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Contact Lenses

by Deepinder K. Dhaliwal, MD, Mojgan Hassanlou, MD, FRCSC

Contact lenses often provide better visual acuity and peripheral vision than do eyeglasses and can be prescribed to correct the following:

Either soft or rigid lenses are used to correct myopia and hyperopia. Toric soft contact lenses (which have different curvatures molded onto the front lens surface) or rigid lenses are used to correct significant astigmatism; they are satisfactory in many cases but require expert fitting.

Contact lenses are also used to correct presbyopia. In one approach, termed monovision, the nondominant eye is corrected for near vision (reading) and the dominant eye is corrected for distant vision. Rigid and soft bifocal and multifocal contact lenses can also be successful, but the fitting procedure is time-consuming because precise alignment is essential.

Neither rigid nor soft contact lenses offer the eyes the protection against blunt or sharp injury that eyeglasses do.

Care and Complications

Instructions for hygiene and handling lenses must be strictly observed. Poor contact lens hygiene may lead to infection of the cornea or persistent inflammation. Contact lenses occasionally cause painless superficial corneal changes. Contact lenses can be painful when

  • The corneal epithelium is abraded (see Corneal Abrasions and Foreign Bodies), the eye becomes red, and the cornea stains with fluorescein.

  • The lenses fit poorly (eg, too tight, too loose, poorly centered).

  • There is too little moisture to keep the lens floating above the cornea.

  • The lenses are worn in a nonideal environment (eg, O 2 -poor, smoky, windy).

  • A lens is improperly inserted or removed.

  • A small foreign particle (eg, soot, dust) becomes trapped between the lens and the cornea.

  • The lenses are worn for a long time (overwear syndrome).

In overwear syndrome, spontaneous healing may occur in a day or so if lenses are not worn. In some cases, active treatment is required (eg, topical antibiotic eye drops or ointments). Dilating the eye with mydriatic drops can ease photophobia. Mydriatics work by temporarily paralyzing the muscles of the iris and ciliary body (movement of the inflamed muscles causes pain). In overwear syndrome or any other condition in which pain does not quickly resolve when lenses are removed, an ophthalmologist should be consulted before lenses are worn again.

Risk factors for contact lens–related corneal infection (keratitis) include the following:

  • Poor lens hygiene

  • Overnight or extended wear

  • Use of tap water in the cleaning regimen

  • Eyes with a compromised ocular surface (eg, dryness, poor corneal sensation)

Infections require rapid treatment by an ophthalmologist.

Corneal ulcer

A corneal ulcer, which is a potentially vision-threatening infection of the cornea, is suspected when a contact lens wearer has intense eye pain (both foreign body sensation and ache), redness, photophobia, and tearing (see also Corneal Ulcer). Use of contact lenses increases risk of corneal ulcer. The risk increases about 15 times if contact lenses are worn overnight. Corneal ulcers can be caused by bacteria, viruses, fungi, or amebas.

Diagnosis is by slit-lamp examination and fluorescein staining. A corneal epithelial defect (which stains with fluorescein) and a corneal infiltrate (collection of WBCs in the corneal stroma) are present. At times, the corneal defect is large and dense enough to be seen with handheld magnification or even with the naked eye as a white spot on the cornea. Microbiologic analysis of cultures and smears of the corneal infiltrate, contact lens, and contact lens case is indicated.

Contact lens use is stopped. Antibiotic eye drops are given empirically for possible bacterial infection. Initial therapy is broad-spectrum, using a fluoroquinolone antibiotic eye drop every 15 to 60 minutes around the clock for the first 24 to 72 h, then at gradually longer intervals. Additional antibiotic eye drops, such as cefazolin, vancomycin, or concentrated tobramycin, are used if the ulcer is large, deep, or close to the visual axis. The antibiotic may be changed or stopped later based on culture results. Neglected cases may respond poorly or not at all to treatment, and severe vision loss may result.

Rigid Corneal Contact Lenses

A rigid lens is able to revise the natural shape of the cornea into a new, better refracting surface than a soft lens and thus tends to provide more consistent improvement in refraction for people who have astigmatism or an irregular corneal surface. Older polymethyl methacrylate rigid contact lenses have been replaced by gas-permeable contact lenses (GPCLs) made of fluorocarbon and polymethyl methacrylate admixtures. GPCLs are 6.5 to 10 mm in diameter and cover part of the cornea, floating on the tear layer overlying it.

Rigid contact lenses can improve vision in people with myopia, hyperopia, and astigmatism. Rigid contact lenses can also correct corneal irregularities, such as keratoconus. In most cases, patients with keratoconus see better with rigid contact lenses than glasses.

GPCLs can be designed to fit the eye exactly. For complete wearing comfort, they require an adaptation period, typically about 4 to 7 days. During this time, the wearer gradually increases the number of hours the lenses are worn each day. Importantly, no pain should occur at any time. Pain is a sign of an ill-fitting contact lens or corneal irritation. Wearers usually have temporary (< 2 h) blurred vision (spectacle blur) when wearing eyeglasses after removing rigid contact lenses.

Soft Hydrophilic Contact Lenses

Soft contact lenses are made of poly-2-hydroxyethyl methacrylate and other flexible plastics (such as silicone hydrogels) and are 30 to 79% water. They are 13 to 15 mm in diameter and cover the entire cornea. Soft contact lenses are often replaced daily (disposable single-use), every 2 wk, or monthly.

Soft contact lenses can improve vision in people with myopia and hyperopia. Because soft contact lenses mold to the existing corneal curvature, anything greater than minimal astigmatism cannot be treated unless a special toric lens, which has different curvatures molded onto the front lens surface, is used. Weighting the lower aspect of the toric lens maintains its orientation by reducing lens spinning.

Soft contact lenses are also prescribed for treatment of corneal abrasion, recurrent erosions, or other corneal disorders (called bandage or therapeutic contact lenses). Prophylactic antibiotic eye drops (eg, fluoroquinolone qid) may be advisable with a bandage lens. Extended wearing of soft contact lenses, especially in aphakia after cataract surgery, is practical, but an ophthalmologist should examine the patient regularly. The patient should clean the lenses once/wk.

Because of their larger size, soft contact lenses are not as likely as rigid contact lenses to eject spontaneously and are less likely to allow foreign bodies to lodge beneath them. Immediate wearing comfort allows for a brief adaptation period.

Soft contact lenses have a higher incidence of corneal infections than GPCLs, particularly when soft lenses are worn overnight. When dry, soft contact lenses are brittle and break easily. They absorb a certain amount of moisture (based on the water content) from the tear film to retain adequate shape and pliability. Therefore, patients with dry eye are usually more comfortable wearing lenses that have a low water content.

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