The first and most important step in the treatment of all contact lens complications is discontinuation of the contact lens. Whenever a complication is encountered or even suspected, the lens should be removed from the eye immediately and not reinserted until the cause of the problem has been determined and the eye has completely healed.

Removing the lens from the eye may be difficult in some emergency situations. The use of a local anesthetic may facilitate removal of the lens but may render the lens unwearable from that moment onward; moreover, all local anesthetics are relatively toxic to the eye and therefore unsuitable for use except in the short term. It is sometimes possible to remove a lens after application of only one or two drops of artificial tear or buffer solution, which causes the lens to float off the ocular surface so that it can be readily removed. This is the recommended method for removing stuck lenses in cases of tight lens syndrome (TLS) or overwear syndrome. Likewise, prior instillation of a few drops of a wetting solution is helpful when a lens must be removed from an anxious patient or a child.

Once a contact lens has been removed from the eye, its surface should be cultured, and it should be examined in the laboratory for defects and deposits. The lens should be meticulously cleaned and disinfected before it is returned to the patient, or else the original disease process—such as conjunctivitis or keratitis—may be reactivated. Unfortunately, patients often disregard medical advice and reinsert their lenses too soon after an injury or bout of infection, after inadequate disinfection, or when the lenses have been found to be defective. Any of these errors can reactivate the problem that necessitated removal of the lenses in the first place.

Once the lens has been removed, the second therapeutic step is the treatment of the problem in the eye, in accordance with standard ophthalmological practice. In the selection of medications, preservative-free eye drops and ointments are generally to be preferred, as wearers of contact lenses are at risk for a wide variety of complications related to the long-term effect of complex chemical compounds. These complications are due to interactions between the organic polymer structure of the lens material and the toxic or allergenic substances found in cleaning and disinfectant solutions, which have a chronic deleterious effect on the anterior ocular segment. Predictably, problems caused by any specific type of lens care product usually respond poorly to treatment with preparations containing the same type of preservative.

The length of time the patient must wait before reinserting the lens after the lesion has healed depends on the specific type of complication and its consequences for the eye. In general, after an ocular infection or traumatic lesion has healed, the contact lens should not be reinserted for at least 21 days. Severe complications, such as a corneal ulcer, require longer lens-free intervals, while, for a minor condition such as conjunctivitis, a few days will suffice.

Blepharospasm improves once its cause is diagnosed and eliminated. If it is due to mechanical irritation, it can be treated changing the contact lenses or the fitting concept, or by the regular use of artificial tears. The increased flow of tears associated with blepharospasm can be normalized more quickly, if necessary, with mildly astringent, soothing eye drops.

If blepharospasm impedes removal of a contact lens in an emergency situation, a local anesthetic can be given to eliminate it. A soft contact lens must be discarded after local anesthetic is used, because it can take up the anesthetic and re-release it to the eye, creating the risk of toxic keratopathy.

Ptosis is treated by elimination of its cause. If it is due to foreign-body irritation from the contact lens, it usually resolves without further treatment within a few days or, at most, weeks of the discontinuation of the lens, and requires no further treatment. If it is due to irritation of the tarsal conjunctiva, it can be eliminated by the instillation of mildly astringent eye drops.

Levator dysfunction is irreversible in rare cases after decade-long wearing of contact lenses. If the ptosis is cosmetically unacceptable or impairs vision, surgery can be performed to widen the palpebral fissure.

Lid edema, too, is treated by elimination of its cause. The treatment of choice is calcium, given by the oral or (in extreme, acute cases) parenteral route, or sometimes cortisone in severe cases. Medical consultation should be obtained when lid edema does not seem to be related to the wearing of contact lenses, in which case a systemic illness may be responsible.

Redness, swelling, and scaling of the lid margins imply intolerance to the contact lens material, lens care products, or other agents used in the eye. The possible causative substances include not only the cleaning and disinfecting solutions but also the wetting solutions that are often recommended to improve wearing comfort. Even eye ointments and drops that are used to treat contact lens complications can evoke an allergic response at the lid margin. The response usually takes the form of a classic squamous blepharitis. In many cases, squamous blepharitis that was present to some degree before the contact lenses were fitted is exacerbated by an allergic response to the contact lens or lens care solutions. The offending factor can sometimes be identified with a skin-prick test, but may be hard to eliminate, because such factors are both numerous and ubiquitous in the environment.

