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Original Article

Prevalence of contact lens-related

complications among wearers in Saudi Arabia
Yousef Homood Aldebasi1, Muhammad Ijaz Ahmad1,2, Manzoor Ahmad Qureshi1,3, Salah Mesalhy Aly4
Department of Optometry, College of Applied Medical Sciences, Qassim University, Kingdom of Saudi Arabia, 2Department of
1

Ophthalmology, Allied Hospital, Punjab Medical College, Faisalabad, 3Department of Ophthalmology, Liaquat University of Medical and
Health Sciences, Jamshoro, Pakistan, 4Department of Pathology, College of Veterinary Medicine, Suez Canal University, Ismailia, Egypt

Address for correspondence: Dr. Muhammad Ijaz Ahmad, Department of Optometry, College of Applied Medical Sciences, Qassim University, Kingdom of Saudi Arabia.
E-mail: dejazbhatti@gmail.com

ABSTRACT
Purpose: To study the compliance of contact lens (CL) wearers and the prevalence of CL-related ocular
complications. Materials and Methods: This was a cross-sectional study conducted from December 2012 to May
2013 which included CL wearers coming to outpatient department or emergency department where these patients
underwent ophthalmic examination. An interview was performed about the use and care of CLs. Results: The
study included 102 patients, where 26 (25.50%) were men and 76 (74.50%) were women. Patients ages ranged
from 13 to 55 with an average (mean standard deviation) 29.48 years. Results showed myopia in 41 (40.19%),
hyperopia 13 (12.74%), astigmatism 37 (36.27%), keratoconus 8 (7.84%), and others 3 (2.94%). More than 2/3
of the patients had, at least, one complication in their eyes. The average complication rate of gas permeable (GP)
lenses was significantly (P < 0.04) lower than soft CLs (SCLs) (0.75). The most common complications were papillae,
giant papillary conjunctivitis, conjunctival injection, corneal infiltrates, and corneal abrasions in both GPs and SCLs
wearers. Silicone SCLs had a lower average number of complication rates per eye (0.73) than nonsilicone SCLs
(0.76), but the difference was not statistically significant (P = 0.19). Extended wear CL use was associated with
higher complication rate (86.84%) as compared to daily wear CL use (67.85%) and it was statistically significant
(P < 0.03). Conclusion: Use of CL is associated with ocular complications. Most of these complications are minor
and easily manageable. It is advised that patients should adhere with the recommendations of both manufacturer
and optometrist to avoid complications.

Key words: Contact lens-related complications, gas permeable lenses, silicone

INTRODUCTION as they are used for correction of different refractive

Throughout the world, the number of contact lens
(CL) wearers is estimated close to 125 million and
approximately 38 million people use the CL in the
United States.[1] CL complications will remain important
part of ophthalmic and optometric practice as long
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errors. Good patient compliance with the use of
CL is very important to avoid the CL-related ocular
complications and can be defined as the adherence
of the CL wearer to instructions recommended by the
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DOI: How to cite this article: Aldebasi YH, Ahmad MI, Qureshi MA, Aly SM.
10.4103/1858-540X.184238 Prevalence of contact lens-related complications among wearers in Saudi
Arabia. Sudanese J Ophthalmol 2016;8:14-9.

14 2016 Sudanese Journal of Ophthalmology | Published by Wolters Kluwer Health - Medknow

