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Discussion of the Management of Complications Associated with the Various Types of Contact Lenses
Symposium: Contact Lenses .,.
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DISCUSSION OF THE MANAGEMENT OF COMPLICATIONS ASSOCIATED WITH THE VARIOUS TYPES OF CONTACT LENSES HAROLD A. STEIN, MD TORONTO, ONTARIO OPHTHALMOLOGISTS have within their educational expertise the ability not only to detect complications and problems of contact lens wear at an early stage, but to reverse these complications. There was a time when ophthalmologists turned a blind eye to contact lens technology. No longer is this possible. The papers presented indicate that a great many problems still exist for both daily wear and extended wear contact lenses. The ability to recognize these problems and deal with them is the mam theme of this symposium. PRODUCT AVAILABILITY
A great many new polymers for both hard and soft contact lenses are beginning to appear. Coupled with this is the development of new lens design. More and more chemical solutions for cleaning, rinsing, storing, and lubricating soft contact lenses are becoming available.
Submitted for publication Oct 24, 1978. From the University of Toronto, Ontario. Presented in combination with the Contact Lens Association of Ophthalmologists at the 1978 Annual Meeting of the American Academy of Ophthalmology, Kansas City, Mo, Oct 22-26. Reprint requests to 170 Bloor St W, Toronto, Ontario, M5S 1T9.
The FDA, within their guidelines of providing a reasonably safe product for the American public, will continue to approve new products and new contact lenses. Thus ophthalmologists are now faced with a larger variety of available material and fitting methods than have ever been offered before. This will permit them to successfully fit with contact lenses a great many more patients. One must remember, however, that with this increased number of lenses and chemical agents comes an increased number of problems that must be dealt with. Such problems as confusion of available disinfecting systems, the mixing of hard lens chemicals for soft lenses, and the incompatibility of different chemical systems have been outlined by Morgan. OPHTHALMIC RESPONSIBILITY
The comfort factor and the rapid initial success of soft contact lenses has resulted in many more contact lens wearers today than were present five years ago. Ophthalmologists must be able to recognize and deal with the corresponding increase in contact lens related problems. Conditions of chronic lensinduced corneal hypoxia must be recognized early so that these corneal changes can be promptly reversed.
1142
VOLUME 86 JUNE 1979
SYMPOSIUM ON CONTACT LENSES
The hazards of infection through contact lenses pointed out by Bohigian and Freeman are real and must be dealt with early. These are not pleasant conditions to treat, but if recognized and treated early, the prognosis for vision is hopeful.
PATIENT COMPLIANCE
One major problem is patient compliance with the schedules prescribed for them. Noncompliance with care systems, improper hygiene, and the mixing of chemical systems are seldom admitted by the patient and cause no end of concern to the fitter, the lens manufacturing company, and the manufacturers of solutions and thermal disinfecting systems.
LENS-RELATED PROBLEMS
Gruber has pointed out the ill effects on the cornea of poor centration of soft lenses. Poorly fitting lenses that decenter not only are responsible for poor vision, but may cause marginal erosions of the cornea and result in ulcer formation. Morgan has reported the persistence of epithelial corneal problems from inadequate rinsing of chemical disinfectants from contact lenses. Honan described a number of visual defects, including spectacle blur, arising from poorly constructed hard lenses. This blur after removing hard lenses is caused by corneal changes induced by hypoxia with changes in the refraction of the eyes. Hard lenses must be designed and manufactured well to provide adequate venting.
1143
PROBLEMS OF APHAKIC LENSES
Aphakia in itself creates problems for the contact lens wearer. In aphakia, the high plus power required means much thicker lenses and possible interference with corneal oxygenation. In addition, following cataract surgery, there is a decrease in corneal sensitivity. This decreased sensitivity may permit a poorly fitting contact lens to seem comfortable and well tolerated while it continues to produce chronic corneal insult. The decreased tear flow in the elderly aphakic patient is another source of problems including drying out of the soft lenses, corneal erosions, and possibly, ulcer formation. Decreased tear production may produce staining in the 3-o'clock and 9-o'clock positions with hard contact lenses or be responsible for deposit formation on soft contact lenses. Proper and adequate instruction to the elderly patient or a close relative is mandatory. The elderly patient must fully understand and follow the care routine that is recommended. Too often, complications result from improper compliance to maintenance systems for contact lenses.
