contact lens case reports

Piggybacking to Stave Off 3 and 9 O'Clock Staining

contact lens case reports
Piggybacking to Stave Off 3 and 9 O'Clock Staining

Most practitioners believe that 3 and 9 o'clock staining is the most common complication associated with gas permeable (GP) lens wear. This complication is defined as a disruption of the epithilial surface at 3 and 9 o'clock because of peripheral desiccation or mechanical (lens) trauma.


Figures 1 and 2. RE's left eye with 3 & 9 o'clock staining from a GP lens (top) and with a piggyback lens system.

Staining Stages

In the early stages, the patient is often asymptomatic and the cornea exhibits only a fine, dust-like area of epithelial punctuate staining peripherally, along the horizontal meridian.

In its advanced stage, the patient can experience extreme discomfort with a total loss of wearing time. Objectively, the peripheral cornea will exhibit a coalescence of the interpalpebral staining with possible opacification, vascularization, corneal thinning, erosion and ulceration.

Table 1 lists some of the anatomical and lens design characteristics cited in ophthalmic literature as mechanisms for 3 and 9 o'clock staining. Many conflicting articles exist concerning the etiology and management of 3 and 9 o'clock staining, so it's not surprising that we often find it difficult to isolate an exact cause. Moreover, after 50 combined years of managing this condition, we believe that practitioners rarely cure a patient of 3 and 9 staining -- rather, we modulate its severity with various therapies.


TABLE 1Characteristics Cited As Mechanisms for Staining


  • Lens diameter too large or too small

  • Optical zone diameter too large or too small

  • Peripheral lens design

    • edge profile

    • edge thickness

    • edge contour

    • edge lift

  • Lens centration

  • Lens material

  • Wearing schedule

  • Negative tear meniscus

  • Blinking patterns

One Possible Solution

For example, we successfully fit patient RE, a 28-year-old female with a two-year history of early keratoconus, with GP lenses. However, within weeks she began to exhibit the signs of 3 & 9 o'clock staining. Over the next six months, the staining steadily worsened despite the patient's and our Herculean efforts to manage the condition (Figure 1). Her wearing time decreased to eight hours each day, and she complained of sore and chronic red eyes.

We fit her with CIBA Vision Focus Night & Day lenses on a daily wear basis and piggybacked the GP lenses on top of these (Figure 2). Two days later, RE presented with white, comfortable eyes and a wearing time of 14 to 16 hours each day. Her only complaint was that it took us so long to try the piggyback system.

Patrick Caroline is an associate professor of optometry at Pacific University and an assistant professor of ophthalmology at the Oregon Health Sciences University.

Mark André is director of contact lens services at the Oregon Health Sciences University and is an adjunct assistant professor of optometry at Pacific University.