Panelists share strategies for treating infections in lens wearers

Round Table Participants
	---Monique Cupryn, OD, is a family practice resident at Northeastern State University College of Optometry in Tahlequah, Okla.		---John A. McCall Jr., OD, is in private practice with his father in Crockett, Texas. He is also a member of the Editorial Board of Primary Care Optometry News.
	---Ian B. Gaddie, OD, FAAO, is in private practice with his father in Louisville, Ky.		---Scot B. Morris, OD, is in a large multispecialty practice in the Kansas City, Mo., metropolitan area.

Michael D. DePaolis, OD, FAAO: Let’s first discuss disseminated infiltrative keratitis. This is the contact lens wearer who presents with an acutely red eye or eyes; it may be either unilateral or bilateral. If it is bilateral, it is most often asymmetric. How do you know whether it is lens related or not?

Ian B. Gaddie, OD, FAAO: The case history is most important. We need to find out if the patient has been engaged in extended wear and how frequently the patient cleans and replaces the lenses. Additionally, determining whether it is bilateral or not provides a lot of insight. It’s often helpful to look for signs of corneal hypoxia and to look at the degree of corneal hypoxia. Determine whether the patient has had other systemic problems, such as an upper respiratory viral infection.

Scot B. Morris, OD: By the time we see these patients in the cornea subspecialty practice, they’ve already been put on antibiotics or combination antibiotic/steroid drops. Once patients have been treated with various topical pharmaceuticals, diagnosis becomes more difficult. History is crucial in determining onset, initial symptoms and location. As Dr. Gaddie commented, we need to then evaluate the levels of inflammation, infection, hypoxia and depth as well as location.

Adenopathy and the diagnosis

Dr. DePaolis: Does adenopathy play a role in making that differential diagnosis?

Monique Cupryn, OD: Yes. If you’re trying to differentiate between epidemic keratoconjunctivitis (EKC) and contact lens-related infiltrates, other systemic signs and symptoms including adenopathy certainly play an important role in your differential. In a patient who has EKC, follicular conjunctivitis would likely be present before he or she shows up in your office, so you could use that as part of your
differential diagnostic testing. Additionally, history of an upper respiratory tract infection or recent contact with someone who’s had a red eye is a good tip-off as well; I like to use history as well as signs and symptoms to differentially diagnose.

Dr. DePaolis: Would you pull these patients out of their lenses for a washout period, or would you be more aggressive in your approach?

John A. McCall Jr., OD: They are going to come out of the lenses. A lot of these are difficult on the differential diagnosis, so I first look around the limbus and see what the pannus and any vessel infiltration may look like. Before we go to the dentist, we tend to floss and make everything look good. These patients may be wearing lenses for 3 or 4 months at a time, but they may wear the best looking pair of lenses when they come to see us.

I like to look around the periphery and find out if there has been some chronic abuse going on. Once you start asking the hard questions, most patients don’t deny how long they have been wearing the lenses. So they’re going to come out of the lenses.

EKC has many different treatments. Ophthalmologists are very free with steroids. My general philosophy is to give patients 7 days to build up antibodies and fight it on their own. Then, if they’re greatly improving, they don’t get a steroid. If, after 7 days, things are getting worse and infiltrates are interfering with vision, then we hit them with a steroid.

Dr. Cupryn: I agree with Dr. McCall. I don’t throw steroids in the mix right away. For the first week, I give them tears and cool compresses. Then, if they are not getting better or are getting worse, I tend to go with the steroids.

Contact lens related only

Dr. DePaolis: Let’s say that this proves not to be adenoviral. If it is purely contact lens-related, how do you manage it?

Dr. Morris: It depends on what the infiltrate looks like and where it is located. The location helps me determine whether it has the potential to be infectious or whether it is truly a sterile inflammatory response.

Dr. DePaolis: Let’s take it one step further. You’ve taken the patient out of the lenses, and you’ve treated the patient either for adenoviral keratoconjunctivitis or for contact lens-related infiltrative keratitis. The patient returns for a follow-up in a few weeks. His or her eyes are white and quiet, the patient is comfortable and he or she would like to return to lens wear. You do a slit lamp exam and everything looks normal, except for some faint remnants of the original infiltrative keratitis. Would you allow this patient to return to the lenses? If so, what mandates will you have in terms of wearing time, hygiene and frequency of replacement?

