Eye problems in contact lens wearers
BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6337 (Published 27 November 2019) Cite this as: BMJ 2019;367:l6337
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor,
We read with interest the article by Shahid et al. on associated eye problems in contact lens wearers. 1
Contact lens related complications are indeed common and associated with significant costs to both individual and society.2 3 As highlighted by the authors, many complications have been attributed to poor lens wear and hygiene habits. Despite efforts by public health agencies, eye care practitioners and industry partners, no intervention has been proven to be consistently effective in enacting behavioural change. 4 Even amongst healthcare professionals, compliance with lens wear and hygiene habits remains poor. 5
Evolving evidence-based recommendations necessitates currency with existing recommendations for practitioners to practice effectively. Although information is readily available through the internet, health-related information can be inaccurate and outdated.6 Use of these suboptimal resources by practitioners may further contribute to discrepancies in information provided to contact lens wearers regarding optimal contact lens wear and hygiene habits. This can be challenging not only for primary care practitioners, but even for contact lens practitioners, caregivers and experienced contact lens wearers as they seek to navigate this labyrinth of recommendations to gain access to timely and evidence-based advice.
Mobile health technology may be beneficial in this regard and has been increasingly used in the healthcare space. This represents a unique opportunity to educate and encourage behavioural change in accordance with best practice recommendations, and also to collect information prospectively. A survey of patients with chronic Ophthalmic conditions, such as Glaucoma, demonstrated that 72.3% of patients approached were interested in adopting mobile applications to assist with understanding their condition, medication adherence and appointment scheduling reminders.7 Younger patients were also more likely to be open to the use of mobile health applications.7 This is encouraging, given that contact lens wearers predominantly belong to a younger demographic.
The contact lens industry has begun exploring these options. Industry-led efforts have shifted from traditional stand-alone applications developed solely to market contact lenses, resulting in the release of mobile health solutions for both patients and eye care practitioners. These include applications to facilitate reminders for lens replacement and eye care appointments such as the Acuminder™ by Johnson & Johnson Vision Care Inc, and those that include education information such as LensFacts from OPTI-FREE® by Alcon. Practitioner based applications include the OptiExpert™ application by CooperVision to facilitate contact lens fittings. The Menicon Bloom™ Myopia Control Management System also contains a unique mobile phone application; Menicon’s Virtual Dr, to facilitate communication between practitioners and patients.
Outside of industry-branded applications, there have been standalone mobile applications created by third party developers. These solutions aim to identify compliance with recommended lens wear and care habits, and encourage proper lens wear behaviour. Data made available to eye care practitioners can be used to personalise consultations and provide bespoke and targeted recommendations to wearers. Incorporating machine learning capabilities may also assist with early identification of adverse events. Other benefits include the ability to digitise monitoring of intervention efficacy, such as the use of contact lenses as part of a myopia control strategy.
This truly represents an exciting new frontier for healthcare in exploring the unique possibilities that mobile health interventions, artificial intelligence and deep learning techniques may offer. It is envisioned that these capabilities will further facilitate efforts in encouraging compliance with recommended lens wear and hygiene habits, thereby improving health outcomes. This will also empower eye care practitioners and primary care physicians with the necessarily tools and metrics to care for their patients effectively.
References
1. Shahid SM, Ahmed SN, Khan Y. Eye problems in contact lens wearers. bmj 2019;367
2. Collier SA, Gronostaj MP, MacGurn AK, et al. Estimated burden of keratitis—United States, 2010. MMWR Morbidity and mortality weekly report 2014;63(45):1027.
3. Lim CH, Stapleton F, Mehta JS. Review of Contact Lens–Related Complications. Eye & Contact Lens 2018;44:S1-S10.
4. Cope JR, Collier SA, Nethercut H, et al. Risk behaviors for contact lens–related eye infections among adults and adolescents—United States, 2016. MMWR Morbidity and mortality weekly report 2017;66(32):841.
5. Ibrahim NK, Seraj H, Khan R, et al. Prevalence, habits and outcomes of using contact lenses among medical students. Pakistan journal of medical sciences 2018;34(6):1429.
6. Fisher JH, O’Connor D, Flexman AM, et al. Accuracy and reliability of internet resources for information on idiopathic pulmonary fibrosis. American journal of respiratory and critical care medicine 2016;194(2):218-25.
7. Waisbourd M, Dhami H, Zhou C, et al. The Wills Eye glaucoma app: interest of patients and their caregivers in a smartphone-based and tablet-based glaucoma application. Journal of glaucoma 2016;25(9):e787-e91.
Competing interests: No competing interests
Dear Editor
We read with great interest the article by Shahid and colleagues and congratulate them on this publication.
Whilst we appreciate the authors’ view that early antimicrobial treatment in microbial keratitis is beneficial, we would not advocate General Practitioners to start levofloxacin 0.5% upon identification of a “corneal infiltrate visible on ophthalmoscopy” before referring to ophthalmology.
