Comfort continues to be an issue with contact lens wear and, although there may be variations among individuals, end-of-day comfort is reduced across all lens materials and designs (Cheung et al. 2007, Fonn and Dumbleton 2003, Martin et al. 2010). Additionally, discomfort remains the primary reason for discontinuation of lens wear (Richdale et al. 2007). While a great deal of research has been focused on the impact of soft contact lens wear on the cornea (corneal swelling, neovascularisation, endothelial changes, corneal staining, corneal infiltrates and microbial keratitis), there has been far less research on the conjunctiva. 

The conjunctiva is a thin, transparent mucous membrane that covers the posterior surface of the eyelids (palpebral conjunctiva) and the outer surface of the sclera (bulbar conjunctiva). This membrane is made up largely of collagen, lymphocytes, plasma and mast cells, nerve fibres and blood vessels. The entire conjunctiva is covered by non-keratinised epithelium, which is thinnest in the palpebral regions and thickest at the fornices. Away from the lid margin and limbus this epithelium contains specialised mucus-secreting goblet cells, which play a vital role in forming the anchoring mucous layer of the tear film. 

The conjunctiva responds to soft contact lens wear in various ways and associations between conjunctival changes and symptoms of dryness have been reported (Begley et al. 2003, Korb et al. 2002, Pult et al. 2008a). However, it is not entirely clear whether these physiological changes are the underlying cause of reduced comfort. The first steps to understand better the conjunctival responses to soft contact lens wear are to assess, grade and monitor change. Therefore, the primary objective of this article is to describe typical conjunctival responses to soft contact lens wear and to summarise various commonly used grading techniques that can be implemented in clinical practice. A secondary objective is to provide suggestions for management strategies. The tables in each section offer examples of both general grading schemes as well as commonly referenced specific grading scales, any of which may be used.