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CLAE 864 No. of Pages 3
Contact Lens and Anterior Eye xxx (2015) xxxxxx
Contents lists available at ScienceDirect
Contact Lens and Anterior Eye
journal homepage: www.elsevier.com/locate/clae
Correspondence
What happens when one leaves soft contact
lenses in for three weeks? A case of bilateral,
severe pseudomonas keratitis from contact
lenses purchased over the internet
Keywords:
Keratitis
Corneal ulcer
Soft contact lenses
Pseudomonas aeruginosa
Dear Sir,
A 50-year-old male contact lens wearer was referred to the out-
of-hours emergency eye clinic for a three-day history of worsening
bilateral eye redness, pain and rapid loss of visual acuity over the
course of the previous 24 h. He obtained his daily disposable soft
(silicone hydrogel) lenses from the Internet, he was not registered
with a GP and did not attend optometrists for review. His visual
acuities (VA) were perception of light (PL) in the right eye (RE) and
hand movements (HM) in the left eye (LE). He presented with
bilateral, extensive, corneal ulceration with a 5 mm hypopyon in
the right eye and no view of the posterior segment in either eye.
The patient reported to have left his contact lenses (CL) in situ
for over three weeks, having previously worn CL for two weeks at a
time with no problem and wanting to try to extend the interval in
order to save money. He had no signicant past ophthalmic or
systemic medical history.
On examination, he presented with severe bilateral conjuncti-
val hypaeremia, an extensive right epithelial defect (11 mm in
diameter) with right central stromal inltrate (8 mm diameter)
(Fig. 1A and B) and a large left central epithelial defect (5.7 mm
diameter) with left stromal inltrate (4.2 mm diameter) (Fig. 1C
and D). There was a 5 mm hypopyon in the right eye (Fig. 1A) and
the CL were not in situ.
The corneal scrapes and cultures showed growth of Pseudomonas
aeruginosa bilaterally and the patient responded well to hourly
guttae ciprooxacin combined with oral levooxacin, followed by
topical guttae dexamethasone 0.1% drops following healing of the
epithelial defect. By day 28 the VA had only marginally improved to
HM RE, due to signicant right corneal stromal scarring (Fig. 2A).
The vision in the LE had improved to 6/12 with reduction in the
stromal inltrate (Fig. 2B).
Although contact lens related keratitis (CLRK) is not an
uncommon condition, bilateral cases are rare. In a retrospective
study spanning three years of twenty patients with overnight
contact lens wear there was only one bilateral case [1]. Similarly, a
retrospective case series in Saudi Arabia, specically looking at
extended wear CL, reported two bilateral cases of CLRK over two
years out of 11 patients; both cases regained BCVA of 6/6 [2].
http://dx.doi.org/10.1016/j.clae.2016.01.004
1367-0484/ 2016 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: J.J.S.L. Hoffman, L. Pelosini, What happens when one leaves soft contact lenses in for three weeks? A case of
bilateral, severe pseudomonas keratitis from contact lenses purchased over the internet, Contact Lens & Anterior Eye (2016), http://dx.doi.org/
10.1016/j.clae.2016.01.004
P. aeruginosa is an aerobic gram-negative rod found throughout
the environment, particularly in soil and water. It is the
commonest cause of bacterial keratitis in CL wearers, accounting
for approximately 63% of CLRK [3]. It is typically sensitive to
aminoglycosides and uoroquinolones, therefore the recom-
mended rst-line therapy for CLRK consists in hourly uoroquin-
olone drops, such as ciprooxacin or ooxacin, as these are less
toxic to corneal epithelium than gentamicin drops, and more
comfortable to use [4].
Soft CLs offer an ideal breeding ground for microorganisms.
Bacteria are able to form a biolm on the posterior surface of the CL
through adherence to the silicone hydrogel and other molecules
[5]. Additionally, it is being increasingly reported that P. aeruginosa
and other keratitis-implicated organisms are developing resis-
tance to certain antimicrobial components within soft CL care
solutions [6]. It is therefore felt by some authors that daily
disposable soft CL are safer compared to those that are left in
solution overnight [7,8]. However, it must be emphasized that this
is only the case for lenses worn one day only and not for overnight
wear, and certainly not for up to two to three weeks which is what
our patient had been practicing for some time prior to developing
keratitis. Risk of CLRK can be reduced by 6070% by not wearing CL
overnight [9]. Conversely, the risk of CLRK may be increased by up
to 20 times in those patients who sleep in their CL [7,8].
In this case, soft silicone hydrogel lenses had been worn for
3 consecutive weeks highlighting the absolute importance of the
optometrist's role in patient education. There are three main
reasons where optometrists play a valuable role in the safe supply
of contact lenses which cannot be achieved through non-face-to-
face dispensing arrangements. Firstly, the optometrist helps
ensure a correct and acceptable t. In 63% of individuals using
self-selected plano contact lenses the t was unacceptable [10].
Secondly, and arguably most importantly, the optometrist gives
training in the safe use of lenses and correct hygiene use. In a
review by Young et al., all cases of cited microbial keratitis from
unregulated sources lacked simple hygiene measures such as lens
disinfection, and in some cases practices such as washing lenses
in tap water were clearly dangerous [11]. Thirdly, optometrists
are a clear point of contact if patients develop any problems with
their eyes and without this supervision there may be an increased
delay before seeking professional help. By purchasing CL from
unregulated sources, such as the Internet, patients bypass this
advice and potentially expose themselves to the increased risks
associated with improper use, delaying appropriate diagnosis and
developing permanent visual disability.
Unregulated purchase of CL over the Internet only accounts for
about 6% of patients presenting with complications from CL use,
however this may result in patients not being educated about CL
hygiene and the possible complications of extended wear,
potentially increasing the risk of microbial keratitis [11]. There
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Fig. 1. (A) Right eye at presentation. Note hypopyon and extensive stromal inltration. (B) Right eye at presentation demonstrating uorescence of large central epithelial
defect following instillation of G. uorescein 1% under cobalt blue lter. (C) Left eye at presentation. (D) Left eye at presentation demonstrating uorescence of central
epithelial defect following instillation of G. uorescein 1% under cobalt blue lter. (For interpretation of the references to color in this gure legend, the reader is referred to
the web version of this article.)

