A red eye is a red flaga classic sign of inflammation that alerts us that something is wrong and
requires our attention. Many patients presenting with red eye are squeezed into an already packed
schedule. The challenge to quickly make the proper diagnosis can be compounded if a patient is a
contact lens wearer. What processes can we employ to identify the problem efficiently and treat it
effectively?
Is There a Question?
Ocular redness can be due to a host of possible causes, some contact lens-related, some not (Table
1). One of the best tools to help get us to the source is a good history. One study in a hospital
emergency department explored what tools were most instrumental in making the proper diagnosis
(Paley et al, 2011). For both senior residents (four years in practice) and experienced clinicians
(greater than 20 years), a good case history was found to be among the most valuable tools,
superseded only by a combined case history and physical examination (Table 2). While imaging
studies can obviously provide valuable information, it is interesting to note that, at least in this study,
they ranked fairly low in diagnostic value compared to simply asking the right questions and being a
good listener.
TABLE 2 Value of Diagnostic Tools for Both New and Experienced Clinicians (%)
Residents
Experienced Clinicians
19.8
19.3
0.8
0.5
1.1
1.3
Hx + Physical examination
39.5
38.6
Hx + Basic tests
14.7
14.7
16.9
18.5
6.5
6.1
Imaging studies
How do you conduct a good case history? Although often viewed by clinicians as a headache and yet
another demand placed upon them by the big brother healthcare system, the history of present
illness (HPI) is a wonderful tool to employ (Table 3). Lets walk through some of the key parts of an
HPI and discuss how it helps us quickly arrive at the proper diagnosis of a red eye.
Element
Explanation
Location
Duration
Severity
Quality
Context
Modifying factors
Timing
Figure 6. Lissamine green staining of the bulbar conjunctiva in a dry eye patient.
If burning occurs shortly after contact lens application, patients may have sensitivity to the contact
lens storage solution, or they may have transferred lotion or perfume from their fingers to the lens
surface. If you suspect that the culprit may be a foreign substance, but the patient denies it, ask
about hand soap. Many commercially available hand soaps contain common irritants.
Photophobia suggests anterior chamber involvement, which could be secondary to corneal irritation;
therefore, always look for corneal compromise in these cases (Figure 7).
Figure 8. Corneal neovascularization from extended wear of a low-Dk soft contact lens.
Mechanical/Allergic Mechanical causes of contact lens red eye usually present unilaterally or
asymmetrically. Lens damage is a common culprit. An infrequent cause is a superior epithelial arcuate
lesion (SEAL). Found on the superior cornea, SEALs are thought to result from chafing of the
peripheral cornea by the posterior contact lens surface. Tight overlying eyelid pressure and a highmodulus contact lens material are thought to predispose a patient to this condition (Holden, 2001).
SEALs are often asymptomatic, so be sure to lift the upper lid and examine the superior cornea in all
contact lens wearers reporting a red eye.
Contact Lens-Induced Papillary Conjunctivitis Contact lens-induced papillary conjunctivitis
(CLPC), sometimes interchangeably referred to as giant papillary conjunctivitis (GPC), is an
inflammation of the palpebral conjunctiva. It is thought to be a result of mechanical irritation from a
poor lens edge design or deposits on the lens surface. These surface deposits are also thought to
trigger an allergic/hypersensitivity response.
CLPC is more likely to occur with wear of silicone hydrogel lens materials and with extended lens wear.
It is less likely to be a problem with daily disposable lenses (Sankaridurg et al, 2001), so switching
patients to this wearing modality can be used as a treatment strategy. Topical steroids or
antihistamine/mast cell stabilizers can also be quite helpful in quieting this condition.
Non-Infectious Corneal Inflammatory Events Corneal inflammatory, or infiltrative, events (CIEs)
have been classified in the following way (Sweeney et al, 2003):
Serious and symptomatic (e.g., microbial keratitis [MK])
Clinically significant and symptomatic (e.g., contact lens-induced peripheral ulcer, contact lensinduced acute red eye, infiltrative keratitis)
Clinically non-significant and asymptomatic (e.g., asymptomatic infiltrative keratitis and
asymptomatic infiltrates)
With a reported incidence of 26.7% (Szczotka-Flynn and Diaz, 2007), non-infectious CIEs are
commonly encountered in clinical practice. Non-infectious CIEs tend to occur in the peripheral cornea,
and the eyes are generally quieter compared to those that have infectious lesions. Although the vast
majority of CIEs are non-infectious, some overlap in clinical signs and symptoms can occur, so
approach all with suspicion.
Wagner and colleagues (2011) have found a greater risk for CIEs in contact lens wearers in late
adolescence and early adulthood. They also found a higher incidence in patients wearing silicone
hydrogel lenses. Other studies have found that wearing silicone hydrogel lenses leads to a two-times
increase in the incidence of CIEs compared to those wearing hydrogel lenses (Szczotka-Flynn and
Diaz, 2007; Radford et al, 2009). There is evidence suggesting that this may be associated with higher
binding levels of bacteria to silicone hydrogel lens surfaces (Subbaraman et al, 2011).