Farris has pointed out that serious ocular trauma can follow insertion and removal of a contact lens in the post-cataract patient and can even result in hyphema and wound disruption. The patient, the eye, and the time chosen to initiate the use of contact lenses for the aphakic patient must be carefully chosen. The elderly patient or a close relative must be able to remove the lens, if necessary, whether it be an extended wear or daily wear lens. One problem that is frequently seen is
1144
HAROLD A. STEIN
the elderly aphakic patient napping without removing his contact lenses and causing corneal hypoxia.
OPHTH AAO
careful and continuing follow-up care of extended wear patients can both serious problems and medicolegal involvement be avoided.
EXTENDED WEAR LENSES
Extended wear lenses may soon become available throughout North America to provide a reasonable alternative to the avalanche of intraocular lens implantation that is occurring. The danger today lies in using contact lenses for extended wear that were not specifically designed and tested for this use. While a variety of problems with extended wear lenses are still present, Binder has pinpointed the two most prevalent ones, deposit formation and chronic corneal hypoxia, which remain even with the newer lenses designed for extended wear. Deposit formation on the lens, which is much greater in the elderly, interferes with oxygen transmission and can lead not only to corneal hypoxia, but often to changes in the lens parameters such as steepening of the contact lens. If this can be identified early, it can be dealt with before irreversible corneal changes occur. Extended wear lenses today are dependent on careful monitoring by a conscientious practitioner and a patient who is dedicated to return regularly for follow-up visits. Only by
SUMMARY
Whether they fit contact lenses or not, ophthalmologists must not only be aware of ocular complications resulting from contact lenses but must also know how to correct these complications. There is now a substantial number of patients wearing contact lenses. Patients who require a professional opinion concerning their suitability for contact lenses, the status of their present contact lenses, or problems with their lenses are entitled to the best diagnostic acumen that can be offered in determining potential problems and taking medical steps to reverse these problems. This symposium has served to crystalize some of the problems that ophthalmologists will face with increasing frequency as contact lens wearers become a larger segment of the public. Ophthalmologists must combine knowledge and clinical experience with the human eye with an in-depth study of the rapidly expanding field of contact lens technology.
.,.
.,.
DISCUSSION OF THE MANAGEMENT OF COMPLICATIONS ASSOCIATED WITH THE VARIOUS TYPES OF CONTACT LENSES HAROLD A. STEIN, MD TORONTO, ONTARIO OPHTHALMOLOGISTS have within their educational expertise the ability not only to detect complications and problems of contact lens wear at an early stage, but to reverse these complications. There was a time when ophthalmologists turned a blind eye to contact lens technology. No longer is this possible. The papers presented indicate that a great many problems still exist for both daily wear and extended wear contact lenses. The ability to recognize these problems and deal with them is the mam theme of this symposium. PRODUCT AVAILABILITY
A great many new polymers for both hard and soft contact lenses are beginning to appear. Coupled with this is the development of new lens design. More and more chemical solutions for cleaning, rinsing, storing, and lubricating soft contact lenses are becoming available.
Submitted for publication Oct 24, 1978. From the University of Toronto, Ontario. Presented in combination with the Contact Lens Association of Ophthalmologists at the 1978 Annual Meeting of the American Academy of Ophthalmology, Kansas City, Mo, Oct 22-26. Reprint requests to 170 Bloor St W, Toronto, Ontario, M5S 1T9.
The FDA, within their guidelines of providing a reasonably safe product for the American public, will continue to approve new products and new contact lenses. Thus ophthalmologists are now faced with a larger variety of available material and fitting methods than have ever been offered before. This will permit them to successfully fit with contact lenses a great many more patients. One must remember, however, that with this increased number of lenses and chemical agents comes an increased number of problems that must be dealt with. Such problems as confusion of available disinfecting systems, the mixing of hard lens chemicals for soft lenses, and the incompatibility of different chemical systems have been outlined by Morgan. OPHTHALMIC RESPONSIBILITY
The comfort factor and the rapid initial success of soft contact lenses has resulted in many more contact lens wearers today than were present five years ago. Ophthalmologists must be able to recognize and deal with the corresponding increase in contact lens related problems. Conditions of chronic lensinduced corneal hypoxia must be recognized early so that these corneal changes can be promptly reversed.
