Contact Lens-Related Corneal Ulcer: a Teaching Case Report

Home , Corneal ulcer, Slit lamp

Background orneal ulcer, also known as ulcerative keratitis and infectious keratitis, is most often C associated with contact lens use or misuse. The following case report involves a 30-year-old African-Amer- ican female who developed a corneal ulcer after falling asleep in her contact Contact Lens-Related lenses. It discusses the differential diagnosis, risk factors and pharmacological Corneal Ulcer: treatments for corneal ulcers as well as the educational component necessary to transfer the information from a di- A Teaching Case Report dactic to a clinical setting. The case is appropriate as a teaching guide for second- third- and fourth-year students. While second-year students may bene- Trinh Khuu, OD, FAAO fit from a review of ocular anatomy and pharmacology, third- and fourth-year Aurora Denial, OD, FAAO students can learn the sequence of care for a contact lens-related corneal ulcer ranging from initial diagnosis to treatment and proper patient education for the prevention of future episodes. This topic is important to teach because of the potentially sight-threatening conse- quences of corneal ulcers. Abstract Student Discussion Guide Corneal ulcer, or ulcerative keratitis, is essentially an open wound to the eye. It Case description is characterized by disruption of the corneal epithelium and stroma and can be Patient GG, a 30-year-old African- either inflammatory or infectious.This teaching case report reviews the diagnosis American female was referred from and management of a specific contact lens-related corneal ulcer case and includes the urgent care clinic at a neighbor- a discussion of the differential diagnosis, risk factors, and pharmacological treat- hood community health center on ments for corneal ulcers. This topic is important because of the potentially severe Jan. 28, 2006 for pain in her right ocular complications that can arise from overwear of contact lenses. eye (OD). She reported falling asleep in her contact lenses (CLs) two nights Key Words: corneal ulcer, infectious keratitis, ulcerative keratitis, contact lens, prior to the visit and waking the next fluoroquinolone morning with no ocular problems. She continued to wear her CLs until she removed them at noon, when the eye started to bother her. She noted burn- ing, redness, tearing and sensitivity to Dr. Khuu is a graduate of the State University of New York, College of Optometry. She completed light OD and stated that it “feels as if a Family Practice Residency at Dorchester House Multi-Service Center. She works at the Codman there is something in it.” She had not Square Health Care Center in Boston, Mass. used any eye drops and reported no dis- Dr. Denial is an Associate Professor of Optometry at the New England College of Optometry and charge from her eyes. She denied any an instructor at the Codman Square Health Center. recent trauma or surgery to her eye, and confirmed she had not traveled recently to a warm and moist environment. She had not been swimming in her CLs or using tap water to clean them. The patient was on her last pair of CLs and did not know the brand of CLs or solution used. Since she had not saved any of the blister packs, she was not able to bring them to the next visit. She did

Optometric Education 44 Volume 37, Number 1 / Fall 2011 not recall the name or location of her last eye doctor or the date of her last Figure 1 visit. She typically wore her CLs for 10 Example of a corneal ulcer (reprinted with permission from Dr. hours a day and replaced them every Joseph Sowka). two months. This was the second incidence of falling asleep in her CLs. The patient’s medical history was positive for asthma, depression, eczema, and chronic allergic rhinitis. She was taking indomethacin, hydrocortisone cream, albuterol and hydroxyzine hydrochlo- ride tablets. She was a nonsmoker and denied any allergies to medications. She reported no history of ocular disease, eye surgery, diabetes or collagen vascu- lar disease. Entering distance visual acuity with her spectacle lenses was 20/25 OD and 20/20 OS. She reported the OD was blurrier than usual. The pupils were equally round and reactive to light with negative afferent pupillary defect noted OU. Anterior segment evaluation by slit lamp examination revealed clear lashes OU, meibomian gland stasis OU, grade 1 conjunctival hyperemia OD and clear conjunctiva OS. An approximately 0.5-mm, round, deep, well-demarcated white epithelial defect with stromal excavation slightly inferior nasal to the visual axis was seen OD. (A depiction of this defect is seen in Figure 1. It is not Table 1 the actual photo of this patient.) Initial Presentation: Jan. 28, 2006 Use of a 0.6-mg fluorescein sodium strip OD/OS highlighted the area of the de- OD OS fect OD. There was also grade 2 corneal Distance VA with glasses 20/25 20/20 edema affecting the epithelial layer that was slightly larger than 0.5 mm OD Pupils Pupils equal, round and PERRL reactive to light (PERRL) but no hypopyon OD/OS. The anterior Negative APD Negative afferent chamber revealed grade 2 cells and flare pupillary defect (APD) OD but was clear OS. The iris, angle Significant anterior segment findings Grade 1 conjunctival Clear (on Von