Middle East Afr J Ophthalmol. 2011 Jul-Sep; 18(3): 228231.

doi: 10.4103/0974-9233.84053
PMCID: PMC3162736
Antibiotic Susceptibility Patterns of Pseudomonas Corneal Ulcers in
Contact Lens Wearers
Mehrdad Mohammadpour, Zahra Mohajernezhadfard, Alireza Khodabande, and Payman Vahedi
1

Author information Copyright and License information
This article has been cited by other articles in PMC.
Abstract
INTRODUCTION
Pseudomonas aeruginosa is the leading cause of contact lens-induced keratitis and corneal
ulcers.
1
P. aeruginosa is a gram-negative bacterium, which typically produces a sweet odor
which makes it possible to distinguish the bacterium from other bacteria in culture. In most
organs, such as lungs, urinary tract, etc, P. aeruginosa is considered an opportunistic
pathogen with a tendency to cause infections in immune-compromised patients. Likewise
immune-compromised environments within the eye, such as cornea, aqueous humor, and
vitreous humor may also be a host. In the eye, extracellular enzymes cause a rapidly
destructive lesion, which may lead to keratitis, corneal ulcer, and endophthalmitis.
Some predisposing factors such as trauma, contact lens wear, ocular diseases, and intensive
care unit hospitalization may play a role in the development of corneal ulcers.
2
Among these
factors, contact lens-associated keratitis and corneal ulcers are of the utmost importance as
they may lead to cellulitis or endophthalmitis causing devastating disability in an otherwise
healthy patient.
It is common practice to choose the empirical antibiotic therapy against P. aeruginosa in
contact lens ulcers until the results of culture are known. We use this approach in our center
however potential for the development of antibiotic-resistant strain of P. aeruginosa remains
a concern. The hospital where our center is based is one of the main referral hospitals in the
country and the Middle East.
The purpose of this cross-sectional study was to determine the efficacy of empirical antibiotic
therapy as the initial treatment for contact lens-induced corneal ulcers and to compare the
results of antibiograms regarding the most effective initial antibiotic regimen.
MATERIALS AND METHODS
This cross-sectional study included all patients with contact lens-induced corneal ulcers who
were admitted to our center from March 2009 to 2010. After the initial screening, 52 subjects
including 9 males and 43 females whose culture results were positive for P. aeruginosa were
recruited into the study. In our center the routine practice for cases with corneal ulcers is to
perform smears for gram stain and then culture the specimens in three different mediums:
blood agar, chocolate agar, and saburode (for fungal infections). When the culture becomes
positive for bacterial keratitis after 72 h, the antibiogram and susceptibility are determined
within the Mueller-Hinton media.
All subjects were soft contact lenses wearers using either disposable extended-wear lenses or
conventional daily soft contact lenses. The disinfection regimen included hydrogen peroxide
or no hygiene regimen.
RESULTS
The mean age of the cohort was 21.5 years old (range: 17-31 years). In 39 subjects (75%), an
empirical antibiotic regimen was recommended including fortified ceftazidime and
vancomycin (every 5 min for the first hour and then hourly) at presentation and immediately
after corneal scrapings for sensitivity testing. Small eccentric (22 mm or less) ulcers (13
patients (25%)) were prescribed ciprofloxacin every hour after corneal scrapings were
performed. The regimen continued for all subjects over 72 h and then tapered once the patient
and the physician noted an effective clinical response. Cases in which there was no change in
the size of the ulcer and no clinical response after 72 h received a new antibiotic regimen
based on the results of the antibiogram. Some patients underwent amniotic membrane
transplantation. Cases prescribed ceftriaxone and carbenicillin were excluded from the study,
due to inadequate sample size for comparison.
Forty-five (86%) subjects were disposable daily lenses wearers, while 7 subjects (14%) wore
conventional daily contact lenses. Twenty (38%) subjects used hydrogen peroxide for
disinfection of contact lenses, whereas 32 (62%) used no disinfection regimen.
Thirty-nine (75%) subjects were hospitalized, while 13 subjects (25%) were followed in an
outpatient clinic. None of the latter group of subjects required hospitalization during the
follow up.
The ulcer size was 2 or less than 2 mm
2
in 13 subjects (25%), 2 to 3 mm
2
in 23 subjects
(44%), and more than 3 mm
2
in 16 subjects (31%).Thirty subjects (58%) had central ulcers,
whereas 22 subjects (42%) had peripheral ulcers. Hypopyon was present in 12 (23%) subjects
at initial presentation. The mean time to diagnose the ulcer after last wear of contact lenses
was 2 days (range, 12 h to 5 days).
A successful clinical response of 81% was observed in the cohort with the prescribed
antibiotic therapy. Amniotic membrane transplantation was required in 10 subjects (19%)
with a mean age was 21 years old and the mean size corneal ulcer of 44 mm. Hypopyon was
present in 58% of subjects who required amniotic membrane transplantation.
The antibiogram results indicated that100% of the cases of P. aeruginosa were sensitive to
ceftazidime and ciprofloxacin, whereas amikacin, imipenem, and gentamicin were the second
most effective antibiotics [Table 1].

