Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx

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Contact Lens and Anterior Eye

journal homepage: www.elsevier.com/locate/clae

A survey of contact lens-related complications in a tertiary hospital in

China☆
⁎
Weiwei Lia, Xuguang Sunb, , Zhiqun Wangb, Yang Zhangb
a
Tianjin Eye Hospital, Tianjin Ophthalmology and Visual Development Key Laboratory, Clinical College of Ophthalmology, Tianjin Medical University, 4, Gansu Road,
Heping District, Tianjin 300020, China
b
Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Sciences Key
Laboratory, 17 Hou Gou Lane, Chong Nei Street, Beijing 100005, China

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: To describe the type of complications related to contact lens (CL) wear in a tertiary hospital in XX,
Complications China.
Contact lens Methods: A retrospective study of 141 patients who complained discomfort after wearing contact lens on an
China outpatient basis of XX Hospital were conducted from the January 2012 to December 2015. The data included
Meibomian gland dysfunction
patients’ demographics, lens type, history, slit-lamp examination, reports of corneal scrapings, culture, and
Blepharitis
examination of in vivo confocal microscopy. Binary logistic regression was used to analyse the possible factors
which were associated with more severe corneal complications and superficial punctuate keratitis (SPK).
Results: About 86.52% were female and 13.48% were male, the age varied between 12 and 56 years old. Of the
141 patients, 82.27% were soft CL wearers, 2.84% were rigid gas permeable lens (RGP) wearers, and 14.89%
patients used overnight orthokeratology. The most common complication was dry eye (36.88%), followed by
SPK (36.17%) during these cases. Blepharitis and meibomian gland dysfunction (MGD) were noted in 31.91% of
cases. Microbial keratitis was seen in 15 patients including 7 cases of Acanthamoeba keratitis. Age was a sig-
nificant factor to be a case of corneal infection or inflammation [Exp (B)was 0.918, p = 0.030], MGD and
blepharitis was found to be significantly associated with being a case of SPK [Exp(B)was2.276, p = 0.047].
Conclusions: The commonest complication was dry eye in this study, followed by SPK. Lid margin and meibo-
main gland should be paid attention to before contact lens prescription. Younger CL wearers need follow-up
examinations.

1. Introduction 2. Materials and methods

Contact lenses (CLs) are used popular for refractive correction and
medical purposes. It is reported that approximately 125 million people
wear CL worldwide [1]. One study has estimated that 6% of CL wearers
develop a complication each year [2]. So CL related complications are
an important part of ophthalmic practice. The conditions range from
benign allergic conjunctivitis to serious and vision-threatening micro-
bial keratitis [3]. Surveys on CL related complications had been done in
many countries and areas, including Asia [1,4–8]. In this study, the
conditions of CL related complications were analyzed in a tertiary
hospital in XX, China.
This was a retrospective study during the January 2012 to
December 2015. Patients who had refractive errors complained dis-
comfort after wearing CL on an outpatient basis of XX Hospital were
included. Patients who had previous corneal diseases and surgeries
were excluded. The lens type included soft CL (SCL) and rigid CL [rigid
gas permeable lens (RGP) and orthokeratology]. One hundred and
forty-one patients were involved in this study. All the patients were
diagnosed by the same experienced ophthalmologist. The data on pa-
tients’ demographics, lens type, history, chief complaint, slit-lamp ex-
amination were collected. The values of Schirmer’s I test and breakup
time(BUT) were recorded. The reports of corneal scrapings, culture, and
examination of in vivo confocal microscopy in the cases with compli-
cations like microbial keratitis and infiltrative keratitis were also

☆
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
⁎
Corresponding author at: 17 Hou Gou Lane, Chong Nei Street, Beijing 100005, China.
E-mail addresses: lww994012@163.com (W. Li), sunxg2010@163.com (X. Sun), eyewzq@163.com (Z. Wang), 331469388@qq.com (Y. Zhang).

http://dx.doi.org/10.1016/j.clae.2017.10.007
Received 26 March 2017; Received in revised form 30 September 2017; Accepted 6 October 2017
1367-0484/ © 2017 Published by Elsevier Ltd on behalf of British Contact Lens Association.

