Atypical Hyper-Acute Contact Lens - Associated Red Eye Syndrome Triggered By First-Time Scleral Contact Lens Wear

This case study highlights an atypical, ultra-acute onset of Contact Lens–Associated Red Eye (CLARE) syndrome following first-time scleral lens wear in a long-term soft lens user. We aim to emphasise that chronic soft lens wearers may have a compromised ocular surface that is not clinically obvious and may predispose them to exaggerated inflammatory responses when exposed to new triggers.

This case was observed in an ophthalmology clinic during routine contact lens adaptation.

We report a 33-year-old patient with high myopia (OD −9.75 D; OS −8.25 D) and 15 years of soft contact lens wear who developed dry eye and intolerance, requiring a change in correction. Scleral lenses (15.60 mm) were fitted, showing good centration, sagittal depth, and apical clearance without blanching or compression; the ocular surface was initially quiet. Within one hour, while still in the clinic waiting room, she developed acute redness and pain in the left eye. Slit-lamp exam showed marked hyperaemia and subepithelial apical infiltrates staining with fluorescein. The lens was removed, sent for microbiology, and topical antibiotics were started.

Microbial analysis of both the lens and the storage case was negative. After two days of antibiotic treatment, there was complete resolution of the inflammatory signs. The clinical presentation was consistent with an ultra-acute CLARE syndrome triggered by initial scleral lens wear.

The acute onset of redness and discomfort associated with superficial infiltrates should raise suspicion for CLARE syndrome. Chronic soft lens wear may lead to epithelial thinning and ocular surface alteration, increasing susceptibility to inflammatory and infectious complications. Although CLARE is classically linked to overnight lens wear, other triggers must be considered. Particular caution is required in long-term soft lens users. Because of their design, rigid gas-permeable or scleral lenses may provide a safer and more stable long-term alternative, even for high myopia.