Therapeutics in practice

Part 1: The contact lens-related red eye

ontact lens wear has always been a provocative stimulus to ocular changes that may manifest as a red eye, even if the problem is not clinically significant. In all cases of any significance, the differential diagnosis of a condition that can be managed by a contact lens practitioner (rather than requiring referral) is important to patient care. The referral criteria of the contact lens wearer is usually related to the presence of infection when it is paramount that the patient receives immediate treatment as contact lens related infections can be devastating.
practitioner to decide whether the condition is resolving or needs further attention. As good record keeping is essential, the use of a grading system to monitor the patient is important. In assessing a patient with a red eye, the history and ocular examination are key in establishing the diagnosis and appropriate management. The history should distinguish urgent from non-urgent cases and the symptoms will reinforce the level of urgency. Therefore, induced redness complications should be graded for the following reasons: To permit a proper comparison over time To allow the evaluation of the management strategy To facilitate inter-practitioner communication To help protect the practitioner in the event of a medico-legal case The use of a five-point scale is commonplace: Grade 0: No sign no action required Grade 1: Trace simply note Grade 2: Mild sign note and monitor? Intervene similarly grade 4 Grade 3: Moderate sign intervene Grade 4: Severe stop lens wear? Refer A decimal system can be used to increase precision, e.g grade 2.5, but the use of video capture technology and sophisticated

The areas of ocular tissue that manifest the changes in the contact lens red eye (Figure 1) are usually the limbal and conjunctival vessels. Blood flow will be altered to meet the situation presented in the local tissue. There are four mechanisms which alter blood flow: neural control of the vascular smooth muscle; myogenic control where the vessel diameter alters with changes in blood pressure; metabolic control where the waste products of glycolosis accumulate around the vessels causing dilatation and hence an increase in blood flow; and lastly, humoral control associated with agents that circulate in the blood such as histamine. The limbal vessels dilate with physical or physiological stress and can manifest a greater reaction to contact lens wear than that seen on the bulbar conjunctiva in certain cases. Increased limbal redness does not necessarily cause discomfort to the patient but it is an indicator of a problem and can be a precursor to corneal vascularisation. However, the more common sign of conjunctival redness is second nature to wearing any type of contact lens and so its prevalence does not appear to be so well documented. Publications tend to concentrate on a particular problem of which conjunctival redness is a sign, so what is not often taken into consideration is the concept that most, if not all, contact lens wearers will have episodes of redness that may, or may not, be associated with their contact lenses over the many years of wear. Grading of the hyperaemia and associated changes will help the

Table 1
Bulbar and limbal hyperaemia in extended wear (grade 0 = none, grade 3 = extreme)
Conjunctival hyperaemia No lens Limbal hyperaemia No lens 0.89 0.66 1.13 0.33

Figure 1
Contact lens-induced acute red eye

Table 2
Bulbar hyperaemia1,2 (photographic scale: 0 = none, 5 = extreme)
No lenses HGP lenses SCL non-preserved care regime SCL preserved care regime 0.75 0.96 1.54 2.10

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image analysis systems has meant that more objective assessments of changes such as limbal and conjunctival redness can now be documented (see figures in Tables 1 and 2). Generally, in contact lens practice at least, the use of simple pictorial systems is recommended. The two most commonly available are the Cornea and Contact Lens Research Unit (CCLRU) and the Efron scales. It is generally accepted that a level of severity greater than grade 2 is considered to be clinically meaningful and needing attention. Even initial questioning of the length of time the redness, and maybe other symptoms, have been problematic will help the practitioner initially decide whether the problem is one that is able to be managed in the practice or one that requires referral. The presence of pain is an excellent indicator of the urgency of the condition and will often initiate a different route of management to that in which pain is absent. In addition, the type of pain or discomfort, e.g. pricking, sharp, gritty, sore, deep, boring, should be elicited as this will also help with the differential diagnosis. Questioning is often like being a detective as the practitioner needs to get a full picture of the pattern of contact lens use and also must not forget associated issues, such as what comes in to contact with their patients hands or face.

