949101

research-article2020
EJO0010.1177/1120672120949101European Journal of OphthalmologyShehadeh-Mashor et al.

EJO European
Journal of
Ophthalmology
Original research article

European Journal of Ophthalmology

Duration of contact lens removal

1­–5
© The Author(s) 2020
Article reuse guidelines:
before myopic refractive surgery sagepub.com/journals-permissions
https://doi.org/10.1177/1120672120949101
DOI: 10.1177/1120672120949101
journals.sagepub.com/home/ejo

Raneen Shehadeh-Mashor1*, Michael Mimouni2,3*,

Yinon Shapira2,3, Tzahi Sela4, Gur Munzer4
and Igor Kaiserman4,5

Abstract
Purpose: To compare refractive surgery outcomes in patients with different periods without contact lenses prior laser
surgery.
Materials and methods: Patients included in this study underwent myopic keratorefractive laser surgery between
January 2005 and December 2014. Patients were divided into three groups based on the duration of time passed free
of soft contact lens wearing prior to final preoperative evaluation and surgery (<24 h, 1–3 days or >3 days). Spectacle
wearers served as a control group. Postoperative safety index, efficacy index and % of eyes within 0.5 D of the four
groups were compared. A general linear model was used to compare main outcomes while adjusting for age, gender,
preoperative measurements, and procedure type (LASIK vs PRK).
Results: Overall, 19,747 eyes were included. Soft contact lenses were worn by 42.3% (<24 h: 4.8%, 1–3 days: 18.5% and
>3 days: 19.0%) and spectacles by 57.7% prior to surgery. In the PRK group, after adjusting for differences in baseline
variables, the <24-h group had a significantly lower efficacy index than all the other groups. There were no significant
differences between groups in terms of % eyes within ±0.5 D of intended correction (p = 0.55) or safety index (0.20).
In the LASIK group, after adjusting for differences in baseline variables, there were no significant differences between
groups in all primary outcomes.
Conclusion: Soft contact lenses should be removed at least 24 h prior to final preoperative evaluation and refractive
surgery, especially for patients undergoing PRK.

