Contact lenses and your eyelids: lens-induced ptosis, giant papillary conjunctivitis and when to stop

A contact lens sits on the cornea, but it is put in, rubbed, blinked over and removed past the eyelids, usually twice a day, for years. The lids notice. This article covers three things long-term wear can do to them, when it is time to stop, and what a surgeon wants settled before a lens wearer trades the lenses for a laser.

Can wearing contact lenses make an eyelid droop?

It can, mostly after many years of wear. A Japanese case-control study found that people with acquired ptosis, the medical name for a droopy upper lid, were far more likely to have worn hard contact lenses than people without it. The result is an association, not proof of cause.

The numbers are worth stating plainly. In that 2013 study, 51 women with ptosis were compared with 38 women without it. A history of hard lens wear was recorded in 90.2% of the ptosis group and 31.6% of the comparison group, an odds ratio of 19.9 with a wide confidence interval of 6.32 to 62.9. The ptosis group had also worn lenses for longer on average, about 30 years against 23. A confidence interval that wide is the study telling you how small it was. The author also notes that his figure for lens wear in ptosis is far higher than in earlier studies, which he puts down partly to a stricter definition of ptosis.

What does the lid actually do? Contact lens ptosis is described as aponeurogenic, meaning the fault lies in the levator aponeurosis, the tendon-like sheet through which the levator muscle lifts the lid. At surgery that sheet can be found thinned, loosened or detached from its attachment, which is the same picture as age-related ptosis. A 1983 case report described repairing the aponeurosis in a patient whose ptosis was attributed to years of lens wear in one eye. I would treat that as a pointer, not a rule.

Lens history is one question among several when a surgeon looks for the cause of a droop. Others include age, previous eye surgery, and rubbing. I explain the whole list in my article on acquired and age-related ptosis, and what repair involves in the ptosis surgery guide.

Is the risk the same for soft and rigid lenses?

Probably not, and the evidence is thin. A 2015 systematic review of five studies found an increased risk of ptosis in hard lens wearers compared with non-wearers, and in soft lens wearers too. It advised that rigid lens wearers be warned.

That review pooled very few studies, and the study behind the largest figure is the small Japanese one above. The Japanese paper studied hard lenses only. I could not find good data on modern daily-disposable soft lenses and ptosis, so I will not claim they are free of risk, and I will not claim a risk either.

Two honest limits follow. First, nobody can say how many years of wear tips a lid over, and I would distrust any number offered. Second, stopping lenses does not reliably put a stretched aponeurosis back; I found no good evidence either way, only case reports of surgical repair. A lid that has drooped gradually is not an emergency. One that drops within days, or comes with double vision, is a different problem, covered in the page on neurological causes of a drooping lid.

What is giant papillary conjunctivitis, and what is it doing under my upper lid?

Giant papillary conjunctivitis, or GPC, is an inflamed, bumpy lining on the underside of the upper lid. Papillae are small raised bumps, and in GPC they enlarge. It causes itch, mucus, blurred vision and lenses that stop feeling comfortable. It is a recognised complication of lens wear.

A 2020 review lists the risk factors: non-disposable lenses, infrequent lens replacement, long wearing time, poor lens hygiene and atopy, the allergic tendency behind hay fever and eczema. The likely mechanism is two things at once: the lens rubbing the upper lid lining, and an immune reaction to deposits on the lens surface. The same review says the outlook is excellent with proper management. Mild cases settle when lens wear stops. More severe ones need antihistamine drops, and only uncommonly steroids, immune-modulating drops or, very rarely, surgery.

The bumps sit on the inside of the lid, so nothing shows from the front. A surgeon sees them by turning the upper lid over. That matters here because a loose upper lid produces the same bumpy lining. In floppy eyelid syndrome the lid everts easily and the upper lining develops chronic papillary conjunctivitis. A lens wearer with persistent GPC who also has a lax upper lid deserves a proper look at the lid itself; the floppy eyelid page explains what to look for.

Can lenses cause dry eye and lid margin problems?

Yes, they are associated. Lens wear is linked with changes in the meibomian glands, the row of oil glands along the lid margin whose oil slows tear evaporation, and a 2017 review suggests those changes may explain some lens discomfort. Association is not the same as cause.

A 2016 Australian study compared 100 young adults in five groups: three lengths of lens wear, former wearers and non-wearers. Wearers differed from non-wearers in how well the glands expressed oil, how many were plugged or lost, and in tear stability. The changes began within the first two years and did not progress with longer wear. Former wearers who had stopped for up to six months had not returned to normal. It was a single cross-sectional snapshot of young people, so it cannot tell us what happens over decades.

For a lens wearer whose eyes are dry and whose lid margins are crusty or red, the practical point is that the problem may live in the lids rather than the lens brand. The page on blepharitis and my article on dry eyes and the lid margin cover how that is assessed and treated. It is also the first thing a laser surgeon should care about, for reasons in the last section.

When should I stop wearing my lenses?

Take them out and be seen the same day if the eye is red and painful, light hurts it, or vision has dropped. A red eye in a lens wearer may be an infection, and a 2013 JAMA review states that conjunctivitis in lens wearers should be treated with antibiotics.

The NHS adds that pain, light sensitivity or a change in vision needs urgent help. Leave the lenses out until a doctor has looked. Do not reach for leftover drops, and above all not for steroid drops, which I cover in my article on pharmacy eye drops.

Less urgent reasons to pause and be assessed: itching and mucus that returns every time you wear lenses, lenses that now ride badly, a gritty evening eye, or a lid that looks lower than it used to. None of these needs a panic. All of them deserve an eye doctor who looks at the lids as well as the cornea, and an honest review of how often lenses are replaced and cleaned.

If I am tired of lenses, what does a surgeon check before laser eye surgery?

The cornea, the tear film and the eyelids. And you will be asked to leave your lenses out first, because they change corneal shape.

The US Food and Drug Administration advises stopping soft lenses for 2 weeks before the baseline evaluation, toric soft or rigid gas permeable lenses for at least 3 weeks, and hard lenses for at least 4 weeks. Lenses left in too long can lead to inaccurate measurements and a poor surgical plan, and the measurements may need repeating, especially for rigid lenses.

The same FDA page says a surgeon should screen for blepharitis, thin corneas and dry eyes, and notes that LASIK tends to aggravate dry eye. A 2020 review of oculoplastic considerations adds that eyelid conditions that predispose to dry eye should be optimised before keratorefractive surgery. It reports that ptosis can cause topographic corneal changes, that ptosis repair and blepharoplasty can change astigmatism, and that anyone having ptosis repair should be fully healed before refractive surgery so that both settle first. For a lens wearer with a lowered lid, the order matters. My wider view of this is in the pillar article on refractive surgery and your eyelids, and the rest of the set is in the refractive section.

I am an eyelid surgeon, not a laser surgeon, and the laser decision belongs to a refractive colleague. For what each laser does, Dr Chan Li Yen has written a clear guide to LASIK, SMILE and PRK, and for a prescription too high for a laser, her page on implantable lenses. The wider map of eyelid and eye changes that make a face look tired is in the hub article on tired-looking eyes.