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Aldebasi, et al.: Complications of contact lenses
eye care practitioner and the manufacturers of the CLs
for lens care.
Lack of compliance with the instructions for the use
of CLs is common among the users. It is difficult to
establish the true level of compliance because there
is no direct quantitative measure of compliance.
Many studies worldwide have been conducted to
evaluate compliance using different self-reported
written questionnaires, which have shown estimates
of noncompliance ranging from 40% to 91%.[2-7]
Recently, a study conducted in the United Kingdom
for daily lens wearers, where only 0.3% of patients
were fully compliant compared with 2.7% for extended
lens wearers.[8] These studies have also reported many
patients do not know that their CL wear and care
practices are reflective of a noncompliant behavior.[2,9]
Despite the introduction of daily disposable lenses and
one-step no-rub multipurpose disinfecting solutions,
compliance with CL still remains a clinical issue.
Care of CLs, its material, durability, wearing schedule,
and many other factors play an important part in
causing ocular complications. The prevalence of
CL-related ocular complications has been reported to
be as high as 39%.[10-12]
Noncompliance with CL care has been associated with
CL-related complications. There is a significant need to
enhance compliance but the strategies to effectively
enhance the compliance are limited.
The purpose of this study is to evaluate compliance
of CL wearers and the prevalence of CL-related
complications beside their association with type of
CLs, wears schedules and other care systems.
MATERIALS AND METHODS
Ethical approval for this study was primarily obtained
from Ethical and Research Committee of Deanship of
Scientific Research, Qassim University, Kingdom of
Saudi Arabia.
This was a cross-sectional study conducted during
December 2012 to May 2013 in collaboration with
King Fahd Specialist Hospital Buraidah, which is a
tertiary care hospital in Qassim Province. Patients
coming to outpatient department (OPD) or emergency
department either directly or referred from peripheral
basic health units or ophthalmologists were included in
this research. One-hundred and two patients received
in the emergency/OPD ranging from 13 to 55 years
were included in the study. The category of lenses was
defined as nonsilicone soft CLs (SCL) and silicone CLs.
Sudanese Journal of Ophthalmology Vol. 8 Issue 1 Jan-Jun 2016
An informed consent was taken from every patient.
Each CL wearer was interviewed to collect the detailed
information about the use of CLs. Type of CL, duration
of use, wearing time and schedule, duration of lens
use during the day and other information related
to care system were collected. Patients suffering
from CL-related problems underwent ophthalmic
examination. Complete interview was performed to
assess the level of compliance.
The data were collected from the subjects examination
and included visual acuity of each eye (with or
without CLs), refractive errors, best corrected visual
acuity, type of CLs worn, lens care system used,
and wear schedule. Data were collected on the
following complications commonly associated with
CL wear: Giant papillary conjuctivitis (GPC), injection
of the conjunctiva, chemosis of the conjuctiva,
papillae, follicles, other conjunctival complications,
corneal abrasion, corneal edema, corneal infiltrates,
neovascularization of the cornea, diffused superficial
punctate keratitis (SPK), localized SPK, corneal ulcer,
superior epithelial arcuate lesion, and other corneal
complications.
A candidate who used the CLs for a minimum of 8 h a
day for a period of 6 months or more was considered
as CL wearer.
Wearing schedule was either daily or extended wear.
The extended wear was defined as continuous wear
of CL without removal for more than 2-3 days; the
extended wear classification did not include patients
who occasionally napped with their lenses.
Complication rates of CLs were calculated. A P value
of 0.05 or less was considered statistically significant.
Means and standard deviations (SDs) were also
determined. All statistical analyses were run on the
computer, using the Statistical Analysis System (SAS)
program (SAS 9.3) (SAS Institute, Cary, NC, USA).
RESULTS
This study was carried out on a total of 102 patients
waring CLs for various indications during the study
from December 2012 to May 2013 where 26 (25.50%)
were men and 76 (74.50%) were women. Patients
ages ranged from 13 to 55 years with an average age
of 29.48 (mean SD) years.
Of the 102 patients who visited the hospital for different
reasons, among those 48 (47.05%) came for painful
red eye, 33 (27.50%) with decreased visual acuity,
15 (14.70%) CL intolerance and 6 (5.88%) came for
follow-up of CL progress evaluation [Figure 1].
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Aldebasi, et al.: Complications of contact lenses

The diagnoses included myopia in 41 (40.19%),
hyperopia 13 (12.74%), astigmatism 37 (36.27%),
and keratoconus 8 (7.84%) while 3 (2.94%) were
undiagnosed cases [Figure 2].
The examined patients were using silicone and
nonsilicone SCLs in 94 (92.15%) while 8 (7.85%) were
using gas permeable (GP) lenses [Figure 3].
group 34 (60.71%). Some complications as corneal
ulcers and bacterial keratitis were exclusively found
only in extended wear group.
Out of 94 SCL wearers, 42 were wearing silicone SCLs
and 52 were wearing nonsilicone SCLs. Although, no
statistically significant difference (P = 0.19), eyes with
silicone SCLs had a slightly lower rate of complications

Among the 94 patients who used SCLs; 56 (59.57%)

were daily wear and 38 (40.43%) were found to be
extended wear, but no patients were found to be
extended wearer in GP CL users.

The wear schedule of CLs was recorded as, 64 (62.74%)

used the CLs in daily wear mode and 38 (40.43%) used
the lenses in extended wear mode.

The average number of complications for GP group

was 0.50/eye. Out of the eight patients wearing GPs
alone, the most common complications were papillae
2 (25%). Others include GPC 1 (12.5%), and diffused
SPK 1 (12.5%) [Table 1].

