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J Opt om. 2011;4(4):122-127

Journal
of Optometry
P e e r- r e v i e w e d J o u r n a l o f t h e Spanish General Council of Optometry

ISSN: 1888-4296

Optometry
O c t o b e r- D e c e m b e r 2 0 1 1 | Vo l . 4 | n . 4

Journal
Editorial
Research in Optometry: A challenge and a chance
115 D.P. Piero

Case Reports
Herpes-zoster virus ophthalmicus as presenting sign of HIV disease
117 Udo Ubani

Contact-lens-related microbial keratitis: case report and review

122 Mark Eltis

of 128
134
140
Original Articles
The new numbers contrast sensitivity chart for contrast sensitivity measurement
Bharkbhum Khambhiphant, Wasee Tulvatana, Mathu Busayarat

Contrast sensitivity evaluation with ilter contact lenses in patients with retinitis pigmentosa: a pilot study
G. Carracedo, J. Carballo, E. Loma, G. Felipe, I. Cacho

Corneal thickness measurements with the Concerto on-board pachymeter

Hassan Hashemi, Shiva Mehravaran, FarhadRezvan, SaraBigdeli, Mehdikhabazkhoob

Accuracy of Visante and Zeiss-Humphrey Optical Coherence Tomographers

147 and their cross calibration with optical pachymetry and physical references
Jyotsna Maram, Luigina Sorbara, Treford Simpson

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CASE REPORT

Contact-lens-related microbial keratitis: case report and review

Mark Eltis

Privat e Pract ice, Toront o, Ont ario, Canada

Submit t ed 31 May 2011; accept ed 26 Sept ember 2011

KEYWORDS Abstract Bact erial kerat it is is a serious, pot ent ially blinding, complicat ion most oft en involving
Kerat it is; overnight cont act lens wear. This case report reviews t he management of a pat ient wit h bact erial
Ulcer; kerat it is and discusses t he et iology, different ial diagnosis, classi cat ion and risk fact ors associat ed
Fort i ed ant ibiot ics; wit h t he condit ion.
Bio lm 2011 Spanish General Council of Opt omet ry. Published by Elsevier Espaa, S.L. All right s reserved.

PALABRAS CLAVE Queratitis microbiana relacionada con lentes de contacto: caso clnico y anlisis
Querat it is;
lcera; Resumen La querat it is bact eriana es una complicacin grave que puede causar ceguera y a
Ant ibit icos menudo se asocia con el uso de lent es de cont act o durant e t oda la noche. En est e caso clnico
reforzados; se analiza el t rat amient o de un pacient e con querat it is bact eriana y se aborda la et iologa, el
Bio lm diagnst ico diferencial, la clasi cacin y el t rat amient o de la enfermedad.
2011 Spanish General Council of Opt omet ry. Publicado por Elsevier Espaa, S.L. Todos los derechos
reservados.

Introduction
Bacterial keratitis (corneal ulcer) is a sight-threatening contact
lens complicat ion. 1-12 Eit her unt reat ed or severe bact erial
keratitis may result in perforation and endophthalmitis. 10,13
Cont act lens (CL) wear is t he main risk f act or, 3,6,14,15 and
sleeping in cont act lenses is t he maj or risk f act or among
cont act lens wearers. 4,8,9 Est imat es put t he number affect ed
annually by bact erial kerat it is in t he U. S. at 30, 000 and
higher. 10,15,16
A corneal ulcer is de ned by a corneal in lt rat e associat ed
wit h an overl ying epit hel ial def ect . 12, 14, 15 Corneal ul cers
generally occur when t he normal eyes nat ural resist ance t o
inf ect ion has been compromised f rom eit her t rauma or

*Corresponding aut hor. Hudson Bay Cent re, Concourse Level. 44 Bloor St . East . Toront o, Ont ario M4W 3H7
E-mail: Mark.elt is@gmail.com (M. Elt is).

