UNIVERSITY OF GONDAR

CMHS
DEPARTMENT OF OPTOMETRY
Advanced contact lens seminar presentation on :
Mechanical complication of contact lens wear
Prepared by: Abebizuhan Zigale (Msc 1st year student)

Submitted to: Mr Natnael L (Assistant proff of clinical optometrist)

1 09/04/2022
 Objectives
 At the end of this presentation you will able to:

Define mechanical complication of contact lens wear

List different types of mechanical related contact lens complications

Describe the ethiopathopysiology of contact lens wear

Describe the clinical features of mechanical related contact lens complications

Identify the management option of mechanical contact lens complications

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 Outline
Introduction

Definition

Classification

Etiology and risk factor

Clinical features

Management option

Reference

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 Introduction
 Contact lenses can be used for many years without problems only if they are made of

well chosen material, correctly shaped and properly fitted.

 The ocular complication range from harmless irritation to sight threatening corneal

ulceration even vision loss.

 Contact lens complications are related to

1.mechanical trauma to the conjunctiva and cornea

2.acute and chronic hypoxia from decreased transmissibility of oxygen

3.allergic reactions from protein deposits in the contact lenses

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 1.Mechanical complication Induced by Silicone Hydrogel
Contact Lenses
 Mucin balls

 Superior epithelial arcuate lesions(SEAL)

 Epithelial wrinkling

 Conjunctival epithelial flaps

 Lid wiper epitheliopathy

 Meibomian gland dysfunction

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 A. Mucin balls

 Formed by the mechanical interaction of a lens with the mucin layer of the tear

film by the upper eyelid during blinking

 Mucin balls are seen most commonly silicon hydrogel lenses.

 Seen within minutes of lens insertion.

 Size, and numbers, increase with increasing wearing time.

 Tend to be patient-specific.

 Seen in both adapted and unadopted wearers.

 25% exhibit >10 mucin balls.

 8% have >35 mucin balls.

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 Etiology
Strong interfacial forces

 Aqueous deficient tears beneath silicone hydrogel lenses

Mucin-rich tears rolled up onto discrete balls

Balls enlarge and indent epithelium

Very large balls collapse to doughnut-like appearance

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 Clinical features
Symptoms
None
 Vision can be slightly compromised in extreme cases
Signs
• Up to 200 small grey dots in direct illumination
• Small transparent dots in indirect retroillumination
• Reversed illumination
• Large mucin balls may collapse; doughnut-like
• Seen almost exclusively with silicone hydrogel lenses

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 Treatment
 Fit lenses steeper

 Rewetting drops

 More frequent lens removal

 Refit with lens other than silicone hydrogel

Prognosis
• Mucin balls and epithelial fluid-filled pits disappear within hours of lens removal
• Mucin balls will recur

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 B. Superficial Epithelial Arcuate Lesion—SEAL

Epithelial defect in arcuate pattern often at the periphery or mid-periphery, usually

superior.
It may be seen in a tight fitting soft lens or due to pressure of lid on the lens.

Etiology
Mechanical chafing of superior cornea
Inward pressure of upper lid
Contributing factors:
corneal topography
rigid lens modulus
mid-peripheral lens design
 lens surface
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 Clinical features
Symptoms
Asymptomatic
Signs
• Superior arcuate stain parallel to limbus
• Full thickness lesion also known as ‘epithelial splitting’

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 Treatment
 Alter lens design
less mid-peripheral bearing

Alter lens type

 lower modulus material

 better surface characteristics

 Following lens removal

 recovery in 3 days

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 C.Epithelial wrinkling
 Epithelium forms concertic-like folds
 Anterior stroma may also be slightly folded
Etiology
 Mechanical aetiology
 Critical lens factors
 highly elastic hydrogel material
custom design
extremely thin
 50–55% water content
 steep fitting