Hypoxia

Physiological implications
Conjunctival redness is a fundamental indicator of the physiological status of the contact lens wearing eye. Vasodilatation of the rich plexus of arterioles is due to relaxation of smooth muscle, whilst a passive mechanism is a vessel blockage often near the limbus. Hyperaemia is seen in regional areas depending on the cause and the vessels will move on push or lid manipulation. There are various studies1,2 which demonstrate that adapted soft lens wearers exhibit more hyperaemia than adapted hard gas permeable (HGP) wearers. Often there are no symptoms but otherwise, the patient will notice itchiness, congestion of the vessels, a warm or cold feeling or a non-specific mild irritation.

The supply of oxygen from the atmosphere is inhibited by all forms of contact lens wear3. If there is not enough oxygen available in the cornea to convert the glucose (by means of glycosis) into sufficient energy to allow the waste product, lactic acid, to diffuse quickly out of the tissue, then less energy is available for cellular activity. This results in too much lactic acid being produced, which builds up in the stroma, and so is strongly implicated in the cause of corneal oedema by causing an osmotic imbalance. The amount of available oxygen is different for each lens type, material and method of fitting. For soft lenses, the oedema seen on the slit lamp is often more obvious peripherally in the myope, which is presumably why there is an association between hypoxia and an increase in limbal hyperaemia4. It is now reasonable to state that any myope over 4.00D should always be fitted with a high water content material. In general, if a patient is wearing soft lenses for a significant part of the day, they should be fitted with a mid to high water content material5. HGP lenses, from a design concept of size and movement, will provide more atmospheric oxygen to the cornea. Again, mid to high oxygen materials are advisable and there is a plethora of choice. As hyperaemia seems to be linked to hypoxic implications, it is particularly obvious with soft lens extended wear (Table 1)6 .
Acidic shift

Causes
The aetiology is often complex but the main causes of a contact lens-related red eye come under the following headings: metabolic; contact lens solution hypersensitivity; contact lens deposition; allergy; mechanical trauma; and tear deficiency.

Metabolic
During metabolic activity, the concentration of chemicals in the interstitial fluids is changed leading to vessel dilation and an increase in blood flow. The situations which relax arteriole smooth muscle are hypoxia and an acidic shift in pH.

Although corneal changes resulting from contact lens wear are primarily due to hypoxia, there is an effect due to a change in corneal pH which must be taken into account. The pH effects, which account for some of the corneal complications accompanying contact lens wear, have been demonstrated to show that intracellular pH can control many cellular functions including glycolysis, membrane ion secretion and mitotic activity7. Stromal pH is lowered during contact lens wear, and it has been suggested that a CL-lowered pH may cause changes in corneal structure and function. It appears that lactic acid accumulation, in combination with carbon dioxide build-up (hypercapnia), is responsible for acidosis of the stroma and presumably the epithelium. Lenses inducing low carbon dioxide transmissibility induce greater levels of hypercapnia8. There is also an increase in the production of osmotically active particles9 and an increase in potassium (which overloads the capacity of the sodium-potassium pump)9 due to repeated action potentials.

Contact lens solution hypersensitivity

A high proportion of soft lens problems relate to solution reactions10. However, with