1888-4296/ $ - see front mat t er 2011 Spanish General Council of Opt omet ry. Published by Elsevier Espaa, S.L. All right s reserved.
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Cont act -lens-relat ed microbial kerat it is: case report and review
cont act l ens wear. 10 Bact er i al i nf ect i on account s f or
approximat ely 90%of microbial kerat it is. 9 Microbial kerat it is
increased in prevalence f ollowing t he int roduct ion of sof t
l enses i n t he 1970s. 3 The most common pat hogens
implicat ed are st aphylococci and pseudomonas. 5,6,11,13,14,17-19
While most corneal ulcers in Nort h America are bact erial in
or i gi n (account i ng f or appr oxi mat el y 90% of cases of
microbial kerat it is) and are most of t en caused by cont act
l ens wear, t rauma (of t en f ungal ) is t he l eading cause of
ulcers in developing count ries. 2,5,8,9
Case report
A t went y-six-year-old female present ed t o our clinic on May
21, 2009 wit h a painf ul right eye which was swollen shut .
The pat ient had been seen in our cl inic f or rout ine eye
exams in 2006 and 2007 and was a wearer of cont act lenses
(O2 Opt i x '2. 75 D OU, BC 8. 6 DIA 14. 2). She had been
ref erred back t o us by her f amily physician, who believed
she had eit her a foreign body t rapped in her right eye or a
corneal ulcer. The pat ient had slept in her cont act lenses
t he previous night . She denied using wat er eit her t o clean
or t o st ore her l enses and cl aimed t o have changed her
mult ipurpose solut ion on a night ly basis. The pat ient also
replaced her lenses fort night ly. There was no hist ory eit her
of swimming wit h t he cont act lenses or of inj ury t o t he eye
involving veget at ion.
The young woman s ocul ar and medi cal hi st or y was
negat ive, and she denied eit her t aking medicat ion or having
allergies. Her present ing visual acuit y was 20/ 20 in each eye
wit h glasses at dist ance. Slit lamp evaluat ion revealed diffuse
conj unct ival inj ect ion and a small circular epit helial defect
wit h underlying st romal in lt rat ion in t he midperiphery of
t he right eye. The pat ient had a t race ant erior chamber
react ion and small amount s of mucopurulent discharge.
The different ial diagnosis considered in t his case includes
t he following:
Bact er i al ker at i t i s (cor neal ul cer ) r epr esent s t he
overwhelming maj orit y of cont act -lens-relat ed microbial
kerat it is (CLMK) 9 and is de ned by st romal loss wit h an
overlying epit helial defect . 18 The ulcer is associat ed wit h
over ni ght c ont ac t l ens w ear. 4, 8 Pai n, r ed ness,
mucopurulent discharge, phot ophobia and an ant erior
chamber react ion may be present . 10
Fungal ker at i t i s is associat ed wit h t raumat ic corneal
inj ury, especially f rom veget able mat t er. 11,13 The f ungal
l esi on gener al l y has f eat her y bor der s and may be
surrounded by sat el l it e inf il t rat es. 18 This condit ion is
more common in developing count ries. 2,5,6,8
Acant hamoeba ker at i t i s mani f est s as an ext r emel y
painf ul ring-shaped inf ilt rat e possibly associat ed wit h
ei t her swi mmi ng whi l e weari ng cont act l enses12, 18 or
generally poor cont act lens disinfect ion (t he use of eit her
t ap wat er or saline inst ead of mult ipurpose solut ion). 13
The pat ient usually has severe pain disproport ionat e t o
clinical ndings. 12 The condit ion develops over a period
of several weeks. 18
Her pes si mpl ex ker at i t i s is due t o t he react ivat ion of
l at ent Herpes simpl ex virus-1 (HSV-1) which migrat es
down t he axon of t he branch of t he t rigeminal nerve t o
123
t he cornea. 13 Dendrit es wit h t rue t erminal bulbs may be
present on t he cornea, 12 and corneal sensit ivit y may be