Dr. Gaddie: It depends on the patient. Different patients have different demands and expectations about their contact lens wear. They often don’t understand the potentially serious nature of what’s happening. In most cases, if they have been on a steroid treatment or an antibiotic/steroid combination, I let them go back to their lens wear with a few mandates.

If they’ve been using their lenses from waking moment to bedtime, I ask that they reduce their contact lens wear by at least 50%. Also, if they are not already in frequent replacement lenses, I put them in a frequent replacement lens.

Dr. DePaolis: Does anyone have a different approach?

Dr. Morris: If infiltrates are still present, I keep patients on steroids and out of contacts until the infiltrate is resolved. Many studies have shown that when a secondary inflammation arises, it is much more severe and much more difficult to deal with than the first one.

Infectious vs. sterile

Dr. DePaolis: Let’s talk about unifocal infiltrative keratitis. How do you make the distinction between an infectious corneal ulcer and a sterile microbiologic staphylococcal infiltrate?

Dr. Morris: If you put a patient on an antibiotic and it doesn’t go away, it is probably not infectious. Many things factor into that. If patients are contact lens wearers, their risk of infection goes up significantly, and we’re much more careful with those patients. When I see a superior marginal infiltrate, I am much more likely to feel that it is a sterile inflammatory ulcer.

The first time I see them, I will put them on a good broad-spectrum, bacteriocidal antibiotic drop.

Dr. DePaolis: What else is important in determining whether it is sterile or infectious?

Dr. Cupryn: Clinical presentation of the patient plays a role. If you look at their lid margins and you see it’s 2 to 3+ blepharitis, that would certainly be a good clue that it could be a marginal ulcer, a hypersensitivity type of reaction. If they’ve worn extended-wear lenses, that’s a clue to the opposite.

Patient symptoms

Dr. DePaolis: When we think of infection, our suspicion increases as it relates to the presence of a contact lens. Do patient symptoms play a role?

Dr. Gaddie: They play a huge role. Patient symptoms and the size of the actual infiltrate are very important. If the patient has a red eye and feels like there is something in the eye, then it’s probably infiltrative in nature. If the patient is in severe pain and is basically unable to open the eye, you can usually bet it’s infectious.

Dr. DePaolis: Is there anything else that makes you think infectious?

Dr. McCall: First is pain. I put a lot of emphasis on what the patient feels like when he or she comes in. Infectious corneal ulcers hurt. Certainly, the feathered edges, the edema and the stromal edema that may surround the ulcer will give you many clues as to what’s going on. If it’s marginal and close to the edge and you’ve got some vessel infiltration coming along, then it has probably been going on quite a while, and it is probably a sterile type of environment.

Anterior chamber reaction

Dr. DePaolis: Can you comment on the depth of the lesion and the anterior chamber reaction?

Dr. McCall: If I see anterior chamber reaction, I’m looking hard for an infection.

Dr. Morris: Polymorphonuclear leukocytes (PMNs) and the corneal appearance are big factors. Inflammation takes a little bit of time to develop, and you usually see a fairly large, yet somewhat subtle, area of focal edema around a sterile inflammatory ulcer. With infectious ulcers it takes a little bit of time for the PMNs to migrate to the central part of the cornea and you are more likely to see an anterior chamber reaction.

Most sterile ulcers do not start in the epithelium and work their way down. They start in the anterior stroma and work their way out. You’re not likely to see true staining defects with a sterile ulcer but may see “negative” staining patterns or increased tear instability in the area of involvement.

Now, with a true, active corneal ulcer that’s penetrating through the epithelium, you’re much more likely to see a staining defect in the excavation of the epithelium and Bowman’s. Often, with sterile ulcers, the epithelium and Bowman’s membrane will look relatively normal.

Criteria for culturing

Dr. DePaolis: Let’s talk about cultures. At some point, you get that infiltrate that falls in between. You get conflicting responses from patients’ symptoms, and you get conflicting responses from clinical presentation. What are the criteria for culturing?

Dr. Cupryn: Central visual axis location definitely mandates culturing. I would definitely also culture a nonresponsive ulcer or conjunctivitis.

Dr. Morris: Again, these patients have usually been on antibiotics for about a week by the time they get to us, and culture is probably not going to tell us a whole lot, because they’ve killed just about everything.

