Quite an eyefull

Wendy Knoops; Roshini Sanders

Unilateral conjunctival and lid infections are often treated in general practice. They are more likely to be related to trauma or foreign body irritation and it has always been debatable as to how long these infections should be treated in primary care before referral to a hospital ophthalmic clinic.

A 53-year-old bank service manager presented with a chronically irritable left eye, intermittent discharge, slight swelling of the eyelid and mild erythema. There was no loss of vision. His symptoms were managed in primary care for 1 year by his GP, optometrist and a local primary care eye clinic. There was poor response to a variety of antibiotics and bacterial swabs, including testing for chlamydia, were negative. As a result, he was referred to the regional ophthalmology department.

Examination at the ophthalmology department of the affected eye revealed mild blepharitis of upper and lower lids, mild erythema and moderate swelling and induration of the left upper eyelid. Eversion of the left upper eyelid revealed a deeply embedded contact lens in the tarsal plate with conjunctivalisation of the lens and a surrounding area of inflammatory granulomatous tissue. At the slit lamp, the contact lens was removed leaving an indentation in the tarsus of similar shape and size to the lens. The contact lens was sent to microbiology, which did not grow any organisms including testing for acanthomoeba.

Further questioning revealed that the patient had lost a gas permeable contact lens 14 years ago. Since 1980, there have been published cases reporting retained contact lenses in the eye for several years. Hard gas permeable contact lenses seem to be the main culprits in all of these cases, usually migrating and settling in the upper eyelid. Patients were more likely to present with inflammation or a mass in the eyelids rather than infection.

We wish to highlight the need to perform eversion of the upper eyelid in cases of prolonged and non responsive ophthalmic infection and inflammation. This is also essential where there is unilaterality of signs and negative laboratory tests. While this remains an unusual scenario it serves to remind clinicians not to overlook this simple and necessary step towards complete ophthalmic examination.