Red eye in a contact lens wearer
- Emergency
A painful red eye in a contact lens wearer is a corneal infection until proven otherwise. Remove the lens, keep its case, and refer the same day.
See it in 3D: Cornea
What it is
Contact lenses are the main risk factor for microbial keratitis in healthy adults. Sleeping in lenses, poor case hygiene and contact with tap water, swimming pools or rivers raise the risk. Pseudomonas aeruginosa causes rapidly progressive ulcers; Acanthamoeba causes pain out of proportion to the signs; fungi follow trauma with plant material. Early treatment with intensive antimicrobial drops saves the cornea.
How to recognise it
- Pain, light sensitivity and reduced vision rather than mere discomfort.
- A white or grey spot (infiltrate) on the cornea, with a staining defect.
- Pus in the anterior chamber (hypopyon).
- Pain far greater than the visible signs, history of tap water or swimming in lenses: Acanthamoeba.
- Sleeping in lenses or extended wear.
What to do at once
- Remove the lens and do not reinsert it; ask for the lens and its case to be kept.
- Measure visual acuity.
- Stain with fluorescein and look for an infiltrate, a defect and a hypopyon.
- Do not patch the eye and do not start a steroid.
- Refer to ophthalmology the same day for corneal scraping, culture and intensive antimicrobial drops.
Mistakes that cost sight
- Patching a contact lens abrasion favours Pseudomonas infection.
- Acanthamoeba keratitis is often mistaken for herpes; a ring-shaped infiltrate and nerve pain are clues.
- Lens-related problems that are not infections include tight-lens syndrome, giant papillary conjunctivitis and lens deposits.
Next step / Initial management
- Any infiltrate, pain or reduced vision: ophthalmology the same day; corneal scraping and culture of the lens and case.
- Treatment by ophthalmology: hourly broad-spectrum antibiotic drops (fluoroquinolone or fortified drops), adjusted to culture.
- Mild discomfort without staining or infiltrate: stop lens wear and review within 24 hours.
- Prevention: no sleeping or swimming in lenses, no tap water on lenses or case, replace the case regularly.
Test yourself
Think of the answer, then tap the question to see it.
What must be done first with a painful red eye in a contact lens wearer?
Remove the lens, keep the lens and its case for culture, and refer the same day without patching or steroids.
Which organism causes fast-progressing ulcers in lens wearers?
Pseudomonas aeruginosa.
Which features suggest Acanthamoeba keratitis?
Pain far worse than the signs, exposure of the lenses to tap water or swimming, and a ring-shaped infiltrate.
Connections
See it in 3D1
The structures of Durgical's 3D anatomy where it is found.
In Pharmacology4
Educational content; not a clinical guideline and no substitute for assessment by a health professional. For sudden visual loss, severe eye pain, a chemical burn or an eye injury, go to an emergency department at once.
Sources: Bacterial Keratitis (StatPearls Publishing (NCBI Bookshelf), 2023); Acanthamoeba Keratitis (StatPearls Publishing (NCBI Bookshelf), 2023).
Spotted a mistake?We are always improving for the community. Tell us what is wrong and our team will review it.Report a mistake
Representative model, for educational purposes only.