6.3 Contraindications & Factors for Successful Wear
Key Takeaways
- Absolute contraindications include active eye infection, severe dry eye, corneal ulcer, active uveitis, severe allergic/immune sensitivity, and inability to handle or insert lenses — fitting must not proceed
- Relative contraindications (blepharitis, GPC history, low tears, high astigmatism, corneal vascularization, reduced sensation, compliance concerns) require modulating lens type, material, or care system rather than refusing the fit
- Lifestyle contraindications include heavy smoking and very dusty or unsanitary work environments — counsel on daily disposable or defer fitting
- Five success factors — motivation, manual dexterity, adequate tears, healthy ocular surface, and realistic expectations — predict long-term wear success
- Distinguish absolute from relative contraindications on the exam: absolute means no fit; relative means modify the fit
6.3 Contraindications & Factors for Successful Wear
Quick Answer: Absolute contraindications to contact lens fitting include active eye infection, severe dry eye, corneal ulcer, active uveitis, severe allergic or immune sensitivity, and the inability to handle or insert lenses. Relative contraindications — blepharitis, GPC history, low tears, high astigmatism, corneal vascularization, reduced corneal sensation, and compliance concerns — require modifying lens type, material, or care regimen rather than refusing the fit. Five success factors (motivation, manual dexterity, adequate tears, healthy ocular surface, realistic expectations) predict long-term wear.
Absolute vs. Relative Contraindications
The CLRE exam tests the distinction between absolute contraindications (fit must not proceed at all) and relative contraindications (fit may proceed with modifications). Misclassifying these is a common error.
Absolute Contraindications
| Condition | Why Fitting Must Not Proceed |
|---|---|
| Active eye infection (bacterial, viral, fungal conjunctivitis, keratitis) | Lens acts as a reservoir; worsens infection; risks corneal ulcer |
| Corneal ulcer (active) | Lens wear exacerbates epithelial defect; risk of perforation |
| Severe dry eye (Schirmer <5 mm, filamentary keratitis) | No lens will tolerate; urgent dry-eye treatment first |
| Active uveitis / iritis | Lens trauma worsens inflammation; synechiae risk |
| Severe allergic or immune sensitivity (recurrent GPC unresponsive to treatment, severe solution allergy) | Lens wear perpetuates immune reaction |
| Inability to handle or insert lenses (severe tremor, dementia, profound cognitive impairment without caregiver) | Cannot manage lens safely; consider daily disposable only if caregiver present |
| Active ocular inflammation of any cause | Defer until quiet |
Relative Contraindications (Modify the Fit)
| Condition | Modification Required |
|---|---|
| Blepharitis | Treat first; lid hygiene; daily disposable; avoid EW |
| GPC history | Daily disposable or RGP; mast-cell stabilizer; shorter wearing time |
| Low tears (borderline Schirmer 5-10 mm) | High-Dk low-water silicone hydrogel; lubrication; shorter wearing time |
| High astigmatism (>2.00 D) | Toric soft, RGP, scleral, or hybrid — not spherical soft |
| Corneal vascularization | Avoid EW; high-Dk lens; monitor; refer if deep |
| Reduced corneal sensation (post-HSV, diabetic) | High-Dk; daily wear only; close follow-up |
| Mental or physical difficulty with compliance | Daily disposable; caregiver support; simpler regimen |
| Filtering bleb / post-ocular surgery | Defer per surgeon; consider scleral when cleared |
| Mild allergic conjunctivitis | Fit during quiescent period; daily disposable |
Lifestyle Contraindications
Lifestyle factors can also contraindicate or modify fitting:
- Heavy smoking — smokers have higher rates of dry eye, NICU (neonatal ICU) workers and smokers show reduced tear stability; lens tolerance is reduced. Counsel on risk; daily disposable and frequent lubrication are reasonable.
- Very dusty, dirty, or unsanitary work environments (mining, poultry farming, certain construction) — daily disposable is the only reasonable option; some environments require deferring the fit entirely.
- Chronic cannabis use — associated with conjunctival hyperemia and dry eye; not a formal contraindication but counsel on redness vs. infection distinction.
- Poor hygiene — daily disposable eliminates solution handling and is the modality of choice when hygiene is in question.
Factors for Successful Wear
Five factors predict successful long-term contact lens wear. The prefitting evaluation assesses each:
- Motivation — discussed in 6.1. Highly motivated patients (especially functional and therapeutic) comply with replacement schedules, hygiene, and follow-up.
- Manual dexterity — can the patient touch their eye, hold their lids open, and manipulate a 14 mm soft lens or 9 mm RGP? Parkinson's, essential tremor, severe arthritis, and hemiparesis challenge insertion. Trial insertion in the office is the test.
- Adequate tears — assessed by symptoms, Schirmer, TBUT, and slit-lamp. Without an adequate tear film, no lens is comfortable and the risk of staining, infiltrates, and infection rises.
- Healthy ocular surface — no active blepharitis, conjunctivitis, keratitis, or significant staining. The slit-lamp exam (Domain III) documents this; prefitting history directs the exam.
- Realistic expectations — the patient understands that lenses may not provide 20/20, that adaptation is required, and that red/painful eyes mean remove and call.
Decision Algorithm
When a contraindication is found, follow this sequence:
- Identify the contraindication on history or exam.
- Classify as absolute or relative.
- If absolute — defer fitting; treat the underlying condition; document; re-evaluate when quiet.
- If relative — modify the fit (modality, material, care system, wearing schedule); counsel the patient; document the modification rationale.
- Document everything — the chart must reflect why a fit was deferred or modified.
Common Exam Traps
- Red, painful eye in a current wearer is not a contraindication decision — it is a 'remove lens, refer immediately' emergency, not a prefitting scenario.
- Pregnancy is a relative contraindication for new fits, not absolute — existing wearers can continue if tolerating.
- Mild dry eye is not a contraindication — it is a modification trigger.
- Able to handle lenses with caregiver support — does not classify as absolute inability.
The Slit-Lamp Foundation
The prefitting history in 6.1 and 6.2 feeds directly into the slit-lamp exam (Domain III) and the contraindication decision in this section. A patient who reports dry-eye symptoms on history gets a careful TBUT, Schirmer, and vital dye evaluation. A patient on isotretinoin does not get fit. A patient with active blepharitis gets lid hygiene first. The exam expects this chain of reasoning: history → exam → contraindication classification → fit or defer.
Key Takeaways
- Absolute contraindications: active infection, corneal ulcer, severe dry eye, active uveitis, severe immune sensitivity, inability to handle lenses — do not fit
- Relative contraindications: blepharitis, GPC history, low tears, high astigmatism, corneal vascularization, reduced sensation, compliance concerns — modify the fit
- Lifestyle contraindications: heavy smoking, very dusty or unsanitary environments — counsel or defer
- Five success factors: motivation, manual dexterity, adequate tears, healthy ocular surface, realistic expectations
- Document the rationale for any deferred or modified fit
A patient presents for a first contact lens fitting with active bacterial conjunctivitis in the right eye and a Schirmer test of 3 mm without anesthesia. What is the appropriate action?
A 35-year-old patient with a history of giant papillary conjunctivitis (GPC) two years ago, now asymptomatic, requests contact lenses. What modification is most appropriate?