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Corneal Staining as a Response to Contact Lens Wear

Desmond Fonn, Dip.Optom., M.Optom., Rachael Peterson, Ph.D., and Craig Woods, Ph.D.

that stain with fluorescein. In severe cases, the punctate staining

Objective: To review the effects of contact lenses on the corneal surface.
becomes confluent but only in very rare cases does it result in
Methods: A review of the literature and in-house research of corneal
staining and its various forms of presentation. dellen (Fig. 2). The reason for including this example is to
Results: Corneal staining manifests in many different forms. The severity demonstrate the severity of the staining with faint stromal glow
of staining or insult of the cornea is usually determined by the extent (area surrounding the lesion because of seepage of fluorescein into the
of coverage), density, and depth. The cause of staining is multifactorial, stroma. It highlights the utility of fluorescein.
and its location is often linked to the type of lens that is being worn, the The other two examples of superficial staining induced by soft
solution used to clean/disinfect the lens, the state of hydration of the soft contact lens wear have different origins. Figure 3 is an example of
lens, and the state of the cornea that has been affected by the lens. solution-induced corneal staining (SICS), which is caused by an
Conclusions: Sodium fluorescein dye effectively highlights corneal in- interaction of multipurpose soft lens-disinfecting solutions and soft
tegrity changes referred to as corneal staining. This review describes the
contact lenses.9 15 The typical presentation illustrated in this figure
manifestations, the cause, the mechanisms, and the methods of remediation
is less punctate staining centrally than the annular periphery.
of corneal staining.
Although peripheral staining in some cases might appear confluent
Key Words: EpitheliumSolution-induced corneal stainingSmile and dense, the condition is still termed superficial because of its
stainFluoresceinPunctate stainingCell sloughingContact lenses transient nature.
To varying degrees, hydrogel contact lenses dehydrate during
(Eye & Contact Lens 2010;5: 318321)
wear. Although this review is about objective signs, it is worth
mentioning that subjective responses to lens dehydration have also
THE CLINICAL MANIFESTATIONS varied, where some studies have found a correlation between
Contact lenses can affect the integrity of the ocular surface hydrogel dehydration and decrease in lens comfort, whereas others
manifesting in macro terms as surface damage, which must affect have not.16 24 Figure 4 is an example of inferior punctate corneal
epithelial cells and are best imaged or viewed by instillation of staining sometimes referred to as Smile Stain because of its
sodium fluorescein. The clinical manifestation of corneal staining location in the lower third of the cornea. It is induced by lens
is dependent on the type of tissue insult and is described accord- dehydration as a result of evaporation of fluid from the anterior
ingly. Examples are abrasion, erosion, ulceration, and superficial surface during wear. The assumption is that as the front surface of
punctate staining, and the cause for most of these conditions is well the lens evaporates, secondary pervaporation of the postlens tear
established. It is unnecessary for the purpose of this review to film occurs, causing disruption of the epithelium resulting in
include examples of mechanical insult associated with contact lens corneal staining. The condition can be exacerbated by using very
wear such as abrasions or erosions or even corneal ulceration. thin high water content lenses.25,26
Most of these examples will demonstrate that fluorescein has
seeped into the stroma because the lesions extend beyond the
epithelium. However, three examples of punctate staining are WHAT IS PUNCTATE CORNEAL STAINING?
Vital dyes such as fluorescein and Lissamine green, which now
Superficial punctate corneal staining implies that the effect is
is used in preference to rose Bengal, are used to highlight ocular
restricted to the superficial layers of the epithelium but the term
surface damage by enhancing the contrast of damaged area or cells
does not describe how extensive the staining is. Although the three
from the surrounding tissue. Surface damage allows fluorescein to
examples have different magnification, it is obvious that the extent
penetrate into the corneal epithelial cells or between cells. If the
and density of the staining differs. Three and nine staining (Fig. 1)
damage is excessive, it can lead to fluorescein leakage into the
is essentially caused by desiccation of the peripheral cornea and is
stroma. The most convenient and clinically useful and definitive
a very common problem induced by rigid lens wear.1 8 Under high
technique for observing and diagnosing corneal damage is with the
magnification, it appears that there are cellular punctate changes
use of sodium fluorescein. Water soluble fluorescein is instilled
into the eye and is viewed with a biomicroscope using a cobalt
From the Centre for Contact Lens Research, School of Optometry, blue excitation filter in combination with a yellow barrier filter to
University of Waterloo, ON, Canada. enhance the contrast against surrounding undamaged tissue. This
The authors have no funding or conflicts of interest to disclose.
Address correspondence and reprint requests to D. Fonn, Centre for
process is described as staining, and to improve the contrast and
Contact Lens Research, School of Optometry, University of Waterloo, eliminate surface reflexes, interference filters can be used.27
Ontario, Canada; e-mail: There is controversy whether fluorescein only enters damaged
Accepted July 22, 2010. or devitalized cells or whether it is able to penetrate healthy cells.
DOI: 10.1097/ICL.0b013e3181f35d54 Norn28 claimed that fluorescein does not stain healthy, dead, or

318 Eye & Contact Lens Volume 36, Number 5, September 2010
Eye & Contact Lens Volume 36, Number 5, September 2010 Corneal Staining and Contact Lens Wear

