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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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Year : 2014  |  Volume : 21  |  Issue : 3  |  Page : 232-235  

Cosmetic soft contact lens associated ulcerative keratitis in Southern Saudi Arabia

Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Web Publication19-Jun-2014

Correspondence Address:
Dr. Almamoun Abdelkader
Department of Ophthalmology, Abha Private Hospital, 1794 Abha, Kingdom of Saudi Arabia

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-9233.134677

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Purpose: To review the microbiologic profile, clinical course, treatment, and outcome of patients with cosmetic contact lens (CL)-associated ulcerative keratitis.
Materials and Methods: Observational noncomparative case series selected from an ongoing prospective series. Forty-six subjects examined at a corneal specialty practice in Abha, southern Saudi Arabia between April 2012 and June 2013, who presented with corneal stromal infiltrate on slit-lamp examination, were included in the study.
Results: All patients were emmetropic, and lenses were worn solely for cosmetic purposes. Nine (19.5%) of 46 CL-wearing patients presented with laboratory-proven infectious keratitis. Pseudomonas was the most common organism (6/9; 66.6%). Staphylococcus species were the second most common, occurring in two (22.2%) of the nine cases. Streptococcus viridans in one case (11%). Laboratory-based medical therapy led to the healing of ulcers in all cases. Thirty-seven (80.4%) patients had sterile infiltrates.
Conclusions: Over-the-counter use of cosmetic lenses is rapidly increasing. The easy availability of these lenses is resulting in severe sight-threatening complications in some young emmetropic individuals. Prompt treatment of microbial keratitis is important to prevent vision loss.

Keywords: Corneal Ulcer, Cosmetic Contact Lens, Keratitis

How to cite this article:
Abdelkader A. Cosmetic soft contact lens associated ulcerative keratitis in Southern Saudi Arabia. Middle East Afr J Ophthalmol 2014;21:232-5

How to cite this URL:
Abdelkader A. Cosmetic soft contact lens associated ulcerative keratitis in Southern Saudi Arabia. Middle East Afr J Ophthalmol [serial online] 2014 [cited 2021 Oct 26];21:232-5. Available from: http://www.meajo.org/text.asp?2014/21/3/232/134677

   Introduction Top

Corneal contact lenses (CLs) are worn for cosmetic, visual, or therapeutic purposes by many patients. Improper use of CL can cause numerous complications. CL-associated microbial keratitis remains a serious condition with sight-threatening complications. Early diagnosis, identification of the responsible organism, and prompt antimicrobial therapy are mandatory for effective treatment.

Several studies have reported an increased risk of infectious keratitis with the use of soft CL. As the CL wearing population has increased, many studies have been performed on the complications associated with soft CL use. [1],[2],[3],[4],[5] The popularity of colored CLs has increased among younger generations in recent years. Abuse of CL wear and failure to follow the specific instruction when using CL could result in sight-threatening complications. The risk factors of CL-related corneal ulcers are: Overnight wear, extended continuous wear, lower socioeconomic status, smoking, dry eye, and poor hygiene. [6] Other known factors predisposing to corneal ulcer formation are the lens material, lens design, lens wearing schedule, lens care patterns, and immunosuppressive state. [7]

A corneal ulcer develops when there is a break in the corneal epithelium. In the normal eye, the surface of the cornea is constantly lubricated by the tear film. The tears play a major role in delivering adequate oxygen to the cornea and maintaining adequate lubrication for the cornea. Studies have shown that continuous overnight use of CL is a major risk factor for corneal ulcer formation. [8] CL wear during sleep results in reduced tear flow and oxygen delivery to the cornea. Hence, hypoxia and hypercapnia of the corneal epithelium occur, resulting in ischemic necrosis. A study found that the relative risk for overnight CL wear (for any lens type) was 5.4 times higher than for non-CL users. [7] Superimposed bacterial infections especially with Pseudomonas aeruginosa can be very severe and can lead to catastrophic blindness if they are not treated promptly. [9]

In this study, I evaluate the clinical characteristics, clinical management, and outcome of CL-induced keratitis (CLIK) associated with cosmetic CL wear.