Before lid margin inflammation or ocular allergy is treated, the cause of the allergic diathesis should be identified, in consultation with a dermatologist if necessary, and the patient should refrain from wearing lenses until all symptoms and abnormal findings in the eye have resolved. Only then should the patient try to wear contact lenses again. A new lens material or new lens care system can be tried, possibly a peroxide-based system, as peroxide is not in itself allergenic.

Infectious and allergic lid problems should be treated with anti-inflammatory, antibiotic, and corticosteroid eye drops that are instilled three to four times daily, or, even better, an ointment applied to the affected areas two to three times daily. Multivalent mixed preparations are recommended. Salicylate eye baths improve comfort.

Traumatic lid injuries generally heal within a few days if the patient stops wearing contact lenses and applies reepithelializing eye drops or ointment three to four times a day. Small cuts usually heal without treatment. Surgical intervention is needed to preserve lid function only for the rare larger or heavily bleeding wounds. In such cases, the preservation of an intact lid margin is very important, for otherwise the wearing of contact lenses may be problematic in future.

Antibiotic eye drops or ointment are used three to four times daily only for deeper injuries or where there is a risk of bacterial infection. Daily or twice-daily eye baths with a 1% salicylate solution improve comfort.

The treatment of giant papillary conjunctivitis (GPC) is often unsatisfactory. Papillary hypertrophy regresses slowly and is sometimes present weeks after the patient has stopped wearing lenses. Cortisone is of no benefit. Most eye drops contain preservatives and only worsen the condition by denaturing the proteins normally found in the tear fluid, leading to further irritation.

The only treatment that has proved useful to date is with 2–3% cromolyn sodium or lodoxamide eye drops, instilled two to five times a day, just as in vernal conjunctivitis (a disorder of related etiology). At least 3 weeks and sometimes as long as 3 months of treatment will be required, and contact lenses should not be worn during this time. If the contact lenses are medically indicated and cannot be discontinued (e.g., in keratoconus), then the first daily dose of the preparation should be given early in the morning, at least 15 or 20 minutes before the lenses are inserted. One or two further doses should be given at midday, during a short lens-free interval, and the last dose in the evening, after the lens is removed. These measures prevent interaction of the medication with the lens material.

Patients who wear contact lenses while being treated for GPC should always remove and clean their lenses after 4–6 hours of wear and wait 20–30 minutes before reinserting them. This should prevent the lenses from becoming spoiled. If GPC should flare up again when the lenses are reinserted, the lens material should be changed immediately to avoid a full-blown recurrence. Furthermore, once GPC has resolved, the lens care system should be changed. In light of the complex etiology of GPC, a preservative-free system is generally preferred.

Acute chemosis must be treated immediately, whatever its cause. The conjunctiva should be rinsed immediately with corticosteroid eye drops, which the patient should then continue to instill every 1–2 hours during waking hours. The chemosis then usually resolves within 1 day. Only rarely is a Passow operation under local anesthesia necessary to restore lid function when chemosis interferes with lid closure.

It is important to be sure that the cortisone drops do not contain the same preservative agent that precipitated the problem. The use of unit-dose, preservative-free eye drops or ointment is recommended.

Mechanically induced conjunctival hemorrhage is characterized by a focal, circumscribed injury of the superficial conjunctival vessels and generally requires no treatment other than discontinuation of the contact lens until the lesion is healed. The same is true of small hemorrhagic conjunctival erosions caused by faulty lens insertion or removal or by the wearing of defective lenses. Eye drops should not be used; instead, healing and re-epithelializing ointments can be applied 3–4 times daily.

Extensive conjunctival hemorrhages in contact lens wearers are treated just as in other patients. Reepithelializing and soothing ointments or gels are sufficient treatment for all but the largest hemorrhages. In rare cases of persistent bleeding, treatment by laser, cautery, or suture under local anesthesia may be required.

Heparin-containing ointments promote the resorption of conjunctival hemorrhages. If hemorrhage has occurred in the setting of therapeutic anticoagulation, it may be advisable to interrupt this treatment for a few days after consultation with the internist.

