Young contact lens wearer presents with pain, injection and decreased vision in left eye

The patient wore biweekly disposable contact lenses for 12 hours a day. He began wearing the current pair 5 days before presentation.

Issue: October 1, 2006

ByLindsay M. Smithen, MD

ByMichael H. Goldstein, MD

A 16-year-old boy was referred to the cornea service at the New England Eye Center for evaluation of a 1-day history of pain, injection, blurry vision and photosensitivity in the left eye. The patient, a soft contact lens wearer, reported a foreign body sensation in his left eye on the day before presentation. He removed his contact lens and rinsed his eye with tap water, which only increased the symptoms. The patient reported wearing biweekly disposable contact lenses for 12 hours a day. He began wearing the current pair 5 days before presentation and denied sleeping in the lenses. The patient had a history of soaking his lenses overnight in Bausch & Lomb Renu with MoistureLoc solution. He had been wearing contact lenses for 5 years and had never experienced any contact-related problems. His contact lenses were comprised of 62% polymacon, a hydrophilic polymer and 38% water.

The medical and ocular histories were both negative. The patient was on doxycycline for the treatment of acne. He did not smoke cigarettes.

Shazia Ahmed

My Hanh T. Nguyen

Examination

The patient’s best corrected visual acuity was 20/20 in the right eye and 20/80 in the left eye, which pinholed to 20/60. The right pupil was briskly reactive while the left pupil reacted sluggishly. IOP was 9 mm Hg in the right eye and 10 mm Hg in the left.

Slit lamp examination revealed 360° of superficial, fine neovascularization in the peripheral cornea of the right eye. Examination of the left eye (Figures 1 and 2) showed significant conjunctival injection, most notably in the perilimbal area. Diffuse microcystic edema with fine keratic precipitates, mild diffuse anterior stromal haze and an irregular epithelium could be seen. There was substantial (4+) anterior chamber inflammation with a 0.4 mm hypopyon out of proportion to the corneal changes. There were no focal infiltrates appreciated.

External photograph of left eye showing significant perilimbal injection and anterior stromal haze centrally.

Slit lamp photograph of left eye revealing a stromal haze centrally.

Images: Smithen L and Goldstein M

What is your diagnosis?

Eye pain, decreased vision

Although the differential diagnosis of a patient with injection, pain and blurry vision associated with contact lens use can be broad, the differential diagnosis in this particular case can include infectious keratitis (bacterial and fungal highest on the list) and contact lens-induced acute red eye (CLARE — also known as tight lens syndrome or contact lens overwear syndrome). Fungal keratitis has received significant public attention recently and was of concern in this case as our patient used Renu with MoistureLoc solution.

In order to assist with the diagnosis, the patient’s contact lenses and case were sent to the microbiology lab for cultures looking for bacteria (aerobic and anaerobic), fungus and Acanthamoeba. Corneal cultures were not performed, as there was no epithelial defect or focal infiltrate. The patient was advised to suspend contact lens use and was started on Vigamox drops (moxifloxacin HCl ophthalmic solution 0.5%, Alcon) every hour and Cyclogyl (cyclopentolate HCl, Alcon) three times a day.

The patient returned for follow-up the next morning with only minor improvements in his symptoms but a marked improvement in his clinical examination. The vision in the left eye remained 20/80 but pinholed to 20/40. There was still significant conjunctival injection. Corneal edema, although still present, was mild, and a faint corneal haze could still be seen centrally. The anterior segment inflammation showed a dramatic improvement from the previous day; there were one to two cells per high-powered field, and no hypopyon was present.

Two days after presentation, the patient’s symptoms improved significantly. He no longer had any pain or discomfort. Vision improved to 20/50 (pinholed to 20/30), and there was a significant decrease in conjunctival injection and corneal edema. Again, there was one cell per high-powered field without hypopyon. Localized anterior haze could still be seen in the corneal stroma centrally. There was no epithelial defect.

All cultures for bacteria, fungus and Acanthamoeba returned negative. On gram stain, there were no polymorphonuclear cells and no organisms seen. The exact classification of our patient’s pathology remains unknown, as the patient presented with signs and symptoms of both infectious keratitis and CLARE.

Discussion

There has been much discussion in the literature regarding our ability to differentiate and classify contact lens-related corneal infiltrative events. Sweeney et al classified such events into four categories: microbial keratitis, CLARE, contact lens-induced peripheral ulcer and infiltrative keratitis. There have been many articles following the Sweeney classification that address the difficulty in classifying contact-related corneal infiltrative events and question the utility of doing so. Efron and Morgan found that only 20% of contact-related infiltration fell cleanly into one of the four categories, whereas 56% could be classified as one of two conditions and 13% could be classified as one of three. This case illustrates how difficult it is to classify contact-related corneal infiltration.