   Materials and Methods Top

This study adhered to the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board. Written, informed consent was obtained from all patients. The study comprised all consecutive patients presenting with CLIK between April 2012 and June 2013 at a corneal specialty practice in Abha (southern Saudi Arabia). The history included duration of current CL use, initial symptoms, sharing of CLs, and CL hygiene practices. "Extended wear" was defined as a 24-h use at least once per week, less frequent overnight wear was defined as "daily wear". Based on the clinical characteristics, patients were assigned according to the location of the ulcer to one of two categories, namely central keratitis, presenting in a central, approximately 6 mm diameter zone of the cornea, and peripheral keratitis, manifesting within 2 mm of the limbus. The visual acuity of each eye of the patient was measured using the standard Snellen projector chart. One drop of topical anesthesia 0.5% proparacaine hydrochloride (Alcaine, Alcon, USA) was instilled if the patient could not open the eye due to blepharospasm or photophobia. The fluorescein strips were used and the corneal ulcer was examined using a slit lamp biomicroscope. Both CLs and carrying box were sent to the laboratory for culture and sensitivity tests. Proparacaine hydrochloride 0.5% was used to anesthetize the cornea. Corneal scrapings with Gram's stain microscopy and culture with antibiotic sensitivity tests were performed. The culture specimen was obtained from the edge and the bed of the ulcer. The material was inoculated on culture media (blood agar, chocolate agar, and Sabouraud agar); gram staining was carried out and subsequently culture and sensitivity tests were performed. The initial treatment protocol of patients with bacterial keratitis was either (1) topical ciprofloxacin (Ciloxan; Alcon, Inc., Fort Worth, TX, USA) and gentamicin (1.4%) every minute for 5 min and then every 30 min for the 1 st day, to be tapered according to clinical response; or (2) topical Vigamox (moxifloxacin HCl 0.5%, Alcon Inc., Fort Worth, TX, USA) every minute for 5 min and then every 30 min for the 1 st day, to be tapered according to clinical response. Antibiotic therapy was modified as required based on culture and antibiotic susceptibility reports. Final visual outcome at the last follow-up was evaluated.

Statistical analysis was performed using the Student's t-test and a P value less than 0.05 was considered statistically significant. Data were expressed as mean, range, and standard deviation (SD).

   Results Top

Forty-six patients with CLIK due to cosmetic CL wear comprised the study group. All patients were emmetropic, and lenses were worn solely for cosmetic purposes. All lenses were purchased without an eye examination, proper fitting, wear and care instructions, or follow-up. Twenty-four lenses were dispensed without prescription or fitting from an unlicensed optical shop, nine patients had shared lenses with friends/relatives. Six patients admitted to sleeping with the lenses on. None of the patients followed the recommended CL handling and storage techniques. Twenty-two out of 46 patients (47.8%) had central ulcerative keratitis and 24 (52.2%) had peripheral ulcerative keratitis. The average size of the ulcer was 4.3 mm. No eyes developed anterior chamber reaction or hypopyon. The mean age of all patients was 26.76 ± 5.9 years, 44 were female (95.7%) and two males (4.3%). Six (13%) patients used nondisposable soft CLs and 40 (87%) patients used disposable CLs. Thirty-seven (80.4%) of the total number of patients had a daily wearing schedule and nine (19.6%) used their CLs for longer than recommended. Mean wearing time per day was 14.4 ± 4.8 h. The characteristics of CL wearers examined for CLIK are summarized in [Table 1].
Table 1: Characteristics of contact lens wearers examined for contact lens-induced keratitis

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Nine (19.5%) of 46 CL-wearers patients presented with laboratory-proven infectious keratitis. Pseudomonas aeruginosa was the most common organism (6/9; 66.6%). Staphylococcus aureus was the second most common, occurring in two (22.2%) of the nine cases. Streptococcus viridans was isolated in one case (11%). Laboratory-based medical therapy led to the healing of ulcers in all cases. Thirty-seven patients (80.4%) showed sterile infiltrates with no growth. [Table 2] presents the isolated microorganisms that were found in the central and the peripheral CLIK cases.
Table 2: Microbial isolates from corneal scrapings

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All patients in this series were managed on an outpatient basis. Thirty-five (76.1%) patients were treated with topical ciloxan (ciprofloxacin 0.3%) and gentamicin (1.4%) eye drops and nine patients (21.7%) were treated with topical vigamox (moxifloxacin HCl 0.5%). Two (4.34%) patients were treated with moxifloxacin and other fortified drugs (fortified vancomycin (50 mg/ml). All cases responded well to topical therapy and none required surgical intervention.

The mean follow-up period for all patients was 3.19 ± 1.16 months. Visual acuity was tested in all eyes with keratitis at the time of presentation and at the last visit. The predominant symptoms and clinical signs were eye pain, redness, lacrimation, swollen lids, blepharospasm, and a decrease in visual acuity. Sixteen (34.8%) eyes of 46 patients with keratitis had visual acuity of <6/60 at the time of presentation and all patients had best spectacle-corrected visual acuity of >6/12 at the last visit [Table 3].
Table 3: Distribution of patients by visual acuity

