Rational design of antibiotic-free antimicrobial contact lenses: Trade-offs between antimicrobial performance and biocompatibility

Microbial keratitis associated with contact lenses (CLs) wear remains a significant clinical concern. Antibiotic therapy is the current standard of care. However, the emergence of multidrug-resistant pathogens necessitates the investigation of alternative strategies. Antibiotic-free antimicrobial contact lenses (AFAMCLs) represent a promising approach in this regard. The effectiveness of CLs constructed with a variety of antibiotic-free antimicrobial strategies against microorganisms has been demonstrated. However, the impact of these antimicrobial strategies on CLs biocompatibility remains unclear. In the design and development of AFAMCLs, striking a balance between robust antimicrobial performance and optimal biocompatibility, including safety and wearing comfort, is a key issue. This review provides a comprehensive overview of recent advancements in AFAMCLs technology. The focus is on the antimicrobial efficacy and safety of various strategies employed in AFAMCLs construction. Furthermore, this review investigates the potential impact of these strategies on CLs parameters related to wearer comfort. This review aims to contribute to the continuous improvement of AFAMCLs and provide a reference for the trade-off between resistance to microorganisms and wearing comfort. In addition, it is hoped that this review can also provide a reference for the antimicrobial design of other medical devices.