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Fluoroquinolones, contact lens changes for patients with epithelial defects
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Clinical Challenge posed the following question to a panel of experts: Your patient, an otherwise healthy young woman, fell asleep wearing her contact lenses Tuesday night. Her eyes were fine upon waking Wednesday. She fell asleep Wednesday at dinnertime wearing the lenses again and awoke late that night with a red, painful, photophobic eye with discharge. She usually wears the lenses on a daily-wear basis and discards them quarterly. Her exam Thursday morning revealed four perilimbal infiltrates 1 to 2 mm in diameter. Although they do not ulcerate, there is an overlying epithelial defect with positive fluorescein staining. How do you determine if the condition is infectious? How do you treat it? Do you wait for the infiltration process to clear completely before allowing her to return to contact lens wear?
Topical anti-inflammatory, cessation of lens wear
Jeffrey Krohn, OD, FAAO: The patient history described above certainly seems to indicate an edematous/inflammatory response to physiological stress from contact lens wear. Asking the patient about the amount and consistency of the discharge would also provide some insight into a possibly infectious etiology: a thick, repetitive discharge would more likely suggest bacterial involvement, while a clear, watery discharge is more consistent with a noninfectious reaction.
Evaluating the ocular tissues with the biomicroscope, I would concentrate my observation on whether the response of the ocular tissues is “internal” or “external.” I usually think of an infectious process as being external, where the eye looks worse in an anterior direction. An infectious response typically presents with a bulbar conjunctiva that is extremely injected (worse under the eyelids), a palpebral conjunctiva with a proliferation of papillae and corneal lesions with greater epithelial involvement (staining) than the subepithelial infiltrative response underneath.
A true inflammatory response looks more internal, where the response of the eye appears to be coming from within. The bulbar conjunctiva is injected but in a circumcorneal presentation, while the palpebral conjunctiva will be quiet. When infection is not the primary cause, the corneal epithelial defect is typically smaller than the circumferential extent of the infiltrate beneath it. The only exception to this internal/external guide is an anterior chamber reaction – any cells, flare or hypopyon in the anterior chamber must be treated as an infection and would require culturing and aggressive treatment with a fluoroquinolone or fortified antibiotics.
The case described here would seem to be an internal response to contact lens overwear and would be treated adequately with cessation of lens wear. A combination antibiotic/steroid regimen could provide a bit more peace of mind to the anxious practitioner and would be prudent if the signs and symptoms were mixed. All contact lens wear should be suspended until the inflammatory response is completely clear. This typically takes 5 to 7 days. Refitting the patient into a more physiologically appropriate lens is indicated (i.e., shorter replacement cycle, increased Dk/L.)
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Fluoroquinolones, temporary cessation of lens wear
Joseph B. Studebaker, OD, FAAO: The young woman’s history in this case would seem to point toward an underlying, hypoxic etiology for her infiltrative keratitis. Additionally, an important consideration in this case history includes the reported symptoms of ocular pain/photophobia. Certainly these historical factors — especially when encountered in combination with the associated observation of an overlying, staining epithelial defect — would increase the clinical index of suspicion relative to the presence of infectious corneal disease.
Lid eversion as well as careful inspection of the conjunctivae and lids/ocular adnexae for identifying clinical signs of bacterial, viral or allergic disease is mandatory in these cases. Culturing is another testing option to consider in some cases. However – in accordance with currently accepted clinical guidelines – I do not always culture in cases where the keratitis and epitheliopathy is more mild (epithelial breaks or ulcers < 2.0 mm in size), peripherally located and therefore less likely to result in sight-threatening sequelae.
For this particular case, I would prescribe a topical fluoroquinolone such as ciprofloxacin or ofloxacin in solution form every 15 to 30 minutes during the first day and possibly Ciloxan (ciprofloxacin, Alcon) ointment at bedtime in lieu of drops. After 24 hours, I would reassess the epithelial integrity and overall anterior segment status. If visible indications of satisfactory epithelial resolution/reduction in staining are observed after approximately 72 hours, yet the degree of underlying infiltration remains significant at that point, I will sometimes cautiously add a site-specific corticosteroid such as loteprednol to the treatment regimen. This decision depends, in part, upon how quickly the patient desires to return to contact lens wear.
I have these patients discontinue all contact lens wear during the course of their topical treatment and, additionally, over a period of at least 7 days post-corneal resolution depending upon the observed therapeutic response. In selected cases where the overall corneal and symptomatic pictures have improved and the individual is especially impatient and eager to return to contact lens wear, yet asymptomatic infiltrates or peripheral corneal scarring persist, I will sometimes cautiously permit the patient to resume contact lens wear under close clinical supervision. But I’m sure to carefully and candidly discuss the relative risks of a “fast-track” return to lens wear in such cases.
Finally, I would most likely discuss the potential benefits of a shorter contact lens replacement interval (i.e., a monthly lens discard cycle) and probably the option of refitting in a higher water content and/or more oxygen permeable material.
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Fluoroquinolones, cessation and change in lens wear
Joseph P. Shovlin, OD, FAAO: Symptoms of infection include pain, photophobia, decreased acuity and foreign body sensation. Clinical signs of infection are significant lid swelling and reactive ptosis, stromal infiltration, surrounding edema, epithelial defect, anterior chamber reaction, cellular debris in the tear meniscus and hypopyon. In this particular case, even though the signal data may reflect a microbial process (pain, photophobia, discharge, fairly large infiltrates, and some epithelial involvement) and the extent to which the signs and symptoms exist, there are several reasons why this is probably a sterile response.
Although there is no mention of signs of lid disease, anterior chamber involvement or whether the patient feels better after having removed the lens, the clinical impression leans in favor by the laws of parsimony to a sterile response. Our diagnosis is marginal keratitis. The infiltrates are multiple, non-suppurative and are arranged in a perilimbal fashion. However, in light of the fact this is a contact lens wearer who has worn her daily wear lenses overnight and has some signs and symptoms that may suggest infection, I would favor a conservative approach, withholding initial use of topical steroids. Prudent therapy would include the use of a broad-spectrum antibiotic such as a fluoroquinolone every 1 to 2 hours while awake and ointment for bedtime, with a re-evaluation in 24 hours.
With improvement on the next visit, a slow taper is in order. If the inflammation has increased but the epithelium is now intact, the judicious use of a topical steroid would be in order. Should the clinical findings worsen with seemingly appropriate therapy, the treatment plan should be modified significantly, including an attempt at laboratory diagnosis. Remember, rarely can one be faulted for not using a steroid; unfortunately the converse is not true.
The patient can generally return to safe lens wear after the signs of inflammation including redness, epithelial staining and edema, and active infiltration have resolved. An opacity, often gray in appearance, can linger for quite some time and should not remain an impediment to safe lens wear on a daily basis once the other signs of inflammation have subsided. The patient will need to be re-educated on lens protocol and some attempt should be made to minimize any co-existing risk factors such as lid disease. Some changes in lens type, replacement cycle and accouterment may be conducive to safe lens wear and go a long way to minimize the risk of recurrence.
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