Conjunctival trauma in contact lens wearers is generally treated just as in other patients. Contact lens wear is temporarily discontinued, antibiotic ointment or eye drops are applied, and the lesions usually regress within a few days. The course of healing should be documented with frequent follow-up examinations because there may be coexistent contact-lens-induced microlesions of the corneal epithelium, which, if bacterial conjunctivitis should develop, can rapidly turn into a focus of superficial keratitis or a corneal ulcer.

The threat of corneal infection is even greater when resistant organisms are present. Thus, whenever infection occurs after injury of the anterior ocular segment, cultures of the eye, lens, and lens case must be performed, and the sensitivity spectrum of the pathogenic organisms determined.

Conjunctival irritation of mechanical or metabolic origin is adequately treated by temporarily discontinuing the contact lens and instilling mildly astringent eye drops. Nonprescription vasoconstrictive agents, so-called “eye whiteners,” should not be used, as they will mask the disease process and make it impossible to document improvement. Patients who disregard medical advice and use such preparations usually continue wearing their contact lenses as well.

Bacterial conjunctivitis in a contact lens wearer requires topical antibiotic treatment, as the pathogenic bacteria may otherwise spread and attack the chronically micro-traumatized cornea, causing a corneal infiltrate or ulcer.

Because antibiotic resistance develops rapidly, and because treatment usually needs to be initiated before the culture results are available, we recommend treating conjunctivitis and keratitis in contact lens wearers with broad-spectrum antibiotic or gyrase-inhibitor eye drops or ointment. These should be applied every 2–3 hours, depending on severity.

The treatment of viral conjunctivitis in a contact lens wearer is usually directed against its cause. Mild cases are adequately treated with astringent eye drops, or, alternatively, with virustatic or virucidal agents. Bacterial superinfection, if present, necessitates combining these agents with an antibiotic.

Cortisone is useful in the treatment of severe cases of epidemic keratoconjunctivitis, but it should be used sparingly and only after exclusion of corneal herpes or other corneal lesions.

Fungal conjunctivitis is difficult to treat, because few ophthalmic fungistatic or fungicidal preparations are available. These must be used three to four times daily for at least 3 weeks. The patient’s immune status should be studied, as this type of infection generally arises in the setting of systemic illness or immune compromise.

Scleral lesions in the contact lens wearer are treated in the same way as conjunctival lesions, according to their etiology. Soothing and anti-inflammatory ointments or eye drops may be used.

Corneal edema in a contact lens wearer is treated by removing its cause, that is, the contact lens. Once lens wearing is discontinued, edema usually resolves within a few days. If it persists, it can be treated for a few days more with mildly astringent eye drops. Short-term use of nandrolone-containing, hyperosmolar, or buffered eye drops given locally two to three times a day speeds the healing process by restoring the osmotic stability of the cornea.

Corneal epithelial defects are highly prone to recurrence and sometimes create a therapeutic problem because, once healed, they can reappear shortly after the patient resumes wearing contact lenses. The lenses should therefore not be reinserted until it is certain that the corneal epithelium has become firmly reanchored to the underlying tissue. This normally takes at least 3 weeks but may take much longer in contact lens wearers because of the chronic foreign-body irritation caused by the lens. If corneal erosion recurs, a therapeutic, gel “bandage” contact lens may be indicated.

Specific treatment for corneal erosion, beyond the temporary interdiction of contact lenses, is generally not required. The epithelial lesions usually disappear overnight after the lens is removed; it is only rarely necessary to treat for a few days with mildly astringent eye drops or ointment. When contact lens wearing is resumed, the lens material and lens care system should be of a new type.

Pseudoherpetic corneal erosions in contact lens wearers are best treated with re-epithelializing eye drops or ointment. Antibiotic ointment should be given locally in addition in case of bacterial superinfection.

A fresh corneal epithelial erosion can be treated with preparations that promote healing, such as dexpanthenol, or with antibiotics three to four times daily. Once the epithelium is fully healed, the instillation of nandrolone eye drops two to three times daily for 2–3 weeks will prevent recurrence.