Please cite this article as: Li, W., Contact Lens and Anterior Eye (2017), http://dx.doi.org/10.1016/j.clae.2017.10.007
W. Li et al. Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx

collected. A multifunctional topographer (Keratograph 5 M, Oculus, Table 2

Inc) was used to exam the meibomian gland images. This study was Results of binary logistic regression analyses for the factors possibly associated with
corneal infection and inflammation.
conducted in accordance with the Declaration of Helsinki.
The complications commonly associated with CL wear [1,3] include Factor B Exp(B) p value
superficial punctuate keratitis(SPK), corneal edema, corneal abrasion,
contact lens-induced acute red eye(CLARE), infiltrative keratitis, con- Gender −0.011 0.989 0.986
Age −0.085 0.918 0.030
tact lens peripheral ulcers(CLPUs), microbial keratitis, neovasculariz-
Lens type −0.288 0.750 0.601
tion of the cornea, giant papillary conjunctivitis(GPC), superior limbic Years of CL wear(≤2 years or > 2 years) 0.347 1.415 0.532
keratoconjunctivitis(SLK), injection of the conjunctiva, follicles, allergic
conjunctivitis, and other conditions like dry eye, blepharitis and mei- CL, contact lens.
bomian gland dysfunction(MGD). Dry eye was diagnosed as following
one of the two criteria: (1) presence of symptoms of dry eye; either complication. Blepharitis and MGD were noted in 45 (31.91%) cases.
BUT≤5s or Schirmer’s I test ≤5 mm/5 min; (2) presence of symptoms Microbial keratitis was seen in 15 patients (9 cases of SCL and 6
of dry eye; positive ocular surface fluorescein staining; either 5s < cases of orthokeratology). Seven patients (8eyes) were Acanthamoeba
BUT≤10s or 5 mm/5min < Schirmer’s I test ≤10 mm/5 min. Ble- keratitis, tap water was used for lens cleaning in 3 cases who used or-
pharitis was identified as following criteria: (1) a long history of chronic thokeratology. One patient was wearing SCL during bath, and another
ocular inflammation, recurrent styes or chalazia, with or without se- patient wore SCL overnight. All corneal scraping were positive for
borrheic dermatitis or acne rosacea. (2) presence of the following Acanthamoeba, and Acanthamoeba cysts were seen by in vivo confocal
symptoms: itching or burning of eyelids, eye dryness, irritation, tearing, microscopy in all cases. Culture for Acanthamoeba was positive in 6
redness, photophobia, foreign body sensation, contact lens intolerance. cases. Two patients had therapeutic keratoplasty while others re-
(3) clinical examination include lid margins hyperemia, morphological sponded well to medical therapy. Eight patients (8 eyes) were diag-
change of the lid margins, altered eyelash appearance, change of nosed as bacterial keratitis, 4 patients wore SCL overnight. Pseudomonas
meibum character. Lid margins hyperemia is necessary [9,10]. The aeruginosa were isolated in 3 cases, Staphylococcus was isolated in 1
diagnosis of MGD was made by clinical examination, based on gland- case. All of the eight patients responded well to medical therapy.
ular obstruction and meibum quality [10,11]. The results of binary logistic regression were summarized in Tables
Statistical analysis was performed using the SPSS statistical software 2 and 3. The results showed that age was a significant factor to be a case
package (SPSS for Windows, version17.0; SPSS, Inc, Chicago, IL). of corneal infection or inflammation [Exp(B)was 0.918, p = 0.030].
Binary logistic regression was used to analyse the possible factors which Younger CL wears seem to have more corneal infection and in-
were associated with more severe corneal complications (infection and flammation. Except 29 cases of corneal infection or inflammation, MGD
inflammation, including microbial keratitis, CLARE, infiltrative kera- and bepharitis was found to be significantly associated with being a
titis and CLPUs [12]) and SPK. A p value less than 0.05 was considered case of SPK during the remaining 112 cases [Exp(B)was2.276,
statistically significant. p = 0.047].

