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소프트 콘택트렌즈 착용에 관한 부작용 Peter B. Lee, OD 121 st General Hospital Seoul, Korea.

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Presentation on theme: "소프트 콘택트렌즈 착용에 관한 부작용 Peter B. Lee, OD 121 st General Hospital Seoul, Korea."— Presentation transcript:

1 소프트 콘택트렌즈 착용에 관한 부작용 Peter B. Lee, OD 121 st General Hospital Seoul, Korea

2 CL 부작용의 위험 요소 Hypoxia ( 저산소증 ) –virtually all CLs reduce O 2 supply to cornea Desiccation / Alteration of tear film( 렌즈탈수 / 각막건조 ) –CLs are much thicker than tear film –SCLs evaporate to the atmosphere Deposit build-up( 침전 ) –SCL>RGP, but all develop deposits made of proteins, mucous, lipids, dirt, and microbes

3 CL 부작용의 위험 요소 Mechanical( 물리적 요소 ) –Tightness & looseness –Abrasions & friction Inflammatory response( 염증 ) –Proteins and other surface deposits –Microbes and their toxins –Solution preservatives and other components

4 Contributory Factors ( 문제가 될 수 있는 요소 ) Lens material –Dk( 산소 침투성 ) –Wettability and deposit attraction –Stiffness and other physical characteristics Lens design and fitting –Lens-to-cornea relationship –Position and movement –Thickness profile

5 Wearing time( 착용 시간 ) –DW vs. EW –Daily vs. part-time –Patient’s physiology Patient compliance( 착용자의 순응도 ) –Wear time –Cleaning and disinfection –Lens replacements –Follow-up visits

6 Effects of Hypoxia ( 저산소증에 인한 문제점 )

7 Effects of Hypoxia 1.Epithelial and stromal edema( 각막부종 ) 2.Decrease in epithelial mitosis( 상피 분열 ) 3.Increase in stromal lactate accumulation( 유산 축적 in anterior chamber) 4.Decrease in corneal sensitivity

8 Corneal Edema( 각막부종 ) The cornea requires a certain amount of oxygen to prevent swelling, or edema During sleep, the oxygen supply is reduced to approx. 8%, compared to about 21% during waking hours The cornea swells 3% to 4% overnight Therefore, it appears the cornea needs more than 8% O 2 to prevent swelling

9 Corneal sensitivity( 각막 민감도 ) »Millodot and O'Leary (1980) found that the cornea needs at least 8% oxygen to prevent a reduction in corneal sensitivity

10 Oxygen Requirements The cornea requires 8% to 13% O 2 to maintain normal corneal thickness, metabolism, and sensitivity. What are today’s contact lenses able to deliver?

11 Oxygen Requirements CLs are not rated by % O 2 delivered Transmissibility (Dk/L) is a rough indicator of how well a CL transmits oxygen Dk/L is the most common measure to rate how well contact lenses deliver oxygen to the cornea Other methods have also been developed but are not in widespread use

12 Epithelial Edema( 각막 부종 )

13 Epithelial edema manifests as clouding of the epithelial tissue, usually centrally, with associated punctate epithelial staining, steepening of the corneal curvature and possible irregularity of the corneal surface Epithelial Edema( 각막 부종 )

14 원인 Low Dk( 산소 침투성 ) contact lens wear (PMMA more likely than soft lenses) Long-term, extended hours or extended wear( 연속 착용 )

15 증상과 진단 Poor endpoint visual acuity Distorted keratometry mires, steepening of K's Central circular clouding (CCC) Punctate epithelial staining centrally Increased minus on refraction

16 치료 / 처치법 Discontinue lens wear or immediate refit to higher Dk material Refit to higher Dk material Decrease wear time Looser fit for better tear exchange Monitor K and SR changes –Prescribe new spectacles when stable to allow decreased CL wear time

17 Stromal Edema( 고유층 부종 ) Stromal edema manifests as fine wrinkling (striae) or folds in Descemet's membrane Striae and folds appear with approx. 6% stromal edema Stromal clouding requires extensive edema, at least 15%, and is usually not induced by contact lens wear

18 Stromal Edema

19 원인 Thick lens design (aphakic, prism ballast), low Dk material or EW

20 증상과 진단 Mild edema: 6 to 7% Striae in deep stroma Moderate edema: 10 to 15% Folds in deep stroma Severe edema: > 18% Central haze on sclerotic scatter

21 치료 / 처치법 Increase Dk/L: higher water content, thinner design Looser fit for better tear exchange

22 Microcysts( 상피 미세낭종 ) / Vacuoles( 엑포 )

23 Microcysts are tiny cystic bodies containing cellular debris They form at the basal cells and slowly migrate towards the corneal surface They are visible with reversed illumination, indicating that the cystic material has a higher index of refraction than the surrounding corneal tissue