Fig. 2. (A) Right eye at day 7 following treatment showing reduction of size of corneal stromal inltrate and resolution of hypopyon. (B) Left eye at day 7 following treatment
showing peripheral clearing of cornea and reduction of stromal inltrate.

is a clear argument for increased regulation of sources of supply Conict of interest

such as the Internet to prevent similar cases. The evidence showing
that regulating the supply of plano CL has produced a clear
reduction in the number of cases of MK reported in both the United
States and United Kingdom is supporting this view [11].
This case highlights the severe potential complications of using
contact lenses inappropriately and not adhering to advice offered
by optometrists or ophthalmologists. The role of the optometrist
giving sound, preventative advice in relation to CL should not be
underestimated. Face-to-face consultations offer the advantage of
tailoring the advice to the patient and answering any questions
that they may have. Cases such as this may be prevented by further
regulating the supply of CL, together with education and close
supervision of CL wearers.
The authors declare no conict of interest.
Financial disclosure
No nancial disclosure.
References
[1] C.-H. Hsiao, H.-C. Lin, Y.-F. Chen, D.H.K. Ma, L.-K. Yeh, H.-Y. Tan, et al., Infectious
keratitis related to overnight orthokeratology, Cornea 24 (2005) 783788.
[2] K.F. Tabbara, H.F. El-Sheikh, B. Aabed, Extended wear contact lens related
bacterial keratitis, Br. J. Ophthalmol. 84 (2000) 327328.
[3] E.H. Yildiz, S. Airiani, K.M. Hammersmith, C.J. Rapuano, P.R. Laibson, A.S. Virdi,
et al., Trends in contact lens-related corneal ulcers at a tertiary referral center,

Please cite this article in press as: J.J.S.L. Hoffman, L. Pelosini, What happens when one leaves soft contact lenses in for three weeks? A case of
bilateral, severe pseudomonas keratitis from contact lenses purchased over the internet, Contact Lens & Anterior Eye (2016), http://dx.doi.org/
10.1016/j.clae.2016.01.004
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Cornea 31 (2012) 10971102, doi:http://dx.doi.org/10.1097/
ICO.0b013e318221cee0.
[4] N. Morlet, M. Daniell, Microbial keratitis: whats the preferred initial therapy?
View 2: empirical uoroquinolone therapy is sufcient initial treatment, Br. J.
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[5] D.J. Evans, S.M.J. Fleiszig, Why does the healthy cornea resist Pseudomonas
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[6] L.B. Szczotka-Flynn, Y. Imamura, J. Chandra, C. Yu, P.K. Mukherjee, E. Pearlman,
et al., Increased resistance of contact lens-related bacterial biolms to
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[7] M. Green, A. Apel, F. Stapleton, A longitudinal study of trends in keratitis in
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ICO.0b013e318156cb1f.
[8] M. Green, A. Apel, F. Stapleton, Risk factors and causative organisms in
microbial keratitis, Cornea 27 (2008) 2227, doi:http://dx.doi.org/10.1097/
ICO.0b013e318156caf2.
[9] F. Stapleton, N. Carnt, Contact lens-related microbial keratitis: how have
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(London) 26 (2012) 185193, doi:http://dx.doi.org/10.1038/eye.2011.288.
[10] V.R. Moodley, A study of the suitability of disposable coloured contact lenses
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ICL.0b013e3182a70ef7.
Jeremy J.S.L. Hoffman*
Lucia Pelosini
Department of Ophthalmology, East Surrey Hospital, Canada Avenue,
Redhill, RH1 5RH, United Kingdom
* Corresponding author.
E-mail address: jeremy.hoffman@nhs.net (J. Hoffman).
Received 20 October 2015
Accepted 13 January 2016

Please cite this article in press as: J.J.S.L. Hoffman, L. Pelosini, What happens when one leaves soft contact lenses in for three weeks? A case of
bilateral, severe pseudomonas keratitis from contact lenses purchased over the internet, Contact Lens & Anterior Eye (2016), http://dx.doi.org/
10.1016/j.clae.2016.01.004