Even in a corneal subspecialty clinic, culturing is very difficult. You must have fresh culture media, you hope the lab picks it up and you must pray that it’s not a Friday when this patient comes in because the culture may not be tested until Sunday or Monday.

It is not initially going to change the way we treat, because it will take 24 to 48 hours to identify what it is. Unless you have Gram’s stains in your office and can grow media in your office, you’re still going to treat with one of the fluoroquinolones or a fortified antibiotic. A culture would be nice, but, unfortunately, you can’t always rely on a culture.

Dr. DePaolis: So it’s time to consider a culture when it’s located in the central axis or when the patient has been started on a primary mode of treatment and hasn’t responded. Is there anything else in the clinical presentation that would make you consider a culture?

Dr. McCall: The best shot of getting a culture is before any antibiotic has touched the eye, so the most important time to make that call is before you’ve initiated treatment.

Dr. Cupryn: Often, when we culture, a 50% yield is pretty good. You’re not always going to get a positive culture even if something is there. So, Gram’s staining becomes very useful because you get to know right away what type of organism you’re dealing with.

Dr. Gaddie: Proper culture technique is a pinnacle issue. A patient with a hot, painful eye will have a lot of blepharospasm. If you don’t control the lids, you will coat your whole specimen with lid bacteria, and the chance of getting a fruitful yield from the culture is very low. However, medicolegally, just attempting to get a culture is better than doing nothing.

Treating a sterile response

Dr. DePaolis: If you’ve deemed it to be a sterile microbiologic response, how will you treat it?

Dr. Gaddie: If I’m pretty sure that it is a sterile infiltrative process, I like to use a combination of steroid and antibiotic treatment. My treatment of choice is TobraDex (tobramycin dexamethasone, Alcon), just because I’m comfortable with it. For the vast majority of cases, tobramycin gives the proper coverage that we need on an antibiotic basis, and the dexamethasone is a powerful steroid that produces results. I’ve always been in favor of using the strong steroids, especially when I’m confident that the ulcer is not infectious.

Dr. DePaolis: Will someone comment on ciliary spasm and cyclopleging?

Dr. Morris: Absolutely. If the condition is inflammatory, patients are getting cyclopleged, especially if there is even a trace amount of anterior cell reaction. It’s going to reduce their pain, reduce the ciliary spasm and reduce the anterior chamber reaction long term. The goal is to treat the lesion and provide comfort to the patient. If you do not cycloplege they are likely to have continued pain for an additional 2 to 3 days. I typically start with Pred Forte (prednisolone acetate, Allergan) as my steroid of choice.

Dr. DePaolis: As a matter of practicality, assuming that you’ll be seeing this patient back in 24 to 48 hours, do you ever just cycloplege with 5% homatropine or 1% atropine in the office to see how quickly the eye quiets down or do you immediately prescribe TobraDex and homatropine?

Dr. Morris: It depends on the situation and the patient.

Dr. Cupryn: Some of my colleagues actually recommend against sending homatropine or any type of cycloplegic home with patients, but I feel comfortable sending them home with 5% homatropine or dropping them with cycloplegic in-office. Pain control and quieting the anterior chamber are essential.

Dr. DePaolis: Do you ever patch?

Dr. McCall: Never.

Treating an infectious ulcer

Dr. DePaolis: What will you prescribe for a patient with an infectious ulcer?

Dr. Cupryn: If the patient is a contact lens wearer, I will take him or her out of the lenses and use fortified antibiotics. Infectious ulcers have a 98% cure rate if you use fortified antibiotics. I would also cycloplege the patient and give him or her oral analgesics. Once the ulcer is smaller, maybe less than 1 mm or so, I would think about using a steroid.

Dr. Morris: In private practice, fortified antibiotics are a little bit harder to come by. You must send patients to the hospital, and their insurance doesn’t always cover the medications. The systemic analgesics are a great idea, whether they are over-the-counter or prescription. I usually treat with Ciloxan (ciprofloxacin, Alcon). If I’m really unsure and I think this might be a Pseudomonas case, I might put the patient on an aminoglycoside as well.

Another thing that we have started doing in our practice, especially if it’s a sight-threatening central axis problem, is to prescribe ascorbic acid for the first 7 days. Ascorbic acid slows down collagenase, prevents breakdown and prevents some of the scarring process.

