My last patient today was a challenging case of contact lens intolerance. The patient, a 13-year-old myopic female, had first come to the office several months ago with mild conjunctival inflammation and fluorescein staining of both corneas. I did what I usually do in similar cases: stopped the contact lens wear, prescribed a fluoroquinolone eye drop, and followed up in several days. This worked well, and the patient resumed contact lens wear with instructions to return if symptoms reappeared.
Sure enough, she was back 4 weeks later with recurrent epithelial stippling and mild conjunctival inflammation. When I told the patient to again stop lens wear, she exclaimed that she couldn’t do that because she needed the lenses for 2 hours every other day for danceline practice. Since most of the contact lens intolerance I see in daily wear patients can be traced to their multipurpose disinfection solution, and since in this case there was little risk of microbial keratitis, I acquiesced to part-time wear but using peroxide disinfection. She improved, and eventually I agreed that she could return to full-time daily wear.
Today when I examined her she was 20/20 in both eyes, the eyes were white and quiet, and she was asymptomatic. But to my surprise, on slit lamp examination there were focal dots of staining in the temporal cornea of one eye without other signs. At this point, the problem could not be a multipurpose solution, and I saw no reason to suspect that the contact lens itself was the culprit. To make matters more complex, she had nine giant papillae on the tarsal conjunctiva of the right upper lid. (They had been there before, but I had dismissed them as having little relevance to the corneal surface disorder.)
Since she had a white eye and was asymptomatic, I said it was alright to continue wearing the lenses, if she again reduced her wearing time. I spent the last 10 minutes of the exam talking with the patient and her mother about the long term. I told them that I would watch the young girl closely and possibly switch her from her current silicone hydrogel to a traditional hydrogel lens. Spectacles would, of course, be a perfect solution, but this was not in the cards for my patient.
I then mentioned that refractive surgery might be an option when she came of age. I let them know that I think refractive procedures are currently quite excellent and will only get better in the years between now and when she becomes a serious candidate.
That night, I read Dr. Reinstein’s article (in this issue) on small-incision lenticule extraction (SMILE), and I myself smiled at the thought of how good the options had become for young myopes who, like my patient, do not want to wear glasses. Currently performed outside the US, the SMILE procedure minimizes corneal nerve damage, spares the biomechanically stronger anterior cornea, and requires just one laser. I can scarcely imagine what technology will be like in 2020 when this patient is old enough for refractive surgery. This is something to smile about, and I believe my challenging contact lens patients will also be smiling.
Robert C. Campbell, MD, Editor-in-Chief