First-Time Multifocal Wearer with Burning, Itching, and a Homemade Care Regimen
A 71-year-old retired music teacher is fitted with monthly replacement silicone hydrogel multifocals (Dk/t ≈ 100). Three weeks later she reports burning and stinging on insertion, redness by evening, a "greasy film" that forces her to remove the lenses early, and itchy bumps under the upper lids. She uses a store-brand multipurpose solution "for all soft lenses", fills the case and tops it up rather than discarding, rinses lenses with tap water "when in a hurry", and has used the same case since the fitting. She has mild dry eye and takes an oral antihistamine seasonally. Slit lamp: 2+ papillary reaction on the upper tarsal conjunctiva, mild bulbar hyperemia, no corneal staining, lenses show a fine surface film.
1. Separate the competing explanations for her symptoms. Which findings support and which argue against each?
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Her symptoms are a composite, and treating only one cause will fail:
- Solution toxicity / preservative sensitivity. Supports: burning and stinging immediately on insertion, evening redness, a film on the lens. Multipurpose solutions contain preservatives (PHMB, polyquaternium-1) that cause exactly this punctate, dose-related discomfort. Argues against: it doesn't explain the papillae or the itch.
- Giant papillary conjunctivitis. Supports: itch, upper tarsal papillae, coating film on the lens, decreasing comfortable wear time. Argues against: GPC alone doesn't usually cause immediate burning on insertion.
- Case biofilm / contamination. Supports: an old case, topping up rather than discarding, tap-water rinsing - this produces a contaminated reservoir that re-inoculates every lens and can drive both irritation and papillary reaction. This is the most likely shared driver of both symptom clusters.
- Deposit-related coating. The visible surface film supports this; monthly replacement with inadequate cleaning accelerates it.
- Dry eye and antihistamine. Contributes to end-of-day redness and discomfort but does not produce papillae.
The most parsimonious reading is contaminated case plus preservative exposure in a patient who already has a papillary reaction - the lens is being re-contaminated nightly.
2. Design a care regimen and replacement schedule for her, justifying each element rather than listing products.
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The regimen must remove preservative exposure and break the contamination cycle, and it must be simple enough for her to follow.
- Peroxide-based disinfection system (or a preservative-free option compatible with her lens material). Justification: eliminates the preservative that is burning on insertion, and hydrogen-peroxide systems are the most effective against the biofilm that a topped-up case harbours. Warn her explicitly about neutralisation time - inserting before neutralisation is complete causes severe stinging.
- Rub and rinse both surfaces with the appropriate solution before disinfection. Justification: no disinfection system removes an established deposit film on its own, and mechanical cleaning is what stops the greasy coating.
- Fresh solution every single time; never top up; empty and air-dry the case face down, uncovered. Justification: topping up preserves a stagnant, organism-friendly pool.
- Replace the case monthly - hers is weeks overdue and is a reservoir, not a container.
- No tap water at any step, ever. Justification: acanthamoeba and Pseudomonas risk, and her epithelium is already stressed.
- Keep monthly lens replacement but consider shortening to a two-weekly or daily disposable multifocal so that the deposit and papillary load never accumulates. Daily disposables also remove the case and solution from her routine entirely, which fits her handling style.
Treat the GPC as a separate problem: a short lens holiday, topical mast cell stabiliser/antihistamine, then refit with more frequent replacement.
3. Write the teaching points you would deliver, and how you would verify adherence at the one-month visit.
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Teaching points - give the reason with each rule:
- "That burning is the preservative in your old solution. Peroxide neutralises to plain saline, so nothing stings."
- "Never put a lens in before the disc stops bubbling - it will burn badly."
- "Fresh solution, every night; an old case is a petri dish, which is why your lids itch."
- "No tap water at any point - not to rinse, not to store. Water carries organisms that can permanently damage the cornea."
- "If your eye is red and painful, take the lens out and call - don't wait to see if it settles."
Verification at one month - do not ask "are you doing okay?":
- Teach-back: ask her to walk you through last night's routine step by step, in her own words, and to demonstrate the rub-and-rinse.
- Inspect the case: a clean, dry, recently replaced case is objective evidence; a cloudy or topped-up case is objective evidence of the opposite.
- Inspect the lenses for film and deposits at the visit, not just the eye.
- Check the prescription and solution bottles she actually has at home - bring them in.
- Review the papillary reaction and comfortable wearing time as the outcome measures; if papillae have not regressed, escalate the plan rather than repeating the instructions louder.
Document the teaching, the teach-back, and the observations.