the advent of newer multipurpose solutions, the incidence has reduced to probably less than 5%. Careful questioning is always necessary to reveal either patient error or the offending solution. Exposure to chemical agents incorporated into contact lens care systems give a hyperaemic reaction1,2 that is usually bilateral, although sometimes a hypersensitivity to a care system agent may be sectorial (Table 2). Proteolytic enzymes and preservatives in contact lens solutions are all toxic to some extent, but reactions are unusual unless the irritant is in particularly high concentrations, or is held in contact with the eye for a prolonged period of time. Delayed hypersensitivity can manifest months or years later following continued use of a product, and is a T-cell mediated reaction. Superior limbic keratoconjunctivitis is an example of a delayed response that usually manifests due to a thiomersal hypersensitivity and is seen as severe superior corneal staining with associated limbal and conjunctival changes11. There are many other reasons for a hypersensitivity reaction causing a red eye12. Aftercare visits may reveal that the patient is using hard lens solutions with soft lenses, or confusing soaking and cleaning solutions and even using enzyme tablets in conjunction with an incorrect solution. It is still possible to find people who forget to neutralise lenses stored in hydrogen peroxide, which is a true toxic reaction. Otherwise, the other main issues are using preserved comfort drops in an otherwise non-preserved regime, changing to a brand different from that originally recommended by the practitioner, or being sold an incorrect solution as well as buying a solution overseas with the same name but a different formulation. Although a lot of attention is paid to disinfecting solution efficacy, which does vary with different care systems, it is important to remember that good lens hygiene and compliance play a key role in minimising risks of a reaction or even more seriously a corneal infection. Most toxic or allergic reactions result in diffuse staining over the whole cornea that may appear before the symptoms are evident. This type of corneal change may be picked up at an aftercare visit where the patient is coming for a routine appointment and not complaining of any symptoms. On identifying a diffuse pattern of staining in a patient using a preserved system, the first action of choice is to change the care regime, preferably starting the new system with a fresh lens. Most multipurpose solutions are used for monthly, three monthly or even six monthly planned replacement lenses but if the patient is wearing a conventional soft lens that is not near to its years end then putting the lens through a saline

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dilution for 24 hours should allow the start of the new system; a check-up about a week later will show whether the problem has disappeared. Typical situations are the ones where one observes diffuse staining and possibly some minor palpebral changes in a patient using a system preserved with polyhexamethylene biguanide (Dymed) who, when transferred to a polyquad preserved system, shows no evidence of staining on a further visit, the previous signs now having disappeared. In more serious cases with pronounced symptoms, the signs seen are conjunctival, limbal and palpebral hyperaemia, conjunctival chemosis, corneal superficial punctate keratitis and infiltrates. Another way of managing the problem is to change the patient to daily disposable lenses. This is why daily disposable lenses, besides being useful for people lazy and non-compliant about using their care systems, are also a very useful way of dealing with these sensitivity problems.

minimal or moderate complaints of redness.

Allergy
A wide range of substances may induce an acute conjunctival allergic reaction, the severity of which is determined by the duration and concentration of the antigen, the degree of sensitisation and the immunological status of the patient. The most frequently associated problem with contact lens wear is contact lens associated papillary conjunctivitis (CLAPC).
Contact lens-associated papillary conjunctivitis (CLAPC)

Contact lens deposition

Red eyes are also seen with contact lens deposition, usually a reaction to denatured protein. Another scenario is staphylococcal exotoxins accompanied by a Type IV (cell mediated) immune response to cell wall antigens and other foreign proteins. The result is a keratoconjunctivitis, which resolves on discontinuation of lens wear. Typical symptoms are chronic irritation, feelings of dryness and redness. Findings are bulbar and tarsal hyperaemia, conjunctival follicles and superficial keratopathy. Predisposing associations are atopy and posterior eyelid margin disease. Such events usually resolve completely and permanently on discontinuation of lens wear. The individual may have become so sensitised that even the continued presence of small quantities of allergens can be sufficient to sustain a response even in the absence of a contact lens. However, the use of daily disposable lenses on a part-time basis can often keep a patient happy for social wear. More simple reasons may be the contamination by make-up or facial creams that can disturb the lens surface or tear film stability, which can then give rise to

