Gram negative bacteria and contact lens induced acute red eye

Padmaja R Sankaridurg; Nagesh Vuppala; Athmanathan Sreedharan; Jyothi Vadlamudi; Gullapalli N Roa

ORIGINAL ARTICLE

Year : 1996 | Volume : 44 | Issue : 1 | Page : 29-32

Gram negative bacteria and contact lens induced acute red eye

Padmaja R Sankaridurg, Nagesh Vuppala, Athmanathan Sreedharan, Jyothi Vadlamudi, Gullapalli N Roa
Bausch & Lomb Contact Lens Centre & D.N. Zhaveri Microbiology Centre, L.V.Prasad Eye Institute, Road No. 2, Banjara Hills, Hyderabad 500 034, India

Correspondence Address:
Padmaja R Sankaridurg
Bausch & Lomb Contact Lens Centre & D.N. Zhaveri Microbiology Centre, L.V.Prasad Eye Institute, Road No. 2, Banjara Hills, Hyderabad 500 034
India

Source of Support: None, Conflict of Interest: None

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PMID: 8828303

Abstract

Two patients using hydrogel contact lenses on a daily wear schedule slept overnight with the lenses and woke up with a Contact Lens Induced Acute Red Eye (CLARE). The contact lenses recovered aseptically at the time of the event grew significant colonies of Pseudomonas aeruginosa and Aeromonas hydrophila in patient A and Pseudomonas aeruginosa and Serratia liquefaciens from patient B. Similar organisams from the contact lenses were recovered from the lens case and lens care solutions of patient B. In both the patients the condition resolved on discontinuation of lens wear. Patient compliance as a requirement for successful contact lens wear is highlighted with the illustration of these cases.

Keywords: Contact Lens Induced Acute Red Eye - Hydrogel lenses - Gram Negative bacteria

How to cite this article:
Sankaridurg PR, Vuppala N, Sreedharan A, Vadlamudi J, Roa GN. Gram negative bacteria and contact lens induced acute red eye. Indian J Ophthalmol 1996;44:29-32

How to cite this URL:
Sankaridurg PR, Vuppala N, Sreedharan A, Vadlamudi J, Roa GN. Gram negative bacteria and contact lens induced acute red eye. Indian J Ophthalmol [serial online] 1996 [cited 2023 Sep 21];44:29-32. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1996/44/1/29/24602

Contact lenses offer an unique and viable mode of visual correction and are also of therapeutic value in a range of ocular disorders. However, several reports in the literature have clearly shown that contact lens wear is not totally compatible with ocular physiology and is associated with various complications.[1],[2] Evidence also suggests that an increased number of these complications are seen with hydrogel lenses used on an extended wear schedule. Some of these conditions include inflammatory responses such as Contact Lens Induced Acute Red Eye (CLARE), and Culture Negative peripheral Ulcers (CNPU) and sight threatening responses such as infectious keratitis.[3][4][5]

While the aetiology of a CLARE response is not clearly understood, it is seen that the condition is distinct and typically presents with the patient waking in the early hours with discomfort and pain in the involved eye.[6] Other symptoms include an intolerance to lens wear associated with redness, lid swelling and mild to moderate amount of photophobia. Clinical signs include severe bulbar and limbal injection and the presence of diffuse subepithelial to anterior stromal infiltration in the periphery of the cornea. Most often the presentation is unilateral and epithelial involvement is usually minimal.

Zantos and Holden in 1978 proposed that a CLARE response may be a result of toxins released due to breakdown of contaminants and debris beneath a tight lens.[3] However,it was seen that even a flat fitting lens could result in a response.[5] Recent studies reported that patients experiencing CLARE may form a group of contact lens wearers who repeatedly show high levels of gram negative bacterial contamination of their contact lenses.[7] The release of endotoxin from the breakdown of the cell wall of these bacteria was considered to trigger off the inflammatory response.

More recently, we found that 3 out of 5 patients who presented with CLARE had significant contamination of their contact lenses with Hemophilus influenzae at the time of event. All the patients were using disposable hydrogel lenses on a 6N extended wear schedule.[8]

We report 2 cases of bilateral presentation of CLARE that occurred during the course of daily wear with hydrogel lenses. Both the patients were noncompliant with lens wear and reported to have slept in their lenses prior to presentation.