Herrick estimation) and lens hyperemia Round, deep, well- were normal OU. One drop of fluo- demarcated white rescein sodium/benoxinate ophthalmic epithelial defect with solution (Fluress) was instilled OD/OS, stromal excavation ~ 0.5 mm in size slightly and intraocular pressures measured at inferior nasal to visual 10:10 a.m. by Goldmann applanation axis tonometry were 13 mmHg OD and 13 Grade 2 corneal edema mmHg OS. The tentative diagnosis at No hypopyon this time was corneal ulcer OD. Data Fluorescein staining Positive staining Clear depicted an excavated from the examination on Jan. 28, 2006 corneal defect are listed in Table 1. Anterior chamber Grade 2 cells and flare Clear Follow-up #1: Jan. 31, 2006 Intraocular pressures (GAT) @ 10:10 a.m. 13 mmHg 13 mmHg The patient missed her 24-hour follow- up appointment but returned on Jan. 31, 2006, three days after her initial visit. She reported a 50% improvement in redness, pain and irritation OD. As prescribed at the initial visit, she had

Optometric Education 45 Volume 37, Number 1 / Fall 2011 been using moxifloxacin (Vigamox) five times per day OD and cyclopentolate Table 2 (Cyclogyl) bid OD. She had also been Follow-Up #1: Jan. 31, 2006 using over-the-counter Walgreen’s arti- OD OS ficial tears three times per day, which had been recommended by the store Distance VA with glasses 20/30+2 20/20

pharmacist. The patient reported no Pupils Pupils equal, round and PERRL reactive to light (PERRL) changes to vision or health since the last Negative APD eye exam. Negative afferent pupillary defect (APD) Distance visual acuity with spectacle Significant anterior segment findings Grade 1+conjunctival Clear correction was 20/30+2 OD and 20/20 hyperemia Corneal scar ~0.5 mm OS. Pupils were equally round and re- slightly inferior nasal to active to light with negative afferent pu- visual axis pil defect noted OU. Anterior segment Fluorescein staining Inferior punctate Inferior punctate evaluation with slit lamp revealed clear epithelial erosion (PEE) epithelial erosion (PEE) No staining in area of lashes OU, mild meibomian gland sta- ulcer sis in the lids OU, grade 1+ hyperemia Clear Clear in the inferior conjunctiva OD and no Anterior chamber hyperemia OS. A corneal scar, approxi- Intraocular pressures (GAT) @ 9:30 a.m. 12 mmHg 12 mmHg mately 0.5 mm, was present slightly inferior nasal to the visual axis OD. A 0.6- mg fluorescein sodium ophthalmic strip Table 3 was instilled OD/OS, which revealed Follow-Up #2: Feb. 3, 2006 inferior punctate epithelial erosion (PEE) OU and no staining in the area OD OS of the ulcer OD. All other structures, including the iris, angle and lens were Distance VA with glasses 20/25+1 20/20 unchanged from the previous visit. The Pupils Pupils equal, round and PERRL reactive to light (PERRL) secondary anterior chamber reaction Negative APD Negative afferent had resolved. One drop of fluorescein pupillary defect (APD) sodium/benoxinateophthalmic solu- Significant anterior segment findings Corneal scar ~ 0.5 mm Clear tion was instilled OD/OS and revealed in size inferior nasal to intraocular pressures of 12 mmHg visual axis OD and 12 mmHg OS at 9:30 a.m. by Goldmann applanation tonometry. Clear Clear Data from this examination is shown in Fluorescein staining Table 2. The assessment was that the patient had Anterior chamber Clear Clear

a resolving corneal ulcer OD with resul- Intraocular pressures (GAT) @ 1:20 p.m. 10 mmHg 10 mmHg tant stromal scar and resolved secondary uveitis OD. The patient was instructed to continue moxifloxacin fives times per day OD and to discontinue the cyclo- pentolateas her pain had subsided. The dosed a half hour prior to the visit. She axis OD. One 0.6-mg fluorescein sodi- patient was also instructed to discon- was also using preservative-free artificial um ophthalmic strip was instilled OD/ tinue the Walgreen’s artificial tears and tears as instructed tid OU. She reported OS and revealed mild inferior PEE OU to start using preservative-free artificial no changes to vision or health since the and instantaneous tear break-up time tears (TheraTears) tidOU to treat the last eye exam. (TBUT) OD/OS. All other structures superficial punctate keratitis. She was including iris, angle, anterior chamber to return in three days for follow-up Distance visual acuity with spectacle correction was 20/25+1 OD and 20/20 and lens remained unchanged OU. One or sooner with worsening symptoms or drop of fluorescein sodium/benoxinate pain. OS. Pupils were equally round and reactive to light with negative afferent pu- ophthalmic solution was instilled OD/ Follow-up #2: Feb. 3, 2006 pillary defect noted OU. Anterior seg- OS and revealed intraocular pressures The patient returned three days later on ment evaluation by slit lamp revealed of 10 mmHg OD and 10 mmHg OS Feb. 3, 2006. She reported improved clear lashes OU, meibomian gland sta- at 1:20 p.m. by Goldmann applanation vision with no pain, redness, tearing or sis OU, and clear conjunctiva OU. A tonometry. Lensometry indicated a pre- discharge OD. The patient was still us- corneal scar approximately 0.5 mm in scription of -5.25 sphere OD and -5.00 ing moxifloxacin five times per day, last size was seen inferior nasal to the visual sphere OS. Data from this examination are shown in Table 3.