decreased. 18
Her pes zost er ker at i t i s may invol ve pseudodendrit ic
lesions present on t he cornea. 12 Typically, painf ul skin
vesicles are present along a dermat omal dist ribut ion not
cr ossi ng t he mi dl i ne. 18 The condi t i on i s due t o a
react ivat ion of Herpes zost er virus (HZV) and migrat ion
t o t he rst division of t he t rigeminal nerve t o t he skin
and eye. 13 Herpes zost er kerat it is is most common in t he
aged and t he immunocompromised. 18
Mar gi nal ker at i t i s i s a r eact i on t o st aphyl ococcal
exot oxi ns. 13 Margi nal kerat i t i s general l y occurs wi t h
coexi st i ng condi t i ons of ei t her bl ephari t i s or ocul ar
r osacea and i s usual l y accompani ed by mul t i pl e
subepit hel ial marginal inf il t rat es separat ed f rom t he
limbus by a clear zone. 18 The condit ion is oft en bilat eral
and r ecur r ent . 18 Cor neal st ai ni ng i s al so possi bl e. 12
Conj unct ival inj ect ion is usually localized. 18
The pat ient s skin was clear, and she had neit her dendrit es
nor pseudodendrit es on her cornea. There was no hist ory of
eit her cold sores or an immunocompromised st at e. She
had not used ei t her t ap wat er or sal i ne i nst ead of
mult ipurpose solut ion t o clean her cont act s. The ulcer was
round wit h neit her f eat hery borders nor a ring shape, and
t he pain seemed proport ional t o t he size of t he dist urbance.
There was no hist ory of eit her blepharit is, acne rosacea or
an eye inj ury involving veget at ion. The pat ient had slept in
her lenses and was exhibit ing t he classic signs and sympt oms
of cont act -l ens-rel at ed microbial kerat it is (CLMK). The
pat ient was diagnosed wit h bact erial kerat it is.
A drop of Cyclopent olat e 1%was inst illed in t he right eye
t o help t o cont rol pain and t o prevent synechia format ion.
Wit h a let t er explaining her condit ion, t he pat ient was sent
t o West ern Hospit al Emergency Depart ment for t reat ment .
In t he emergency room, t he diagnosis of a corneal ulcer
was con rmed and Vigamox was prescribed: one drop in t he
right eye every t wo hours. A follow-up was scheduled in t he
opht halmology depart ment for t he next day.
Follow-up #1
The pat i ent w as seen by st af f at West er n Hospi t al
Opht hal mol ogy on May 22, 2009. Her present i ng vi sual
acuit y wit h spect acle correct ion for dist ance was 20/ 20 OD
and OS. Pupi l s wer e equal and r eact i ve t o l i ght and
accommodat ion. Slit lamp examinat ion revealed a small
corneal inf il t rat e wit h mil d st aining overt op. There was
marked improvement in t he pat ient s condit ion and t he
dose of Vigamox was subsequent ly reduced t o one drop four
t imes daily for ve days. The small ulcer was at t ribut ed t o
cont act lens noncompliance, and she was inst ruct ed not t o
wear cont act lenses unt il her follow-up in one week.
Follow-up #2
The pat ient ret urned t o West ern Hospit al Opht halmologist
on June 15, 2009. (Uncl ear is why, af t er one week, t he
pat i ent had not ret urned as schedul ed. ) The at t endi ng
opht halmologist inst ruct ed t he pat ient never t o sleep in her
cont act l enses and inf ormed t he pat ient of t he risks of
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124
cont act l ens noncompl i ance. The exami nat i on w as
unremarkabl e, and eyes al l cl ear was wri t t en i n t he
r ecor d. Nei t her was t he ul cer pr esent nor wer e t he
sympt oms of discharge, redness and pain from t he rst visit .
Discussion
Cont act -lens-relat ed microbial kerat it is (CLMK) is a severe
and pot ent ially blinding condit ion requiring urgent t reat ment
t o cont ain damage and t o improve prognosis. 6,9,10,11 Microbial
kerat it is af f ect s approximat ely 5 in 10,000 wearers. 4 (One