Material and methods

Case 1

A 26 year old male presented to the contact lens service in October 1994, complaining of redness in both eyes since 20 days. The patient had been using soft contact lenses on a daily wear schedule for 2 years and reported that he slept in his lenses overnight 20 days ago and woke up with a severe red eye and burning sensation in both his eyes. The patient reported that he was traveling at the time of event. The lens age at presentation was 2 years and the parameters of the lenses except for power (RE:-8.00 LE:-7.50Dsph) were not known. He also complained that while the symptoms have decreased in intensity, they were not eliminated. The patient was using a chemical disinfection procedure with 2 separate solutions; one for cleaning and another for rinsing and soaking(Classic Laboratories, India).

Visual acuity with contact lenses was 6/9, N6 in both the eyes. On examination with a slit lamp biomicroscope, both the contact lenses had large number of brownish yellow deposits and in addition, the right lens had large yellow deposits on the lens [Figure - 1]. While the lids appeared to be normal both the limbal conjunctivae were severely injected. The contact lenses were removed using aseptic precautions, placed in vials containing sterile phosphate buffered saline of 2ml and sent for microbial analysis. In addition, lower lid and conjunctival (upper palpebral, lower conjunctival) swabs were also taken using sterile calcium alginate swabs (Spectrum Laboratories Inc, USA). Examination of the cornea revealed diffuse subepithelial infiltration of the peripheral cornea in the superior quadrant of both the eyes. The infiltration extended approximately 0.5mm from the limbus and there was no lucid interval between the infiltrates and the cornea. The epithelium appeared to be normal and there was no staining with 1% sodium fluorescein. Standard microbiological procedures were used to analyse the contact lenses and the lid and conjunctival swabs. At the end of 48 hours of incubation, the contact lens from the right eye showed significant growth of Pseudomonas aeruginosa and Aeromonas hydrophila and the contact lens from the left eye grew significant colonies of Aeromonas hydrophila. While the palpebral conjunctival swabs of both eyes grew significant colonies of Staphylococcus epidermidis there was no growth from the swabs from other regions.

The patient was discontinued from lens wear and monitored. Three days later the infiltration was found to have subsided completely and the ocular status was within normal limits. At this visit the patient was refit with new lenses and introduced to a single, one bottle,multipurpose lens care system and instructed to adhere to a strict lens care routine and wearing schedule.

Case 2

A 30 year old male, high myope, presented to the contact lens service complaining of severe redness, pain, watering and photophobia in both eyes of one day duration. The patient's history was suggestive of PMMA lens wear for 3 years followed by daily wear of hydrogel lenses for 2 years. The lens care regimen consisted of separate solutions for cleaning and soaking (Sparkles, Ascon Deccan, India). The soaking solution combined as a rinsing agent. The parameters of the contact lenses were not known except for the power (BE -15.OODsph). The patient was non compliant with daily wear with reported history of overnight lens wear at a frequency of atleast five times a month. The patient reported that two nights before his presentation to the clinic he slept overnight in his lenses and woke up with minor discomfort. The lenses were cleaned, rinsed and reworn. However, the patient reported that symptoms gradually worsened during the day and that he continued to wear his lenses as he was away from home and did not have his spectacles. The lenses were removed at the end of the day cleaned, rinsed and soaked overnight and worn the next day. As the symptoms worsened during the course of the day, the patient presented to the clinic.

Visual acuity with contact lenses at the time of presentation was 6/36 in the right eye and 6/24 in the left eye. Both the eyelids appeared to be oedematous. Examination on a slitlamp biomicroscope showed the contact lens fit assessment to be within normal limits and there were no significant front or back surface deposits. Both the bulbar and the limbal conjunctiva was severely injected. The contact lenses were then removed using aseptic precautions and sent for microbial analysis.