FIG. 3. Solution-induced corneal staining exhibiting less staining

FIG. 1. The 3 and 9 oclock corneal staining induced by rigid gas centrally than peripherally.
permeable contact lens wear.
as diffuse punctate staining (extent grade 1 and above) in at least
degenerated cells but it is the disruption of the cell junctions that four of the five regions of the cornea.15 Solution-induced corneal
stain, whereas Feenstra and Tseng29 and Wilson et al.30 stated that staining may cover the cornea evenly or present in a more annular
individual cells will stain with fluorescein. They concluded that pattern having greater density in the peripheral cornea.10,35 It most
fluorescein was not filling intercellular spaces. Observations with often presents as low-grade punctate staining without any associ-
high magnification slitlamp microscopy would suggest that punc- ated discomfort or dryness symptoms, and for these reasons, it has
tate staining looks as if epithelial cells are affected. However, been classified as clinically insignificant. However, there are
Morgan and Maldonado-Codina31 have suggested that the exact reports of sufficient severity in a couple of trials to result in
mechanism that causes ocular surface staining is not well under- discontinuation from lens wear.10,36
stood. Solution-induced corneal staining is a transient phenomenon,
and at least two reports suggested that superficial epithelium was
maximally affected between 2 and 4 hr postlens insertion, with
significantly less staining after 6 hr of lens wear.11,37 More re-
Various multipurpose disinfecting solutions used in combina- cently, Bandamwar et al.38 reported that SICS gradually increased
tion with silicone hydrogel lenses and hydrogel lenses32,33 initiate after lens insertion and appeared to peak at 1 hr and this level was
a corneal reaction characteristic of Figure 3 and, in some cases, maintained until at least for 2 hr.
induce substantial corneal staining. Solution-induced corneal stain- Corneal staining and cellular changes that supposedly imbibe
ing has been described as a toxic reaction, although there is fluorescein are not well understood nor is the cause of SICS.31,34 It
disagreement on the use of the toxic term,34 and it is categorized is further complicated by an apparent paradox where in vitro
results of multipurpose solution (MPS) cytotoxicity is high com-
pared with low levels of clinical corneal staining with the same
solution.39,40 Depending on the level of corneal staining induced

FIG. 2. Dellen resulting from persistent 3 and 9 staining (Reprinted

with permission from Fonn D, Sorbara L. Rigid gas permeable lens
problem-solving. In: Bennett ES, Weissman BA, eds. Clinical Contact
Lens Practice, 2nd ed. Philadelphia, PA, Lippincott Williams & FIG. 4. Soft lens dehydration-induced corneal staining also called
Wilkins, 2005, pp 341354). Smile Stain occurring in the lower third of the cornea.

2010 Lippincott Williams & Wilkins 319

D. Fonn et al. Eye & Contact Lens Volume 36, Number 5, September 2010

by solution/silicone hydrogel lens interaction, it is possible to view by the knowledge that SICS decreases quite dramatically from 2 hr
and image what appears to be epithelial damage using white light of lens wear to 6 hr of lens wear,11,12,37,38 and the premise was that
with a slitlamp biomicroscope even with fairly low to moderate the cells that stained were sloughing. Peterson et al.43 demon-
magnification without the instillation of fluorescein. Schneider et strated that corneal staining was greatest at 2 hr, less at 4 hrs, and
al.37,41 was also able to image epithelial cellular activity in re- least at 6 hr as was shown previously. By using the cell collection
sponse to MPS/silicone hydrogel lens exposure using confocal apparatus immediately after corneal staining grading, the cell
microscopy. The reaction appeared to cause epithelial cells to collection yield at 4 hr was significantly greater than at 2 and 6 hr
become hyper-reflective. This phenomenon was not because of the hypothesizing that at 2 hr, the SICS-affected cells take up fluores-
presence of fluorescein because the confocal microscope is non- cein but remain on the eye until a releasing mechanism allows the
fluorescent and uses white light. These studies also demonstrated cells to slough, presumably because of the change in the tight
that hyper-reflectivity of epithelial cells peaks approximately 1 hr junctions between cells. Chuang et al.44 have shown that MPS may
after instillation of the lens-solution combination and a co-occur- have negative effects on human corneal epithelial viability and
rence of hyper-reflective superficial cells and SICS occurs with a barrier function. Peterson et al. demonstrated that preliminary
specific lens-solution combination. Solution-induced corneal stain- indications are that some of these sloughed cells contain fluores-
ing is one of the more widely debated contact lens research cein but more work is required to refine the techniques for
questions, and the next section will describe work that suggests examination of the sloughed cells.
that a third interactive component besides the silicone hydrogel
and the disinfecting solution may play a role.
Superficial punctate corneal staining of the epithelium was
A POSSIBLE CAUSE OF SOLUTION-INDUCED described in this short review. There are a number of causes
CORNEAL STAINING associated with contact lens wear that are more commonly ob-
In an experiment conducted at the Centre for Contact Lens served with soft lenses and probably silicone hydrogel lenses
Research (R.C. Peterson, D. Fonn, C.A. Woods, L. Jones, unpub- because of their market dominance and the use of multipurpose
lished data), which was prompted by a clinical observation, 20- solutions. It seems that there is better understanding of punctate
adapted soft contact lens wearers were recruited to wear balafilcon staining because of technologic development and being able to
A lenses after presoaking the lenses overnight in polyhexameth- image cells both in vivo and in vitro. Studies on solution-lens
ylene biguanide-based MPS ReNu MultiPlus (Bausch & Lomb, interactions has facilitated potential strategies for preventing and
Rochester, NY). Before overnight storage, one of the lenses minimizing staining.
(randomly chosen) was rubbed and rinsed for 20 sec with ReNu
MultiPlus after removal of the lens from the blister pack, and the
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