2010 st udy gives a rat io of more t han double t hat .) 15 The use
of cont act lenses overnight is t he single most common risk
fact or in t he developed world. 6,9
There are approximat ely 125 million cont act lens wearers
globally. 7 Corneal ulcers are a maj or cause of vision loss
worldwide. 2 Considering t he large number of cont act lens
wearers, t here are import ant public healt h consequences
for microbial kerat it is and ot her decept ively rare diseases
wit h signi cant morbidit y. 4
Though t he int roduct ion of silicone hydrogels has allowed
physiological levels of oxygen t o reach t he ocular surface,
t he i nci dence of cor neal ul cer s has not dr amat i cal l y
decreased. 3,4,9,17,20 In fact , t here has been an upward t rend
in ulcers in t he U.S. 6
Mechanism behind ulceration
Alt hough progressive research cont inues t o make inroads
i nt o a f ul l er und er st and i ng of t he mechani sm of
ul cerat ion, 20 several f act ors pl ay a rol e in cont act -l ens-
relat ed kerat it is. They include bact erial adherence t o t he
lens, f ormat ion of biof ilm on t he lens and in t he st orage
case, resist ance of microorganisms t o disinfect ion syst ems,
st agnat ion of t ear lm behind cont act lenses and reduced
resist ance of t he cornea t o infect ion. 9,20
In bact eri al kerat i t i s, bact eri a accessi ng t he corneal
st roma cause damage and an in ammat ory response which
result in loss of t ransparency. 3 Alt hough some bact eria can
i nvade a heal t hy cornea, most ent er t hrough ei t her an
abnormalit y or a defect in t he corneal surface. 10
Corneal ulcerat ion is mercif ully less common t han t he
presence of bact eria on ocular surf aces. 11,20 Clearly, under
normal condit ions, t he corneas count ermeasures are highly
effect ive against invaders. 3,20 Hypoxia may increase bact erial
binding, compromise corneal int egrit y and impair wound
healing. 4 These effect s are reduced but not eliminat ed wit h
silicone hydrogel lenses. 9 Hypoxia, which is unlikely t o be
t he sol e f act or i n cor neal ul cer at i on, i s most l i kel y a
cont ribut or. 3
Changes t o ocular surf ace biochemist ry underneat h t he
cont act lens may be why cont act lens wearers are more
suscept ible t o inf ect ion. 20 Int eract ion wit h cont act lenses
can override t he corneas defence mechanism and increase
t he rat e at which pat hogens adhere t o t he ocular surf ace
and al l ow pr ogr essi on t o mi cr obi al ker at i t i s. 9, 17, 20 The
adhesion of bact eria t o cont act lenses is considered a maj or
r i sk f act or f or ser i ous cor neal pr obl ems (par t i cul ar l y
St aphylococcus epidermis and Pseudomonas aeruginosa). 17,20
Cont act lenses are a suit able surface for bact erial adhesion
and biof ilm f ormat ion. 20 They sust ain a large quant it y of
M. Elt is
organisms in prolonged cont act wit h t he cornea. 9,17 Rougher
cont act l enses sur f aces ar e pr one t o mor e ext ensi ve
bact er i al adhesi on and mi cr obi al col oni zat i on f r om
i mperf ect i ons i n t he l ens surf ace, where deposi t s may
form. 17
Gram negat ive bact eria may survive at t he upper inner
ri m of t he case where, due t o t he ai r-l i qui d i nt erf ace,
bio lms have a higher likelihood of occurring. 7 Therefore, a
pat ient making cont act wit h t hat area of t he case while
handl i ng a l ens bef or e i t s i nser t i on may be sever el y
reinfect ing t he lens. 7
Cont ami nat i on of t he cont act l ens case has been
associat ed wit h microbial kerat it is. 9 The case has been
shown t o be more heavily cont aminat ed t han eit her lens
or solut ion. 7 The same st rains have been isolat ed f rom a
cor neal ul cer and t he cont act l ens case. 7 Level of
