Published in Contact Lens

Contact Lens Complications In Non-Compliant Patients

This is editorially independent content
8 min read

Gain an understanding of how non-compliance in contact lens wearers can cause complications and the steps optometrists can take to prevent them.

Contact Lens Complications In Non-Compliant Patients
Contact lens wear, overall, is a safe way to correct vision and be spectacle-free. The introduction of new material technologies and lens options over the last two decades has given eyecare providers (ECPs) more opportunities to avoid complications than ever before.
Silicone hydrogel materials, for instance, have eliminated concerns about and complications associated with hypoxia.1
The first generations of silicone hydrogel lenses may have come with their own mechanical and surface complications, but those have also essentially been eliminated with updated generations of silicone hydrogel materials.2-4

Overview of contact lens complications

While advanced contact lens technologies have helped to reduce mechanical and hypoxia-related complications, ECPs may still encounter contact lens-related complications that result in inflammation and possibly infection of the cornea. These types of complications typically present with symptoms of redness, irritation, light sensitivity, and pain.
While it is imperative that an ECP is able to accurately diagnose and manage cases of corneal infiltrative events and potential microbial keratitis when they encounter it,2 it is arguably more important that the ECP and patient understand how to prevent inflammatory and infectious complications before they occur.
Incidence rates and risk factors associated with corneal infiltrative events and microbial keratitis have been studied extensively over the years. It can be overwhelming to parse through the differences between risk factors associated with all of the different aspects of contact lens wear, like replacement, overnight wear, and material.
Read on to learn what is most likely to complicate contact lens wear and how to avoid ocular health compromise before it happens.

Preventing microbial keratitis

Microbial keratitis is the complication we want to avoid most because an infection in the cornea can lead to permanent vision loss. Microbial keratitis is rare in contact lens wearers, but if/when you suspect a patient might be experiencing an infectious corneal event, it is certainly considered an emergency.
Prevention, therefore, is imperative, and all contact lens wearers should understand best practices for preventing infectious complications. One key factor that increases the risk for microbial keratitis is overnight wear.5-9
Although modern silicone hydrogel materials offer oxygen permeability that allows for sufficient oxygen transmission when a patient sleeps in their contact lenses, the risk of microbial keratitis still increases with overnight wear, regardless of the material.
Even occasional overnight wear (less than one night per week) can dramatically increase a patient’s risk for microbial keratitis.7,9 Hygiene is also a major contributor to microbial keratitis risk. If a patient has poor habits when it comes to hygiene practices like hand washing, storage case hygiene, and storage case replacement, their risk for microbial keratitis increases.7-10
Some issues with hygiene practices could be eliminated by prescribing a daily disposable modality. For microbial keratitis, it has been reported that daily disposable lens wear doesn’t reduce the absolute risk of infection, but it does result in less severe disease presentation and subsequent vision loss.6

Avoiding corneal infiltrative events

Corneal infiltrative events (CIEs) are any type of inflammation in the cornea. They might present as mild, asymptomatic infiltrates or more symptomatic peripheral ulcers. It has been suggested that CIEs should be considered as a continuous spectrum of disease.11
This means that mild CIE presentations may progress to more severe presentations and, presumably, could allow for an opportunistic infectious condition if left untreated. Prevention of CIEs, therefore, not only keeps patients from experiencing irritating and painful inflammatory keratitis events but could also prevent more serious cases of microbial keratitis.
CIEs share some similar risk factors with microbial keratitis. Overnight wear, once again, is a major risk factor for developing any type of CIE.12-16 As well, hygiene habits like not rubbing reusable lenses with solution, topping off solution, and poor case hygiene/replacement have all been associated with an increased risk of CIEs.17,18
Some studies have reported silicone hydrogel materials result in more CIEs and that multipurpose solutions may be more likely to cause a CIE in patients wearing reusable contact lenses,13-15 but more research likely needs to be done to make a definitive conclusion about those relationships.