Optometric Education 46 Volume 37, Number 1 / Fall 2011 The diagnosis was stromal scar resulting Discussion topics b. patient education from corneal ulcer due to CL overwear 1. Ocular anatomy of the cornea c. gas permeable CLs vs. soft OD and meibomian gland stasis with CLs secondary dry eye OU. The patient was a. layers of the cornea instructed to discontinue moxifloxacin b. blood supply to the cornea Educational Guidelines c. metabolic activity of the and to continue the preservative-free Literature review artificial tears tid OU. She was advised cornea on warm compresses bid and lid scrubs d. scarring in the cornea Corneal ulcers, although debilitating bid OU for the meibomian gland stasis. 2. Etiology and differential diagnosis and potentially sight-threatening, are The patient was asked to return in two of corneal ulcers quite a rare disease entity. The incidence weeks for a comprehensive eye exam of ulcerative keratitis caused by contact a. differentiating between bacte- and CL fitting. She was instructed to lenses is believed to be approximately rial, fungal, acanthamoebic discontinue CLs until her next visit. She 71,000 cases per year, with an average and herpes types was educated on the risks of extended of 1.7 ulcerations annually per practi- b. how bacteria invade tissue 1 wear and the need for proper lens care. tioner . A corneal ulcer is caused by a c. signs and symptoms She was to return to the clinic sooner break in the corneal epithelium and/or 3. Evidence needed to diagnose stroma and can lead to the entrance of than two weeks if any of the symptoms 2 of pain, redness or decreased vision re- a. history of CL wear a micro-organism through the break . surfaced. Unfortunately the patient did b. physical exam and signs of cor- Although more common unilaterally, it not return. neal ulcer can present bilaterally and can vary in c. staining pattern of corneal size and severity1. Patient demographics Learning objectives ulcers include younger patients and those liv- At the conclusion of the case discussion, d. culture use, e.g., when to cul- ing in developed nations, both who are students should be able to: ture and what to do when not more likely to wear contact lenses3. Cor- 1. Describe the corneal ocular anato- equipped to culture neal ulcers are more common among my and metabolism in relationship e. inflammation vs. infection males due to their greater likelihood of sustaining ocular trauma6,9. The etiol- to microbial infection and its con- 4. Risk factors for corneal ulcer sequences. ogy can be bacterial, fungal, parasitic or a. decreased oxygen related to viral and will determine the course of 2. Describe the etiology and differen- CLs, DK, materials, oxygen treatment. Other less common risk fac- tial diagnosis of a corneal ulcer. exchange of CLs vs. oxygen tors for corneal ulcers include trauma, 3. Describe the evidence needed to demand of cornea dry eye, exposure keratopathy and lid diagnose an infectious corneal ul- b. care of CLs and case disposal, abnormalities4. With delays in treat- cer. including improper disinfec- ment, or when left untreated, corneal tion with water ulcers, especially those centered along 4. Identify the risk factors associated c. role of dry eye, blepharitis, the visual axis, can be quite serious and with a corneal ulcer. being immunocompromised, sight-threatening5. 5. Identify treatment options, includ- etc., in increasing risk of cor- A major risk factor for developing a cor- ing standard of care, implications neal ulcer neal ulcer is overnight use of soft con- of the management plan and evi- d. role of environmental and oth- tact lenses, and the risk increases with dence-based medicine. er factors, such as age, gender each consecutive night of continuous 6. Determine appropriate contact and tobacco use, in increasing wear6,7. The closed-eye environment lens fitting options after corneal ul- risk of corneal ulcer causes metabolic stress on the cornea cer resolution. e. soft CLs vs. gas permeable by trapping bacteria from tear stasisand CLs 7. Differentiate between inflamma- allowing pathogenic bacteria to in- tory and infectious corneal ulcers. 5. Treatment options vade the vulnerable and compromised cornea8. It appears that lens to cornea Key concepts a. pharmacological treatment, including off-label use, mode of interactions during lid closure contrib- 1. The pathophysiology of a corneal action of drug, use of steroids, ute more to corneal hypoxia than the ulcer, including bacteria invasion actual characteristics of a contact lens dosage and standard of care, 6,9 of cells and tissue response. differences between the fluoro- such as oxygen permeability . Thus, 2. The body’s natural immunological quinolones new contact lens materials such as sili- response to bacterial invasion. b. patient education cone hydrogel (which have higher DK) c. complications and implica- have been developed in recent years to 3. The role of medication in enhanc- tions increase oxygen permeability and re- ing the body’s response to an in- duce corneal hypoxia that contributes vading organism. 