14.2 SEAL, CLARE, VLK, SLK & CLPU

Named Contact Lens Complications

Quick Answer: Five eponymous complications dominate follow-up: SEAL (arcuate 12 o'clock mechanical), CLARE (sterile inflammatory red eye from endotoxins in extended wear), VLK (limbal vascularization + inflammation, RGP/scleral), SLK (superior limbitis with thyroid association), and CLPU (small peripheral ulcer — sterile early, may become infected). Differentiate by location, signs, and wear modality.

Comparison Table

SEAL — Superior Epithelial Arcuate Lesion

Presentation: Arcuate (arc-shaped) staining at 12 o'clock, under the upper lid, typically in a high-modulus SiHy lens wearer. The lesion is an epithelial split caused by the mechanical interaction of the lens edge with the superior cornea under upper lid pressure.

Risk factors: High-modulus SiHy (first-generation), steep base curve, thick lens edge, large diameter with edge impingement.

Management:

• Switch to a lower-modulus SiHy or hydrogel lens.
• Flatten the base curve to reduce edge lift against the cornea.
• Select a lens with a thinner, more rounded edge.
• Reduce diameter if edge impingement is the trigger.
• Mild SEAL may heal with lens discontinuation alone; severe cases need prophylactic antibiotics and short topical steroid under ophthalmology supervision.

CLARE — Contact Lens Associated Red Eye

Presentation: Acute red eye in an extended-wear patient with conjunctival injection, corneal infiltration, but no epithelial ulcer. Pain is moderate; discharge is minimal. Classically bilateral or unilateral after overnight wear.

Etiology: Sterile inflammatory response to endotoxins produced by gram-negative bacteria (often Pseudomonas or gram-negative flora) colonizing the lens or storage case. The intact epithelium prevents true infection, but the inflammatory cascade produces infiltrates.

Management:

• Discontinue extended wear permanently — CLARE is a sentinel event for EW risk.
• Remove lens; culture lens and case if any epithelial defect is present.
• Topical antibiotic prophylaxis until epithelium intact.
• Topical steroid only under ophthalmology supervision and only after infection excluded.
• Refit to daily wear with daily disposable if possible.

VLK — Vascularized Limbal Keratitis

Presentation: Inflammation and vascularization at the limbus, usually superior, with staining and epithelial whorls. Most common in RGP or scleral wearers with chronic edge interaction at the limbus.

Etiology: Chronic inflammation at the limbus from lens edge mechanical trauma and hypoxia drives vessel extension into clear cornea.

Management:

• Discontinue lens wear to halt vascularization.
• Anti-inflammatory treatment (topical steroid under ophthalmology).
• Refit with a lens that vaults the limbus (larger scleral, different RGP edge).
• Document pre-fit limbal status — pre-existing vessels recur faster.

SLK — Superior Limbic Keratoconjunctivitis

Presentation: Inflammation of the superior limbus and superior tarsal conjunctiva with foreign body sensation, photophobia, and stringy mucus. Soft lens wearers may develop a friction-related SLK; thyroid disease is a systemic association that must be ruled out.

Signs: Papillary reaction on superior tarsal conjunctiva, staining of superior cornea and limbus, thickening and redundancy of superior bulbar conjunctiva.

Management:

• Discontinue soft lens wear temporarily.
• Treat thyroid disorder if present (workup: TSH, free T4).
• Topical lubrication; may need supratarsal steroid injection or 10% N-acetylcysteine for severe cases (ophthalmology).
• Refit with a lens that minimizes superior friction (different material, lower modulus, smaller diameter).

CLPU — Contact Lens Peripheral Ulcer

Presentation: Small peripheral corneal infiltrate or ulcer with mild to moderate injection. Peripheral location is the key discriminator from microbial keratitis, which tends to be central and more severe.

Pathophysiology: Inflammatory response — often sterile in early stage, but the epithelial break can seed bacterial infection. Do not assume sterility.

Management:

• Culture the ulcer and lens/case before treatment if any epithelial defect is present.
• Discontinue lens wear.
• Antibiotic treatment — broad-spectrum topical, often fortified tobramycin/cefazoline or fluoroquinolone.
• Short course of steroid only after infection is excluded and under ophthalmology.
• Refit after complete healing; consider daily disposables.

Key Takeaways

• SEAL = mechanical 12 o'clock arc; lower modulus, flatten BC, thin edge.
• CLARE = sterile endotoxin red eye; stop extended wear.
• VLK = limbal vessels + inflammation; RGP/scleral; discontinue and treat inflammation.
• SLK = superior limbitis; rule out thyroid disease.
• CLPU = peripheral infiltrate/ulcer; culture, do not assume sterile.