24 Microcysts / Vacuoles

25 Vacuoles form similarly to microcysts but are fluid filled They are visible with unreversed illumination, indicating that the cystic material has a lower index of refraction than the surrounding corneal tissue

26 Microcysts / Vacuoles Although they do not induce any symptomalogy, the presence of microcysts and vacuoles indicate a chronic hypoxic condition and a resulting alteration of corneal metabolism Removal of the offending contact lens will result in their disappearance over the course of several weeks

27 원인 Several weeks (6 to 12 or more) of low Dk/L lens wear Extended Wear

28 증상 및 진단 Small cysts in epithelium visible with retroillumination Microcysts: reversed illumination (higher index than cornea) Vacuoles: unreversed illumination (lower index than cornea)

29

30 치료 / 처치법 Increase Dk/L D/C extended wear D/C lens wear if more than 50 are observed Monitor for 3 to 6 months for resolution –# may increase after d/c lens wear due to abnormal processing of epithelial cells

31 Vascularization( 혈관신생 ) Cellular debris and other metabolic by- products may be other stimuli to vessel growth Almost all soft lens patients will demonstrate some amount of vascularization

32 Vascularization( 혈관신생 )

33 In most cases, vascularization is asymptomatic, but encroachment into the visual axis may result in a reduction in vision Vascularization can be graded according to the number of quadrants and the extent to which the vessels have grown into the cornea

34 원인 Long-term wear of any soft lens, but particularly lenses with low Dk/L (aphakic, prism ballasted, etc.) Extended wear

35 진단 Varying degrees of vessels encroaching into previously avascular cornea –Grade 1: Sectorial or circumlimbal vessel extension less than 0.5 mm, or 1 or 2 vessels extending less than 1.5 mm into cornea. –Grade 2: Sectorial or circumlimbal vessel extension 0.5 to 1.5 mm into cornea.

36

37 치료 / 처치법 Grade 1 or 2: monitor Q6mos Grade 3: decrease wear time, increase Dk/L or refit to RGP material Grade 4: refit to RGP material or D/C lens wear Though vasc may regress, vessel walls do not disappear –Watch for development of ghost vessels

38 Polymegethism( 폴리메가티즘 ) A permanent condition of endothelial cell( 내피 ) change such that the cells are no longer uniform but are of varying sizes

39 Endothelial blebs( 내피 물집 ) Transient, small, dark, non-reflective areas that appear shortly after lens insertion

40 원인 Long-term wear of any soft lens, but particularly lenses with low Dk/L (aphakic, prism ballasted, etc.), extended wear

41 치료 / 처치법 Change to higher Dk or RGP Monitor for further cellular changes, corneal edema

42 DRY EYE / DESICCATION

43 Soft Lens Desiccation( 탈수 ) Soft lenses dehydrate when exposed to the atmosphere As the lens dehydrates, it draws water from the post-lens tear film, resulting in dryness of the cornea in these areas Tear flow dynamics from tight or high modulus soft lenses may contribute to this staining pattern

44 원인 Thin, high water soft lens Borderline dry eye Extended wear Incomplete / infrequent blink Dry environment Heavy protein deposition

45 진단 Inferior central arcuate punctate staining

46 치료 / 처치법 Lubricating drops: unpreserved Thicker lens design, prism ballast Lower water content, non-ionic (group 1) Lenses that have high water retention (Proclear, Extreme H 2 0, Soflens 66) Frequent replacement (if deposited with protein) Punctal plugs

47 INFLAMMATION / INFECTION

48 Contact Lens-Induced Papillary Conjunctivitis (GPC)- 유두상결막염 Typical symptoms –Itchiness –Stringy mucous discharge –Lens intolerance Hallmark sign is large papillae on the superior palpebral conjunctiva

49 A combined immunological and mechanical response to denatured tear proteins that have adhered to the lens surface( 렌즈의 침전물에 의한 일종의 알레르기성 반응 )

50 원인 Aged soft lens –high water content –ionic Aged rigid lens –silicone acrylate Poor compliance to cleaning regimen No enzymatic cleaning

51 증상 Itchiness Mucous discharge: white ropy Lens awareness / intolerance

52 진단 Large papillae on upper tarsal conjunctiva –SCL: diffuse distribution –RGP: more common along lid margin (zone 3) Heavily protein coated contact lens Poorly designed lens edge White, ropy mucous discharge

53 Diagnosis / Treatment: Stage 1 Itching Mucous discharge Upper tarsus hyperemic but relatively normal Discontinue lens wear or immediate refit in new lens Unpreserved lubricants