6. Contact lens use after corneal ulcer to corneal ulcer formation9,12. resolution 4. The role of CL wear in influencing In addition to overnight contact lens corneal metabolism and increasing a. when to restart CLs, when to wear, other risk factors for corneal ul- susceptibility. refit CLs Optometric Education 47 Volume 37, Number 1 / Fall 2011 cers include poor lens hygiene, use of ism. Cultures should also be taken of gray or white inflammatory cells homemade saline solutions, reuse of the patient’s contact lenses and solu- invade the cornea. They usually oc- contact lens solutions, the use of tap tions1,15. A study found that 67% of cur near the limbus but can present water without proper drying, poor case negative corneal scraping cases showed anywhere. They are commonly as- hygiene such as not replacing cases a positive contact lenses culture1. sociated with contact lens overwear regularly and delayed lens replace- Although new multi-purpose solu- and usually present later in the day. ment11,15,16. In addition, environmental Management is best achieved by tions and no-rub formulations have 15 factors, such as climate and tempera- been developed in recent years to im- discontinuing CL wear . ture, affect the risk for corneal ulcers. prove patient compliance, they have • Corneal ulcer is an umbrella term For example, the higher incidence of not been as effective against certain for an inflammatory or infectious Gram-positive organisms in temper- 13 microbes such as Acanthamoeba and event that is characterized by red- ate zones and higher incidence of CL Fusarium. The outbreak of Fusarium ness, pain and sometimes decreased wearers in developed nations have like- keratitis in the United States between vision. Examples of corneal ulcers ly resulted in a greater number of mi- 2 June 2005 and July 2006 resulted in include inflammatory CLPU or in- crobial keratitis cases here . A study has 164 confirmed cases and was linked to fectious microbial, fungal or Acan- indicated a 30% increase in microbial 2 the use of MoistureLoc multi-purpose thamoeba keratitis. In infectious keratitis in developed countries . solution13,16. Studies have also found corneal ulcers, both Gram-positive In addition to risk factors, it is impor- that most CL-related corneal ulcers are and Gram-negative bacteria can tant to understand the relationship bacterial in origin (60%) followed by colonize the corneal surface. Symp- between corneal anatomy and ulcers. fungal (38%) and Acanthamoeba kera- toms can vary from mild to severe. The cornea is a multi-layered epithelial titis (2%)5. The overwhelming majority Treatment is best with a broad- sheet broken down into five distinct have found Pseudomonas aeruginosa to spectrum antibiotic7. layers: epithelium, Bowman’s layer, be the main causative bacterial organ- o CLPU is a unilateral inflam- stroma, Descemet’s membrane and ism1,17,18,19. Pseudomonas thrives because 17 matory event usually associat- endothelium . Of these, the stroma, it survives the moist environment of ed with extended-wear silicone which makes up 90% of the cornea, is contact lenses storage cases and solu- hydrogel lenses. It is character- the largest. The cornea has an arsenal tions and can quickly cause destruction 1 ized by a small, sterile whitish of defenses, including the antimicrobial of the cornea . Other less common bac- gray ulcer typically located at properties of the tear film and the phys- terial isolates include Staphylococcus au- the corneal-limbal border. It is ical tight cellular junctions of the cor- reus, Streptococcus pneumoniae, Serratia 20 usually caused by colonization neal epithelium. In order for microbial marcescens and Moraxella species . of the contact lens surface by keratitis to occur, an organism must 11 The differential diagnosis of ulcerative pathogenic Gram-positive bac- penetrate through the stromal layer . keratitis includes: contact lens associat- teria, usually Staph aureus or Scarring can ensue when the defect ed red eye (CLARE), infiltrative kerati- Staph epidermidis. It is usually affects the stromal layer or beyond. A tis, corneal ulcer, contact lens peripheral limited to the epithelium and corneal ulcer can vary in size, depth and ulcer (CLPU) and microbial keratitis. not associated with much an- severity. It is best viewed with different • CLARE is an acute unilateral in- terior chamber reaction or sig- illuminations on the slit lamp. Initially, nificant pain. Symptoms may a wide diffuse illumination is used to flammatory sterile keratitis associated with colonization of Gram- range from mild to moderate. locate and obtain a gross view of the le- Discontinuing CL wear usu- sion. A parallelopiped illumination al- negative bacteria on contact lenses (usually Pseudomonas). The typical ally helps to resolve the condi- lows for a more three-dimensional view tion11,15. It can also be treated of the lesion, and an optic section can patient wears extended-wear hydrogel lenses and awakens with with topical antibiotics or ste- be used to assess the depth of the lesion. roids6. Sodium fluorescein dye is used to high- ocular pain, tearing, variable de- light the area of epithelial defect. Posi- creased vision and photophobia. o Microbial keratitis is a serious tive fluorescein staining often contours There are mid-peripheral corneal infection of the cornea char- to the shape of the lesion. infiltrates in severe cases. Cases are acterized by excavation of the usually resolved by discontinuing corneal epithelium, Bowman’s A corneal culture is indicated in certain CL wear11,15. Hence, sterile kerati- layer and stroma with infiltra- scenarios. A culture is warranted when tis is more benign and is not usu- tion and necrosis of tissue15. the corneal ulcer is large (>2 mm), ally associated with vision loss.The It can cause vision loss with a greater than one-third the thickness of incidence of sterile keratitis linked risk of 0.3 to 3.6 per 10,0008. the cornea, centered along the visual to contact lens wear is in the range The incidence ranges from 1.8 axis, occurs in “at risk” populations (i.e., of 1% to 7% of soft lens wearers to 2.44 per 10,000 CL wear- elderly, immunocompromised or mon- annually6. ers per year13. The risk is higher ocular patients), or does not respond to with soft contact lenses com- 7 • Infiltrative keratitis is a cellular re- antibacterial treatment . Corneal scrap- pared to rigid gas permeable ings and cultures are needed in many sponse in which corneal infiltrates 13 or multiple discrete aggregates of lenses (2/3 compared to 1/3) . cases to determine the causative organ- Approximately 10% of infec-