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 Clinical features
Symptoms
Extremely painful
Extreme vision loss
Parallel time course of discomfort and vision loss
Signs
Linear wave patterns of epithelial pooling
Patterns intersect at about 70°
 Discrete spots of staining appear at intersection of patterns

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 Treatment
 Remove lens immediately

 Refit with lenses avoiding design features described in ‘Aetiology’

 Good out come mostly

 expect complete recovery

 can take up to a week to fully recovery

 Rate of recovery related to period of wear

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 D. CONJUNCTIVAL EPITHELIAL FLAPS
 Bulbar conjunctival lesions that are best observed with fluorescein

 Occurs due to mechanical interactions between a lens edge and the bulbar

conjunctiva.
 Higher modulus lens materials along with a non–rounded edge design can increase

the risk of developing CEFS

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 Conti……
 In 65% of cases, they occur bilaterally and are mostly in the superior quadrant

 CEF is significantly greater in CW than in DW, especially after a minimum of a week

of CW with Silcon hydrogyl CLS and 3 weeks with RGP lenses

Management
 Modifying the wearing modality (e.g CW to DW)

 Changing to a lower-modulus or rounded-edge lens

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 E. LID WIPER EPITHELIOPATHY
 The lid wiper is part of the marginal conjunctiva of the upper eyelid that has a

rubbing effect on the ocular surface during blinking.

 Essential for spreading the tear film over the ocular surface or the surface of a cl.

 When the tear film is thinned or a lens surface does not provide a stable and wettable

surface resulting mechanical/frictional effect on the lid wiper as the lid travels across
the ocular or lens surface during blinking
 As a result of insufficient boundary lubrication, the lid wiper is traumatized and

develops into LWE

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 Clinical feature……….
Symptoms
 Dryness ,discomfort
Sign
 Epithelium of the marginal conjunctiva is stained with applications of
fluorescein or lissamine green dye.

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 Treatment
 Artificial tears ,steroids, punctual plugs

 Ointment at night after lens removal

 Efficient blinking during lens wear

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 F. MEIBOMIAN GLAND Dysfunction
 MGD is a form of posterior blepharitis

 Blocked meibomian orifice

 Increased keratinization of duct walls

 The mechanism for CL-induced MGD is unclear

 Chronic blockage of meibomian glands may eventually lead to anatomical changes in

meibomian glands
 Loss of meibomian glands depends on the duration of CL wear

 Caused by Silicon hydrogyl CLs

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 Etiology
 Increased turnover of ductal epidermis

Abnormal meibomian oils

- more keratin proteins

 Absence of lid rubbing

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 Clinical features
Symptoms
 Smeary vision
 Greasy lenses
 Dry eye
 Lens intolerance
Signs
• Cloudy, creamy, yellow expression
• Poorly wetting lenses
• Tear meniscus frothing
• No secretion if blocked
• Distended or distorted meibomian glands seen in retroillumination

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 Treatment
• Warm compresses

• Heating devices

• Lid scrubs/hygiene

• Mechanical expression

• Antibiotics

• Tears/lipid supplements

• Essential fatty acids

• Sex hormones

• Surfactant lens cleaning

• Intraductal probing
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 2.Mechanical and Pressure-Related Complications(RGP related
complications)

Lens Adherence

Corneal Warpage

Corneal Shape Changes

Ptosis

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 Lens Adherence
 Common consequence of overnight RGP lens wear .

• Overall, 48% of RGP lens EW users.

• 95% experience occasional adherence.

• Worse with flat-fitting lenses (84%).

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 Etiology
 Lens factors:

 Flat central fitting

 Reduced edge lift

 Large total diameter (TD)

 Limited movement

 Lid pressure - alterations unlikely to prevent adherence in susceptible wearers

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 Etiology conti……..
 Patient Factors (factor that exacerbates)
 Physical properties of the cornea
 Thickness (thin)
 Rigidity (low)
 Indentation susceptibility (high)
 Eyelid tightness (tight)
 Ocular rigidity (low)
 Corneal toricity (low)
 Diurnal variation in IOP (a postulation)

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 Clinical feature………..
Symptoms
Asymptomatic
Symptomatic presentation
Ocular pain.
 Eye Redness.
 Mild ocular irritation or discomfort.
 Tiredness.
 Foreign body sensation
Spectacle blur following lens removal.

