Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 174 Emergency (2014); 2 (4): 174-177 BRIEF REPORT Clinical Presentation and Microbial Analyses of Contact Lens Keratitis; an Epidemiologic Study Seyed Ahmad Rasoulinejad1, Mahmoud Sadeghi2, Mohammad Montazeri3*, Hesam Hedayati Goudarzi4, Mahmood Montazeri3, Nadali Akbarian5 1. Department of Ophthalmology, Babol University of Medical Sciences, Babol, Iran 2. Infectious Diseases Research Center, Babol University of Medical Sciences, Babol, Iran 3. Young Researchers Club, Islamic Azad University, Babol branch, Babol, Iran 4. Department of Ophthalmology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran 5. School of Nursing and Midwifery, Babol University of Medical Sciences, Babol, Iran Abstract Introduction: Microbial keratitis is an infective process of the cornea with a potentially and serious visual im- pairments. Contact lenses are a major cause of microbial keratitis in the developed countries especially among young people. Therefore, the purpose of the present study was to evaluate the frequency and microbiological characteristic of CLK in patients referred to the emergency department (ED) of teaching hospitals, Babol, Iran. Methods: This is a cross-sectional study of all patients with contact lens induced corneal ulcers admitted to the teaching hospitals of Babol, Iran, from 2011- 2013. An ophthalmologist examined patients with the slit-lamp and clinical features of them were noted (including pain, redness, foreign body sensation, chemosis, epiphora, blurred vision, discomfort, photophobia, discharge, ocular redness and swelling). All suspected infectious corneal ulcers were scraped for microbial culture and two slides were prepared. Data were analyzed using SPSS software, ver- sion 18.0. Results: A total of 14 patients (17 eyes) were recruited into the study (100% female). The patients’ age ranged from 16-37 years old (mean age 21.58±7.23 years). The most prevalent observed clinical signs were pain and redness. Three samples reported as sterile. The most common isolated causative organism was pseudomonas aeroginosa (78.6%), Staphylococcus aureus 14.3%, and enterobacter 7.1%, respectively. Treatment outcome was excellent in 23.5%, good in 47.1%, and poor in 29.4% of cases. Conclusion: Improper lens wear and care as well as the lack of awareness about the importance of aftercare visits have been identified as potential risk factors for the corneal ulcer among contact lens wearers. Training and increasing the awareness of adequate lens care and disinfection practices, consulting with an ophthalmologist, and frequent replacement of contact lens storage cases would greatly help reducing the risk of microbial keratitis. Key words: Keratitis; contact lenses; ophthalmology, epidemiology, anti-bacterial agents Cite this article as: Rasoulinejad SA, Sadeghi M, Montazeri M, Hedayati Goudarzi H, Montazeri M, Akbarian N. Clinical presenta- tion and microbial analyses of contact lens keratitis; an epidemiologic study. Emergency. 2014;2(4):174-7. Introduction: 1 icrobial keratitis is an infective process of the cornea with a potentially sight-threatening condition and serious visual impairments (1). Untreated or severe keratitis may lead to significant public health problems like perforation of cornea and endophthalmitis (2, 3). Contact lenses are a major cause of microbial keratitis in the developed countries espe- cially among young people with about 12% hospitalized cases requiring corneal transplantation (4, 5). Contact lenses may reduce the epithelial barrier function by interfering with normal epithelial cell proliferation and differentiation. With the growth of soft contact lens *Corresponding Author: Mohammad Montazeri; Young Researchers Club, Islamic Azad University, Babol branch, Babol, Iran. Tel: +981112415102; Email: mm.montazeri@gmail.com Received: July 2014; Accepted: July 2014 wear, the incidence of this problem raised globally (3, 6). There are several differences in the incidence of con- tact lens keratitis (CLK) across the world (7). Pseudo- monas aeruginosa can adhere to the surface of the con- tact lens and colonize during wear and survive in con- tact lens storage cases. These processes maybe lead to corneal ulcers; a severe infection can cause permanent blindness (8). Although corneal ulcer is a rare complica- tion of contact lens wear, increasing in the number of lens wearers and the risk of blindness, provide im- portant reasons to evaluate patients with contact lens induced corneal ulcers (9, 10). The number of contact lens wearers has dramatically increased in Iran, par- ticularly among young adults in recent years. Therefore, the purpose of the