CLAPC is an inflammation of the papillary conjunctiva of, usually, the upper lids, characterised by the presence of irregularly shaped papillae. These may appear similar to those found with vernal catarrh, but are histologically different and progress in four distinct stages13: 1. Preclinical stage with mild increase in mucous production. 2. Conjunctival hyperaemia and thickening with slight elevation of the normal papillae. Vascular tufts can be seen in the papillae. 3. Formation of larger papillae from coalescent smaller papillae, often starting from the inner and outer canthi. 4. Formation of elevated, giant papillae with flattened heads. Contact lens wearers are usually seen at stages 1 or 2 (Figure 2). The symptoms are quite distinctive. The patient complains of ocular itching, which becomes more pronounced on lens removal and yellow, mucous discharge, which is most pronounced on waking. In addition, blurred vision may be reported as a result of deposits on the lenses and mucous being smeared periodically across the lens surface. As the condition progresses, the patient will complain of reduced lens tolerance as the contact lens is decentered and moves excessively14. Patients with CLAPC demonstrate a wide variety of lid types but a useful technique is to compare the lower lid with the upper, thereby using the lower lid as a base line indicator for the amount of hyperaemia and size of papillae. A symptomatic patient with CLAPC will almost always demonstrate increased hyperaemia of the upper lid compared to the lower. CLAPC may be either unilateral or bilateral and, although more typically a problem with the wear of soft lenses, it can be found with all lens types15. The aetiology is probably multi-factorial. In an immediate hypersensitivity response, immunoglobulin type E (IgE) antibodies proliferate and set off a reaction that leads to mast cell degranulation and release of inflammatory mediators. Protein deposition has been implicated but lipids,

Figure 2
Contact lens-associated papillary conjunctivitis stage 2

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calcium and mucous could be the contaminant. Early generation soft lens solution preservatives have been strongly implicated. For delayed hypersensitivity, the antigens are the same as for immediate hypersensitivity. Atopic individuals are more susceptible. Causes of CLAPC include an allergic response to a lens material and/or mechanical irritation from contact lens wear. Essentially, in CLAPC, the conjunctiva thickens, the number of mucous-secreting non-goblet cells is increased and there is a dramatic redistribution of inflammatory cells. Although this may occur with both lens types, there is a difference in the appearance of CLAPC in an HGP lens wearer compared to a soft lens user soft lenses induce numerous papillae located on the tarsal plate whilst in HGP lens wear they are coalesced near to the lid margin. Resolving CLAPC may require several courses of action. In soft lens wearers, changes to the modality of contact lens wear are essential, preferably changing to daily disposable lenses or a maximum of a one-month wearing schedule. If on extended wear, it is vital to stop and consider a daily wear option. If disposability is not an option as the patient needs to wear conventional soft lenses, then new soft lenses should be fitted ensuring that a surfactant cleaner is used daily for up to 30 seconds and enzyme tablets are used more frequently. It is useful to recommend non-preserved solutions. In HGP lens wearers, as with soft lenses, a different material should be considered; avoid silicon acrylates but consider fluoropolymers or a new hybrid material. To reduce mechanical factors, fit a thinner lens design, alter the lens material or even cease lens wear, for up to three months. Recommend the use of mast cell stabilisers, such as Opticrom (2% sodium cromoglycate), Alomide or Rapitil, or in extreme cases referral for medical treatment with steroids such as Predsol-n or NSAIDs (non-steroidal anti-inflammatory agents), can also be considered. None of these medications are recommended in conjunction with soft lens wear and they will not produce immediate relief from symptoms, or a reduction in the size of the papillae. Cold compresses and ocular lubricants are more likely to produce rapid symptomatic relief whilst it will take a few days or weeks for the symptoms to subside. If the patient is atopic, there is more likely to be a change in papillary reaction after one months use of a mast cell stabiliser, so a further month should calm the situation effectively, although it may take many months to be resolved. However, although atopic subjects have greater success with a mast-cell stabiliser, the problems may recur.

can induce an increase in hyperaemia without manifesting any other problems. Following on from this, one should always check that it is not the conjunctiva that is moving when checking lens fitting characteristics, as lenses can embed in the conjunctival tissue and both move together rather than each freely on a blink. Contrary to this is the impact of wearing silicone hydrogels where the graded hyperaemia is often less than the normal or their wear will reduce the reaction seen with soft lens wear16. This is surprising as silicone hydrogels have a high modulus of elasticity and so are stiffer than other soft lens materials. As one would expect more mechanical trauma rather than less with silicone hydrogels, one must conclude that the increase in oxygen with these materials must be the overriding factor.
Foreign bodies