1142
VOLUME 86 JUNE 1979
SYMPOSIUM ON CONTACT LENSES
The hazards of infection through contact lenses pointed out by Bohigian and Freeman are real and must be dealt with early. These are not pleasant conditions to treat, but if recognized and treated early, the prognosis for vision is hopeful.
PATIENT COMPLIANCE
One major problem is patient compliance with the schedules prescribed for them. Noncompliance with care systems, improper hygiene, and the mixing of chemical systems are seldom admitted by the patient and cause no end of concern to the fitter, the lens manufacturing company, and the manufacturers of solutions and thermal disinfecting systems.
LENS-RELATED PROBLEMS
Gruber has pointed out the ill effects on the cornea of poor centration of soft lenses. Poorly fitting lenses that decenter not only are responsible for poor vision, but may cause marginal erosions of the cornea and result in ulcer formation. Morgan has reported the persistence of epithelial corneal problems from inadequate rinsing of chemical disinfectants from contact lenses. Honan described a number of visual defects, including spectacle blur, arising from poorly constructed hard lenses. This blur after removing hard lenses is caused by corneal changes induced by hypoxia with changes in the refraction of the eyes. Hard lenses must be designed and manufactured well to provide adequate venting.
1143
PROBLEMS OF APHAKIC LENSES
Aphakia in itself creates problems for the contact lens wearer. In aphakia, the high plus power required means much thicker lenses and possible interference with corneal oxygenation. In addition, following cataract surgery, there is a decrease in corneal sensitivity. This decreased sensitivity may permit a poorly fitting contact lens to seem comfortable and well tolerated while it continues to produce chronic corneal insult. The decreased tear flow in the elderly aphakic patient is another source of problems including drying out of the soft lenses, corneal erosions, and possibly, ulcer formation. Decreased tear production may produce staining in the 3-o'clock and 9-o'clock positions with hard contact lenses or be responsible for deposit formation on soft contact lenses. Proper and adequate instruction to the elderly patient or a close relative is mandatory. The elderly patient must fully understand and follow the care routine that is recommended. Too often, complications result from improper compliance to maintenance systems for contact lenses.
Farris has pointed out that serious ocular trauma can follow insertion and removal of a contact lens in the post-cataract patient and can even result in hyphema and wound disruption. The patient, the eye, and the time chosen to initiate the use of contact lenses for the aphakic patient must be carefully chosen. The elderly patient or a close relative must be able to remove the lens, if necessary, whether it be an extended wear or daily wear lens. One problem that is frequently seen is
1144
HAROLD A. STEIN
the elderly aphakic patient napping without removing his contact lenses and causing corneal hypoxia.
OPHTH AAO
careful and continuing follow-up care of extended wear patients can both serious problems and medicolegal involvement be avoided.
EXTENDED WEAR LENSES
Extended wear lenses may soon become available throughout North America to provide a reasonable alternative to the avalanche of intraocular lens implantation that is occurring. The danger today lies in using contact lenses for extended wear that were not specifically designed and tested for this use. While a variety of problems with extended wear lenses are still present, Binder has pinpointed the two most prevalent ones, deposit formation and chronic corneal hypoxia, which remain even with the newer lenses designed for extended wear. Deposit formation on the lens, which is much greater in the elderly, interferes with oxygen transmission and can lead not only to corneal hypoxia, but often to changes in the lens parameters such as steepening of the contact lens. If this can be identified early, it can be dealt with before irreversible corneal changes occur. Extended wear lenses today are dependent on careful monitoring by a conscientious practitioner and a patient who is dedicated to return regularly for follow-up visits. Only by
SUMMARY
Whether they fit contact lenses or not, ophthalmologists must not only be aware of ocular complications resulting from contact lenses but must also know how to correct these complications. There is now a substantial number of patients wearing contact lenses. Patients who require a professional opinion concerning their suitability for contact lenses, the status of their present contact lenses, or problems with their lenses are entitled to the best diagnostic acumen that can be offered in determining potential problems and taking medical steps to reverse these problems. This symposium has served to crystalize some of the problems that ophthalmologists will face with increasing frequency as contact lens wearers become a larger segment of the public. Ophthalmologists must combine knowledge and clinical experience with the human eye with an in-depth study of the rapidly expanding field of contact lens technology.