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Friday / August 19.
HomemicontactOh, My Eye! And What Lies Within

Oh, My Eye! And What Lies Within

There have recently been some rather interesting reports of ‘lost’ soft contact lenses found in the eye. These cases raise some important issues.

In one case, reported in the British Medical Journal (July 2017) an ophthalmological team preparing a patient for cataract surgery found a ‘bluish mass’ in the upper fornix. According to Optometry Today in the UK, the team initially determined that there were 17 lenses in the mass that they removed. Of course surgery was delayed due to a potentially increased risk of endophthalmitis. At a subsequent follow up another 10 lenses were removed from the eye, for a total of 27 lenses! The patient had not previously reported any issues but admitted the eye did feel better after these foreign bodies had been removed. She felt that any mild discomfort she had experienced in the past was simply due to old age and dry eye. She had been a soft lens wearer for 35 years but admitted to not attending regular optometric reviews.

The team decided to publish this record-breaking case as they felt it highlighted the need for regular eye examinations, which is being hampered by the easy online availability of disposable contact lenses.

In another case, also published July 2017, in BioMed Central Ophthalmology, the authors reported finding a rolled up bandage soft lens in the ‘upper fornix trap’. In this case bandage lenses had been applied to relieve persistent ocular pain resulting from dry eye. At a follow up visit a lens was removed from her left eye but no lens was found in the right. Some six and a half years later, lid eversion revealed a retained foreign body, in the form of the missing, rolled-up bandage lens. They conclude, “The ‘upper fornix trap’, where the contact lens may be retained by the upper tarsal edge, presents an anatomical hazard for contact lens users”.

next time you have a patient complaining of discomfort… don’t just flippantly palm then off. Take a proper look

Soft contact lenses are more likely to be retained relatively asymptomatically due to their soft, flexible nature and a tendency to roll up into a tube-like shape. Although rare, there have also been cases of hard and RGP lenses retained under the upper lid and in at least one case, the lens had been surrounded by conjunctival tissue and had to be surgically excised.

The authors felt their case highlighted the importance of a thorough eye examination “including double eversion of the upper eyelids and sweeping of the fornices with cotton buds, and maintaining clinical suspicion of contact lens retention”.

Experience

In all my years of contact lens practice I have only had one instance where double eversion was necessary. On a number of occasions over the decades, I’ve seen patients who insisted there was a lens or lens fragment under the lid. Some of these patients reported having seen at least one optometrist and/or ophthalmologist in the previous hours or days who had informed them that there was ‘nothing in their eyes’. In all these cases I found and removed a rolled up soft lens or fragment. One particular brand of an early version of daily disposables was particularly prone to split. This sometimes occurred while being worn and was probably secondary to a nick in the edge by a fingernail, while handling the lens prior to insertion. Patients would often say they had removed a half or a quarter of the lens but were sure there was still a piece in the eye.

Tips and Tricks

The best, fastest and least invasive way to determine if there is a soft lens or fragment in the eye is to simply instil a drop or two of fluorescein (NaFl). A soft lens will absorb plenty of NaFl and light up like a Christmas tree under blue light illumination, enhanced further by viewing through a yellow filter. Performing this examination in a slit lamp can be tricky and it also tends to be too bright, making the patient uncomfortable and creating excess lacrimation. A Burton Lamp can be used, but these days there is a far more practical and flexible tool available that works a treat. Said instrument is the hand-held, battery powered blue light LED ‘Flu Blu’ 6X yellow filter magnifier. It is a winner in my view. It’s about the size of a large smartphone and similar to the common ‘lollipop style’ hand magnifiers. Lightweight and unencumbered by wires, it is also a fantastic tool for examining NaFl patterns in RGP fitting. I’ve used one daily for a number of years and find it indispensable. It’s also great for imaging and recording RGP fits and gross staining, via a smartphone, through the magnifier. I hand hold the magnifier with my left hand and shoot through the yellow magnifier with my iPhone in my right hand.

When used for finding soft lens remnants and ‘lost lenses’ under the lids, one can often see a sliver of highly fluorescent lens material just poking out under the tarsal plate. Before everting and fishing around, I get the patient to look up, down, left and right while pressing my finger against the lid as high up as I can. I use the ‘water melon pip’ technique to try and squeeze it out of its resting place. If this fails, I do a single eversion. More often than not, the lens or edge pops into view. Sometime I will use a silicone tipped soft lens tweezer to try and grab the visible part of the lens (or very carefully use epilation forceps to the same effect). If that fails, to make 100 per cent sure there is nothing in there, use the aforementioned double eversion or cotton bud sweep.

Flu Blu is available from Corneal Lens Corporation in NZ or Contact Lens Centre in Australia and is pretty good value for money compared to a much more expensive and cumbersome Burton Lamp or to similar products available overseas that cost a lot more.

Although I don’t often use bandage lenses, which are most commonly used after refractive surgery, I have used them with great success. I published one of the first case reports of extended wear silicone hydrogels used to manage recurrent corneal erosion syndrome in an epithelial basement membrane dystrophy, over a decade ago. I haven’t found them to be particularly beneficial in common garden variety dry eye – as we know, contact lens wear is often related to symptomology of ‘dry eyes’. They can however be of benefit in ‘pathological’ cases of aqueous deficient dry eye such as Sjögren’s syndrome or in bullous keratopathy. For the most part they are a relatively rare application of soft lenses and a specialist technique.

Considering the case of the poorly compliant soft lens wearer, next time you have a patient complaining of discomfort, or one that feels they have something in their eye, don’t just flippantly palm then off. Take a proper look.

Patients will often ask you how it is that you found their lens remnant in a matter of minutes, while other practitioners had not and casually showed them the door.

They remember these things.

Simple acts really build loyalty, which is so critical in today’s competitive arena.

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