Medical Mystery: An eye with a greenish discharge

Tears – and even an odd discharge – plagued the patient until the source of the problem was found.

Mrs. A is a very pleasant 81-year old woman who had undergone a corneal transplant due to corneal swelling in her left eye 22 years ago. It remained clear until about five years ago, after which the transplant was repeated.

But she found that her vision never really improved after the second transplant, and she paid routine visits to her local eye doctor to manage chronic irritation in the left eye. That eye had also developed glaucoma (high eye pressure), for which she was using eyedrops (brimonidine and latanoprost).

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Christopher J. Rapuano, MD., chief of Cornea Service, Wills Eye Hospital

About 10 months ago, she began noticing even more tearing and discharge from her left eye. Her doctor tried a variety of medications without success. Thinking she might be having an allergic reaction to her glaucoma medications, he stopped them.

Yet there still wasn’t significant improvement, so he started an antibiotic drop (moxifloxacin). When that didn’t work, she was referred to see me.

She told me she had weeping and a greenish discharge from the left eye for the last 10 months. Her right eye was fine. None of the treatments she tried made it any better or worse.

I found that her vision was pretty good in the right eye (20/60) but very poor in the left eye: She could only see my hands waving in front of her. She said her vision had been very poor in her left eye for years. Her eye pressure was normal on the right but somewhat high on the left, which didn’t surprise me, as she had been off her glaucoma medications.

Her right eye examination was essentially normal, except that she had developed a cataract (moderate clouding of her crystalline lens), which explained why her vision wasn’t better. Her left eye was slightly red and there was a mild mucous discharge.

Her corneal transplant was swollen, but did not appear infected. I looked under her lower eyelid and noted some chronic inflammation. When I flipped her upper eyelid back, I noted moderate inflammation and more mucous discharge.

What was going on?

 

Solution

When I lifted Mrs. A’s upper left eyelid, I was surprised to see what looked like a small, clear, crescent shape.

Gently searching under her eyelid, I saw that it was a soft contact lens, which I carefully removed.

I then asked Mrs. A to relax in the chair, and I told her that I had just removed a soft contact lens from her eye.

She proceeded to tell me that her eye doctor had been treating her with soft contact lenses to help relieve her eye pain from her swollen corneal transplant. In eyes with chronic painful corneal swelling, a clear, soft contact lens (often called a bandage contact lens) can be used to act as a barrier, keeping the eyelid from rubbing directly on the swollen cornea, significantly decreasing the pain.

She told me that her contact lens occasionally fell out, and the pain came back, so the doctor would replace it.

Hearing this news, I thought I should take another look.

Using an instrument to explore the space under her eyelid, I was absolutely amazed to find and remove a total of 14 soft contact lenses!

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These are the 14 soft contact lenses that were removed from under a patient’s upper eyelid. They appear yellow as they were stained with the yellow fluorescein dye commonly used in eye doctor’s offices to examine the corneas.

Though she and her eye doctor had thought the contact lens had fallen out, many of them had migrated under the upper eyelid and just stayed there. Mrs. A had somewhat sunken eyes and an unusually large space under her upper eyelid, which is probably why the contact lenses did not cause significant pain. However, they were causing chronic inflammation which was producing her tearing and discharge.

Contact lenses can occasionally move off the center of the cornea. Because most people use contacts to correct their vision, they notice a lens shifting right away because they suddenly can’t see as well. Usually, they try to recenter the contact lens or find it if it has fallen out.

Rarely, a contact lens can migrate under the upper eyelid, which is what happened to Mrs. A, but she didn’t notice a change in vision, as her vision was poor all the time. Due to the anatomy of the eye and eyelids, the contact lens cannot go behind the eye. Fortunately for Mrs. A, her symptoms resolved within about a week after the contact lenses were removed.

Contact lens tips:

  • If you lose your contact lens and you aren’t sure whether it is still in your eye, see your eye doctor to make sure it hasn’t migrated under your upper eyelid. This is not an exam you should try to do yourself, as you could injure your eye.
  • If you have a red or irritated eye, take your contact lens out immediately and do not use it again until your eye is back to normal. If it doesn’t get back to normal within a day or so, see your eye doctor.
  • Don’t sleep in your contact lenses as it increases the risk of infection. While some contact lenses are FDA-approved for overnight use, it just isn’t a good idea.
  • Take your contact lenses out every night and disinfect them. Better yet, use daily disposable contact lenses.
  • Don’t swim in your contact lenses as this also increases the risk of infection.
  • Beware of decorative contact lenses, such as those sold at costume shops, as they have greater potential to damage your eyes.

Christopher J. Rapuano, M.D., is chief of the Cornea Service at Wills Eye Hospital and professor of ophthalmology at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.