Optometric Education 48 Volume 37, Number 1 / Fall 2011 tions result in the loss of two Pseudomonas aeruginosa and multi-drug gatifloxacin did not25. This means that or more lines of visual acuity14. resistant Gram-negative organisms14. moxifloxacin is more bactericidal and Symptoms are typically severe The third-generation fluoroquinolone can penetrate into the aqueous humor and the condition can become levofloxacin 0.5% (Quixin) was in- with four times daily dosing25. Moxi- sight-threatening. It is most of- troduced in 2000 and is more water- floxacin is also 8-16 times more potent ten associated with Pseudomo- soluable than ofloxacin at a neutral pH, against Gram-positive organisms than nas spp, a Gram-negative bac- meaning it demonstrates higher ocular previous-generation fluoroquinolo- teria. Treatment is best with concentrations and thus greater clinical nes26. Moxifloxacin has been found to a broad-spectrum antibiotic, efficacy. Levofloxacin also has increased be resistant against methicillin-resistant such as a fourth-generation activity against Streptococci compared Staph aureus (MRSA). Moxifloxacin has fluoroquinolone15. to second-generation fluoroquinolo- broad-spectrum coverage and excellent Treatment for corneal ulcers includes nes. A newer formulation of levofloxa- activity against Gram-negative organ- removing the offending agent, which cin with ahigher 1.5% concentration isms, such as Pseudomonas aeruginosa. (Iquix) has also been approved by the Although ciprofloxacin has historically in many cases means discontinuing CL 24 wear. Cool compresses may be applied FDA . Although the minimum in- been the fluoroquinolone of choice for for symptom relief. Patients should be hibitory concentration (MIC) for both the treatment of Pseudomonas, it does concentrations of levofloxacin is the not penetrate the cornea as well as mox- counseled to not touch or rub their 26 eyes and to engage in proper visual hy- same, the increased concentration of ifloxacin . Moxifloxacin differs from giene, including frequent hand-wash- levofloxacin 1.5% improves its ability gatifloxacinin that it is a biphasic mole- to penetrate ocular tissue22. The MIC cule, meaning it is soluble in both lipid ing. They may take over-the-counter 26 medications such as acetaminophen or is the lowest concentration of an anti- and aqueous solutions . This allows it ibuprofen for pain14.The most effective microbial that will inhibit the growth to achieve very high concentrations in treatment is an ophthalmic eye drop. of a micro-organism after overnight the eye. Lastly, moxifloxacin has less In the past, aminoglycosides such as incubation. Two newer fluoroquinolo- corneal and conjunctival toxicity than nes, introduced in 2003, moxifloxacin the other fluoroquinolones, including gentamicin and tobramycin were read- 22 ily used14. Although they demonstrated 0.5% (Vigamox) and gatifloxacin 0.3% gatifloxacin and Quixin . good Gram-negative bacterial coverage, (Zymar) are statistically more potent Since this patient was treated, a new they also revealed significant hypersen- than Quixin against Gram-positive fluoroquinolone, besifloxacin 0.6% sitivity in documented cases14. Today, organisms and similar in potency in ophthalmic suspension (Besivance), fluoroquinolones (second-, third- and most cases of Gram-negative bacteria.A has become available. It is a fourth- fourth-generation) are more popular. study found that moxifloxacin had sig- generation fluoroquinolone that was A dilation drop such as cyclopentolate nificantly lower median MICs for near- approved by the FDA in 2009 for the ly all types of Gram-positive isolates 27 may be administered to relieve pain 24 treatment of bacterial conjunctivitis . or inflammation14. The use of steroids than gatifloxacin . However, moxi- It is the first fluoroquinolone developed in bacterial keratitis is controversial18. floxacinand gatifloxacin demonstrated specifically for ophthalmic use. In other equal susceptibility to Gram-negative 28 While some advocate topical steroids 22 words it has no systemic counterpart . to reduce tissue damage and scarring, isolates . Although moxifloxacin and With no systemic use, studies have others fear that steroids will reduce the gatifloxacin are not FDA-approved shown that besifloxacin is less likely to cornea’s immune response and prolong for the treatment of bacterial corneal develop bacterial resistance than other 21 ulcers, they are typically used as “stan- 29 infection . A study found that steroid 23 fluoroquinolones . Because this drug is treatment delayed corneal re-epithelial- dard of care” treatment . A major dif- still relatively new, more studies need to ization but did not cause a significant ference between these fluoroquinolones be conducted to determine drug resis- difference in visual acuity or scar size20. is that the second- and third-generation tance and efficacy. In worst-case scenarios, a surgical cor- fluoroquinolones act on a single DNA- neal transplant