Figure 3
Horizontal hyperaemia associated with three and nine oclock staining

These are much more common with HGP lenses and severe, painful, corneal epithelial abrasions are most commonly associated with the wear of rigid lenses. The damage to the corneal epithelium, however, can sometimes be greater with soft lenses because the foreign body remains trapped behind the lens for a longer period of time. Patients complain of sudden, acute pain during the wearing day often associated with sectorial redness. The lens must be removed and fluorescein instilled to assess the depth of staining with a slit lamp optical section. Treatment consists of irrigation if the foreign body is still trapped, and instillation of a broad spectrum of antibiotics. Usually, the eye should not be padded because of the risk of incubating pseudomonas in a contact lens wearer.
Corneal abrasions

Figure 4
Vascularised limbal keratitis completely by counteracting the cause. Often, the final stage of three and nine oclock staining is a vascularised limbal keratitis (Figure 4). This manifests as a round, ill defined, semi-opaque elevated corneal nodule about 0.50mm from the limbus, located either nasally or temporally at three or nine oclock or at four or eight oclock. Oedema and coalesced superficial staining may be observed adjacent to the lesion. There will be associated localised intra-palpebral conjunctival injection and frequently, an epithelial erosion at the apex of the nodule which has localised, superficial and stromal vascularisation. It is again an HGP-induced problem, the aetiology of which is chronic irritation to the peripheral cornea from large diameter, low edge lift rigid lens designs. The lesion may be secondary to localised tear film disruption. In all rigid lens problems, if the cause is the lens surface then there are a number of new superior wetting lens materials of a hybrid nature, which encourage the spread of the tears over the surface more readily. Whilst adjusting an edge design is simple, getting a patient to comply with rewetting or blinking more frequently, and/or finding the best material for them is much more difficult. Soft lenses, obviously by their hydrophilic nature, require a good tear film to keep up their balance of water, which is necessary for physiological and optical reasons. Although there is initial dehydration when a lens is inserted onto the eye due to the temperature difference between the container and the ocular surface, if there is a further unacceptable amount of water loss the lens will tighten with continued wear. Before we had

Severe abrasions cause symptoms similar to those resulting from foreign bodies. Epithelial mechanical trauma can be caused by poor lens handling, typically by fingernails, inserting or wearing damaged lenses, lenses breaking in the eye, and fitting problems.

Tear deficiency
Localised ocular redness is typically seen with the wear of HGP lenses, commonly known as three and nine oclock staining. Three and nine oclock staining is the disruption of the epithelial surface due to tear film instability or inadequate tear film, incomplete blinking, wide palpebral apertures, lens material surface disturbance or lens design issues. It is common in rigid lens wear but rare with soft lenses. Horizontal hyperaemia is often the initial symptom for the patient, and is typically noticed after a day at work staring at a PC screen (Figure 3). The fluorescein staining observed is in the nasal and temporal corneal margins adjacent to the lens edge. The problem is resolved partially or

Mechanical trauma
With soft lens wear, the direct contact between the contact lens and conjunctiva

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materials with a substantial amount of bound water, one did see a number of cases where the lens would dig into the conjunctival tissue causing conjunctival redness at the lens edge and an impression in the tissue which on lens removal, left an indentation that looked as if the lens was still in place. This is a rare occurrence these days as usually any problematic tightening can be picked up at the initial fitting, but if there is a tear deficiency, a number of changes may arise not all with a corresponding mild to moderate red eye. Tightening of a lens with wear may mean that there is a problem manipulating the lens from the cornea or, often, the patient reports that the lens seems very dry when it is removed. Besides mild redness, the conjunctiva may also show perilimbal staining coincident with the lens edge. In other circumstances where the cornea shows inferior staining in the lower quadrant of the cornea known as a SMILE stain, one does not necessarily see any associated conjunctival redness. Biomimetic materials such as Proclear are useful in these cases due to their amount of bound water, whilst the silicone hydrogels with their low water content should also be helpful in some circumstances. Although thickness of material generates a more stable tear film, the design of some lenses does seem to mean that some of the thinner daily disposables are acceptable for comfort even if it is only for social use. Tear film dysfunction can be due to the quality or quantity of the tears. With longterm contact lens wearers, one needs to discuss the fact that the tear film will change over time, contact lens wear will cause more disruption and if the patient is female, it is likely there will be added changes during the menopause even when taking HRT. These factors, coupled with the tendency for the conjunctival tissue to become more lax with age, will add to the causes of mild conjunctival redness seen with the older generation of contact lens wearers. A large variety of rewetting drops are available, all with a slightly different formulation. Their use will partly depend on which component of the natural tears is most deficient whilst some drops are more

