Unregulated sales of contact lenses worn for novelty or aesthetic purposes is a notorious vector for ocular complications, as doctor oversight is minimal and patients are left to their own devices. Cosmetic contact lens wear accounts for a significant proportion of lens-related infections in Asia, and individuals with corneal infections tend to be young females and obtain their lenses without a prescription, new research published in the American Journal of Ophthalmology reports.

The study, conducted by an international research team from Australia and Singapore, included 694 contact lens wearers who presented with corneal infections over a 12-month period at 11 centers located in eight Asian countries (India, China, Japan, South Korea, Taiwan, Thailand, the Philippines and Singapore). The investigators compared demographics, clinical features, microbiology and compliance between 204 cosmetic lens wearers (29%) and 490 individuals (71%) who wore lenses to correct refractive errors.

“What surprised me initially was the very high proportion of cosmetic lens wearers with infections,” says researcher Fiona Stapleton, PhD, FCOptom, FAAO, associate dean and professor at the School of Optometry and Vision Science, UNSW Sydney. The overall rate was one-third, and in some countries up to 50%.

Cosmetic contact lens infections comprised between 7% and 54% of cases across the region. Compared with individuals who wore corrective lenses, cosmetic lens wearers were more likely to be female (90% vs. 59%) and younger than 25 (68% vs. 44%). Additionally, the cosmetic lens group was more likely to wear the lenses without a prescription and for shorter durations.

As far as material, cosmetic lenses were more likely to be made of hydrogel and manufactured with the pigment located on the back surface of the lens. The frequency of use of hydrogel compared with silicone hydrogel contact lenses is perhaps to be expected, since older technology is cheaper, HEMA is relatively easy to manufacture and licensing regulations in some even highly regulated countries allow sale of HEMA lenses, where a historical regulatory approval is in place.

Similarly, manufacture of the lenses with pigment on the back surface (cornea-facing) is straightforward, employing a process of stamping pigment onto finished lenses. This contrasts with laminate designs where the pigment or colored mask is incorporated between layers of polymer during manufacture, and consequently the pigment layer is more stable and does not contact the ocular surface.

Presenting disease characteristics and visual outcomes were similar in both groups. Lens-related infections in general have a high rate of Pseudomonas aeruginosa, mirroring the findings in the current study, which included a wide range of countries and wearers with different incomes, Dr. Stapleton explained.

While the numbers were small, Acanthamoeba keratitis was more frequent in the cosmetic lens-wearing group compared with the refractive group (9% vs. 1%).

Also of note: other wear habits including frequency of overnight wear and disinfection frequency were broadly similar in the cosmetic lens wearers and the refractive lens wearers with infections.

Internet supply, quality control and regulation of the sale of these products all provide significant challenges in managing this population of vulnerable wearers, the researchers noted.

Specifically, these wearers aren’t getting their lenses from practitioners, but from suppliers including hairdressers or distributors on the internet, and as such, these individuals aren’t receiving the same type of educational information, particularly about water safety, such as avoiding showering with lenses, swimming in lenses and handling the lenses with wet hands, Dr. Stapleton explains. “The concern with this group is that it is a young demographic, and these individuals aren’t getting their information the same way as other lens wearers,” she notes.

Another issue is that the severity of these infections is worse if the wearers don’t see a practitioner early if they encounter problems. It’s likely that many wearers don’t have a practitioner to turn to, since they obtained their lenses by alternative sources and don’t have an immediate pathway to care, Dr. Stapleton says.

Colored lenses are common in Asia, but there has been very little research about complications in these wearers, she adds.

The investigation was part of the Asia Cornea Society Infectious Keratitis Study.

Stapleton F, Lim CHL, Kweon S, et al. Cosmetic contact lens-related corneal infections in Asia. Am J Ophthalmol. March 13, 2021. [Epub ahead of print].