present study was to evaluate the frequency and microbiological characteristic of CLK in M mailto:mm.montazeri@gmail.com This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 175 Rasoulinejad et al patients referred to the emergency department (ED) of teaching hospitals, Babol, Iran. Methods: Study design and patients This is a cross-sectional study of all patients with con- tact lens induced corneal ulcers who were referred to the ED of teaching hospitals, Babol, Iran, from 2011 to 2013. Patients were excluded from the study with a previous history of anterior segment surgery, treatment for ocular surface disorders, use of any topical ocular medications, or noninfectious corneal ulcers include autoimmune, neurotropic, toxic, and marginal keratitis. An ophthalmologist examined patients with the slit- lamp and clinical features of them were noted (includ- ing pain, redness, foreign body sensation, chemosis, epiphora, blurred vision, discomfort, photophobia, dis- charge, ocular redness and swelling). All patients wore soft contact lenses, either conventional daily or dispos- able extended wear contact lenses. The use of disinfec- tion solution (hydrogen peroxide formulations) was also asked from patients and registered. Informed con- sent form was received from all participants. Sampling, culture, and susceptibility tests After a detailed ocular examination, all suspected infec- tious corneal ulcers were scraped for microbial culture and susceptibility studies initiated before treatment. After instillation of 0.5% proparacaine hydrochloride, two slides were prepared by an ophthalmologist for the direct microscopic examination using flame-sterilized Kimura spatula or a sterile 21 gauge needle, from the leading edge and the bed of the ulcer. The obtained ma- terials were spread onto labeled slides for Gram and Giemsa stains and also inoculated using cotton swab applicators onto the surfaces of blood agar, chocolate agar, and sabouraud agar plates (for fungal infection assay). If bacterial growth was observed in the media, the culture considered as positive and the resistance to antibiotics determined by the Mueller-Hinton media, too. Results were interpreted according to the guide- lines of the National Committee on Clinical Laboratory Standards (NCCLS) (11). Visual acuity Any reduction in vision was tested using Snellen letter charts and measured in comparison with the unaffected eye. However, when both eyes were affected, the amount of vision loss was calculated using the worse eye and a standard reference of 6/6 Snellen acuity. Sim- ilarly, if there was amblyopia in the unaffected eye, the standard reference of 6/6 was used for analogy. Visual acuity was categorized as no light perception (NLP), counting fingers (CF), hand motion (HM), loss of two or more lines, and no loss of vision. Definitions CLK is defined as a supportive corneal infiltrate and overlying epithelial defect with the recent history of contact lens use, with or without hypopyon. The ulcer size gives an estimate area of the ulcer to calculate the analysis more easily as follow: size of ulcer = length × breadth / mm2. Disease duration was defined based on the number of days that symptoms were experienced. Duration of hospitalization was referred to the length of stay in hospital. Visual outcome When the corneal healing was not associated with visu- al loss, the visual outcome considered as “excellent”, in patients had < 2 lines loss of visual acuity as “good”; and for loss ≥ 2 lines or patients underwent penetrating keratoplasty as “poor”. Statistical analysis Data were analyzed using the SPSS statistical software version 18.0. Quantitative data were expressed as mean ± standard deviation and qualitative ones as frequency and percentage. Results: 14 patients (17 eyes) were recruited into the study who all of them were female. The patients’ age ranged from 16-37 years old (with mean ± standard deviation 21.58±7.23). The mean lag time between the onset of symptoms and the first time patients referred to the ED was 48 hours. The mean treatment duration was 29±7 days in outpatient and 96±21 days in inpatient cases. 