96-7. Epub 2011 Dec 16
2. McMonnies CW. Hand hygiene prior to contact lens handling is problematical. Cont Lens Ant Eye. 2012 Apr;35(2):65-70.
Epub 2011 Dec 24
Anterior Segment
Conj & Sclera
Cornea
Eyelids
Contact Lenses
Surgery
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CONTACT LENS HEALTH WEEK
November 17–21, 2014
The Centers for Disease Control and Prevention (CDC)
invites you to celebrate Contact Lens Health Week this November!
Help spread the word about
healthy contact lens wear and care.
Learn more and download free
health promotion materials, including:
Printable posters
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Take-Aways
Detailed History: is a powerful tool: give time to it
Where’s the redness?
Itch doesn’t necessarily mean allergy (though it might!)
Burn doesn’t necessarily mean dryness (it might!)
Key Indicators that CL’s are contributory to redness:
– Improvement with contact lens removal
– Worsening with contact lens application
Infographics
Buttons and badges for websites
A library of short messages for
use on social media channels
Likely Contact Lens Culprits:
– Hypoxia (especially with extended wear and high Rx)
– Mechanical/ Allergic
– Infection/ Inflammation
And much more!
www.cdc.gov/contactlenses
For more information, email: [email protected].
Clean Lenses and Clean Hands!
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11/12/2014
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