Keywords
Contact lens, removal, keratorefractive surgery, laser surgery

Date received: 11 October 2018; accepted: 19 July 2020

Introduction 1
 epartment of Ophthalmology, The Baruch Padeh Medical Center,
D
Poriya, Israel
Many candidates for refractive surgery use soft contact 2
Department of Ophthalmology, Rambam Health Care Campus, Haifa,
lenses (SCL) which may induced changes in keratometry, Israel
3
corneal astigmatism, and topographic alterations induced The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel
Institute of Technology, Haifa, Israel
by the contact lenses.1–5 The accuracy of these preopera- 4
Care-Vision Laser Centers, Tel-Aviv, Israel
tive measures affect corneal refractive surgery outcomes.6 5
Department of Ophthalmology, Barzilai Medical Center, Ashkelon and
Thus, prior to undergoing elective keratorefractive sur- the Faculty of Health Sciences, Ben-Gurion University of the Negev,
gery, it is common practice to advise patients to remove Beer Sheba, Israel
contact lenses in order to allow for precise preoperative *Contributed equally to this study.
assessment and measurements.
Corresponding author:
SCL material and duration of wear can affect the time
Michael Mimouni, Department of Ophthalmology, Rambam Health
required for resolution of corneal changes after SCL wear Care Campus, Haaliyah Hashniyah 8, Haifa 3109601, Israel.
discontinuation.7–10 While no specific guidelines are given, Email: michael@intername.co.il
2 European Journal of Ophthalmology 00(0)
SCLs discontinuation for at least 2 weeks before consulta-
tion was recommended by the United States Food and
Drug Administration.11 Whereas, SCL discontinuation for
1 day before consultation was recommended by the Royal
College of Ophthalmologists in the United Kingdom.12
However, there are no guidelines for duration of SCL dis-
continuation before the refractive surgery. In current clini-
cal practice, there is a wide variability among refractive
surgeons related to the recommended time period to dis-
continue SCLs before surgery. Most surgeons agree that
patients wearing SCLs should discontinue SCLs for at
least 3 to 7 days before final refractive assessment and
surgery.13–15
Our study purpose of this study was to compare refrac-
tive surgery outcomes in patients with different periods of
time without contact lenses prior to preoperative evalua-
tion and surgery.
Materials and methods
This study was approved by the ethics committee of the
Barzilai Medical Center.
Study participants
Patients who underwent myopic LASIK or PRK from 1
January 2005 until 31 December 2012 at the Care-Vision
Laser Centers, Tel-Aviv, Israel were included in this retro-
spective study. Patients were included if they were
⩾18 years of age, demonstrated refractive stability for
1 year, were without ocular hypertension, no rigid contact
lens wearing in the past year, no previous ophthalmic sur-
gery and no systemic comorbidities that may affect out-
comes. Patients were excluded if they had myopia greater
than 12 diopters or cylinder greater than 6 diopters. Only
patients with a follow-up time of 3 months or more follow-
ing PRK or 1 month or more following LASIK were
included in this study.
Data collection
The following data were extracted from the medical files
of patients who met the inclusion\exclusion criteria: age,
gender, type of contact lenses used, time free from contact
lenses prior to examination, refractive measurements, and
visual acuities. Of note, the preoperative data included
relates to the final refractive measurements obtained at the
day of surgery. For cases in which both eyes were eligible
only the right eye was included.
Groups
Patients were divided into three groups based on the dura-
tion of time passed free of soft contact lens wearing prior
to the final preoperative evaluation which was performed
at the day of surgery (<24 h, 1–3 days or >3 days).
Spectacle wearers, defined as patients that had not worn
contact lenses in the past year, served as a control group.
Postoperative safety index, efficacy index, and deviation
from target refraction of the four groups were compared.
In the PRK group this was based on measurements 3 to
6 months following surgery and in the LASIK group based
on measurements 1 to 6 months following surgery.
Surgical technique
All patients underwent either microkeratome assisted
LASIK or alcohol assisted PRK (the choice of which was
left to the surgeon) in a similar manner as previously
described by us.16 The common practice in our institution
is not to perform LASIK when the Central corneal thick-
ness (CCT) is less than 500 µm. Patients were routinely
examined the day after surgery as well as 1 week, 1 month,
3 months, 6 months, and thereafter as necessary.
Statistical analysis
Data were analyzed with the Minitab Software, version 17
(Minitab Inc., State College, PA). For comparison of mul-
tiple group averages one way analysis of variance was
used. For the analysis of categorical variables, Chi-Square
was used. A multivariate general linear model was per-
formed in an attempt to determine whether time free of
contact lens remained significantly associated with safety
index, efficacy index, and deviation from target refraction
after accounting for differences between groups at base-
line. In all analyses a two-sided p value <0.05 was consid-
ered statistically significant.
Results
Overall, 19,747 were included in the final analysis. The age
of the participants was 25.8 ± 5.8 years and 56.6% were
male. The mean spherical equivalent was −3.86 ± 2.09 D
(range −12 to −0.50 D). Soft contact lenses were worn by
42.3% and spectacles by 57.7% prior to final preoperative
evaluation and surgery. Although all patients were instructed
to discontinue contact lenses at least 3 to 5 days prior to final
preoperative examination, 4.8% discontinued their use
<24 h prior to examination, 18.5% discontinued 1 to 3 days
and 19.0% discontinued >3 days before examination.
Entire cohort
Table 1 depicts the results of the univariate analysis when
comparing baseline and type of procedure of the groups.
Briefly, the spectacle group was slightly older, had a higher
proportion of males, a lower preoperative spherical equiv-
alent, larger cylinder, and lower proportion of PRK treat-
ments. In univariate analysis, the <24-h group had a
Shehadeh-Mashor et al. 3

Table 1.  Preoperative data and primary outcomes – entire cohort.

Time without contact <24 h 1–3 days >3 days Spectacles p* p**

lenses (n = 941) (n = 3659) (n = 3753) (n = 11,394)
Preoperative
  Age (years) 24.4 ± 5.0 24.3 ± 5.1 24.7 ± 5.2 26.8 ± 6.1 <0.001  
  Days w/o CL 0.79 ± 0.36 2.70 ± 0.47 6.97 ± 4.84 NA <0.001  
  % Male 51.1 50.4 45.2 62.8 <0.001  
  SEQ (D) −4.48 ± 2.13 −4.60 ± 2.12 −4.28 ± 2.02 −3.43 ± 2.00 <0.001  
  Cylinder (D) 0.62 ± 0.62 0.64 ± 0.68 0.65 ± 0.68 0.87 ± 0.87 <0.001  
  % PRK 60.9 69.9 67.8 58.0 <0.001  
Postoperative
 Within ±0.5 D (%) 51.1 53.7 53.6 54.0 0.68 0.30
  Safety index 1.01 ± 0.14 1.03 ± 0.13 1.03 ± 0.13 1.03 ± 0.15 0.021 0.02
(1.01) (1.03) (1.03) (1.03)
  Efficacy index 0.98 ± 0.18 1.00 ± 0.16 1.00 ± 0.17 1.00 ± 0.18 0.007 0.002
(0.97) (1.00) (1.00) (1.00)

P* - ANOVA and chi square wherever appropriate.

