Eur J Ophthalmol 2012; 22 ( Suppl. 7 ): S17-S23 DOI: 10.5301/ejo.

5000079

ORIGINAL ARTICLE

Contact lens–related dry eye and ocular surface

changes with mapping technique in long-term soft
silicone hydrogel contact lens wearers
Tomris Sengor1, Sevda Aydin Kurna1, Nurver Ozbay2, Semahat Ertek2, Suat Aki1,
Ahmet Altun1
1
Ophthalmology Clinic, Fatih Sultan Mehmet Education and Training Hospital, Istanbul - Turkey
2
Pathology Clinic, Fatih Sultan Mehmet Education and Training Hospital, Istanbul - Turkey
Pathology Clinic, Fatih Sultan Mehmet Education and Training Hospital, Istanbul - Turkey
Ophthalmology Clinic, Fatih Sultan Mehmet Education and Training Hospital, Istanbul - Turkey
Ophthalmology Clinic, Fatih Sultan Mehmet Education and Training Hospital, Istanbul - Turkey

Purpose. To evaluate ocular surface changes in long-term silicone hydrogel contact lens wearers.
Methods. Thirty patients were included in this study. Twenty patients (40 eyes) using contact lenses
constituted group 1 and 10 (20 eyes) volunteers constituted group 2. The duration of average contact
lens usage was 7.74±3.3 years. Ocular surface was evaluated by surface staining, tear film break-
up time (TBUT), Schirmer I test, and conjunctival impression cytology with color-coded mapping
technique and by the Ocular Surface Disease Index (OSDI).
Results. The mean break-up time was lower and staining scores were higher in group 1 (p<0.001)
but Schirmer values were not significantly different from group 2 (p>0.05). The mean OSDI score was
34.59±11.93 to 19.28±6.7 in group 1 and 2. Increased metaplastic predominant changes of grade II
and III were observed in the interpalpebral and perilimbal areas in group 1. Significant correlations
were observed in TBUT, cornea staining, and grade II to grade III metaplasia ratios between duration
of the lens usage and contact lens wear time in a day.
Conclusions. Silicone hydrogel lenses produce significant changes on tear film and impression cytology
of the ocular surface in long-term use.

Key Words. Contact lens side effects, Dry eye, Impression cytology, Ocular surface, Ocular Surface
Disease Index
Accepted: October 17, 2011

INTRODUCTION of high water content lenses, which have traditionally

been reported to be associated with less comfort for the
patient than lower water content lenses, potentially due
Contact lens–related dry eye is a poorly understood but to spoiling and deposition (2). Silicone hydrogel contact
very common clinical problem. Symptoms of dryness may lenses are classified as low water content materials (24%-
cause many patients to reduce or discontinue wearing 36%), which is why predictably dehydration should be
contact lenses. minimal and decrease in symptoms of dryness may occur.
Quality of the precorneal tear film influences the ability It is reported that silicone hydrogel lenses are slightly less
of patients to wear contact lenses successfully (1). A irritating to the ocular surface and maintain greater stability
mechanical explanation can be made for contact lens– on goblet cell density (3) on the extended wear module.
related dry eye by increased tear film thinning times They are also reported to be more comfortable and to
(evaporation or dewetting) resulting in increased tear film subjectively induce less dry eye (4).
osmolality. Another contributing factor may be the usage Impression cytology is a simple, noninvasive method to