Unlike microbial keratitis, daily disposable contact lens wearers have a reduced overall risk of developing a CIE.13,14,16 Additionally, it has been reported that older teens and young adults are at a higher risk of developing a CIE than other age groups,13,15,16 perhaps in response to changes in lifestyle and responsibility for individual healthcare practices that occur during these years.13

Strategies for improving patient communication and compliance

When the factors that increase a patient’s risk for inflammatory or infectious corneal events are considered, it is apparent that most could be avoided with thoughtful consideration during the fitting process and effective communication about how to properly handle the contact lenses.
Whenever possible, a patient should be fitted with a daily disposable option. Daily disposable wearers are more likely to be compliant with the replacement schedule (compared to biweekly or monthly replacement wearers).19
By fitting a daily, you not only reduce the risk of developing a CIE and a more severe form of microbial keratitis—you also eliminate the need for the patient to be compliant with solution use and case hygiene, making it even less likely that they will develop a complication.
Regardless of what replacement modality is prescribed, make sure there is clear, in-office communication about how to properly handle the lenses. It has been reported that up to 90% of soft contact lens wearers have some level of non-compliance with lens care practices like lens replacement and case hygiene.19-22

Understanding what patients don’t know about contact lens hygiene

It is important, therefore, to not assume a patient knows when to replace lenses and how to care for them. Making a brief mention of the replacement schedule at the completion of an exam and/or including replacement and hygiene instructions on prescription materials can encourage healthy behaviors.
Don’t assume a patient knows when to replace their lenses or if it is correct to do things like sleep, shower, or swim in their lenses. We know that compliance is important in preventing complications, so ensure each patient knows what good contact lens compliance means for them.
Finally, make sure patients know the symptoms associated with the early stages of contact lens complications. For microbial keratitis, the earlier the patient presents to an ECP for care, the less severe the disease process they will experience.23
Because of this, patients should know that they should discontinue contact lens wear and seek out an ECP if they experience any symptoms associated with ocular inflammation or infection, like redness, pain, and light sensitivity.