Bullous keratopathy is difficult to treat and frequently recurs. It seems reasonable to use astringent eye drops (in combination with a hyperosmolar preparation, if the stroma is involved). Therapeutic soft lenses can be useful as long as the lesion was not itself the result of a toxic reaction to a soft lens of the same type. If bullous keratopathy is caused purely by mechanical disruption of the epithelium in an otherwise healthy contact lens wearer, it will generally heal within 3–4 weeks after discontinuation of the contact lens and provision of reepithelializing eye drops.

The initial step of treatment in tight lens syndrome is the removal of the adherent lens, with the aid of artificial tears or buffer solution if necessary to prevent corneal epithelial injury. If used, these eye drops should be instilled repeatedly at 5-minute intervals (just as in chemical burn injuries), until the lens no longer sticks to the cornea and moves with each blink. Antibiotic eye drops or ointment must be given locally for a few days thereafter, as this will help prevent corneal ulceration, a frequent complication of TLS.

All forms of toxic keratopathy, and especially the very severe variety seen in mixed solution syndrome, mandate the immediate discontinuation of contact lenses, which should not be reinserted for several weeks or months.

There is no specific treatment for this condition. Cortisone is of no use in massive toxic reactions, and the preservatives found in most eye drop preparations tend to worsen the problem. Symptomatic relief can be gained by the use of astringent eye drops, such as a preservative-free 2% silver protein acetyl tannate solution applied three to four times daily; alternatives are corneal anabolic eye drops and cromolyn eye drops. In case of superinfection, preservative-free antibiotic preparations should be used.

The discontinuation of contact lenses results in the regression of all contact-lens-induced metabolic disturbances, in particular those that result from an impaired delivery of vitamins and other essential substances to the cornea by way of the tear fluid. Corneal deprivation syndrome (CDS) results either from the depriving effect of lens materials of various types or from the increased metabolic demand of the cornea in contact lens wearers, or both; it usually resolves with no treatment besides removal of the lens. Complete healing usually requires discontinuation of the lens for 1–2 weeks, in severe cases as long as 3 weeks.

Corticosteroids and antibiotics do not accelerate healing, nor is the local application of nandrolone of any value. Hypertonic salt and glucose solutions are also of no use. Only the application of 1–2 drops of multi-vitamin and multi-amino-acid solution appears to help.

The first step of treatment for post-heat syndrome is the immediate removal of the lenses, which generally requires instillation of a local anesthetic to counteract the associated blepharospasm. As in all chemical burns of the eye, buffering eye drops or ointment should be given repeatedly for the next 24–48 hours, and, if there is a tissue defect, antibiotics should be given as well. The contact lenses are no longer wearable and must be discarded. Allergy to the lens material should be ruled out before insertion of a new lens of the same type.

The treatment of choice for bacterial keratitis or corneal ulceration in a contact lens wearer is the same as that used for bacterial conjunctivitis in persons who do not wear contact lenses: local application of high-dose antibiotic eye drops or ointment, with the selection of agent based on the pathogenic species and its spectrum of antibiotic sensitivity.

When treatment must be initiated before the culture results are available, as is usually the case, broad-spectrum antibiotic coverage is recommended with an agent such as gentamicin or a gyrase inhibitor. In the initial phase of treatment, antibiotic ointment should be applied every 1–2 hours (or eye drops every hour). The treatment must be continued for a minimum of 9 days; stopping earlier may lead to the breeding of resistant organisms, which then produce recurrent infection.

Acanthamoeba corneal ulceration in contact lens wearers is rare and difficult to treat. Current recommendations are for the local application of propamidine in combination with neomycin or polymyxin B; in severe cases, ketoconazole is given orally in addition. As in all deep infections of the cornea, mydriatics such as homatropine or scopolamine should be given concomitantly (after glaucoma has been excluded).

Corneal neovascularization as a complication of contact lens wear always regresses within a few months after the patient stops wearing contact lenses, leaving behind collapsed “ghost vessels,” which require no treatment.

Contact-lens-induced corneal neovascularization is said to regress more rapidly if nandrolone-containing or astringent eyedrops are applied two or three times daily for a maximum of 6 weeks. On the other hand, the treatment of neovascularization into a transplanted cornea requires the local or even systemic administration of cortisone or immunosuppressive agents.