If surface cleanliness is important, you would expect that wear of a daily disposable contact lens would
significantly reduce the likelihood of CIEs. This has, in fact, been found to be the case. One study
found that the risk of CIEs decreased by 12.5 times when lenses are changed on a daily basis
(Chalmers et al, 2012). This beneficial effect has been shown to occur for both hydrogel and silicone
hydrogel daily disposable lens wearers (Chalmers et al, 2015).
Corneal Infection/Inflammation The incidence of MK has remained relatively unchanged over the
past few decades, even with the introduction of silicone hydrogel lenses. The risk of MK is
approximately five times greater for those wearing lenses on an extended wear basis and is estimated
to be between 18 and 25.4 per every 10,000 wearers (Poggio et al, 1989; Schein et al, 2005;
Stapleton et al, 2008).
There is also evidence suggesting that poor storage case hygiene can put patients at almost as much
risk for MK as extended lens wear can (Szczotka-Flynn, 2009). It is now recommended that cases be
cared for in the following way: discard old solution, rub case with clean fingers for at least five
seconds, rinse with disinfecting solution, wipe dry with a clean cloth, and store (with lids off) upside
down in a clean area (Wu et al, 2010). There is evidence to suggest that cases may develop significant
contamination after two weeks of use (Lakkis et al, 2009). So, at minimum, monthly case replacement
would be advisable. Of course, another option is to simply fit patients with daily disposable lenses, in
which a storage case is not needed and therefore removed as a potential source of contamination.
A corneal lesion is most likely to be infectious (versus sterile) if it is more centrally located, is 2mm or
greater in size, and, in general, causes a very hot eye. Approximately 90% of all MK is due to
bacterial infection (Musa et al, 2010), in which case you would expect associated mucus production.
However, some viral, parasitic, and immune-related stromal necrosis will not have this associated sign
(Srinivasan et al, 2008), so absence of mucus does not rule out infection.
MK is an ocular emergency requiring aggressive therapy. In cases of bacterial ulcers, there is evidence
that adding a topical steroid two to three days after starting antibiotic treatment reduces scarring,
leading to improved visual outcomes (Ray et al, 2014). Consider co-managing MK patients with a
corneal specialist, particularly if the lesion is central and may lead to permanent vision loss.
Contact Lens-Induced Peripheral Ulcer In 1998, Grant and associates coined the term contact
lens-induced peripheral ulcer (CLPU) to describe small, round, peripheral infiltrates with an overlying
absence of epithelium. CLPUs present unilaterally. They can be asymptomatic, but it is not unusual for
them to be accompanied by mild discomfort. CLPUs result from colonization of gram-positive bacteria,
particularlyStaphylococcus species, on the contact lens surface; they are often associated with a
recent history of overnight contact lens wear. Treatment includes temporary discontinuation of contact
lens wear and close monitoring for the next 24 to 48 hours to ensure that the lesion is not, in fact,
infectious. This concern leads many eyecare providers to often prescribe, as a precautionary measure,
a broad-spectrum antibiotic until the epithelial lesion is healed.
Contact Lens Acute Red Eye Any patient who is sleeping in contact lenses and awakes with a
unilateral, acute red eye with no, or minimal, corneal staining is likely suffering from contact lens
acute red eye (CLARE). CLARE is an inflammatory response to the accumulation of gram-negative
bacteria. Temporarily ceasing lens wear should result in significant resolution of ocular redness within
a day or two. Again, when in doubt, prescribe a broad-spectrum antibiotic.
Infiltrative Keratitis (IK) Corneal infiltrates, which can be observed in both symptomatic and
asymptomatic patients, are an accumulation of white blood cells in the epithelium or anterior stroma.
They are a response to an inflammatory stimulus, which can include a wide array of
possibilities. Figure 9 is the left eye of a patient who presented with complaints of a unilateral red eye
with mild discomfort. Further examination found mild infiltrates in the right eye as well. Switching the
patient from a multipurpose contact lens care system to a hydrogen peroxide-based system resolved
the infiltrates (Figure 10).
Figure 10. Same eye as Figure 9 one week later with infiltrative keratitis resolved.
Any time a patient presents with a red eye, even when squeezed into an already busy schedule, take a
detailed history. It will be time well invested because it will streamline your physical examination,
allowing you to more accurately diagnose and more effectively treat the patient. With keen listening
and thoughtful observation, everybody wins. CLS
For references, please visit www.clspectrum.com/references and click on document #237.
Dr. Quinn is in group practice in Athens, Ohio. He is an advisor to the GP Lens Institute and an
area manager for Vision Source. He is an advisor or consultant to Alcon and B+L, has
received research funding from Alcon, AMO, Allergan, and B+L, and has received lecture or
authorship honoraria from Alcon, B+L, CooperVision, GPLI, SynergEyes, and STAPLE
program. You can reach him at tgquinn5@gmail.com.