may be indicated if the replicating enzyme while the fourth- Discussion ulcer perforates the cornea19. generation fluoroquinolones target two DNA-replicating enzymes, thus low- Gathering information The second-generation fluoroquino- ering the likelihood of bacterial resis- In the case presented, the young wom- lones, ciprofloxacin 0.3% (Ciloxan) tance24. an reported generic symptoms of eye and ofloxacin 0.3% (Ocuflox), were There are numerous reasons moxi- pain and redness in one eye. The astute introduced in the 1990s and are FDA- clinician should ask probing questions approved for the treatment of bacterial floxacin seems to be more effective 22 and was chosen for treatment (in this about the circumstances surrounding conjunctivitis and keratitis . Although the symptoms as well as CL use and these broad-spectrum antibiotics tar- case) over gatifloxacin and the second- generation fluoroquinolones. Studies recent ocular trauma. If CL wear is get both Gram-positive and Gram- established, specific questions regard- negative organisms, their effectiveness show that moxifloxacin penetrates the cornea and aqueous humor significant- ing the history of CL wear should be has been steadily decreasing due to 6 22 ly better than gatifloxacin . Likewise, addressed.The clinician should inquire bacterial resistance . Ciprofloxacin has about the type of CLs worn as well as demonstrated the greatest effectiveness moxifloxacin was found to have 10 times the MIC for an organism, while the type of CL solution used as these against Gram-negative bacteria such as factors can contribute to the type of

Optometric Education 49 Volume 37, Number 1 / Fall 2011 infection presented. In this case unfor- potential microbe or organism. At the cone hydrogels). A suitable alternative, tunately, the patient did not know the first visit, a prescription was given for if the patient is willing to try a different type of CLs worn or the CL solution moxifloxacin 0.5% ophthalmic solution modality, is a daily disposable CL. One used. Although this information can be to be used every 30 minutes OD that example is 1-Day Acuvue TruEye, the useful, clinical decision-making often day and then every hour OD for the first daily disposable silicone hydrogel requires the clinician to make reason- next two days. Cyclopentolate 1% bid lens, which debuted in June 2010 in able judgments based on the informa- OD was also prescribed to temper the the United States. Frequent replace- tion available. anterior chamber reaction, to prevent a ment of CLs helps to prevent long-term Confirmation of diagnosis posterior synechiae, and to reduce eye buildup of proteins and deposits on the pain. Moxifloxacin was chosen over the lens surface. Therefore, it is important The diagnosis at first visit was corneal second-generation fluoroquinolones to educate patients on the replace- ulcer with secondary uveitis from CL because of its greater spectrum of cov- ment schedule for their CLs. In addi- overwear OD. This was determined erage, lower antibacterial resistance and tion to selecting the most suitable CLs, mainly from the patient’s report of sud- ease of dosage. It was chosen over gati- it is important to educate patients on den onset redness and pain after fall- floxacin because of its longer half-life proper hygiene, including lens cleaning ing asleep in her CLs along with the (and thus less-frequent dosing sched- and care regimens and frequent case re- presence and location of a paracentral ule) and greater penetration into the placement. Patients must be counseled circumscribed corneal infiltrate with cornea24. Also, it has a lower incidence extensively to not overwear CLs and stromal excavation producing positive of toxicity and is preservative-free31. Be- to not sleep in them. Rigid gas perme- staining. Other differentials were con- sifloxacin may be a good choice due to able CLs are another alternative to soft sidered and ruled out. For instance, its lower dosing schedule. contact lenses but they are often less de- herpes simplex was ruled out because Follow-up sirable for patients who are already ac- fluorescein staining did not show a typ- customed to the comfort of a soft CL. ical dendritic pattern. Fungal keratitis The patient was instructed to go to the Rigid lenses also allow favorable oxygen was ruled out because the patient de- emergency room with any increased permeability to the cornea. nied any recent ocular trauma and the pain or decrease in vision over the As illustrated by this case, corneal ul- lesion did not present a feathery bor- weekend. An appointment was sched- cer therapy involves not only removal der. Acanthamoeba keratitis was ruled- uled for the following Monday because of the offending agent but also use of out because the patient did not swim the clinic was not open on the week- topical agents including antibiotics, a in her CLs and did not recently travel end. The patient was warned about the culture when warranted, a change in to a warm and moist environment. The potential for a slight vision reduction CL materials and fit, and modification process of clinical decision-making in- after resolution of the ulcer. Her pri- of CL maintenance and care. volves justification of diagnosis as well mary care physician was notified of the as ruling out other potential diagnoses. findings. Conclusion Management Resolution of ulcer This case demonstrates the role of tak- Treatment with antibiotics should be CL wear can resume only after the cor- ing a careful history and the role of close aggressive and immediate in most cases