Among the 94 patients using SCLs alone, the average Figure 1: Describes the mode of presentation of contact lens users in
number of complications was 0.75/eye and the percentages

most common complications for SCL wearers was

conjunctival injection 16 (17.02%). Other complications
were recorded such as conjunctival chemosis 11
(11.70%), corneal infiltrates 9 (9.57%), corneal abrasions
8 (8.51%), corneal neovascularization 7 (7.44%), SPK
6 (6.38%), GPC 6 (6.38%), follicles 3 (3.19%), bacterial
keratitis 2 (2.12%), bacterial keratitis with hypopyon 2
(2.12%), and corneal ulcer 1 (1.06%) [Table 1].

The complication rate was much higher in extended

wear group 37 (97.36%) as compared to daily wear
Figure 2: Summarizes the percentage of various diagnoses detected in
Table 1: Ocular complications by contact lens type contact lens users
Category Complications GP n (%) SCL n (%)
Conjunctiva GPC 1 (12.5) 6 (6.38)
Conjunctival injection 0.0 16 (17.02)
Chemosis 0.0 11 (11.70)
Papillae 2 (25)
Follicles 0.0 3 (3.19)
Cornea Corneal abrasion 0.0 8 (8.51)
Corneal edema 0.0
Corneal infiltrates 0.0 9 (9.57)
Neovascularization 0.0 7 (7.44)
Superficial punctate 1 (12.5) 6 (6.38)
keratitis
Corneal ulcer 0.0 1 (1.06)
Bacterial keratitis 0.0 2 (2.12)
Bacterial keratitis with 0.0 2 (2.12)
hypopyon
Total number: 75, GP: Gas permeable, SCLs: Soft contact lenses,
GPC:Giant papillary conjuctivitis Figure 3: Summarizes the percentages of contact lenses used in this study

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Aldebasi, et al.: Complications of contact lenses

than with nonsilicone SCLs. The frequency of specific DISCUSSION

complications was broadly similar across silicone and
nonsilicone SCLs [Table 2]. The results from this study indicate that more than 50%
of CLs wearers were not compliant with the instructions
Regarding the compliance and care of the CLs, it was of the manufacturers. It was also detected that about
found among the SCL users 38 (40.83%), sleeping 50% of the users did not consult the professional
with the CLs showed the highest percentage of optometrists for CL usage and purchasing the CLs
complications. Fit thing and prescription of CLs were from optical shops and opticians without professional
another important segment, and it was found in our advice from the optometrists. In this study, different
study that 51% of the total cases got the CLs from modalities of CL were included, and more than 2/3
optician or optical store and remainder almost 49% of the patients had at least one complication in their
got from the professional optometrist. eyes. The most common recorded complications
were papillae, GPC, conjunctival injection, corneal
Regarding the compliance with manufacturer infiltrates, and corneal abrasions. This high rate of
recommended replacement frequency (MRRF), complications is possibly explained by the fact that,
57 (56%) wore their CLs more than the MRRF or large numbers of patients were using the lenses as
optometrist instructions. extended wear mode and showed more complications.
Furthermore, the majority of these patients who visited
Regarding the CL hygiene, 51 (50%) mentioned that the emergency department for their examination were
they cleaned their CLs cases infrequently and many not as a routine visit, this further explains the possibility
times with tap water. Related to the cleanliness of of the high rate of complications. A study conducted at
lenses 63 (61.76%) told that they did not rub and rinse the United State of America showed the complication
the lenses daily and also not replacing the solution rate in approximately 50% of the cases where the
daily. most common encountered complications were GPC,
papillae, and neovascularization.[13]
The average complication rate for GP lenses (0.50)
was lower than for SCLs (0.75) and the difference was Nagachandrika et al.; (in India) showed the
statistically significant (P < 0.04). complications in 1/4 of the CL wearers. The most
common complications encountered in this study were
Silicone SCLs had lower average complication rates CL-induced papillary conjunctivitis (6.39%), corneal
(0.73) than nonsilicone SCLs (0.76), but the difference vascularization (4%), and SPK (3.5%). Patients wearing
was not statistically significant (P = 0.19). rigid GP lenses demonstrated fewer complications as
compared to SCLs.[14]
Extended wear CL use was associated with higher
complication rate (86.84/eye) compared to daily wear Regarding the nature of complications, the current
CL use (67.85/eye) and it was statistically significant study showed GPC as the most common complication
(P < 0.03). followed by corneal infiltrates, corneal abrasions,
and conjunctival papillary response. GPC was more
Table 2: Contact lens-induced ocular complications by common in GP lenses as compared to SCLs. Above
soft contact lens type mentioned studies also have shown more or less same
Category Complications Silicone Nonsilicone type of complications where GPC was particularly more
n (%) n (%) common in these studies.[13,14] Furthermore, a study
Conjunctiva GPC 4 (7.14) 3 (5.76) conducted in Nepal showed the CL induced papillary
Conjunctival injection 6 (14.28) 9 (19.23) conjuctivitis as a major complication in SCL and it was
Chemosis 5 (11.90) 6 (11.53) detected in 36.9% of patients. The other complications
Papillae 0.0 0.0
were SPK in 16.2%, conjuctivitis in 18.2%, meibomian
Follicles 2 (4.76) 1 (1.92)
gland dysfunction in 8.6%, CL-induced peripheral ulcer
Cornea Corneal abrasion 4 (4.76) 4 (7.69)
in 4%, corneal vascularization in 3.5%, and microbial
Corneal edema 0.0 0.0
keratitis in 3%.[15]
Corneal infiltrates 4 (4.76) 5 (9.61)
Neovascularization 3 (7.14) 4 (7.69)
In our previous experimental study conducted
Superficial punctate keratitis 2 (4.76) 4 (7.69)
in 2010-2011, of the 52% cases of bacterial keratitis,
Corneal ulcer 1 (2.38) 0.0
corneal infiltrates were the most common complication
Bacterial keratitis 1 (2.38) 1 (1.92)
Bacterial keratitis with 0 2 (3.84)
found in 48% of the cases followed by corneal
hypopyon abrasions, GPC and corneal vascularization in 8%,
Total number: 71, GPC: Giant papillay conjuctivitis 10%, and 6% of the cases, respectively.[16]

