A Prudent Solution for CIEs
Understand your options when a patient presents with sterile infiltrates.
W. LEE BALL, O.D., F.A.A.O., JACKSONVILLE, FLA.
Some practitioners have recently seen an increase in the incidence of sterile corneal infiltrative events (CIEs) among silicone hydrogel lens wearers who use multi-purpose solutions (MPS).1
These inflammatory events, with symptoms that include conjunctival redness, pain, discharge, photophobia, lid edema, tearing and irritation, are uncomfortable and inconvenient for patients. It is a negative experience that may lead to dissatisfaction or permanent dropout from contact lens wear.
As practitioners, we’re concerned about potential risk of infection from a breakdown of the corneal epithelial surface, and inflammatory events are an indication of insult to the cornea. An increase in the incidence of sterile CIEs, even not widespread or well documented, may be cause for concern. Once the CIE is resolved, it can be confusing to know what to change to avoid a recurrence.
Here are four options for treating these patients to avoid such a recurrence and why some are more prudent than others:
Change lens material.
One option is to switch to a different silicone hydrogel material. There are health and financial arguments against this approach. If the problem is MPS-related, the condition may recur even with a different lens material, particularly in an already sensitized eye.
Also, keep in mind the economics of prescribing a different lens. When changing a lens, the number of visits increases from the original presentation with the CIE and the follow-up visit to confirm that treatment has resolved the condition. This medical care is typically reimbursed by the patient’s insurance. But if a new lens is prescribed at the second visit, the practitioner must schedule a third visit — a contact lens follow-up. Because of this, you should calculate cost and chair time when reimbursement for the third visit is often not as likely.
A slit lamp examination reveals two subepithelial infiltrates with no epithelial defects.
Change care regimen.
Many practitioners may opt to switch to a hydrogen peroxide-based care system. In this case, it is important that patients understand they cannot use the previous MPS for a final rinse before insertion. Otherwise, they risk re-exposing themselves to the initial stimulus for the inflammatory event.
One could consider a different MPS. However, given that each solution has different active and inactive ingredients and different rates of toxicity and uptake into lens materials, this may result in a trial and error process to find the right accessory product to the lens you have prescribed.
Change both lens and care regimen.
Another option is to cover all bases by changing both the lens and the care regimen. This makes it impossible to know which change really solved the problem.
Also, depending on the patient’s age, prescription, modality and other factors, there may not be another contact lens that meets his/her needs quite the same as the previous lens, in addition to the health and economic considerations already discussed.
Switch to daily disposable lenses.
The final option is to consider transitioning the patient to daily disposable lenses. This modality eliminates solution toxicity and lens-solution interaction altogether — two common causes of inflammatory events, in order to avoid a recurrence.
With today’s advances in one day offerings, the majority of patients can be successfully fit in a daily disposable lens. Even though this option may require an additional visit, by moving the patient to a shorter wear cycle and eliminating care regimens, you can to turn the patient’s negative experience into a positive one.
Keep in mind the economics in prescribing a different lens.
It behooves us to make evidence-based decisions to solve patients’ problems. Practitioners who have had several cases of CIEs may want to review their charts to look for commonalities. Your initial perception may seem to indicate a problem with a specific material or solution. But after conducting a chart audit, it may become clear what is actually occurring in your patient population. Taking a step-wise approach to solving patient problems rather than making impulsive changes improves quality of care in your office. OM
1. Carnt N, Evans V, Naduvilath T, et al. Contact lens-related adverse events and the silicone hydrogel lenses and daily wear care system used. Arch Ophthalmol. 2009 Dec;127(12):1616-23.
Dr. Ball is associate director, professional affairs for VISTAKON Division of Johnson & Johnson Vision Care, Inc. Send comments to firstname.lastname@example.org.