© 2011 Wichtig Editore - ISSN 1120-6721 S17

Contact lens–related dry eye and ocular surface changes
examine conjunctival epithelium. In 1977, Egbert et al (5)
documented the usage of cellulose acetate filters to detect
goblet cell density in patients with dry eye syndrome.
Nelson et al devised a 3-stage classification based on
nuclear/cytoplasmic ratio of conjunctival epithelium and
goblet cell density (6).
Squamous metaplasia in conjunctival epithelium, decrease
in goblet cells due to tear film instability and increased
irritation (3), and abnormal chromatin in nuclei are reported
in contact lens wearers. Previous studies on impression
cytology (7-10) generally used a single or average grade for
one specimen over a limited area of conjunctiva. Using a
single average grade for one specimen and attributing this
grading over a large area may obscure very valuable data
(11). Color-coded mapping technique in impression cytology
is a method aimed to demonstrate metaplastic changes in
a wide area of conjunctival epithelium. During this mapping
technique, different stages of metaplastic changes are
marked with different colors on a millimetric scale paper
and then, the distribution degree and percentage of ocular
surface metaplasia are determined (12).
The aim of the study was to evaluate tear functions and
ocular surface changes by using impression cytology with
color-coded mapping technique and contact lens–related
dry eye symptoms in long-term soft silicone hydrogel
contact lens wearers.
METHODS
Thirty patients (60 eyes) were enrolled in the study. Forty
eyes of 20 patients using contact lenses constituted group
1 and 20 eyes of 10 volunteers who did not wear contact
lenses in the past and during the study constituted group
2 (the control group). Patients in group 1 were all using
silicone hydrogel contact lenses with low water content
(Lotrafilcon A [24%], Focus Night & Day, or Senofilcon A
[38%], Acuvue OAsys).
Patients with any previous ophthalmic surgery, ocular
trauma, long-term use of topical medication, or systemic
diseases were excluded. Informed consent was obtained
from all the patients following all the guidelines for
experimental investigation in human subjects required by
the Institutional Review Board.
During slit-lamp biomicroscopy, the presence of blepharitis,
meibomitis, or any abnormality in cornea, conjunctiva, and
lid were recorded.
S18 © 2011 Wichtig Editore - ISSN 1120-6721
Tear quality was measured with TBUT, tear production
was measured with Schirmer I test (without using topical
anesthesia), and ocular surface was evaluated by corneal
and interpalpebral conjunctival staining and by conjunctival
impression cytology.
Corneal fluorescein staining was examined with cobalt
blue illumination and graded using the Oxford Scheme
6-point scale (from 0 to 5). After instilling Lissamine green,
interpalpebral conjunctival staining of temporal and nasal
conjunctivas were graded with the Oxford Scheme (13).
Impression cytology was performed in superior-temporal
and inferior-nasal quadrants with the 11-mm diameter
semicircular (forming a large perilimbal ring) cellulose
acetate filter papers with 0.025 µm pore size (Millipore
GSWPO 4300). This system was preferred to obtain
samples from a large area (Fig. 1).
Cytologic changes were evaluated under light microscopy
according to Nelson’s grading system with the color-coded
mapping technique (12). The grades of impression cytology
per square millimeter under light microscope were marked
on the millimetric scale paper. A different color was used
for each grade. The percentage of distribution of grades
was calculated and a color map was prepared for each
specimen (Fig. 2).
Dry eye symptoms were scored by a questionnaire (OSDI,
Allergan Inc, Irvine, CA), which measures range and
severity of symptoms and impact of symptoms on patient’s
performance of daily functions. Twelve items of the OSDI
questionnaire were graded on scale from none (= 0) to all (=
4) of the time. Total OSDI score was calculated according
to a formula (14). Thus a score on a scale of 0 to 100 was
obtained with higher scores representing a greater disability.
Descriptive statistics were used to summarize all variables.
Mann-Whitney U, Kruskal-Wallis, and Pearson tests were
used for statistical analysis.
RESULTS
The mean age of the patients was 28.77±4.29 years in
group 1 and 29.2±2.86 years in group 2; female:male ratio
was 11:9 in group 1 and 6:4 in group 2 (p>0.05). The mean
duration of average contact lens usage was 7.74±3.30
years (range 3 to 12). All the patients in group 1 were using
new generation silicone hydrogel contact lenses on a daily
wear modality. The mean lens diopter was –2.79±2.35 D
(range –2.0 to –6.50).
Sengor et al
Fig. 1 - Impression cytology was performed with the 11-mm-
diameter semicircular cellulose acetate filter papers in the superior-
temporal and inferior-nasal quadrants.
The duration of contact lens wear in a day was 14.32±1.47
hours (range 12 to 16). None of the patients was wearing
contact lens while sleeping. All the patients were using
multipurpose solutions for contact lens care.
During biomicroscopy, papillary conjunctivitis in 12 patients
(60%), meibomitis in 2 patients (10%), corneal vascularization
in 3 patients (15%), and hyperemia in 2 patients (10%) were
observed. Mild ptosis was observed only in 1 patient (5%).
The mean Schirmer I test value was 11.76±3.88 mm
(range 2 to 15) in group 1 and 12.90±3.32 mm (range 6 to
20) in group 2. The mean TBUT was 7.57±2.67 seconds
(range 4 to 15) in group 1 and 13.90±2.63 seconds (range
9 to 15) in group 2. The mean TBUT was statistically
significantly lower in group 1 (p=0.000), but there was
no statistically significant difference in Schirmer values
between the groups (p=0.3648). The mean OSDI score
was 34.59±11.93 in group 1 and 19.28±6.70 in group 2
(p=0.00) (Tab. I). OSDI scores positively correlated with
TBUT, cornea staining, and grade II metaplasia ratio in the
superior-temporal quadrant and grade III metaplasia in the
inferior-nasal quadrants (p<0.001, Pearson).
The mean corneal staining score was 0.68 (range 0 to 1) in
group 1 and 0.05 (range 0 to 1) in group 2, the mean nasal
conjunctiva staining score was 1.15 (range 0 to 2) in group
1 and 0.05 (range 0 to 1) in group 2, the mean temporal
staining score was 0.28 (range 0 to 1) in group 1 and 0.00
in group 2, according to Oxford Scheme. Corneal and
conjunctival staining scores were statistically significantly
higher in group 1 (p<0.001).
Squamous metaplasia grade ratios for superior-temporal
quadrant were 9.67% grade 0 in group 1 and 34.30%
© 2011 Wichtig Editore - ISSN 1120-6721
Fig. 2 - Mapping technique for impression cytology: the grades of
per square millimeter under light microscope were marked on the
millimetric scale paper and colored according to the figure and
the percentage of distribution of grades was calculated for each
specimen.
grade 0 in group 2 (p=0.0572); 44.03% grade I in group 1
and 20.30% grade I in group 2 (p=0.0019); 35.40% grade
II in group 1 and 0.40% grade II in group 2 (p=0.0000);
2.92% grade III in group 1 and 0.00% grade III in group 2
(p=0.0195). Squamous metaplasia grade ratios for inferior-
temporal quadrant were 6.78% grade 0 in group 1 and
33.19% grade 0 in group 2 (p=0.0468); 39.47% grade
I in group 1 and 17.06% grade I in group 2 (p=0.0016);
49.21% grade II in group 1 and 4.75% grade II in group 2
(p=0.0000); 3.44% grade III in group 1 and 0.00% grade III
in group 2 (p=0.0195) (Tab. II).
Increased metaplastic changes predominantly grade II and
isolated areas of grade III were observed in the interpalpebral
and perilimbal areas with a sharp demarcation line with the
areas under the lid during the mapping of the cytologic
changes in group 1 in both quadrants while in group 2
only isolated areas of grade I to grade II metaplasia were
observed in the inferior-nasal areas (Figs. 3 and 4).
Significant correlations were observed between contact
lens wear time in a day with TBUT, cornea staining, and
grade II to grade III metaplasia ratios in superior-temporal
and inferior-nasal quadrants (p<0.001, Pearson). Duration
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Contact lens–related dry eye and ocular surface changes