3. Results 4. Discussion

There were 141 patients included in this study, 122(86.52%) were
female and 19(13.48%) were male. The age varied between 12 and 56
years old (mean 28.08 ± 7.97 years old). Of the 141 patients, 116
(82.27%) were SCL wearers(including 11 colored cosmetic CL wearers),
4 (2.84%) were RGP wearers, and 21 (14.89%) patients used overnight
orthokeratology.
The complications showed in Table 1. Eighty-six patients (60.99%)
had more than one complication. More than one third of the patients
(36.88%) had dry eye. The commonest corneal complication was SPK
(36.17%), and GPC (16.31%) was the most common conjunctival
It is reported that the prevalence of CL related ocular complications
was to be as high as 39% [13]. Many practitioners focused on the
studies in this area. However, few studies reported CL related compli-
cations in China so far. The aim of this study was to describe CL related
complications in a tertiary hospital in XX.
In this study, the patients of SCL wearers were the most, this is
consistent with other studies [1,4,5] and the surveys of trends in CL
prescribing [14–16]. Another reason may be that rigid CL had a lower
average number of complications than SCL due to its lens material and
wear modality [1]. Moreover, most RGP wearers were keratoconus in

Table 1
The complications in different lens types.

Complications No. of patients(%) SCL(%) RGP(%) orthokeratology(%)

Microbial keratitis Bacterial keratitis 8 (5.67%) 7(6.03%) 0(0) 1(4.76%)

Acanthamoeba keratitis 7 (4.96%) 2(1.72%) 0(0) 5(23.81%)
SPK 51 (36.17%) 44(37.93%) 1(25%) 6(28.57%)
Corneal edema 1 (0.71%) 1(0.86%) 0(0) 0(0)
Corneal abrasion 3 (2.13%) 1(0.86%) 1(25%) 1(4.76%)
CLARE 3 (2.13%) 3(2.59%) 0(0) 0(0)
Infiltrative keratitis 5 (3.55%) 5(4.31%) 0(0) 0(0)
CLPUs 6 (4.26%) 6(5.17%) 0(0) 0(0)
Neovasculariztion 7 (4.96%) 6(5.17%) 0(0) 1(4.76%)
GPC 23 (16.31%) 20(17.24%) 0(0) 3(14.29%)
SLK 1 (0.71%) 1(0.86%) 0(0) 0(0)
Injection of the conjunctiva 4 (2.84%) 2(1.72%) 0(0) 2(9.52%)
Follicles 7 (4.96%) 5(4.31%) 0(0) 2(9.52%)
Allergic conjunctivitis 15 (10.64%) 14(12.07%) 0(0) 1(4.76%)
Dry eye 52 (36.88%) 45(38.79%) 2(50%) 5(23.81%)
Blepharitis and MGD 45 (31.91%) 42(36.21%) 0(0) 3(14.29%)

SCL, soft contact lens; RGP, rigid gas permeable contact lens; SPK, superficial punctuate keratitis; CLARE, contact lens-induced acute red eye; CLPUs, contact lens peripheral ulcers; GPC,
giant papillary conjunctivitis; SLK, superior limbic keratoconjunctivitis; MGD, meibomian gland dysfunction.