P** - General Linear model and Binary Logistic Regression accounting for differences between groups at baseline.

Figure 1.  Safety index. The safety index of the different Figure 2.  Efficacy index. The efficacy index of the different
contact lenses free groups. The <24 h without contact lens contact lenses free groups. The <24 h without contact lens
wear group had a significantly lower safety index than all of the wear group had a significantly lower efficacy index than all of
other groups. the other groups.

significantly lower safety index (p = 0.02) and efficacy
index (p = 0.007). After adjusting for baseline differences
between groups (general linear model) there were signifi-
cant differences in terms of safety index (p = 0.02) and effi-
cacy index (p = 0.002) but not with % of eyes within
±0.5 D from target (p = 0.30). Specifically, the <24-h
group had a significantly lower safety index (Figure 1) and
efficacy index (Figure 2) than each of the other individual
groups. No statistically significant difference in % eyes
within ±0.5  D from intended correction was found
between the <24-h group and the other groups.
PRK only
A sub-analysis of the PRK group only is depicted in Table
2. Briefly, in univariate analysis there were no significant
differences between groups in terms of safety index
(p = 0.20) or % eyes within ±0.5 D (p = 0.06). The <24-h
group had a significantly lower efficacy index when
compared to all other groups (p = 0.005) and this finding
remained significant after adjusting for differences in
baseline (p = 0.01).
LASIK only
A sub-analysis of the LASIK group only is depicted in
Table 3. Briefly, in univariate analysis there were no sig-
nificant differences between groups in terms of efficacy
index (p = 0.28) or % eyes within ±0.5 D (p = 0.10). The
<24-h group had a significantly lower safety index when
compared to all other groups (p = 0.02), however this no
longer remained significant after adjusting for baseline
differences (p = 0.06).
Discussion
In cases where corneal changes induced by CL are present
and time period is not sufficient for complete stabilization
4 European Journal of Ophthalmology 00(0)

Table 2.  Preoperative data and primary outcomes – PRK only.

Time without <24 h 1–3 days >3 days Spectacles p* p**

contact lenses (n = 573) (n = 2556) (n = 2545) (n = 6609)
Preoperative
  Age (years) 23.8 ± 4.7 23.4 ± 4.7 23.8 ± 4.8 25.4 ± 5.8 <0.001  
  Days w/o CL 0.78 ± 0.36 2.71 ± 0.46 6.70 ± 4.49 NA <0.001  
  % Male 51.9 51.8 46.6 64.4 <0.001  
  SEQ (D) −4.98 ± 2.32 −4.99 ± 2.25 −4.63 ± 2.16 −3.86 ± 2.25 <0.001  
  Cylinder (D) −0.70 ± 0.66 −0.70 ± 0.72 −0.69 ± 0.70 −0.94 ± 0.94 <0.001  
Postoperative
 Within ±0.5 D (%) 46.7 51.1 51.0 53.6 0.06 0.55
  Safety index 1.03 ± 0.13 1.04 ± 0.13 1.04 ± 0.13 1.04 ± 0.16 0.20 0.20
(1.03) (1.04) (1.04) (1.04)
  Efficacy index 0.98 ± 0.20 1.01 ± 0.16 1.01 ± 0.17 1.00 ± 0.20 0.005 0.01
(0.97) (1.00) (1.01) (1.01)

P* - ANOVA and chi square wherever appropriate.

P** - General Linear model and Binary Logistic Regression accounting for differences between groups at baseline.

Table 3.  Preoperative data and primary outcomes – LASIK only.