The Sweeney classification characterizes the appearance of microbial keratitis as a defect of the epithelium, Bowman’s layer and stroma with an associated large, irregular infiltrate in the central or paracentral region. Symptoms include severe hyperemia, moderate to severe pain, decreased vision, purulent or mucopurulent discharge, tearing, photophobia and lid puffiness.

CLARE was defined as an acute inflammatory reaction of the cornea, the conjunctiva and occasionally the anterior chamber immediately after eye closure. Although this entity most commonly occurs during overnight contact wear, it can occur upon brief eye closure at any time of the day. The usual presentation is quite similar to that of infectious keratitis and includes unilateral acute corneal inflammation with mild to moderate blepharospasm, severe conjunctival and limbal hyperemia, corneal edema, corneal infiltration (usually multifocal and greatest in the periphery), ocular pain and severe photosensitivity. Often, the patient is unable to remove the contact. Examination reveals minimal to no movement of the lens and may show debris trapped underneath the contact lens. Infiltration of white blood cells in the corneal stroma is not associated with an overlying epithelial defect. Epithelial staining, if present, is minimal and typically coincides with the pattern of debris found under the lens.

CLARE has been reported with daily soft lens overwear, rigid gas permeable lenses and silicone lenses. However, it is most commonly associated with extended-wear hydrogel lenses. Although originally it was believed that CLARE was due to chronic hypoxia secondary to tight-fitting lenses, there is strong evidence to suggest that the origin of CLARE is inflammatory mediators such as endotoxins released from gram-negative bacteria on the lenses, in the solution or on the case. Patients with CLARE symptoms have high levels of gram-negative lens contamination when compared to asymptomatic controls. Additionally, CLARE has been reported in patients with loose-fitting lenses.

Our patient presented with signs and symptoms of both infectious keratitis and CLARE. He had a rapid onset of pain, blurry vision and hyperemia suggestive of infectious keratitis. Additionally, there was central haze. This area, however, was not associated with a defect in epithelium, Bowman’s layer or stroma, and the cultures did not yield any microbial growth. Consistent with CLARE, our patient had a significant inflammatory reaction including 4+ anterior chamber cell, hypopyon and marked corneal edema that responded almost immediately to removal of the contact lens and aggressive antimicrobial therapy. On the other hand, our patient’s symptoms occurred during the day. Almost all CLARE cases begin with pain at night or upon awakening in the morning.

The management of CLARE includes immediate cessation of contact lens wear and a cycloplegic agent if anterior chamber inflammation is present. Some recommend broad antibiotic coverage given the similarity in presentation between CLARE and infectious keratitis. Our patient was treated with a broad-spectrum antibiotic drop to combat possible microbial infection and was given a cycloplegic agent for comfort. His symptoms improved drastically over the first 2 days, which allowed for tapering of the antibiotic and discontinuation of the cycloplegic agent. Four days after initial presentation, our patient had a visual acuity of 20/20 in the affected eye with no pain and no corneal edema or anterior chamber inflammation.

This case demonstrated how difficult it is to classify contact-related corneal infiltrative events and emphasizes the need for careful follow-up. Our patient had signs and symptoms of both microbial keratitis and CLARE. With removal of the contact lens, aggressive antimicrobial therapy, a cycloplegic agent and close follow-up, our patient recovered quickly and completely.

For more information:

Lindsay Smithen, MD, and Michael Goldstein, MD, can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com.

Edited by Shazia Ahmed, MD, and My Hanh T. Nguyen, MD. Drs. Ahmed and Nguyen can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com. Drs. Ahmed and Nguyen have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.

References:

Bernal MD, Acharya NR, et al. Outbreak of Fusarium keratitis in soft contact lens wearers in San Francisco. Arch Ophthalmol. 2006;124:1051-1053.

Efron N, Morgan PB. Can subtypes of contact lens-associated corneal infiltrative events be clinically differentiated? Cornea. 2006;25(6):540-544.

Stapleton F, Ramachandran L, Sweeney DF, Rao F. Altered conjunctival response after contact lens-related corneal inflammation. Cornea. 2003;22(5):443-447.

Sweeney DF, Jalbert I, et al. Clinical characterization of corneal infiltrative events observed with soft contact lens wear. Cornea. 2003; 22(5):435-442. Comment in Cornea. 2004;23:421-423.