Examination of the cornea revealed diffuse and tiny focal areas of subepithelial to anterior stromal infiltration of the peripheral cornea in both the eyes. The infiltration was present in 360° in the right eye and only in the inferonasal quadrant of the left eye [Figure - 2]. The infiltration extended approximately 1.5mm from the limbus in both the eyes and there was no lucid interval between the infiltrates and the cornea. On instillation of 1% sodium fluorescein, trace superficial punctate keratitis was noted in the left eye. On basis of the above findings, a diagnosis of CLARE was made in both the eyes and the patient was advised to discontinue the lens wear and to review after 2 days. The patient was also requested to submit his lens case and lens care solutions for analysis. At the follow up visit, the symptoms had decreased considerably. On examination, the limbal injection had decreased; the density of corneal infiltrates had decreased in intensity, though not eleminated. The patient's lens case and lens care solutions (cleaning and soaking agent) were submitted for microbial analysis. However, there was no information available on the age of the lens care solutions.

All the samples for microbial analysis (Contact lenses, lenscase solution, cleaning solution and soaking solution) were cultured using standard microbiological procedures. At the end of 48 hrs of incubation, both the contact lenses, lens case, cleaning and soaking solution grew confluent colonies of Pseudomonas aeruginosa and Serratia liquefaciens.

Discussion

Pseudomonas aeruginosa, Aeromonas hydrophila and Serratia liquefaciens are gram negative, facultative aerobic bacilli and are known pathogens to humans. The ocular pathogenocity of these organisms is well reported in the literature and ranges from conjunctivitis, keratitis to endophthalmitis.[9]

The above isolated organisms are not part of the resident ocular flora and indicate that the source of contamination is external in nature.[10] This is well exemplified in our first case where the external ocular surface grew only S.epidermidis while the contact lenses grew significant colonies of gram negative bacteria. While Pseudomonas is ubiquitious and widely distributed in soil, water, sewage, gut and even medical care products such as infusion fluids and disinfectants,[11]Aeromonas is commonly distributed in soil, water, sewage and gut.[12] Similarly, the natural habitat of Serratia species includes plants, soil, water and gastro intestinal tract of humans.[13] While the source of contamination is not clearly known with the first case, the contaminated lens care products in the second case prove to be the most likely source.

The presence of limbal injection with diffuse infiltration in the peripheral cornea unassociated with any other changes such as an epithelial involvement or a frank focal infiltration supports an inflammatory response than an infective aetiology. It is further strengthened by the observation that the condition resolved without any treatment following the removal of the contact lenses. We had preyiously hypothesised that the contact lenses laden with the gram negative pathogens were responsible for the inflammatory response as seen with the above cases. The gram negative endotoxins released on the lysis of the cell wall coupled with prolonged contact with ocular surface as seen in extended wear may deliver the antigen effectively thereby inciting an inflammatory response.[8] While we had managed the cases without any medical treatment we suggest that whenever the diagnosis is in question usage of medication needs to be considered.

Clearly, both our patients were non compliant to lens wear schedule. While the importance of compliance to lens wear schedule and hygienic lens care procedures can never be stressed enough, reports in the literature show that a majority of the patients are non compliant to some extent despite clear instructions. This holds true not only for contact lens practice but for several other areas which require compliance to the systems.[14]

Taking into consideration these factors, and the fact that the Indian contact lens wearing population, especially the hydrogel lens wearing population is on the rise, it is our observation that the Indian practitioner would be exposed to more of such presentatations in the years to come.

Another critical issue that needs to be addressed in the wake of such adverse responses is the role played by the contact lens care solutions. From our present cases, while we are unable to comment on the contact lens care solutions of patient A, it is very clear that the lens care solutions of patient B were contaminated. While the chances of lens care solutions being contaminated during the course of lens wear are much greater in comparison to new, unopened lens bottles, it has been demonstrated that 57.1% of the new, unopened solutions available in the Indian market had bacterial contamination with organisms such as Pseudomonas sp, Enterobacter and Acinetobacter species.[15]

In summary, the onus lies on the practitioner to ensure that compliance to lens care procedures are rigidly practised and also to initiate the appropriate measures to ensure that the contact lens care products prescribed to the patient are safe and efficacious.

References

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3.	Zantos SG, Holden BA. Ocular changes associated with continous wear of contact lenses. Aust J Optom 61:418,1978.
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15.	Gopinathan U, Sharma S, Boghani S, et al. Sterility and the disinfection potential of Indian contact lens solutions. Ind J Ophthalmol, vol 42:65-70, 1994.