cont ami nat i on i s associ at ed wi t h t he age of t he l ens
case. 4
The el iminat ion of rub and rinse may decrease t he
amount of microorganisms removed in t he cleaning process
and creat e a carry-over effect (from lens t o case) which
allows t he remaining pat hogens t o form a bio lm in t he case
and t o increase t heir virulence and rat e of survival. 7, 9, 10, 20
Cont act lens wear seems t o reduce t ear exchange; t he
mean eliminat ion rat e in eyes wearing convent ional cont act
lenses is about half of t hat observed in normal non-wearers
of cont act lenses. 9,20 However, silicone hydrogels may allow
signi cant ly higher levels of t ear exchange t han convent ional
l enses. 21 The i mpact of t ear exchange on t he r i sk of
microbial kerat it is is not fully underst ood. 3,20,21
Risk of cont act lens microbial kerat it is varies widely wit h
t he t ype of cont act lens and pat t ern of wear. 10 The rat e of
progressi on of mi crobi al kerat i t i s i s dependent on t he
virulence of t he of f ending pat hogen and host f act ors. 10, 11
Pseudomonas aer ugi nosa, one of t he mor e common
pat hogens in CLMK, is highly dest ruct ive and dif f icult t o
neut ralize because of it s virulent st ruct ure, adapt abilit y
and high rat e of survival under dif f erent condit ions. 3, 20
Anot her highly common pat hogen in CLMK, st aphylococcus,
may account for 45%of all bact erial kerat it is. 11,17
The role of laboratory culture
Because no clinical f eat ures of microbial kerat it is may be
consi der ed pat hognomoni c, t he i dent i f i cat i on of t he
pat hogen is crit ical. 1 In t he U.S., t he most common pract ice
begins t reat ment empirical l y and onl y invest igat es t he
of f ending pat hogen if init ial t reat ment f ails. 1, 2, 10 One U. S.
st udy has shown t hat appr oxi mat el y hal f of Amer i can
opht hal mol ogist s rout inel y cul t ure and onl y 17. 5% gram
st ai n. 16 The same st udy showed t hat onl y 13% perf orm
cult ures more t han ft y per cent of t he t ime. 16
A rest rained approach t o cult ures may be j ust i ed when
we consider t hat over 90%of ulcers in t he U.S. are bact erial
in nat ure and respond t o ant ibiot ics. 2 The policy t hat all
ul cers be cul t ured bef ore t reat ment be init iat ed is, f or
pract ical reasons of t ime and cost , not f ollowed by most
special ist s. 2, 22 Bef ore init iat ing t reat ment , cul t ures are
indicat ed in eit her sight -t hreat ening or severe kerat it is. 10
Smears and cult ures are indicat ed eit her when t he in lt rat e
is large, when it is cent ral, when t here is no response t o
broad spect rum ant i bi ot i cs or when t he observat i on of
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Cont act -lens-relat ed microbial kerat it is: case report and review
at ypical clinical f eat ures suggest s a more exot ic pat hogen
(such as eit her fungus or acant hamoeba). 10,18
Cult ures can also decrease t oxicit y by eliminat ing t he use
of unhelpful medicat ions. 10 Cult ure yields can be improved
by avoiding anaest het ics wit h preservat ives. 10 Cult ures of
eit her t he cont act lens, it s case or t he solut ion may also be
helpf ul. 10, 18 The best approach is t o cult ure and t o t reat
lesions as pot ent ially infect ive. 22
Management
CLMK is assumed t o be bact erial unt il proven ot herwise. 12,18
The goal of t r eat ment i s t he r api d er adi cat i on of t he
pat hogen. 1 Current ly t he gold st andard of t reat ment for
corneal ulcerat ion is t he use of fort i ed ant ibiot ics: eit her
cef azol in 5% and t obramycin 1. 3% or monot herapy wit h
second generat ion uoroquinolones (eit her cipro oxacin or
o oxacin). 8,19
Frequency of re-evaluat ion depends on severit y of disease