Time without contact <24 h 1–3 days >3 days Spectacles p* p**

lenses (n = 368) (n = 1103) (n = 1208) (n = 4785)
Preoperative
  Age (years) 25.4 ± 5.3 26.4 ± 5.5 26.8 ± 5.5 28.8 ± 5.9 <0.001  
  Days w/o CL 0.80 ± 0.36 2.66 ± 0.48 7.55 ± 5.47 NA <0.001  
  % Male 49.9 47.3 42.2 60.5 <0.001  
  SEQ (D) −3.70 ± 1.47 −3.69 ± 1.41 −3.55 ± 1.43 −2.82 ± 1.38 <0.001  
  Cylinder (D) −0.50 ± 0.52 −0.50 ± 0.55 −0.58 ± 0.62 −0.76 ± 0.76 <0.001  
Postoperative
 Within ±0.5 D (%) 56.3 58.3 57.8 54.4 0.10 0.07
  Safety index 1.00 ± 0.14 1.02 ± 0.13 1.01 ± 0.13 1.02 ± 0.14 0.02 0.06
(1.00) (1.02) (1.01) (1.02)
  Efficacy index 0.98 ± 0.16 1.00 ± 0.15 0.99 ± 0.16 1.00 ± 0.16 0.28 0.18
(0.98) (1.00) (0.99) (1.00)

P* - ANOVA and chi square wherever appropriate.

P** - General Linear model and Binary Logistic Regression accounting for differences between groups at baseline.

of these changes, the refractive surgery results might be
compromised affecting the efficacy of the procedure. In
this study, we found that the visual results after refractive
surgery are less favorable when discontinuing SCLs for
less than 24 h before final preoperative evaluation and sur-
gery. A sub-analysis revealed that this was true specifically
for eyes that underwent PRK. However, we found no
advantage for longer discontinuation periods of several
days if lenses were discontinued for at least 24 h.
There is a wide variability among refractive surgeons
related to the recommended time period to discontinue
SCLs before surgery. Most surgeons agree that patients
wearing SCLs should discontinue SCLs for at least 3 to
7 days before final refractive assessment and surgery,13–15
however there are no specific guidelines probably due to
sparse evidence in the literature. Few studies evaluated the
time period needed for the cornea to stabilize after SCLs
discontinuation. Budak et al. evaluated corneal stability by
computerized videokeratography after contact lenses dis-
continuation in refractive surgery candidates. They found
that discontinuation of SCLs for 2 weeks was adequate for
the cornea to return to its baseline topographic features.17
Shorter periods of discontinuation time or surgical results
were not reported in the study.
Ng et al.10 compared the timeline differences among
various methodologies including manifest refraction,
pachymetry, keratometry, and corneal topography, in
assessing refractive and corneal stability after SCLs wear
in keratorefractive candidates. They found that corneal
thickness and curvature were the longest to stabilize
while manifest refraction was the shortest. The mean
time duration-to-stability by manifest refraction was
10.7 days. However, because the first follow up after the
initial exam was 7 days for all subjects, one can only
Shehadeh-Mashor et al. 5
interpret that, on average, at most 11 days from initial CL
discontinuation are required to reach stability. As such,
one cannot conclude, from the aforementioned study,
what the shortest discontinuation time recommended
before surgery is.10
Definitive reports on the influence of previous SCL
wear and discontinuation periods on refractive surgery
outcomes are even fewer. Lloyd-McKernan et al.18 found
that LASIK and LASEK/PRK procedures were even
more effective in the SCL group compared with a control
group without previous SCLs regardless of the discon-
tinuation time (2 weeks vs 24 h) 1 to 6 months following
refractive surgery. However, in the previously mentioned
studies, SCL discontinuation less than 24 h was not
examined.
In this study, we also found that, the visual results after
refractive surgery are not compromised if SCL are discon-
tinued for at least 24 h, but these results are less favorable
when discontinuing SCLs for less than 24 h before surgery,
specifically for PRK. This could be related to incorrect
preoperative refractive measurements caused by the con-
tact lenses wear. In this case, we would not expect a lower
safety index; rather we would expect a significant devia-
tion from target refraction that was not found in this study.
Our results could be related to lens induced corneal irregu-
larity in those who discontinued the lenses for less than
24 h, leading to higher order aberrations affecting the vis-
ual outcomes and leading to lower safety and efficacy
indexes in this group.
This study has several limitations. The main ones
being the short follow-up time and its retrospective
nature. Furthermore, assessment of high order aberra-
tions in the different groups was not assessed. A prospec-
tive study, comparing corneal regularity and high order
aberrations 24 h after contact lens removal compared to
longer discontinuation times could reveal the explana-
tion to our results. In addition, it lacks data on types of
SCLs used before surgery. Nevertheless, the findings of
this study support routine discontinuation of contact
lenses for at least 24 h before keratorefractive surgery
final evaluation. In addition, it seems that surgery can be
safely performed if the candidate is free of soft contact
lenses for 24 h and longer discontinuation time may be
redundant.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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