The disadvantage is that it burns. We’ll have patients use it as often as 4 to 6 times a day. It comes in a solution that’s difficult to find — you will need to find a major medical center in the area or a pharmacy that is good at making up this drop. In rural areas, it may not be easy to find, but most pharmacists, if given direction, can make it.

Dr. DePaolis: What should readers expect when treating a corneal ulcer?

Dr. Gaddie: When treating central infectious corneal ulcers, the patient probably won’t notice a lot of improvement as far as comfort during the first 24 hours. However, they should get some relief in 48 to 72 hours, especially following re-epithelialization of the corneal defect associated with the ulcer. It really depends on the organism and the mechanism by which they got the corneal ulcer.

When to refer

Dr. DePaolis: If a treatment is not working, at what point do you switch to another treatment option? At what point do you refer?

Dr. Cupryn: Patient comfort is an extremely important indicator of response to therapy.

Dr. McCall: My philosophy is to never be the last doctor to see the eye before it goes blind. When you see something going south, it’s time to refer.

Dr. Morris: If you’re not comfortable, you need to get it out of your office. Do the right, safe thing. Even in a cornea specialty clinic, there are times when we’ll refer patients from cornea specialist to cornea specialist, because someone else may have seen a similar problem before. Saving the person’s vision is the ultimate goal.

Dr. Gaddie: I go back to the history of the patient. If the patient was running and got hit with a tree branch or if he or she went scuba diving in a hot tub with contact lenses on, it will probably be a raging infection, so I’ll usually refer.

If I need to culture and I’m in an office where I don’t have that ability, I send it out immediately. If the ulcer is very deep and it’s getting down into the stromal level, that patient is going out.

Dr. Cupryn: As a general guideline, if it’s not responding or showing some type of improvement in 2 or 3 days, a consult is warranted.

Patient noncompliance

Dr. DePaolis: Noncompliance often sets patients up for infection. What aspects of noncompliance put the patient at greatest risk of infection?

Dr. Cupryn: Of course, there is a correlation between wearing schedule and risk of a microbial keratitis. For example, extended wear patients are 5 to 15 times more likely to get a microbial keratitis than daily wear patients. So, proper wearing schedule plays a really important part in avoiding infection.

Dr. Gaddie: Also important is replacement of the lenses. It also depends on the individual patient and his or her cornea. Some patients are just not able to tolerate wearing contact lenses.

Extended wear of the future

Dr. DePaolis: As we embark upon a new generation in materials and have better clinician education, do you think extended wear in the future will be a safer option than it was in 1982?

Dr. Gaddie: No matter what, there are patients who have a low threshold for anoxia, and those patients are going to develop problems, whether you have the super Dk materials or not. However, these patients are in a lot better hands than they were in 1982.

Dr. Morris: Even with the higher Dk values, we still have the same issues. The sensory adaptation from the contacts affects tear production, and we still have tear film interchange. Osmolarity is still a problem.

Dr. McCall: Patients are still going to abuse the system. I’m not a fan of 30-day contact lenses. My comfort level is a week maximum, and I don’t see that changing.

Dr. Cupryn: I wouldn’t feel comfortable prescribing a 30-day lens at this point, either, but I think hyper Dk lens materials are a step in the right direction and their success remains to be seen. n

For Your Information:

• Michael D. DePaolis, OD, FAAO, can be reached at 169 Rue de Ville, Rochester, NY 14618; (716) 271-2990; fax: (716) 271-6321; e-mail: mgadep@aol.com.
• Ian B. Gaddie, OD, FAAO, can be reached 7635 Shelbyville Rd., Louisville, KY 40222; (502) 423-8500; fax: (502) 339-0571; e-mail: IBgaddie@bellsouth.net.
• Scot B. Morris, OD, can be reached at Discover Vision Centers, 11707 Roe Ave., Leawood, KS 66211; (913) 327-3937; fax: (913) 327-5807; e-mail: smorris@discovervision.com.
• Monique Cupryn, OD, can be contacted at 1390 Heritage Lane, #122, Tahlequah, OK 74464; (918) 453-9124; e-mail: mcupryn@hotmail.com.
• John A. McCall Jr., OD, can be reached at 711 E. Goliad, Crockett, TX 75835; (409) 544-3763; fax: (409) 544-7894; e-mail: AmOptBDJAM@aol.com. None of the panelists has a direct financial interest in the products mentioned in this article, nor is any a paid consultant for any companies mentioned.