Fig. 3 - Impression cytology result of a patient in group 1 (contact Fig. 4 - Impression cytology result of a patient in group 2 (control
lens wearers) with color-coded mapping technique. The perilimbal group) with color-coded mapping technique. Isolated areas of grade
area shows predominantly grade II. I to grade II metaplasias were observed in the inferior-nasal areas.

TABLE I - THE MEAN VALUES FOR THE TBUT AND SCHIRMER I AND OSDI SCORES ACCORDING TO THE GROUPS

Group 1: contact lens wearers Group 2: control group pa

TBUT, s 7.57±2.67 13.95±2.63 0.00b

Schirmer I, mm 11.76±3.88 12.90±3.32 0.364

OSDI, score 34.59±11.93 19.28±6.70 0.00b

OSDI = Ocular Surface Disease Index; TBUT = tear film break-up time.
a
p<0.05.
b
p<0.001.

TABLE II - SQUAMOUS METAPLASIA GRADE RATIOS IN THE SUPERIOR-TEMPORAL AND INFERIOR-NASAL QUADRANTS
ACCORDING TO THE GROUPS

Group 1: contact lens wearers, % Group 2: control group, % p

Superior-temporal
  Grade 0 9.67 34.30 0.0572
  Grade I 44.03 20.30 0.0019a
  Grade II 35.40 0.40 0.0000b
  Grade III 2.92 0.00 0.0195a
Inferior-temporal
  Grade 0 6.78 33.19 0.0468a
  Grade I 39.47 17.06 0.0016a
  Grade II 49.21 4.75 0.0000b
  Grade III 3.44 0.00 0.0195a

a
p<0.05.
b
p<0.001.

of contact lens use was also correlated with TBUT, cornea
staining, and grade II metaplasia ratio in the superior-
temporal quadrant and grade III metaplasia in the inferior-
nasal quadrants (p<0.05, Pearson). No correlation was
observed between OSDI and contact lens wear time in a
day or duration of the contact lens use (p>0.05, Pearson).
Eight patients were using lotrafilcon A (24%), Focus Night
& Day, and 12 patients were using senofilcon A (38%),
Acuvue OAsys lenses. There was no statistically significant
difference between lens brands when compared (p>0.05).