but microbial kerat it is should init ially be monit ored on a
daily basis. 10,12 If pain decreases and t he epit helial defect ,
in lt rat e size and ant erior chamber react ion improve, t he
t reat ment may be considered t o be effect ive. 18
Treat ment should be re-evaluat ed aft er 48 hours if t here
is no sign of improvement (alt hough pseudomonas and ot her
gram negat ive bact eria may show increased in ammat ion
despit e appropriat e t herapy wit hin t he rst 24 t o 48 hours). 10
When ul cer s ar e ei t her at ypi cal or unr esponsi ve t o
medicat ion, a mixed bact erial and f ungal inf ect ion should
be consi der ed. 11 Ci pr of l oxaci n oi nt ment at bedt i me
(opt ionally t obramycin in less severe cases) may be useful. 18
Cycloplegic drugs decrease synechia format ion, reduce pain
and manage ant erior chamber react ion. 12,13
Whi l e some exper t s advocat e t he use of t opi cal
cort icost eroids in concert wit h t opical ant ibiot ics, 22 t he
value of t opical st eroids remains cont roversial. 12,13 There is
no conclusive evidence t hat cort icost eroids alt er clinical
out come. 10, 13 Consequent ly, t he amount of cort icost eroids
used t o achi eve cont r ol of i nf l ammat i on shoul d be
minimized. 10 Subconj unct ival ant ibiot ics may be used in
pat ient s wit h poor compliance wit h t opical t reat ment . 13
Syst emic ant ibiot ics are rarely used but may be considered
for severe infect ions. 10,13
Ker at opl ast y may be consi der ed when aggr essi ve
microbial kerat it is doesn t respond t o medical t herapy. 11,18
The procedure aims t o el iminat e t he inf ect ious disease
process and t o est ablish t he int egrit y of t he globe. 11,23 The
procedure offers a microbial cure rat e of 90 t o 100%. 23 Wit h
t he emer gence of mor e pot ent ant i mi cr obi al agent s,
t herapeut ic kerat oplast y is required less of t en. 23 A recent
st udy in Bahrain found t hat only 1%of CLMK pat ient s needed
t herapeut ic kerat oplast y. 6
Af t er t heir int roduct ion in t he 1990s, second generat ion
uoroquinolones quickly became an accept ed alt ernat ive t o
fort i ed ant ibiot ics. 16 Cipro oxacin was t he most frequent ly
used t opical medicat ion 'prescribed t o approximat ely 90%
of pat ient s in t he Port smout h st udy. 14
Relat ive ease of dosing and higher pot ency are among t he
f ac t or s i nc r easi ng i nt er est i n f our t h gener at i on
f l uor oqui nol ones, whi ch ar e al so wi t hout t he r ecent
r esi st ance some bact er i a have devel oped t o Ci l oxan
(ciprof loxacin) and Ocuf lox (of loxacin). 8, 10 The suggest ed
125
i ni t i al dose of ei t her Vi gamox (moxi f l oxaci n) or Zymar
(gat i oxacin) is one drop every one t o t wo hours. 12,18 In less
sever e cases, a r egi me wi t h l ess f r equent dosi ng i s
appropriat e. 10
Moxi oxacin and gat i oxacin bot h have improved pot ency
and impede growt h of organisms resist ant t o t he second and
t hi r d gener at i on ant i bi ot i cs. 8, 10, 19 In a r ecent st udy,
moxif l oxacin and gat if l oxacin were f ound t o have l ower
minimum inhibit ory concent rat ions (MIC) t han f ort if ied
ant ibiot ics and second generat ion uoroquinolones. 8 The
inhibit ory propert y of DNA t opoisomerase IV reduces t he
l i kel i hood t hat pat hogens shal l devel op r esi st ance t o
moxi f l oxaci n and gat i f l oxaci n. 8, 10 Four t h gener at i on
f l uor oqui nol ones r equi r e t wo mut at i ons t o est abl i sh
resist ance whil e t he second generat ion onl y needs one
mut at i on f or r esi st ance t o occur. 19 They have bet t er
penet rat ion of t he cornea and aqueous and t herefore may
l ead t o mor e ef f ect i ve t her apeut i c l evel s and bet t er
prognosis. 8
One st udy by Hsu et al. has found t hat corneal specialist s