suited to an individual than another. Aqueous artificial tears are cellulose derivatives that have a short retention time and require frequent instillation. Polyvinyl alcohol (PVA) is used as a wetting agent to improve the tear break-up time, but it does require buffering and so may give rise to mild discomfort on instillation for a few minutes. However, these agents do not blur vision so are helpful in the work environment. Viscoelastics are gel polymers which, due to their dual nature of high viscosity when stationary but water-like on a blink, tend to be used as an alternative if a better retention time is needed. There are a number of newly released contact lens comfort drops which include sodium hyaluronate as their viscoelastic; these reduce evaporation and enhance the spreading of the tear film during blinking, whilst giving generally a more stable tear film. The more stable the tear film, the happier the ocular surface and the whiter the eye.

Conclusion
Part one of this article has concentrated on the non-inflammatory and non-infective reasons for a contact lens-related red eye. In many instances, a patient may present with one or more causes of contact lens-related red eye as a cause of limbal and or conjunctival redness. Therefore, plans of action or advice can cover a number of issues and if a practitioner is not completely sure of the cause, it is advisable to only change one matter at a time in order to isolate the reason for the associated redness.

References
1. McMonnies CW and Chapman Davies (1987) An assessment of conjunctival hyperaemia in contact lens wearers Part I. Am. J. Optom. Physiol. Opt. 64: 246250. 2. McMonnies CW and Chapman Davies (1987) An assessment of conjunctival hyperaemia in contact lens wearers Part II. Am. J. Optom. Physiol. Opt. 64: 251255. 3. Holden BA, Sweeney DF and Sanderson G (1984) The minimum pre-corneal oxygen tension to avoid corneal

oedema. Invest. Ophthalmol. Vis. Sci. 25: 476-80. 4. Papas EB (2003) The role of hypoxia in limbal vasculature response to soft contact lens wear. Eye & Contact Lens 29 (Suppl) S72-S74. 5. Covey M, Sweeney DF, Terry R et al (2001) Hypoxic effects on the anterior eye of high-Dk soft contact lens wearers are negligible. Optom. Vis. Sci. 78: 9599. 6. Holden BA, Sweeney DF, Swarbrick HA et al (1986) The vascular response to long-term extended contact lens wear. Clin. Exp. Optom. 69: 112-119. 7. Bonanno JA and Polse KA (1987) Corneal acidosis during contact lens wear: effects of hypoxia and CO2. Invest. Ophthalmol. Vis. Sci. 28: 1514-20. 8. Efron N and Ang JHB (1990) Corneal hypoxia and hypercapnia during contact lens wear. Optom. Vis. Sci. 67: 512. 9. Efron N (2004) Contact Lens Complications 2nd ed. Butterworth Heinemann, Oxford. 10. Cho P, Lui T and Chea-su K (1998) Soft contact lens care systems and corneal staining in Hong Kong-Chinese. Contact Lens & Ant. Eye 21; 2: 47-53. 11. Wilson-Holt N and Dart JKG (1989) Thiomersal keratoconjunctivitis, frequency, clinical spectrum and diagnosis. Eye 3: 581-587. 12. Gasson A and Morris J (2003) The Contact Lens Manual: A Practical Fitting Guide 3rd ed. Butterworth Heinemann, Oxford. 13. Allansmith MR, Korb DR and Greiner JV (1977) Giant papillary conjunctivitis in contact lens wearers. Am. J. Ophthalmol. 83: 697. 14. Allansmith MR (1987) Pathology and treatment of giant papillary conjunctivitis: the US perspective. Clin. Ther. 9: 443. 15. Bailey CS (1999) Contact lens complications. Optometry Today 39; 11: 26-33. 16. Papas EB, Vajdic CM, Austen R and Holden BA (1997) High oxygen transmissibility soft contact lenses do not induce limbal hyperaemia. Curr. Eye Res. 16; 9: 942-948.