neal ulcer has healed. It is important to clinical observation in the diagnosis of to eradicate the potential microbe. The choose CLs with high oxygen perme- corneal ulcers. In milder cases, diagno- patient was advised to return in 24 ability (DK), such as silicone hydrogel sis can be made by clinical observation. hours but because the clinic was not lenses. Many variables, such as oxygen However, in moderate cases, presenta- open on the weekend, she returned the content and replacement schedule, tions along the visual axis or situations following Monday30. The patient was must be considered when selecting that do not respond to initial treatment, advised to go to the emergency room if new CLs. Acuvue Oasys, PureVision, a corneal culture is necessary. The prog- symptoms worsened over the weekend. or Ciba Night & Day would be suit- nosis is better with earlier diagnosis and A culture was not taken in this case be- able options for refitting because they treatment. Treatment should be aggres- cause the corneal ulcer was small, not are all silicone hydrogel lenses that al- sive and can be modified as the ulcer on the visual axis and responded to low for greater oxygen permeability and begins to heal. Clinicians must be able treatment. Although obtaining a cor- all are approved for overnight wear6,11. to revise treatment if the corneal ulcer neal scraping is recommended before Although sleeping in contact lenses is does not heal within 24 hours or within prescribing antibiotics, standard of care still not recommended despite labeling an appropriate time frame. Patient non- as stated in American Optometric As- for overnight wear, patient noncompli- compliance is an important issue that sociation guidelines does not require ance is common. Therefore, it is- ad must be considered not only in prescrib- obtaining a corneal culture30. vantageous to fit more highly oxygen ing medication but also in refitting the Patient education permeable CLs. In this case, Acuvue patient with new CLs. Clinicians must Oasys was the desired lens because it is educate patients on the potential causes The patient was counseled to throw not only made of silicone hydrogel but of corneal ulcers, and if they are con- away her current CLs and to stay out also has a two-week replacement sched- tact lens wearers stress the importance of them until the condition resolved. ule (as opposed to the monthly replace- of not overwearing their CLs. Specifi- Close follow-up care is crucial to pre- ment schedule for the other two sili- cally, clinicians should review lens care vent rapid visual deterioration from any Optometric Education 50 Volume 37, Number 1 / Fall 2011 regimens, including recommended re- tolate 1% (Cyclogyl) bid b. Acanthamoeba placement schedule, frequent replace- e. ciprofloxacin 0.3% (Ciloxan) c. Pseudomonas ment of storage cases, not swimming two drops every 15 minutes d. Herpes simplex in CLs, adequate lens disinfection, and for six hours, then two drops e. Staphylococcus avoidance of tap water for cleaning and every 30 minutes for 18 hours 7 Answer key: 1(a), 2(d), 3(e), 4(a), 5(a), soaking lenses . Hopefully, with proper and cyclopentolate 1% (Cyclo- 6(a), 7(a), 8(c), 9(a), 10(c) patient education and advances in CL gyl) bid technology, materials and solutions, f. polymyxin B sulfate/trimethop- To initiate discussion, “why” each an- there will be a significant reduction in rim sulfate (Polytrim) one drop swer was chosen should be elicited from the number and severity of ulcerative every hour and cyclopentolate students. Question #4 should involve a keratitis cases. 1% (Cyclogyl) bid discussion of the off-label use of medication. Lead Questions for 5. The most appropriate follow-up for this patient is: Evaluating Knowledge and References Stimulating Discussion a. 24 hours 1. Mela EK, Giannelou IP, John KX, b. 48 hours Sotirios GP. Ulcerative keratitis in 1. Which of the following is the most c. 1 week contact lens wearers. Eye & Con- likely diagnosis based on the pa- d. 3 days tact Lens. 2003;29(4):207-209. tient’s presenting symptoms? e. return if symptoms worsen 2. Bharathi MJ, Ramakrishnan R, a. corneal ulcer 6. Which of the following is the most Meenakshi R, Kumar CS, Pad- b. contact lens-induced acute red likely potential sequel of this pa- mavathy S, Mittal S.Ulcerative eye tient’s condition? keratitis associated with contact c. primary anterior uveitis a. corneal scar lens wear. Indian J of Ophthalmol. d. infiltrative keratitis b. corneal transplant 2007;55:64-67. 2. Which of the following is the most c. anterior synechiae 3. Green M, Apel A, Stapleton F. Risk likely diagnosis? d. posteriorsynechiae factors and causative organisms in e. glaucoma microbial keratitis. Cornea. Jan a. fungal keratitis 2008;27(1):22-27. b. amoebic keratitis 7. Which of the following is a defense 4. Kaiser P, Friedman N, Pineda c. viral keratitis mechanism of the cornea? R.The Massachusetts Eye and Ear d. bacterial keratitis a. tight cellular junctions of the Infirmary Illustrated Manual of e. primary anterior uveitis corneal epithelium Ophthalmology 2nd Ed. Philadel- 3. Which of the following is most b. corneal endothelial pump phia: Saunders 2004. likely associated with this condi- c. tight cellular junctions of stro- 5. Sirikul T, Prabriputaloong T, Sma- tion? ma thivat A, Chuck R, Vongthongsri A. Predisposing factors and etio- a. history of recent trauma d. epithelial regeneration logic diagnosis of ulcerative kerati- b. swimming in CLs 8. The most common reason for a tis. Cornea. April 2008;27(3):283- c. improper care of