and comprehensi ve opht hal mol ogi st s by overwhel mi ng
maj orit y (76%and 88%respect ively) use fourt h generat ion
f l uor oqui nol ones as t he i ni t i al t r eat ment of choi ce i n
corneal ulcers. 16 Several st udies have found no difference in
ef f icacy bet ween t he f ourt h generat ion f luoroquinolones
and t he gener al l y accept ed al t er nat i ves. 8, 19 Emer gi ng
evidence of resist ance t o fourt h generat ion uoroquinolones
is isolat ed, 8 and t hey can t heref ore be considered j ust as
ef f ect i ve as, i f not more ef f ect i ve t han, t he current l y
accept ed t reat ment s. 10,12,13,16,18,19 However, fourt h generat ion
uoroquinolones are not yet FDA-approved for t reat ment of
bact erial kerat it is. 8,10
Risk factors, prevention and innovations in care
The problem of cont act lens care is a common one; st udies
suggest t hat 40 t o 70%of pat ient s are noncompliant . 24 Healt hy
cont act lens wear depends on many f act ors. They include
age, sex, lens brand, smoking habit s, cleaning regime and
wear i ng r egi me. 25 Hi gher r at es of compl i cat i ons wer e
associat ed wit h men, wit h yout h, wit h smokers, wit h longer
periods of wear and wit h a l ack of hand-washing. 7, 17, 24, 25
(Int ernet purchase, possibly due t o at t it udes and behaviours
associat ed wit h it , was also recent ly ident i ed as a risk.) 4
Noncompliance wit h t he manuf act urers recommended
f requency of repl acement of cont act l enses i s hi ghest
among t eenagers and among t he wearers of non-silicone
hydrogels. 24
Microbial cont aminat ion of cont act lens case and poor
cont act l ens hygiene are al so associat ed wit h microbial
kerat it is. 4 Recent st udies also suggest noncompliance is a
fact or in corneal infect ions relat ed t o CL solut ion. 24 Pat ient s
using hydrogen peroxide solut ions were f ound t o be more
compl iant wit h t he cont act l ens repl acement schedul e,
perhaps because t he care regi me i s more compl ex and
demanding. 24
Daily disposables were f ound t o be associat ed wit h t he
lowest rat e of complicat ions in general. 24 They also have
lower risks f or severe CLMK and associat ed vision loss. 4, 20
Because neit her a case nor a cleaning regime is at issue wit h
dail y disposabl es, t heir use may bot h reduce t he risk of
mi crobi al kerat i t i s and decrease i t s severi t y. 4, 7 St udi es
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126
suggest ing t hat daily wear decreased t he risk of microbial
kerat it is remain cont roversial. 9,15,20,26
Earl y t reat ment can l imit t he scarring and vision l oss
caused by CLMK. 8, 27 Even a slight delay in assessment and
t reat ment can increase t he risk of a poorer out come. 11, 25
Recent st udies show t hat t reat ment delayed by more t han
12 hours increases t he risk of vision loss. 9 Therefore, t imely
recognit ion and t reat ment is of paramount import ance. 1,10
Thi s woul d suggest t hat count r i es shoul d f ol l ow t he
Amer i can model and expand t he scope of pr act i ce of
opt omet rist s t o enable more immediat e access t o crucial
care. 25
Alt hough t he risk t o t he individual is low, t he group at risk
is a vit al one, including t he young, healt hy and of working
age who are at l ow ri sk of i nf ect i on i n t he absence of
overni ght cont act l ens wear. 4, 6, 9 Though l enses may be
approved f or overnight wear, inf orming pat ient s of t he
associat ed risks of such use may decrease t he incidence of
corneal ul cers. 15 Risks incl ude t he dest ruct ive nat ure of
microbial kerat it is and t he pot ent ial for rapid, painful and
permanent vision loss. 10,27 There is evidence t hat overnight
cont act l ens wear er s ar e at gr eat er r i sk of mi cr obi al