Should the patient wish to wear lenses in spite of corneal neovascularization, the fitting concept must be reviewed in the light of the factors that provoked the problem, and the lens must be changed to one made of material with a higher oxygen permeability (Dk) or a different chemical composition. If a toxic response to a lens care product is implicated in the causation of the problem, a new lens care product should be chosen that does not contain the offending substance.

Corneal scars may be treated conservatively in the same manner as corneal clouding of other causes, that is, with nonsteroidal anti-inflammatory agents or nandrolone, given in eye drop form three to four times daily for up to 4 weeks. Conservative management is often unsuccessful, however, and corneal scars that impair vision generally require surgery.

There is no specific treatment for the restoration of a corneal contour that has been deformed by a contact lens; fortunately, the cornea usually returns to its original shape after the contact lens is discontinued. It has been claimed that the application of nandrolone eye drops two to three times daily can accelerate healing. In 80–90% of cases, the cornea returns to its original shape within 3 weeks; refraction for spectacles should be performed no earlier than this.

Cortisone drops or local anabolic drops are useful in the treatment of folds in Descemet’s membrane. Other endothelial changes do not regress, even after long periods of not wearing contact lenses. There is as yet no effective treatment that can stabilize the number of damaged endothelial cells or change their shape and size back to normal.

Intraocular infection as a direct or indirect complication of contact lenses is treated with oral or parenteral antibiotics, with or without cortisone. It should be borne in mind that some types of antibiotics fail to enter the vitreous body or reach a therapeutically adequate intraocular concentration when they are given systemically. In addition to antibiotics, therapeutic mydriasis is a further important component of treatment.

Other types of intraocular process are nearly always unrelated to the wearing of contact lenses and require appropriate ophthalmologic evaluation and treatment. Depending on the form of treatment, it may be necessary for the patient to stop wearing lenses for a time.

Glaucoma in contact lens wearers is treated in the same way as in other patients, and with the same objectives: Stabilization of the intraocular pressure and preservation of the visual field.

The dosage of antiglaucoma medication must be adjusted in contact lens wearers to account for alterations in pharmacodynamics caused by wearing contact lenses. A hard contact lens, for example, considerably prolongs the washout phase of medications delivered in eye drops, so that the quantity or concentration of the applied agent can be reduced by up to 50%.

A soft contact lens similarly prolongs washout and also has a storage effect, in that the hydrophilic lens material acts as a depot for all water-soluble substances. Thus, the concentration of eye drops used to treat glaucoma can be reduced to as little as 25% of the original concentration. No fixed rule can be given for the required adjustment in dose, as it depends on multiple factors, including the water content and mass of the lens and the specific agent used. In general, ionic lens materials take up the agent more readily than anionic materials and deliver it back to the tear fluid more slowly. In any contact-lens wearer, the proper dosage of antiglaucoma medication can only be determined by meticulous individual titration to the response of the intraocular pressure.

In patients with glaucoma who have undergone surgery to create a filtration bleb, the wearing of contact lenses poses the risk of acute injury to the bleb. While contact lenses are not considered to be absolutely contraindicated in this situation, the risks and benefits should be carefully weighed in each case.

Tear deficiency in a contact lens wearer, if untreated, leads to a disturbance of the metabolism of the anterior ocular segment, with resulting complications. Thus, a dry eye in a contact lens wearer should be treated without delay. The results of treatment are often unsatisfactory: although there is a wide variety of artificial tear solutions available on the market, there is as yet no specific medication which, when given for a limited time, will permanently heal the dry eye of the contact lens wearer.

The form of treatment to be used in each patient depends on the particular cause of tear deficiency in that patient, and on the manifestations of tear deficiency syndrome that are found on ocular examination. Before initiating local treatment, the ophthalmologist should assess which endogenous and exogenous factors are responsible for tear deficiency in the individual patient. In unclear cases, medical consultation with an appropriate laboratory work-up is advisable.

An inadequate flow of tears to the eye must be diagnostically distinguished from a wetting disorder, as both types of disorder affect lens wearing comfort in a similar way. It should also be noted that the preservatives found in artificial tear solutions may be incompatible with the contact lens material.