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   Discussion Top

The current study illustrates a significant trend that can cause vision loss in southern Saudi Arabia-the unlicensed sale of plano colored hydrogel CLs by vendors other than eye care professionals. Cosmetic CLs are produced using molecular imprinting and are colored using various methods such as dye dispersion, vat-dye tinting, chemical-bond tinting, and dye printing. [10] Colored lenses were first developed for patients with abnormalities including aniridia or corneal opacity. However, healthy people also currently use colored lenses to change the color or the appearance of their eyes. These lenses are easily available and are sold as cosmetic accessories by unauthorized providers without any medical supervision. [11],[12],[13]

Cosmetic lenses, like any other lenses, can induce epithelial erosion, corneal neovascularization, and infectious keratitis. [12],[13] The color pigments used in these lenses can also induce allergic reactions or toxic keratopathy and render roughness to the lens surface, thereby causing trauma to the corneal epithelium. [14]

The most serious and sight-threatening complication associated with CL use is ulcerative keratitis. Disposable CLs were introduced in the expectation that their use would decrease the risks of severe CL-related complications. [15] However, we found that disposable soft CLs seem to be a risk factor for developing CLIK. In the current study, 87% of the patients with keratitis used this type of CL. Pseudomonas aeruginosa has been reported to be the main organism in all studies reporting substantial numbers of CL wearers. [16],[17],[18],[19] However, Staphylococcus and gram negative organisms other than Pseudomonas are also important. [17],[19],[20] This is consistent with that observed in our series where Pseudomonas aeruginosa was the most common cause of microbial keratitis and Staphylococcus was the second most common among laboratory-proven infectious keratitis.

Interestingly enough, 37 (80.4%) of the 46 patients with CLIK were culture-negative. Only four of these patients received topical antimicrobial treatment prior to the time of presentation. These patients had sterile corneal infiltrates. These infiltrates are suggested to be due to immunological or toxic reactions to CL material, CL color pigments, or to the disinfecting systems. [18] In our series, all cases that were culture-negative responded well to antibiotic therapy. It was encouraging to find good visual recovery in the patients treated in the current study. At the end of the study period all ulcers had healed and visual outcome was stable. All patients had best spectacle-corrected visual acuity of >6/12 at the last visit with no residual corneal scarring.

Over-the-counter use of cosmetic lenses is rapidly increasing. The easy availability of these lenses is followed by severe sight-threatening complications in young emmetropic individuals. Early diagnosis and treatment is paramount to prevent permanent visual impairment. All cases of suspected corneal ulcers seen in the primary care clinic should be promptly referred to an ophthalmologist for confirmation and timely treatment to prevent permanent visual loss. In October 2002, the Food and Drug Administration (FDA) issued a warning against the use of noncorrective, decorative lenses without a prescription or professional fitting. The FDA announced that it would aggressively move to prevent the distribution of decorative CLs directly to consumers. The organization further emphasized that it would seize products that are being marketed and distributed without a prescription and without proper fitting by an eye care professional. Many non-eye care retailers contacted by the FDA voluntarily withdrew these products. [21],[22],[23] We do not wish to discourage the use of CL, but would advise the appropriate authorities that adaptation of CLs needs to be supervised by a specialist who can counsel the wearer on the best available options and encourage patient compliance through regular follow-up. The development of symptoms of pain or redness in a patient with previously comfortable lens should cause the clinician to suspect the presence of bacterial keratitis. The patient must be instructed to seek immediate ophthalmic attention to confirm the presence or absence of this serious complication and initiate appropriate therapy. Wearers of CLs that do not correct their vision may erroneously assume that because a decorative lens is not used to correct a refractive error, they do not need a proper lens fitting, evaluation, or follow-up by a licensed eye care professional. Cosmetic lenses should be properly fitted by a qualified professional and ongoing care must be provided. The single best way to avoid eye infections is to follow proper lens care guidelines as prescribed by the eye care professional. Compliance with recommended hygiene procedures for cleaning and disinfecting lenses is fundamental to safe CL users and hence the prevention of infection. Several types of CL solutions may be ineffective in eradicating some resistant organisms. The two most common methods of CL disinfection are the multipurpose solutions in which a single solution is used for disinfecting, cleaning, and storing lenses and hydrogen peroxide-based systems. Hydrogen peroxide is an effective microbial disinfectant, destroying pathogens by oxidation. [24] Hydrogen peroxide is active against many microbes including the resistant cyst form of Acanthamoeba when used at a concentration of 3% with an exposure time of at least 9 h (overnight). [25]