ker at i t i s especi al l y i n t he ear l y days of t hei r wear
experience. 4 Pat ient s should be part icularly caut ioned never
eit her t o sleep or t o nap in t heir cont act lenses. 10 Teenaged
and young adult s should be especially educat ed on proper
cont act lens procedures and t he pot ent ial for complicat ions.
Demographically common behaviours such as poor hygiene,
binge drinking and cont act lens overuse put t hem at higher
risk. 25
Confocal microscopy is a promising t ool in t he diagnost ic
arsenal and may be used in t he dif f erent ial diagnosis of
i nf ect i ous ker at i t i s, par t i cul ar l y w her e i t i nvol ves
acant hamoeba and fungus. 1,10,12
Col l agen cr ossl i nk i ng ( CXL) w i t h r i bof l avi n and
ult raviolet -light A, has been used successf ully t o halt t he
p r ogr essi on of Ker at oc onus28, 29 b y i nc r easi ng t he
bi omechani cal st r engt h of t he t i ssue and has shown
pot ent i al as a t r eat ment f or sever e cases of bact er i al
kerat it is29, 30, 31, 32. Phot oact ivat ion of ribo avin (a nat urally
occurring vit amin32, 33) is t hought t o damage t he RNA and
DNA of bact eria, viruses and parasit es31,33 and t o inact ivat e
t hem. 29, 31, 32, 33 CXL may also increase t he collagen def ence
agai nst enzymat i c degradat i on. 29 Thi s t echni que coul d
pot ent ially be used as an alt ernat ive t o kerat oplast y when
ucl er s do not r espond t o ei t her syst emi c or t opi cal
t herapy. 29,30,31 A crosslinked cornea is also more resist ant t o
cor neal mel t i ng. 31 Fur t her i nvest i gat i on i s needed t o
det ermi ne t he i deal rol e of corneal crossl i nki ng i n t he
t r eat ment of bact er i al ker at i t i s. 29, 31 The use of t hi s
t echni que i s not yet w i despr ead. 32 Due t o possi bl e
cyt ot oxi c ef f ect s, CXL shoul d be consi der ed onl y i n
kerat i t i s resi st ant t o t herapy and not as a f i rst l i ne of
t reat ment . 29
Bet t er lens st orage design, frequent replacement of t he
case (every 3 t o 6 mont hs) and i mproved hygi ene may
decrease t he incidence of corneal ul cerat ion. 7 Rubbing
cont act l enses when cl eani ng shoul d be encour aged
because t hat met hod may be superi or t o t he no rub
alt ernat ive. 9,10,34
A recent st udy by Hua Zhu et al . f ound t hat rub and
rinse removed bact eria more ef f ect ively t han did rinsing
M. Elt is
alone, wit hout regard t o eit her t he mult ipurpose solut ion
used or t he t ype of cont act lens. 34 Int erest ingly, wit h rinse
onl y mul t i pur pose di si nf ect i on, a r egi me cont ai ni ng
Polyquad solut ion removed more bact eria t han did t hose
wit h PHMB (polyhexamet hylene biguanide), and Gat y lcon
was more resist ant t o bact erial adhesion (wit h rinse only)
t han were ot her silicone hydrogel lenses. 34
A bet t er under st andi ng of t he mechani sm behi nd
mi cr obi al ker at i t i s wi l l hel p eye car e pr of essi onal s t o
recommend and ult imat ely t o creat e bet t er lenses and t o
suggest ways t o decrease t he risks. 20 For t he present , t he
t t ing of pat ient s in silicone hydrogels and daily disposables
while absolut ely advocat ing against sleeping in t he lenses
appears t o be t he best form of prevent ion.
Conclusions
This case of bact erial kerat it is demonst rat ed how rapid
diagnosis and effect ive management in t he init ial st ages of
t he condit ion result ed in quick resolut ion and prevent ed
vision loss. Cont inued research int o t he pat hogenesis of
bact erial kerat it is as well as pat ient educat ion on proper
cont act l ens pr ocedur es wi l l hopef ul l y decr ease t he
incidence of t his pot ent ially devast at ing infect ion.
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