2
W. Li et al.
Table 3
Results of binary logistic regression analyses for the factors possibly associated with SPK.
Factor B Exp(B)
Gender −0.902 0.406
Age −0.028 0.972
Lens type 0.079 1.083
Years of CL wear(≤2 years or > 2 years) 0.066 1.069
MGD and blepharitis 0.822 2.276
Dry eye 0.018 1.198
SPK, superficial punctuate keratitis; CL, contact lens; MGD, meibomian gland dysfunc-
tion.
China which were excluded in this study. So the patients who wear RGP
were the smallest in this survey. The mean age of patients of this survey
is consistent with the mean age of patients in other studies in Asia [4,5].
The rate of female patients was higher than others [4,5,7], most likely
because women are more frequent users in China. Due to the potential
of orthokeratology for myopic control in children, the use of ortho-
keratology was increased in China. It is reported that there are more
than 1.5 million orthokeratology patients in the whole of China [17]. As
a result, many cases of complications associated with orthoeratology
have been observed.
It showed that 60.99% of the patients had more than one compli-
cation, which is higher than the previous study [1]. The most common
complication of this study was dry eye. Dryness and discomfort were
common related problems reported by CL wearers [18]. It was reported
that lens related dry eye is observed in over 50% of contact lens
wearers, which was significantly increased relative to spectacle wearers
and clinical emmetropes using the same criteria [19]. A common ex-
planation is that the lenses can disrupt normal tear physiology through
thinning and break-up of the tear film, with consequent increases in
tear film evaporation [20]. MGD can also affect the lipid layer and be a
cause of dry eye [21]. The rate of blepharitis and MGD in this study was
as high as 31.91%. Although MGD and blepharitis can be found in non
contact lens wearers, some studies found that lens wear is associated
with adverse changes in meibomian gland morphology and in the
condition of the lid margin and meibum [22]. As a result, lid margin
and meibomain gland should be paid attention to before contact lens
prescription. Similar to the India and Nepal study, SPK was also re-
ported as one of the commonest complications in this study [5,7,23].
There are several causes including mechanical injuries, chemical toxi-
city to topical preservatives, hypoxia, tight lens syndrome, overwear
and dry eye [3]. The blepharitis and MGD may also be an important
factor which can cause SPK [24]. GPC was another commonest com-
plication which is consistent with previous reports [1,5,7], but the rate
was a little lower in this study.
Microbial keratitis is the most serious complication of CL wear. In
this study, 10.63% of the patients were infected by Acanthamoeba and
bacteria. This was higher than the surveys in India [5] and Nepal [7],
but lower than the survey in Singapore [4]. There were also several
reports in Asia showing CL wear as the main identifiable risk factor in
microbial keratitis [6,25]. Non-compliance with contact lens wear was
identified as a significant risk factor for microbial keratitis [26], in-
cluding wearing SCL overnight, exposure of the contact lenses to tap
water in this study. It is notably that nearly one half of the microbial
keratitis in this study were Acanthamoeba keratitis, most likely because
this survey was conducted in a tertiary referral center where more se-
vere cases are refer to. Moreover, the author had already reported the
orthokeratology related infectious keratitis including Acanthamoeba
keratitis [27,28], who have some experience in the diagnosis and
treatment of Acanthamoeba keratitis. In addition, blepharitis has been
also reported to be at greater risk of contact lens associated infection,
because there is a known source of pathogenic microbes in close
proximity to the ocular surface, such as Staphylococcus sp. [29].
It was indicated that younger CL wearers had more corneal infection
Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx
and inflammation. That is consistent with previous study, which might
be attributed to their poor CL hygiene and the up-regulation of auto-
immune reaction that begins in late adolescence [30]. Another study
p value
also reported that the mean age of 13 patients who developed severe
0.166 microbial keratitis after the use of colored cosmetic CL were 19 ± 3.8
0.575 years [31]. As a result, teenage and young adult CL wearers should
0.879
correct non-compliant behavior and need follow-up examinations.
0.910
0.047 In conclusion, this study is a case series which just described the
0.672 type of CL related complications in a tertiary hospital in XX, China.
There are some limitations. The patients in this study was those who
complained discomfort after wearing CL rather than all CL wearers, so
those complications which are mild or asymptomatic were rare or not
observed in this study. Because this survey was conduct in one hospital,
there was bias of the rate of complications. The risk factors of these
complications also need further studies.
Conflicts of interest
None.
Acknowledgment
The authors thank Dr. Yanlin Gao for her generous help of com-
ments and data analysis.
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