S20 © 2011 Wichtig Editore - ISSN 1120-6721

Sengor et al
DISCUSSION
The report of the National Eye Institute/Industry Workshop
on clinical trials in dry eyes proposed a classification
scheme that stratifies patients with dry eye from those with
decreased aqueous tear production by the lacrimal glands
to those with increased evaporative loss (15). Contact lenses
were listed as a subcategory of evaporative dry eye in the
overall dry eye schema. Approximately 50% of contact lens
wearers report experience of dry eye symptoms at least
occasionally. It is also shown that contact lens wearers are
12 times more likely than clinical emmetropes and 5 times
more likely than spectacle wearers to report dry eye (16).
Although Farris (17) discussed 20 years ago that contact
lenses might be the cause of dry eye, the etiology was
poorly understood. Possible mechanisms of contact lens–
related dry eye include increased evaporation of the tear
film, inflammation, increased osmolality, dewetting related
to the lack of biocompatibility of the lens surface, or any
combination of these mechanisms (18).
Contact lenses all affect the tear film by increasing the
evaporation rate, and decreasing tear thinning time, and
the effect of a silicone hydrogel material on the tear film is
similar to that of all other lens types (19). The precorneal
tear film is divided into 2 layers when a contact lens is
applied: the pre-lens tear film (PLTF) and the postlens
tear film (PoLTF). The PLTF is thought to be associated
more with wearing comfort and clinical performance; the
PoLTF, with lens fit and movement (20). Thinner PoLTF
are associated with lower tear exchange and may allow
tear film debris and metabolic by-products to accumulate
between the lens and the cornea, causing lens binding
and threatening corneal integrity (21). Evaporative effects
will differ, and while low water content lenses may prevent
evaporation from the PoLTF, it is not clear that evaporation
from the PLTF will be similarly affected. The main structural
alteration to the tear film when lenses are applied is that
which occurs to the superficial lipid layer. The lens sits
within the aqueous layer, not only disturbing the regularity
of the ocular surface, but also leaving a very thin layer for
the lipid layer to form on. Consequently, the PLTF is much
thinner than a normal precorneal tear film and there will be
only a thin lipid layer on top of hydrogel lenses (22, 23).
While higher water content materials are related to dry eye
status (2), contact lens dehydration was not shown to be
related to dry eye in lens wearers. Patients wearing low
water content lenses that maintained their hydration do not
© 2011 Wichtig Editore - ISSN 1120-6721
report dry eye (18). It has also been shown that there is
no correlation between dehydration, movement, diameter,
and dryness symptoms between different water content
hydrogel lenses (24). Instead of dehydration of the lenses,
it is proposed that the polar headgroups associated with
the tear film lipid molecules are attracted to lenses of
higher water content, leaving their nonpolar tails extended
away from the lens surface, leading to evaporation and/
or dewetting (2). New lens materials—silicone hydrogels
with their low water content, high oxygen transmissibility,
and unique biocompatibility—may have some advantages
on this aspect. Our patients were using low water content
non-ionic lenses with 24%-38% water content.
The highest correlation coefficient found with tolerance
to contact lens wear in the literature is TBUT, which is a
measure of tear film stability and symptom scoring tests.
Researchers have found a significant difference of TBUT
and basal Schirmer values between control group and
contact lens wearers. The TBUT and basal Schirmer values
are reported to decrease directly according to the duration
of lens wear (25-27). The mechanism that affects the tear
film is unclear but microtrauma and subclinical inflammation
in the conjunctiva and conjunctival glands may contribute
(26). In our study, TBUT was shorter in the contact lens
wearing group (group 1) than the control group (group 2),
compatible with other studies, but we did not observe
a significant difference for basal Schirmer test results
between control group and contact lens wearers.
Impression cytology has been used to study ocular
surface and conjunctival epithelial changes including
contact lens related. Cytologic alterations are observed
within 3 to 6 months for the contact lens wearers and it
is increased significantly with the duration of contact lens
wear (8, 9, 28).
Direct chronic mechanical irritation and metabolic
inflammation induced by contact lenses contribute to the
development of certain cytologic changes in the ocular
surface such as squamous metaplasia and goblet cell
loss leading to symptoms (8, 24). Research on cytologic
changes induced by contact lenses usually focused on the
superior bulbar conjunctiva (8, 28, 29).