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MCQs Module 7 Part 2 of Therapeutics in practice Part 1: The contact lens-related red eye
1. Under hypoxic conditions, which one of the following substances is strongly implicated in the cause of corneal oedema? a. Glycogen b. Lactate c. Pyruvate d. Carbon dioxide 2. Which one of the following is NOT a mechanism that alters ocular blood flow? a. Neural control of the vascular smooth muscle b. Myogenic control altering vessel diameter c. Metabolic control associated with the release of carbon dioxide d. Humoral control associated with the release of histamine 3. At what stage is it advised to definitely intervene in a contact lens wearer exhibiting hyperaemia? a. Grade 1 b. Grade 2 c. Grade 3 d. Grade 4 4. Which one of the following statements is incorrect regarding the physiological complications of contact lens wearers? a. Adapted hard gas permeable (HGP) lens wearers exhibit more hyperaemia than adapted soft lens wearers b. Either hypoxia and/or an acidic shift in pH results in the relaxation of arteriole smooth muscle c. In a myope wearing soft lenses, oedema is more obvious in the periphery d. Hyperaemia seems to be linked to hypoxia

Please note there is only ONE correct answer

9. Which one of the following will probably have the least effect on CLAPC? a. Lid scrubs b. Change of lens material c. Frequent removal of protein from contact lenses d. Frequent disposing of lenses 10. Which one of the following drugs is used frequently in the treatment of CLAPC? a. Dexamethasone b. Chloramphenicol c. Sodium cromoglycate d. Vitamin A drops 11. After eight hours of use, a soft lens wearer shows an arcuate inferior corneal punctate staining with fluorescein. The most likely cause is: a. CLAPC b. ocular dryness c. conjunctival infection d. faulty contact lens 12. Which one of the following statements is incorrect regarding foreign bodies? a. Foreign bodies are more common in HGP wearers b. The degree of damage to the corneal epithelium may be greater with soft lenses c. Patients will complain of a sudden, acute pain d. All patients with a foreign body should be patched

5. Corneal pH has been implicated in the control of all of the following except: a. glycolysis b. membrane ion secretion c. mitotic activity d. hypersensitivity 6. Which one of the following statements is incorrect regarding delayed hypersensitivity? a. It can manifest over months or years b. It is a T-cell mediated reaction c. SLK is an example of a delayed hypersensitivity reaction d. It is predominantly a B-cell mediated reaction 7. Which one of the following statements is incorrect regarding contact lens-associated papillary conjunctivitis (CLAPC)? a. In the preclinical stage, there is a mild increase in mucous production b. Only vascular tufts can be seen around the base of the papillae c. Giant papillae exhibit flattened heads d. Conjunctival hyperaemia and thickening will be observed 8. All of the following are symptoms of CLAPC except: a. ocular itching which is worse when the lenses are in the eye b. ocular itching which is worse on lens removal c. a yellow mucous discharge which is most pronounced on waking d. blurred vision as a result of protein deposits

An answer return form is included in this issue. It should be completed and returned to: CPD initiatives (c4750h), OT, Victoria House, 178-180 Fleet Road, Fleet, Hampshire, GU51 4DA by September 8, 2004. Under no circumstances will forms received after this date be marked the answers to the module will have appeared in our September 10 issue and scores sent electronically to the accrediting bodies.