I saw the report of 27 contact lenses found in a 65 year old female patient about to undergo cataract surgery in the UK via my Twitter Newsfeed this past Sunday. I use Twitter as an excellent source of ophthalmology case reports and cutting edge studies. Ophthalmology is a visual specialty, and journal highlights offer numerous pearls which help me in my clinical practice everyday.
By Monday morning, a Yale classmate (and Harvard Law grad) posted an NPR article and tagged me in a Facebook post with the question, “Ravi Goel is this even possible? How could she get that close to surgery without anyone noticing it sooner?”
I wondered the same thing!
I responded that after 2 (or at most 3) contact lenses in the visual axis the patient would be legally blind in that eye, unless the lenses settled outside the visual axis. As described, the lenses must have been in the superior or inferior fornix (** As a cataract surgeon in between patients, I originally stated “sulcus” but it’s fornix). I was not sure when or why my UK colleagues were, as reported by NPR, “injecting anesthesia into the woman’s eye.” (ie. pre-op area or in the OR Theater).
“I’ll review original article,” I promised.
I emailed the author, Dr. Rupal Morjaria (Sandwell and West Birmingham Hospitals NHS Trust) who graciously sent me the one page case report from the British Medical Journal. The original article is behind a firewall, and the quickest way to read the article is to email the author directly. Her email response with PDF arrived in 10 minutes. (I also use Yale University Library’s Scan & Deliver Service ($150 annually for alumni) which will send a PDF copy of any article they have in print form. The best kept secret for Yale alums. Received the Yale PDF in 2 hours, a superb bargain which has saved many hours in my research for ophthalmology and historical documents).
As I speculated, the article mentioned that the contact lenses were found in the “superior fornix” and the patient was noted to have “deep set eyes.” I remembered a Johns Hopkins / Wilmer Eye Institute grand rounds case circa 1999 in which a patient with unexplained chronic infections had a contact lens, long forgotten, embedded in a similar location. I remember the roar of disbelief among the Wilmer ophthalmology elite nearly 2 decades later to a superb resident presentation (shout out to Seth Biser MD and his smug look when the origin of the unexplained infection was revealed!).
PubMed, the biomedical literature database, includes a 1966 article in the Japanese ophthalmology literature of “A case of a foreign body granuloma due to a contact lens retained long in the upper fornix.” (Nihon Ganka Kiyo. 1966 Aug;17(8):103-6). In addition, numerous citations for “retained contact lens” have appeared since that first known article (I count 15 of the 100 search results as being scholarly articles which describe a lost or forgotten contact lens retained “in the eye” or “under the eyelid”).
Highlights include a 2013 case in India of a contact lens masquerading as a chalazion and a 2011 British case of an 81 year old male with an embedded rigid contact lens believed to be from a long forgotten fitting 40 years previously. (Yes, 2 score years ago, and which the authors state “appears to be the longest delay in diagnosis reported in the ophthalmic literature”!!).
Congratulations to the 2017 British colleagues and authors on their discovery. I wonder what the pre-operative cataract measurements showed and how the measurements will change in the months ahead without the retained contact lens and changes to ocular surface architecture.
I include a superb 3 minute video from ophthalmology superstar & retina fellow Steve Christiansen MD which explains how contact lenses can be retained in the ocular surface corners (fornix) but not in the eye:
Clinical pearls:
- Never sleep in your contacts!
- If you lose your contact lens, look on the table, in the contact lens case, on the floor etc. until found. On many occasions as an ophthalmology resident, the 3 am Saturday night patient returned home from the Emergency Department to tell me, “You were right, doc, the lens is right here on the sink’s edge!”
- If you cannot find your contact lens and feel any discomfort, see an ophthalmologist and ask them to “flip my lid” (eyelid eversion and assessment of ocular tissues) to evaluate for possible retained contact lens.
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Ravi D. Goel M.D. is a cataract surgeon & comprehensive ophthalmologist at Regional Eye Associates in Cherry Hill, NJ. He is also a clinical instructor at Wills Eye Hospital. His patient-friendly YouTube cataract surgery educational videos are here.
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