According to the chronic mechanical irritation theory, the
most mechanical effect is exposed in the limbus between
the 12 o’clock and 6 o’clock positions (9). Knop and Brewitt
observed cytologic changes and snake-like chromatin
appearance mostly in the 12 o’clock position in 13 out of
14 patients through conjunctiva impression cytology and
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Contact lens–related dry eye and ocular surface changes
fewer amounts in the 6 o’clock position and rarely in the
nasal and limbal conjunctiva in a group of asymptomatic
soft contact lens wearers (10).
Silicone hydrogel lenses are reported to transmit oxygen
that is closely matching to the oxygen available to an eye not
wearing contact lenses (30). Therefore hypoxic response
in the conjunctiva is not expected with silicone hydrogel
lenses. In our study soft silicone hydrogel contact lens
wearers showed severe metaplasia which was increasing
predominantly in the interpalpebral and perilimbal areas.
Mechanical effect of the silicone hydrogel lenses around
the limbus and increased evaporation in the interpalpebral
area, which has an important role in contact lens–related
dry eye, may be responsible for the cytologic changes that
were observed.
The effect of hydrogel contact lenses on ocular surface
with color-coded mapping technique was evaluated in a
previous study (12). Higher degrees of metaplastic changes
were observed around the limbus and in the lower quadrants
with a sharp demarcation line separating them from the
other grades. In this previous study, crescent-shaped filter
papers were put in a vertical manner in the temporal and
nasal quadrants. Differently in this study, filter papers were
cut in a semicircular shape not to leave any unexamined
area and placed in the superior-temporal and inferior-nasal
quadrants to help the manipulation. In this study, increased
metaplastic changes, predominantly grade II and isolated
areas of grade III, were observed in the interpalpebral and
perilimbal areas with a sharp demarcation line with the
areas under the lid during the mapping of the cytologic
changes in the contact lens wearers in both quadrants,
while in the control group only isolated areas of grade I
to grade II metaplasia were observed in the inferior-nasal
areas during impression cytology.
Current clinical tests only rarely correlate with dry eye
symptoms, where the practitioners could diagnose and
treat the condition based on symptoms. A number of
patient questionnaires have been developed to assess
dry eye symptoms, such as McMonnies Questionnaire,
Dry Eye Questionnaire, National Eye Institute Visual
Function Questionnaire, and the OSDI, but most of these
have not been designed specifically for contact lens
patients. Particularly OSDI was found to be a valid and
reliable instrument for measuring the severity of dry eye
disease and it possesses the necessary psychometric
properties to be used as an endpoint in clinical trials (31).
This questionnaire with 12 questions provides a rapid
S22 © 2011 Wichtig Editore - ISSN 1120-6721
and accurate assessment of the range and severity of
dry eye symptoms, as well as impact of symptoms on
patient’s performance of daily functions, which may be
considered important for a contact lens wearer. The dry
eye questionnaire administered by Begley et al (32) showed
that the symptoms of ocular dryness and discomfort are
relatively common among contact lens wearers and that
they worsen toward the end of the day. The contact lens
dry eye questionnaire’s short form developed by Nichols et
al (33) has been shown to be moderately reliable in contact
lens wearers. In our study, OSDI scores were significantly
higher in the contact lens wearers and they were correlated
with TBUT and impression cytology results.
Soft contact lens wearers who were symptomatic
are reported to have a significant increase in both
biomicroscopic and cytologic grades but no correlation was
found between duration of lens use and biomicroscopic or
cytologic grades in a study (34). In our study, we found
correlation between duration of contact lens use and
TBUT, cornea staining, and grade II metaplasia ratio in the
superior-temporal quadrant and grade III metaplasia in
the inferior-nasal quadrants (p<0.05). We also found that
correlation between contact lens wear time in a day with
TBUT, cornea staining, and grade II to grade III metaplasia
ratios in superior-temporal and inferior-nasal quadrants
was even more evident (p<0.001).
In conclusion, silicone hydrogel lenses, despite their high
oxygen permeability and low water content, produce
significant changes on tear film and impression cytology
on long-term use.
The authors report no proprietary interest or financial support.
Address for correspondence:
Sevda Aydin Kurna, MD
Omerli Park 2 Sitesi No: 2
Kadirova Mevkii
Omerli, Cekmekoy
Istanbul 34797
Turkey
sevdaydin@yahoo.com
Sengor et al
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