   References Top

1.Connor CG. Microbiological aspects of extended-wear soft contact lenses. Optom Clin 1991;1:79-93.  Back to cited text no. 1
2.Dart JK, Stapleton F, Minassian DC. Contact lenses and other risk factors in microbial keratitis. Lancet 1991;338:650-3.  Back to cited text no. 2
3.Matthews TD, Frazer DG, Minassian DC, Radford CF, Dart JK. Risks of keratitis and patterns of use with disposable contact lenses. Arch Ophthalmol 1992;110:1559-62.  Back to cited text no. 3
4.Poggio EC, Glynn R, Schein OD. The incidence of ulcerative keratitis among users of daily wear and extended wear soft lenses. N Engl J Med 1989;321:779-83.  Back to cited text no. 4
5.Cheng KH, Leung SL, Hockman HW, Beekhuis WH, Mulder PG, Geerards AJ, et al. Incidence of contact lens-associated microbial keratitis and its related morbidity. Lancet 1999;354:181-5.  Back to cited text no. 5
6.Loh KY, Agarwal P. Contact lens related corneal ulcer. Malaysian Fam Physician 2010;5:6-8  Back to cited text no. 6
7.Dart JK, Radford CF, Minassian D, Verma S, Stapleton F. Risk factors for microbial keratitis with contemporary contact lenses: A case-control study. Ophthalmology 2008;115:1647-54.  Back to cited text no. 7
8.Stapleton F, Keay L, Edwards K, Naduvilath T, Dart JK, Brian G, et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology 2008;115:1655-62.  Back to cited text no. 8
9.Donzis PB. Corneal ulcers from contact lenses during travel to remote areas. N Engl J Med 1998;338:1629-30.  Back to cited text no. 9
10.Phillips AJ, Speedwell L, editors. Contact lenses. 5 th ed. London: Butterworth Heinemann; 2007. p. 519-30.  Back to cited text no. 10
11.Lim TH, Lee JR, Choi KY, Chung KH, Cho BJ. Corneal melting and descemetocele resulting from noninfectious keratitis related to the cosmetic contact lenses. J Korean Ophthalmol Soc 2009;50:774-8.  Back to cited text no. 11
12.Steinemann TL, Pinninti U, Szczotka LB, Eiferman RA, Price FW Jr. Ocular complications associated with the use of cosmetic contact lenses from unlicensed vendors. Eye Contact Lens 2003;29:196-200.  Back to cited text no. 12
13.Steinemann TL, Fletcher M, Bonny AE, Harvey RA, Hamlin D, Zloty P, et al. Over-the-counter decorative contact lenses: Cosmetic or Medical Devices? A Case Series. Eye Contact Lens 2005;31:194-200.  Back to cited text no. 13
14.Choi HW, Moon SW, Nam KH, Chung SH. Late-onset interface inflammation associated with wearing cosmetic lenses 18 months after laser in situ keratomileusis. Cornea 2008;27:252-4.  Back to cited text no. 14
15.Nilsson SE. Ten years of disposable contact lenses--A review of benefits and risks. Cont Lens Anterior Eye 1997:20:119-28.  Back to cited text no. 15
16.Musch DC, Sugar A, Meyer RF. Demographic and predisposing factors in corneal ulceration. Arch Ophthalmol 1983;101:1545-8.  Back to cited text no. 16
17.Alfonso E, Mandelbaum S, Fox MJ, Forster RK. Ulcerative keratitis associated with contact lens wear. Am J Ophthalmol 1986;101:429-33.  Back to cited text no. 17
18.Liesgang TJ, Forster RK. Spectrum of microbial keratitis in South Florida. Am J Ophthalmol 1980;90:38-47.  Back to cited text no. 18
19.Ormerod DL, Smith RE. Contact lens-associated microbial keratitis. Arch Ophthalmol 1986;104:79-83.  Back to cited text no. 19
20.Cooper RL, Constable IJ. Infective keratitis in soft contact lens wearers. Br J Ophthalmol 1977;61:250-4.  Back to cited text no. 20
21.FDA warns consumers against using decorative contact lenses obtained without a prescription or professional fitting. Available from: http://www.fda.gov/bbs/topics/news/2002/new00846.html [Last accessed on 2003 May 1].  Back to cited text no. 21
22.FDA public health Web notification: Non-corrective decorative contact lenses dispensed without a prescription. Available from: http://www.fda.gov/cdrh/safety/declensenorx.html [Last accessed on 2003 May 1].  Back to cited text no. 22
23.FDA issues warning on decorative contact lenses. FDA Consumer Magazine Jan-Feb 2003. Available from: http://www.fda.gov/fdac/features/2003/103_eyes.html. [Last accessed on 2003 May 1].  Back to cited text no. 23
24.Jackett PS, Aber VR, Lowrie DB. Virulence and resistance to superoxide, low pH and hydrogen peroxide among strains of Mycobacterium turberculosis. J Gen Microbiol 1978;104:37-45.  Back to cited text no. 24
25.Zanetti S, Fiori PL, Pinna A, Usai S, Carta F, Fadda G. Susceptibility of Acanthamoeba castellanii to contact lens disinfecting solutions. Antimicrob Agents Chemother 1995;39:1596-8.  Back to cited text no. 25


  [Table 1], [Table 2], [Table 3]

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