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 Clinical features
Signs
 Lens bound to the cornea
 Often decentred
 Usually nasal, overlapping the limbus
 Indentation ring
 due to lens edge
 localized corneal distortion
 Staining
 central
 increased 3 & 9 o’clock
 outside lens edge (arcuate)

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 Conti…………
Adherence lasts <15 min in 50% of cases
• Back surface debris:
 adherent mucus & cellular debris
 arcuate or ring-shaped
 suggestive of adherence on waking
• Conjunctival redness
• Rapid recovery:
 once lens mobility re-established
 following lens removal

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 Management

• Adherence often not preventable

• Patient education:
 assess lenses each morning
 use ocular lubricants
 mobilize lens with lid pressure

• Lens fitting:
 increase tear volume
 fit with slight apical pooling
 reduce total diameter
 Revert to daily wear for:
 at-risk patients
 persistent lens binders
 those showing persistent staining

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 Corneal Warpage
Alterations to corneal shape:
 Intentional – orthokeratology
Unintentional:
 regular
 warpage or distortion
• More likely with rigid lenses, esp. PMMA
• Uncommon with RGP lenses:
 less rigid
 offer superior physiology

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 Etiology
 Surface Asymmetry Index

more likely with rigid lenses

 decentered lens flattens cornea

 Surface Regularity Index

 distortion may be symmetrical

 more likely with rigid lenses

 Corneal indentation

pressure from lens edge

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 Conti……….
 Oedema

 increased fluid

 Physical moulding

 pressure from rigid lenses

supplementary pressure from eyelids

 Associated pathology, e.g. keratoconus

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 Symptoms
 Spectacle blur
 Haze
 if associated with excess oedema

Signs
 Can manifest as change in corneal:
 curvature
 symmetry
regularity
 Corneal indentation
may be associated with corneal binding

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 Treatment
Alleviate rigid bearing

Alleviate hypoxia

 Corneal indentation

patient-dependent

 likely to recur again in same patient

 Keratoplasty for keratoconus

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 Ptosis
 Sign of an RGP lens wearer

 Upper lid rests in a lower than normal position

 Upper lid is more swollen and often redder

 Reversible (dependent on cause)

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 Etiology
 Trauma during insertion & removal due to:

forced lid squeezing

lateral lid stretching

 Rigid lens displacement of tarsus

 Blink-induced lens rubbing

 Blepharospasm

 Papillary conjunctivitis

39 09/04/2022
 Conti……
Lid oedema

Levator aponeurosis:

disinsertion

 dehiscence

 thinning

lengthening

40 09/04/2022
 Clinical features
Symptoms
Complaints of poor cosmesis when excessive
Reduced superior visual field

- only if severe (lowered lid position)

 Signs
Narrowing of palpebral aperture size
no lens: 10.10mm
 soft lens: 10.24mm
 rigid lens: 9.76mm
Large gap between upper skin fold & upper lid margin
Mainly in rigid, but also soft lens wearers
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 Treatment
Cease lens wear for 1-3 months

Cure papillary conjunctivitis

Refit with soft lenses

Lid surgery

Scleral lens ptosis crutch

Spectacle prop

Surgical tape

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 Conti……..
 Preventative

 optimize lens edge shape

 reduce lens thickness

 regular after-care

• Rule out other causes

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 Reference
1.Efron contact lens complications 3rd edition.PDF

2.Contact lens primer .PDF

3. The IACLE Contact Lens Course section 7.PDF

4.Medical contact lens practice 2005 PDF

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 THANK YOU

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