The choice of wetting agent or artificial tear solution requires just as much care as, for example, that of an ophthalmic antibiotic or antiglaucoma agent. The danger of mixed solution syndrome must be borne in mind and averted, as toxic keratopathy may result if the artificial tear solution chosen is incompatible with the patient’s lens care system. Preservative-free solutions are thus to be preferred, though even these should be used sparingly, as improper or excessive use of artificial tears has been shown to cause a significant reduction of the flow of the patient’s own tear fluid.

For local therapy with eye drops there are certain basic guidelines: Salt deficiency is treated with hyper-tonic solutions, mucin deficiency with mucomimetic solutions. Eyes that are dry in the morning are treated with hyposmolar solutions to wash away the mucus that has accumulated overnight during sleep.

The osmolarity of the artificial tear solution should be chosen according to the central corneal thickness (CCT)—hypotonic solution for decreased CCT, hypertonic solution for increased CCT. In view of the problems caused by preservatives in artificial tear solutions, as mentioned above, long-term treatment is best provided with preservative-free solutions, for example, in unit-dose form.

The decision whether to treat dry eye with eye drops, a gel, or an ointment mainly depends on the frequency with which drops will have to be instilled, and on the lens-wearing regimen. A gel or ointment is preferable at times when the patient is not wearing contact lenses, e.g., during sleep, so that drops will not have to be instilled too frequently, although the patient may be bothered by the temporary impairment of vision that these preparations cause. Only eye drops can be used while the patient is wearing contact lenses.

Non-water-soluble medications delivered directly into the cul-de-sac are contraindicated while the patient is wearing contact lenses, as such substances can adhere to and damage the lenses. They can be used to restore the tear film only after the contact lenses have been removed, typically at night.

The proper dosage of medications for dry eye must be determined individually for each patient. Adequate relief for the entire day is often obtained from the instillation of a single drop of artificial tear solution in the morning upon awakening or from the use of a wetting solution during lens insertion. The optimal dosing schedule can only be determined by observing how long the patient is asymptomatic after the instillation of a single drop. The most common error in the treatment of dry eye in contact lens wearers is overdosing. If eyedrops are instilled too frequently, they interfere with the natural regulatory circuit of reflex-driven tear secretion and reduce the patient’s own tear production, thereby worsening the condition they were supposed to treat.

Thus, the treatment for dry eye cannot be considered a routine matter. The eye drops that are chosen for the initial treatment must not be continually re-prescribed without follow-up; rather, the anterior ocular segment must be regularly re-examined to document the effect of treatment. In other words, the treatment of dry eye in a contact lens wearer requires just as much care as, for example, the treatment of glaucoma.

A new form of treatment for dry eye is the application of so-called dry-eye ointment once or twice daily to the lower lid, rather than in the conjunctival sac. The ease of use of this method is its main advantage, particularly for elderly patients. Recent research further suggests that dry eye in contact lens wearers can be efficiently treated with tear-stimulating substances delivered in liposomes in the form of a spray. A single application of spray results in pachymetric stabilization of the cornea and normalization of the elevated temperature of the anterior surface of the eye for up to 2 hours. This form of treatment commends itself for use in the workplace, as a single application of spray onto the closed eyelids can relieve symptoms for several hours.

Eye injuries in contact lens wearers should be treated according to the usual ophthalmological principles, with the addition that antibiotics should always be given, as the wearing of contact lenses confers a higher risk of post-traumatic infection.

After a chemical exposure, the contact lens must be safely removed before the eye is rinsed and treated with buffer solution in the usual fashion. Likewise, whenever ocular trauma is to be treated surgically, the ophthalmologist must first be sure to remove the contact lens, or any contact lens fragments, from the operative field.

In peroxide exposures, the lens must be removed from the eye at once, which may be difficult because of the painful blepharospasm. Copious rinsing with sterile isotonic saline (or, if this is unobtainable, with tap water) helps to dilute the offending chemical and wash it out of the eye. In the ideal situation, a neutralizing solution for peroxide is ready at hand; rinsing with it is the easiest and safest way to neutralize the offending chemical. Afterward, ointment is used to promote reepithelialization. Larger epithelial defects require additional antibiotic coverage.