By preventing inflammation and infection associated with contact lens wear, you promote healthy contact lens habits that will also help reduce the risk of other, less severe, but still disruptive complications.
Preventing complications means your patients stay happy, healthy, and comfortable in their lenses, which is the goal of everyone involved in the contact lens fitting process.
  1. Sweeney DF. Have Silicone Hydrogel Lenses Eliminated Hypoxia? Eye Contact Lens. 2013;39:53-60.
  2. Stapleton F, Bakkar M, Carnt N, et al. Clear - Contact Lens Complications. Cont Lens Anterior Eye. 2021;44:330-67.
  3. Sulley A, Dumbleton K. Silicone Hydrogel Daily Disposable Benefits: The Evidence. Cont Lens Anterior Eye. 2020;43:298-307.
  4. Maldonado-Codina C, Morgan PB, Schnider CM, Efron N. Short-Term Physiologic Response in Neophyte Subjects Fitted with Hydrogel and Silicone Hydrogel Contact Lenses. Optom Vis Sci. 2004;81:911-21.
  5. Dart JK, Radford CF, Minassian D, et al. Risk Factors for Microbial Keratitis with Contemporary Contact Lenses: A Case-Control Study. Ophthalmology. 2008;115:1647-54, 54 e1-3.
  6. Stapleton F, Keay L, Edwards K, et al. The Incidence of Contact Lens-Related Microbial Keratitis in Australia. Ophthalmology. 2008;115:1655-62.
  7. Konda N, Garg P, Sharma S, Willcox MDP. Risk Factors for Contact Lens-Related Microbial Keratitis and Associated Vision Loss in a South Indian Population. Eye Contact Lens. 2021;47:118-26.
  8. Lim CH, Carnt NA, Farook M, et al. Risk Factors for Contact Lens-Related Microbial Keratitis in Singapore. Eye (Lond). 2016;30:447-55.
  9. Stapleton F, Edwards K, Keay L, et al. Risk Factors for Moderate and Severe Microbial Keratitis in Daily Wear Contact Lens Users. Ophthalmology. 2012;119:1516-21.
  10. Stapleton F, Shrestha GS, Vijay AK, Carnt N. Epidemiology, Microbiology, and Genetics of Contact Lens-Related and Non-Contact Lens-Related Infectious Keratitis. Eye Contact Lens. 2022;48:127-33.
  11. Efron N, Morgan PB. Rethinking Contact Lens Associated Keratitis. Clin Exp Optom. 2006;89:280-98.
  12. Radford CF, Minassian D, Dart JK, et al. Risk Factors for Nonulcerative Contact Lens Complications in an Ophthalmic Accident and Emergency Department: A Case-Control Study. Ophthalmology. 2009;116:385-92.
  13. Chalmers RL, Wagner H, Mitchell GL, et al. Age and Other Risk Factors for Corneal Infiltrative and Inflammatory Events in Young Soft Contact Lens Wearers from the Contact Lens Assessment in Youth (Clay) Study. Invest Ophthalmol Vis Sci. 2011;52:6690-6.
  14. Richdale K, Lam DY, Wagner H, et al. Case-Control Pilot Study of Soft Contact Lens Wearers with Corneal Infiltrative Events and Healthy Controls. Invest Ophthalmol Vis Sci. 2016;57:47-55.
  15. Zimmerman AB, Emch AJ, Geldis J, et al. Contact Lens Corneal Inflammatory Events in a University Population. Optom Vis Sci. 2016;93:42-9.
  16. Chalmers RL, Keay L, McNally J, Kern J. Multicenter Case-Control Study of the Role of Lens Materials and Care Products on the Development of Corneal Infiltrates. Optom Vis Sci. 2012;89:316-25.
  17. Dumbleton KA, Woods CA, Jones LW, Fonn D. The Relationship between Compliance with Lens Replacement and Contact Lens-Related Problems in Silicone Hydrogel Wearers. Cont Lens Anterior Eye. 2011;34:216-22.
  18. Sorbara L, Zimmerman AB, Mitchell GL, et al. Multicenter Testing of a Risk Assessment Survey for Soft Contact Lens Wearers with Adverse Events: A Contact Lens Assessment in Youth Study. Eye Contact Lens. 2018;44:21-8.
  19. Dumbleton K, Richter D, Bergenske P, Jones LW. Compliance with Lens Replacement and the Interval between Eye Examinations. Optom Vis Sci. 2013;90:351-8.
  20. Cardona G, Alonso S, Yela S. Compliance Versus Risk Awareness with Contact Lens Storage Case Hygiene and Replacement. Optom Vis Sci. 2022;99:449-54.
  21. Hickson-Curran S, Chalmers RL, Riley C. Patient Attitudes and Behavior Regarding Hygiene and Replacement of Soft Contact Lenses and Storage Cases. Cont Lens Anterior Eye. 2011;34:207-15.
  22. Rueff EM, Wolfe J, Bailey MD. A Study of Contact Lens Compliance in a Non-Clinical Setting. Cont Lens Anterior Eye. 2019;42:557-61.
  23. Keay L, Edwards K, Naduvilath T, et al. Factors Affecting the Morbidity of Contact Lens-Related Microbial Keratitis: A Population Study. Invest Ophthalmol Vis Sci. 2006;47:4302-8.
Erin Rueff, OD, PhD, FAAO
About Erin Rueff, OD, PhD, FAAO

Dr. Erin Rueff received her Doctor of Optometry degree from The Ohio State University (OSU) College of Optometry. Upon graduation, she completed the Cornea and Contact Lens Advanced Practice Fellowship at OSU. After fellowship, she continued at OSU as a clinical instructor and completed a PhD in Vision Science. In 2018, she joined the faculty at the Southern California College of Optometry at Marshall B. Ketchum University. Dr. Rueff’s research interests include contact lens discomfort and compliance. She enjoys teaching students in the clinic and classroom on contact lens and general optometry topics. Her clinical interests include multifocals, gas permeable and scleral contact lenses, keratoconus, and dry eye.

Erin Rueff, OD, PhD, FAAO
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