CLs corneal culture in this case would 287. d. systemic diagnosis of ulcerative be: 6. Keay L, Stapleton F, Schein colitis a. size of epithelial defect O.Epidemiology of contact-lens e. sleeping in CLs b. location of defect related inflammation and microbial 4. The most appropriate initial treat- c. poor response to therapy on keratitis: a 20-year perspective. Eye ment option for this patient is: follow-up & Contact Lens. 2007;33(6):346- a. moxifloxacin 0.5% (Vigamox) d. age of patient 353. one drop every 30 minutes for e. history of CL use 7. Mah-Sadorra JH, Yavuz GA, Naj- the first four hours then one 9. Which of the following best de- jar DM, Laibson PR, Rapuano CJ, drop every hour for the next scribes the pathophysiology of this Cohen EJ. Trends in contact lens- 18 hours and cyclopentolate patient’s condition? related corneal ulcers. Cornea. Jan 1% (Cyclogyl) bid 2005;24(1)51-58. a. increased metabolic stress on 8. Holden BA, Sweeney DF, San- b. prednisolone acetate 1% (Pred the cornea Forte) one drop every four karidurg PR, Carnt N, Edwards K, b. inability of endothelial pump Stretton S, Stapleton F.Microbial hours and cyclopentolate 1% to remove fluid (Cyclogyl) bid keratitis and vision loss with con- c. tear film instability tact lenses. Eye & Contact Lens. c. trifluridine 1% (Viroptic) one d. hyperosmolarity on the cornea drop every hour and cyclopen- 2003;29:131-134. tolate 1% (Cyclogyl) bid 10. Which of the following is the most 9. Das S, Sheorey H, Taylor HR, Va- d. natamycin 5% (Natacyn) one likely etiology of this condition? jpayee RB. Association between drop every hour and cyclopen- a. Fusarium cultures of contact lens and corneal scraping in contact lens-related mi-

Optometric Education 51 Volume 37, Number 1 / Fall 2011 crobial keratitis. Arch Ophthalmol. tal Ophthalmology. 2007;35:421- 31. Kabat AG. How to manage ocular Sept 2007;125(9):1182-1185. 426. infection. Review of Optometry 10. Pinna A, Usai D, Sechi L, Molicot- 21. Srinivasan M, Lalitha P, Mahalak- April 2007;144(11):100-101. ti P, Zanetti S, Carta A. Detection shmi R, Prajna NV, Mascarenhas of virulence factors in pseudomo- J, Chidambaram JD, Lee S, Hong nas aeruginosa strains isolated from KC, Zegans M, Glidden DV, contact lens-associated corneal ul- McLeod S, Whitcher JP, Lietman cers.Cornea. April 2008;27(3):320- TM, Acharya NR. Corticosteroids 326. for bacterial corneal ulcers.Br. J. 11. Sweeney D, Naduvilath T. Are Ophthalmol. 2009;93;198-202. inflammatory events a marker 22. Scoper S.Review of third and for an increased risk of microbial fourth generation fluoroquino- keratitis? Eye & Contact Lens. lones in ophthalmology: in-vitro 2007;33(6):383-387. and in-vivo efficacy. AdvTher. 12. Morgan PB, Efron N, Hill EA, 2008;25(10):979-994. Raynor MK, Whiting MA, Tul- 23. Sowka JW, Gurwood AS, Kabat lo AB. Incidence of keratitis of AG. Fourth generation fluoro- varying severity among contact quinolones and bacterial keratitis. lens wearers. Br J Ophthalmol. Handbook of Ocular Disease Man- 2005;89:430-436. agement. March 2006;25A-26A. 13. Moriyama AS, Hofling-Lima AL. 24. Duggiral A, Joseph J, Sharma S, Contact lens-associated micro- Nutheti R, Garg P, Das T. Activity bial keratitis. Arq Bras Oftalmol. of newer fluoroquinolones against 2008;71(6 supl):32-36. Gram-positive and Gram-negative 14. Mills TJ. Corneal ulceration and bacteria isolated from ocular infec- ulcerative keratitis. Retrieved Sept tions: an in vitro comparison. Indi- 15, 2008 http://emedicine.med- an J Ophthalmol. 2007;55:15-19. scape.com/article/798100-over- 25. McCulley JP, Surratt G, Shine W. view. 4th generation fluoroquinolone 15. Silbert, JA. Corneal infiltrative penetration into aqueous humor complications associated with in humans. InvestOphthalmol Vis. contact lens wear. Review of Op- Sci. 44 Abstract 4927-B251 Vol 2. tometry. April 2004;141(04):1CE- 26. Katz, HR. Vigamox safely treats 8CE. corneal ulcers. Retrieved April 16, 16. Patel A, Hammersmith K. Con- 2009 http://www.eyeworld.org/ew- tact lens-related microbial kera- weeksupplementarticle.php?id=12. titis: recent outbreaks. Current 27. Chang MH, Fung HB. Besifloxa- Opinion in Ophthalmology. July cin: a topical fluoroquinolone 2008;19(4):302-306. for the treatment of bacterial 17. Robertson DM, Cavanagh HD. conjunctivitis. ClinTher. March The clinical and cellular basis of con- 2010;32(3):454-471. tact lens-related corneal infections. 28. Comstock TL, Karpecki PM, Mor- ClinOphthalmol. 2008;2(4):907- ris TW, Zhang JZ. Besifloxacin: a 917. novel anti-infective for the treat- 18. Ali N, Ali M.Bilateral simultaneous ment of bacterial conjunctivitis. infectious keratitis secondary to ClinOpthalmol. April 2010;4:215- contact lens wear: An unusual case 225. report with rare organisms. Eye & 29. McDonald M, Blondeau Contact Lens. 2007; 33(6):338- JM.Emerging antibiotic resistance 340. in ocular infections and the role of 19. Keay L, Edwards K, Naduvilath fluoroquinolones. J Cataract Re- T, Forde K, Stapleton F. Factors fract Surg. Sept 2010;36(9):1588- affecting the morbidity of contact 1598. lens-related microbial keratitis:A 30. American Optometric Associa- population study. Ophthalmol- tion; Optometric Clinical Practice ogy and Vision Science. Oct Guideline: Care of the Contact 2006;47(10):4302-4308. Lenses Patient. St.Louis, MO. Re- 20. Green MD, Apel AJ, Naduvilath T, trieved December 14, 2010 Avail- Stapleton FJ. Clinical outcomes of able http://www.aoa.org/docu- keratitis. Clinical and Experiemen- ments/CPG-19.pdf 40-46.

Optometric Education 52 Volume 37, Number 1 / Fall 2011