64.3% were treated outpatient, 28.6% admitted, and 7.1% needed surgical intervention. Keratitis involved the right eye in seven cases (41.2%) and the left eye in five ones (29.4%). Infection was bilateral in five pa- tients (29.4%), too. All 14 patients were contact lens wearers; there were two cases (14.3%) of therapeutic contact lens and 12 (85.7%) of cosmetic lens users. Overnight lens users were noted in four referees. Four of the 12 (75%) cosmetic contact lens wearers were Table 1: Clinical characteristics of patients with con- tact lens microbial keratitis  Sign and symptom Number (%) Pain and redness 14 (100) Foreign body sensation 11 (78.6) Chemosis 11 (78.6) Epiphora 10 (71.4) Decreased visual acuity 9 (64.2) Hypopyon 5 (35.7) Size of the corneal ulcer <3 mm2 9 (52.9) eyes ≥3 mm2 8 (47.1) eyes Visual acuity Hand motion 4 (28.6) Finger count 4 (28.6) >1/10 Snellen acuity 6 (42.8) Causative organism Pseudomonas aeroginosa 11 (78.6) Staphylococcus aureus 2 (14.3) Enterobacter 1 (7.1) This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 176 Emergency (2014); 2 (4): 174-177 using lenses of another person in time of the infectious event. All cosmetic contact lens wearers chose and wore their lenses without any consultation with ophthalmol- ogists, and 10 (71.4%) subjects applied no disinfection regimen of contact lenses. The most prevalent observed clinical signs were pain and redness that reported in all patients. Table 1 shows the clinical characteristics of patients with CLK. The mean size of ulcer was 3.92±2.11 mm2. There were three samples reported as sterile. The most causative microorganism was pseu- domonas aeroginosa (78.6%). Table 2 indicates the an- tibiogram results that 71.4% of the microorganisms were sensitive to ciprofloxacin, whereas ceftazidime, imipenem, and meropenem considered as the second most effective antibiotics. Treatment outcome was ex- cellent in 23.5%, good in 47.1%, and poor in 29.4% of cases. Discussion: The most prevalent observed clinical signs were pain and redness and the most common causative microor- ganism of CLK was pseudomonas aeroginosa. Treat- ment outcome was excellent in 23.5%, good in 47.1%, and poor in 29.4% of cases. Mela et al. in a retrospec- tive study reported 23 patients with contact lens- related keratitis. All of patients were using soft contact lenses from three days to 20 years (12). In a study by Malaysian National Eye Database Study Group, 202 pa- tients were notified to the contact-lens related microbi- al keratitis registry with a mean age of 26.7 years (71.8% female), during 2007-2008, while all of them wore soft contact lens (13). Evaluation of 56 ulcerative keratitis subjects associated with contact lens wearing showed that contact lens-associated ulcers were seen in 86% of those wearing soft lenses (14). Benhmidoune et al. conducted a descriptive study of 51 patients pre- sented to the ophthalmology hospital in Casablanca with contact lens-related microbial keratitis; the mean age of patients was 22 years, with a sex ratio of 7.5 fe- male to male (15). In the present study all patients con- tacted with lens wearers and there were 2 and 12 cases of therapeutic contact lens and cosmetic lens users, re- spectively. The overnight and extended wear of contact lens is known as a risk factor for microbial keratitis (16). The microorganisms found from the corneal scrapes were not part of the ocular flora and their pres- ence demonstrated that the source of contamination was external (17). It has been shown that some micro- organisms including potentially pathogenic species can survive for hours on contact lenses and have harmful effects on the ocular surface (8). Here, it was found that Pseudomonas is the dominant causative agent in contact lens- related microbial keratitis, accounting for more than 75% of the culture-positive specimens. Pre- vious studies revealed that Pseudomonas aeruginosa is the most common microorganism in contact lens- related microbial keratitis, followed by Gram-positive bacteria, fungi, and Acanthamoeba (12-15, 18, 19). Pseudomonas aeruginosa was the most frequent isolat- ed pathogen in 60% and 79.7% of CLK cases of Mela et al. and Goh et al. study, respectively (12, 13). In Benhmidoune et al. study Corneal bacterial cultures were positive in 47.8% of subjects pathogens found were staphylococcus aureus, pseudomonas aeruginosa, and acanthamœba (15). Pseudomonas was the most common isolate, presented in 13 (23%) of the 56 cases in Galantine et al study (14). Staphylococcus species were the second most common pathogen in 11 (20%) of the 56 cases. Findings of the present study demonstrat- ed on the importance of referral of all contact lens wearers with suspected corneal infection to ophthal- mologists for further treatment. Improper lens wear and care as well as the lack of awareness about the im- portance of aftercare visits have been identified as risk factors for the corneal ulcer among contact lens wear- ers. Training and increasing the awareness of adequate lens care and disinfection practices of users, consulting with an ophthalmologist, and frequent replacement of contact lens storage cases would greatly help reducing the risk of microbial keratitis. Conclusion: Improper lens