54 Diagnosis / Treatment: Stage 2 Enlarged papillae on upper tarsus Hyperemic and edematous upper tarsal conjunctiva Increased itching and mucous Mild blurring of vision Reduced wear time Discontinue lens wear Unpreserved lubricants

55 Diagnosis / Treatment: Stage 3 Large, clover-like papillae that may stain with fluorescein Increase in tarsal hyperemia Increased itching and mucous Lens discomfort Discontinue lens wear Topical antihistamine Topical vasoconstrictor Topical NSAID Refit to disposables or RGPs

56 Diagnosis / Treatment: Stage 3

57 Diagnosis / Treatment: Stage 4

58 Larger, more numerous papillae Exacerbation of symptoms Lens intolerance Discontinue lens wear Topical steroid Topical NSAID Topical mast cell stabilizer / combo Refit to disposables or RGPs

59 Contact Lens Superior Limbic Keratoconjunctivitis

60 Contact Lens Superior Limbic Keratoconjunctivitis ( 상윤부각결막염 ) Immunological response to lens surface deposits and solution preservatives Its superior location suggests that there may be a hypoxia component May also have a mechanical component

61 원인 Soft contact lens wear Protein deposition Use of solutions containing thimerosal

62 증상 Burning, itching Superior bulbar redness Photophobia, tearing

63 진단

64 치료 / 처치법 Discontinue lens wear until resolution Lubricants Topical steroid if severe Refit to different material Patient education on compliance with lens care Discontinue use of thimerosal preserved solutions

65 Acute Red Eye/ 급성충혈 (Tight Lens Syndrome)

66 원인 Extended wear of soft lenses, particularly tightly fitting lenses Extended wear of rigid lens with lens adherence

67 증상 Awaken with unilateral discomfort or pain Redness Tearing Photophobia

68 진단 Subepithelial infiltrates Conjunctival and limbal hyperemia Minimal epithelial staining Debris trapped between lens and cornea

69 치료 / 처치법 Discontinue lens wear until infiltrates resolve Lubricants Prophylactic broad spectrum antibiotic drops if epithelial defect or infiltrates are present (fluoroquinolones, Polytrim) Change wearing schedule to daily wear

70 Case example 26 세, 남 Sx of moderate irritation and localized redness OD for 4 days No pain, discharge, photophobia, blurry vision SCL wearer for 10 years –Focus Monthly: replaces Q2mos –16 hrs/day –Renu MPS

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72 Sterile Infiltrate / Ulcer ( 무감염성 각막궤양 ) An infiltrate is a localized collection of white blood cells An ulcer is an excavated area of the cornea that has undergone necrosis due to immunological or microbial invasion

73 원인 Extended wear, long wear times Low Dk material Preserved solutions Poor compliance with care regimen

74 증상 Mild irritation, tearing Foreign body sensation Localized bulbar redness

75 진단 Peripheral, small diameter white subepithelial fuzzy lesions Overlying epithelial defect / disruption may be present Mild to moderate sectoral injection None to moderate anterior chamber reaction

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77 치료 / 처치법 Discontinue lens wear Culture if epithelial defect present: cannot diagnose as sterile until culture is done Artificial tears if no epithelial defect present Topical broad spectrum antibiotic if epithelial defect present –Fluoroquinolone (Ciloxan, Ocuflox) –Fortified aminoglycoside

78 Continue antibiotic therapy until culture results are in, or until re-epithelialization –qh for 24 hours, then taper Topical steroid possible after re-epithelialization if infiltrates are central and persistent

79 SOLUTION RELATED COMPLICATIONS( 보존액에 의한 부작용 )

80 Preservative Allergies and Sensitivities ( 방부제에 의한 앨러지 ) Chemical care systems provide convenient disinfection with little damage to the contact lenses. However, many of the preservatives in use today are capable of inducing a Type IV delayed hypersensitivity response.

81 원인 Long-term use of preserved soaking/rinsing solution Potential offending agents: –Polyquaternium-1 (Alcon) –Polyaminopropyl biguanide (B&L) –Polyhexamethylene biguanide (Allergan) –Polyhexanide (Ciba) –Chlorhexidine (Boston, Claris) –Benzalkonium chloride (Allergan Wet n Soak) –Thimerosal

82 증상 Redness, itchiness, tearing Irritation with lens wear

83 진단 Diffuse bulbar injection Diffuse SPK Possible subepithelial infiltrates

84 치료 / 처치법 Discontinue lens wear if infiltrates or moderate to severe SPK are present Change preservative system or change to unpreserved care system If infiltrates persist after 2 weeks, consider a steroid Steroid Tx should be aggressive and of sufficient duration


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