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Aldebasi, et al.: Complications of contact lenses
In this study, it was observed that the prevalence of
complications was less in GP CL wearers as compared
to SCL user and difference was statistically significant
and the most complication was papillae formation
followed by GPC and SPK. Our results are almost
consistent with other studies that showing ocular
complications were associated with GP CLs.[17-19]
In this study, it was shown that the prevalence rate
was almost similar between silicone SCL wearers and
nonsilicone SCL wearers although GPC and chemosis
were slightly more prevalent in silicone SCL wearers
possibly because silicone SCL have been shown to
have a high rate of lipid deposition.[20,21]
The extended wear use of CLs was associated with
high complication rate in our sample as compared
to daily wear and the difference was statistically
significant and most common complications detected
were corneal infiltrates and bacterial keratitis. This
case of bacterial keratitis was further resulted into
hypopyon corneal ulcer. Our findings are consistent
with many previous studies conducted worldwide and
indicate that irrespective of lens type, extended wear
is associated with high complication rate particularly
corneal infiltrates and bacterial keratitis.[13,22-26]
In this study, it was found that more than 50% of
wearers purchased their CLs from opticians or optical
stores. Regarding the compliance to instructions about
56% used their lens for more period as recommended.
In the concern of lens hygiene 50% expressed that
they were cleaning the CL case infrequently and
also using tap water for this purpose and about 62%
mentioned that, they did not rub and rinse their lenses
daily and not replacing the solution daily. Our findings
are somewhat closer to some recent studies. In a
study carried by Dumbleton et al. in (Canada,2011)
also showed that 95% of the users purchased their
lenses from professional optometrist but even then
the noncompliance was high, it is indicating that
purchase source of CLs may not affect the level of
compliance, so more work is needed to improve the
level of compliance.[27,28] A study conducted in the
United States of America about the compliance of CL
wearers showed that compliance was better among
those who had extensive discussions with the eye care
practitioners about the use of CL.[29]
Another study showed that patients who are less
compliant with the instructions for using CLs also had
less full eye examination from eye care practitioners.[30]
Eye care practitioners should reinforce the importance
of all aspects of lens wear and care with their patients,
with the aim of reducing ocular complications. So, it
18
is looking very obvious that extended wear use of CL
and noncompliance with instructions always increases
the risk to develop ocular complications.
CONCLUSION
The use of CL is associated with ocular complications
regardless lens type or material. The majorities of
complications are minor and can be easily managed
while others may be severe enough to cause loss
of useful vision. Although most of the recorded
complications of the current study were neither
severe enough nor endangering vision, it is highly
advised patients to adhere with the recommendations
of the manufacturer or the optometrist and always
get the professional management when needed on
time.
Acknowledgment
All the authors are thankful to Deanship of Scientific Research
for funding this project.
Financial support and sponsorship
The Research Deanship of Qassim University, Kingdom
of Saudi Arabia.
Conflicts of interest
There are no conflicts of interest.
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