wear and care as well as the lack of awareness about the importance of aftercare visits have Table 2: Antibiotic sensitivity and resistance pattern of microorganism isolated from corneal ulcers in patients with microbial keratitis  Antibiotic Pseudomonas aeruginosa Staphylococcus aureus Enterobacter Sensitive n (%) Resistant n (%) Sensitive n (%) Resistant n (%) Sensitive n (%) Resistant n (%) Penicillin 0 (0) 11 (100) 0 (0) 2 (100) 0 (0) 1 (100) Ciprofloxacin 9 (81.8) 2 (18.2) 0 (0) 2 (100) 1 (100) 0 (0) Gentamycin 0 (0) 11 (100) 2 (100) 0 (0) 1 (100) 0 (0) Amikacin 5 (45.5) 6 (54.5) 1 (50) 1 (50) 1 (100) 0 (0) Ceftazidime 9 (81.8) 2 (18.2) 0 (0) 2 (100) 1 (100) 0 (0) Cefixime 0 (0) 11 (100) 0 (0) 2 (100) 1 (100) 0 (0) Imipenem 9 (81.8) 2 (18.2) 0 (0) 2 (100) 1 (100) 0 (0) This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 177 Rasoulinejad et al been identified as potential risk factors for the corneal ulcer among contact lens wearers. Training and increas- ing the awareness of adequate lens care and disinfec- tion practices, consulting with an ophthalmologist, and frequent replacement of contact lens storage cases would greatly help reducing the risk of microbial kerati- tis. Acknowledgments: We would like to thank all staffs of ophthalmology de- partments of Babol University of Medical Sciences, Ba- bol, Iran. Conflict of interest: The authors declared no conflict of interests. Funding support: None Authors’ contributions: None References: 1. Fong CF, Tseng CH, Hu FR, Wang IJ, Chen WL, Hou YC. Clinical characteristics of microbial keratitis in a university hospital in Taiwan. Am J Ophthalmol. 2004;137(2):329-36. 2. Lam J, Tan G, Tan DT, Mehta JS. Demographics and behaviour of patients with contact lens-related infectious keratitis in singapore. Ann Acad Med Singapore. 2013;42(10):499-506. 3. Upadhyay MP, Srinivasan M, Whitcher JP. Microbial keratitis in the developing world: does prevention work? Int Ophthalmol Clin. 2007;47(3):17-25. 4. Keay L, Edwards K, Naduvilath T, et al. Microbial keratitis predisposing factors and morbidity. Ophthalmology. 2006;113(1):109-16. 5. Hoddenbach JG, Boekhoorn SS, Wubbels R, Vreugdenhil W, Van Rooij J, Geerards AJ. Clinical presentation and morbidity of contact lens-associated microbial keratitis: a retrospective study. Graefes Arch Clin Exp Ophthalmol. 2014;252(2):299- 306. 6. Mah-Sadorra JH, Yavuz SG, Najjar DM, Laibson PR, Rapuano CJ, Cohen EJ. Trends in contact lens-related corneal ulcers. Cornea. 2005;24(1):51-8. 7. Pacella E, La Torre G, De Giusti M, et al. Results of case- control studies support the association between contact lens use and Acanthamoeba keratitis. Clin Ophthalmol. 2013;7:991-4. 8. Szczotka-Flynn LB, Pearlman E, Ghannoum M. Microbial contamination of contact lenses, lens care solutions, and their accessories: a literature review. Eye Contact Lens. 2010;36(2):116-29. 9. Evans DJ, Fleiszig SM. Microbial keratitis: could contact lens material affect disease pathogenesis? Eye Contact Lens. 2013;39(1):73-8. 10. Haghighi SHO, Begi HRM, Sorkhabi R, Tarzamani MK, Zonouz GK, Mikaeilpour A. Diagnostic Accuracy of Ultrasonography in Detection of Traumatic Lens Dislocation. Emergency. 2014;2(3):[In press]. 11. Kiehlbauch JA, Hannett GE, Salfinger M, Archinal W, Monserrat C, Carlyn C. Use of the National Committee for Clinical Laboratory Standards guidelines for disk diffusion susceptibility testing in New York state laboratories. J Clin Microbiol. 2000;38(9):3341-8. 12. Mela EK, Giannelou IP, Koliopoulos JX, Gartaganis SP. Ulcerative keratitis in contact lens wearers. Eye Contact Lens. 2003;29(4):207-9. 13. Goh PP, Shamala R, Chandamalar S, Tai XY. Contact lens-- related corneal ulcer: a two-year review. Med J Malaysia. 2010;65 Suppl A:120-3. 14. Galentine PG, Cohen EJ, Laibson PR, Adams CP, Michaud R, Arentsen JJ. Corneal ulcers associated with contact lens wear. Arch Ophthalmol. 1984;102(6):891-4. 15. Benhmidoune L, Bensemlali A, Bouazza M, et al. Contact lens related corneal ulcers: clinical, microbiological and therapeutic features. J Fr Ophtalmol. 2013;36(7):594-9. 16. Garg P. Diagnosis of microbial keratitis. Br J Ophthalmol. 2010;94(8):961-2. 17. Bharathi MJ, Ramakrishnan R, Meenakshi R, Kumar CS, Padmavathy S, Mittal S. Ulcerative keratitis associated with contact lens wear. Indian J Ophthalmol. 2007;55(1):64-7. 18. Stapleton F, Keay LJ, Sanfilippo PG, Katiyar S, Edwards KP, Naduvilath T. Relationship between climate, disease severity, and causative organism for contact lens-associated microbial keratitis in Australia. Am J Ophthalmol. 2007;144(5):690-8. 19. Wang AG, Wu CC, Liu JH. Bacterial corneal ulcer: a multivariate study. Ophthalmologica. 1998;212(2):126-32.