This would be potentially harmful to the patient for numerous reasons: antibiotics would interfere with a corneal scrape for microscopy, cultures and sensitivities; antibiotics would not be helpful in fungal or acanthamoebal infections; community pharmacies infrequently stock the correct medication and ordering medication may delay treatment. We have seen patients lose vision whilst waiting more than 24 hours to get their treatment from a community pharmacy. Therefore, we would recommend antimicrobial treatment should be started by an ophthalmologist after a corneal scrape (if appropriate) and dispensed on the same day from the hospital pharmacy. Patients with microbial keratitis should also be reviewed again by an ophthalmologist within 24-48 hours after initiating treatment.
We also believe the article to be misleading by stating that the “typical clinical finding [of acanthamoeba keratitis] is that of a ring infiltrate”. A ring infiltrate is typically present in late disease and can also occur with bacterial infections of the cornea. Early acanthamoeba keratitis may only have subtle corneal epithelial changes without an infiltrate. These changes can be identified on slit lamp examination and missed on ophthalmoscopy. We therefore believe ophthalmoscopy by a General Practitioner, using a high + lens on the direct ophthalmoscope, to be an inferior method of examination as it can be falsely reassuring to see no clinical signs. Early recognition and treatment of acanthamoeba keratitis can prevent the vision loss and loss of an eye.
We would recommend the algorithm to be amended so that all patients with a history of contact lens use and a painful or irritated eye to be referred, without starting antibiotics, to an ophthalmologist on the same day for a comprehensive slit lamp examination.
Competing interests: No competing interests
Dear Editor,
We read with interest 'Eye problems in contact lens wearers' and congratulate Mr Shahid and his team for the excellent article.
We would recommend using fluoroscein in all cases of red eye as this will stain most soft contact lenses or soft lens fragments, making them visible to the naked eye even without a cobalt blue light. For rigid lenses, fluoroscein will pool under the lens revealing its position; these lenses decentre easily and can often be found on the sclera underneath the lids.
Patients sometimes forget they have contact lenses in and they can be difficult to see even with a slit lamp - patients have left their contact lenses in for up to 3 years despite yearly visits to an optician. Some referrals of 'total corneal abrasions' have turned out to be stained contact lenses. If there is any concern of infection the contact lenses should be sent in with the patient enabling the assessing ophthalmologist to send this for culture. Corneal scrapes in such cases may grow Serratia maccerans (a gram negative facultatively anaerobic rod). Delay in treatment can cause large corneal ulcers with severe necrosis and thinning. In most cases, prompt medical treatment can result in a favourable clinical response.
Using fluoroscein (inert and safe if no specific allergy) when assessing a red eye can highlight possible forgotten-about contact lenses aiding diagnosis.
Competing interests: No competing interests
Eliminating Eye problems in contact lens wearers
Dear Editor
Regarding the BMJ article ‘Eye Problems in contact lens wear’ I wish to respond;
The main cause of eye problems associated with soft contact lens wear is the ‘modality’. There are three:
1. Over Night Wear (Extended Wear)
2. Daily wear with daily cleaning and repeated use (Reusable Wear) and
3. Daily-Wear with daily disposable (Daily-Disposable wear)
An added factor is whether the lens material contains Silicone or is simply a softer Hydrogel. There is now universal acknowledgement that the ‘lowest risk) modality is Daily-disposable. The incorporation of Silicone in such lenses, whilst increasing oxygen permeability (beyond what is needed for safe daily-disposable wear) has the negative effect of increasing ‘hardness’ of the material. This in turn, increases the incidence of corneal infiltrates as evidenced by increased appearance of mucin balls. They also carry a price premium.
In summary. By far the risk to be avoided is Loss of Vision eg due to Microbial Keratitis. I have attached three pages of independent research which demonstrate the eye-health benefits of Daily-Disposables. I am perturbed that Reusables and Extended-wear contact lens modalities are still being prescribed with, as far as I can see, no information for wearers as to the comparable risk factors, now so convincingly demonstrated.
I should declare an interest; I invented the daily-disposable lens and today make and sell millions annually via www.daysoft.com bringing the cost to a price-point comparable to Reusables. Daysoft’s extensive post market surveillance data covering sales of over 500 million lenses demonstrate the inherent safety of switching wearers to daily-disposable hydrogel lenses. The optical profession does not, in my opinion, sufficiently lay-out the relative risks due to commercial pressures. The section of the article in the BMJ “How patients were Involved” points to there being too little information in primary care about possible causes. I have copied Mr Hadley, Chairman of the General Optical Council. He is familiar with my views.
The comparable risk factors to which I refer are available from me by email (Ron.Hamilton@daysoft.com). They quantify the relative risks and should be given to ‘patients’ for informed consent.
Competing interests: No competing interests