Table 1
Antibiogram results for the sensitivity and resistance of Pseudomonas aeruginosa
DISCUSSION
Contact lens wearers are at increased risk for the development of bacterial keratitis and
corneal ulcers.
3,4
P. aeruginosa is the most common cause of contact lens-related ulcers.
5
P.
aeruginosa tends to adhere to the surface of the contact lens and is transferred through
damaged corneal epithelium penetrating deeper layers of the cornea and causing corneal
ulcers. A severe infection can cause permanent blindness.
Previous studies have estimated the incidence of bacterial keratitis from 2/100,000 yearly for
rigid contact lens, 2.2-4.1/100,000 per year for daily wear soft contact lens and 13.3-
20.9/10,000 per year for extended-wear soft contact lenses.
47
The risk with therapeutic
contact lenses is even higher at approximately 52/10,000 yearly.
6
Some authors
6
believe that
the introduction of silicone hydrogel contact lenses (which can be worn up for 30 nights) and
daily disposable contact lenses have changed the incidence of corneal infection and that
newer studies are warranted for accurate estimates of contact lens-induced keratitis and
corneal ulcer.
The major risk factors for microbial keratitis and corneal ulcer are overnight wear, smoking,
male gender, and socioeconomic factors.
4,68
The current study found a greater number of
female subjects than males with corneal ulcers. However a conclusion on the possible role of
gender as a risk factor from the results of the current study is not possible due the small
sample size. Advertising campaigns encouraging the use of colored contact lenses as a
fashion accessory for women may have resulted in greater use of contact lens that may
explain the discrepancy between our study and previous studies.
Preventive methods that decrease the risk of Pseudomonas-induced keratitis are being
actively investigated. To date, the efficacy of these preventive strategies remains unproven.
These methods include alternative disinfecting systems, silver-containing contact lenses,
antimicrobial chitosan, polyquats, cationic peptides, and selenium.
9
Although the current
widespread use of cosmetic contact lenses and the threat of keratitis even under the best
conditions are of great concerns, the introduction of disinfecting systems may help to
decrease the infection rate in the future.
Clinically, treatment failure might be surmised by some predisposing factors such old age,
medium or large ulcers, hypopyon, and poor visual acuity.
10
The current study confirms the
possible role of hypopyon and the large size of the ulcer, both of which were dramatically
higher in the group of patients who underwent amniotic membrane transplants during the
course of their treatment (19% of patients). We cannot comment on the possible role of old
age or visual acuity, as these two factors were not considered in the current study.
Pinna et al,
1
reported that multiple antibiotic resistance was present in all strains of P.
aeruginosa, while the susceptibility rate was 100% to aminoglycosides and fluoroquinolones.
This was also confirmed by Ly et al,
10
who found out that most corneal ulcers were sensitive
to ciprofloxacin and aminoglycosides. In the current study, nearly all cases were resistant to
more than four antibiotics, while sensitivity to ceftazidime and ciprofloxacin was 100%.
Interestingly, resistance to cefazolin and vancomycin was observed in all subjects in the
currently study. Currently no single antibiotic is effective against all bacterial species causing
microbial keratitis. Initial broad-spectrum therapy is recommended until the offending
microorganism is identified in culture. Combination therapy with an antibiotic active against
gram-positive bacteria (e.g., vancomycin, bacitracin, neosporin, cefuroxime, or cefazolin) and
an agent active against gram-negative bacteria (e.g., tobramycin, gentamicin, amikacin,
ceftazidime, ciprofloxacin, levofloxacin, or ofloxacin) provides good initial broad-spectrum
antibiotic coverage. Although vancomycin is an anti-staphylococcal antibiotic to which
resistance is rarely seen, its use should be reserved for the treatment of staphylococcal
infections resistant to all other antibiotics.
Although some authors suggest the fortification of the first generation of cephalosporins with
aminoglycosides as an effective initial treatment in corneal ulcers
9
our study strongly suggest
that cefazolin in not efficacious in these patients. The results of the current study suggest the
concurrent use of ceftazidime and amicacin or ceftazidime and ciprofloxacin as the initial
treatment. An alternate antibiotic regimen should be considered in patients who do not show
clinical response or who develop toxicity from the agent(s) prescribed for initial therapy.
Antimicrobial sensitivity testing facilitates the selection of appropriate agents for this group
of patients. This therapeutic approach is necessary to reduce the development of strains
resistant to nearly all antibiotics.
The following clinical parameters are useful in monitoring the clinical response to antibiotic
therapy: blunting of the perimeter of the stromal infiltrate, decreased density of the stromal
infiltrate, reduction of stromal edema and endothelial inflammatory plaque, reduction in
anterior chamber inflammation, reepithelialization, and cessation of corneal thinning. The
frequency of topical antibiotic administration should slowly be tapered as the stromal
inflammation resolves.
In the current study, almost the entire cohort was resistant to chloramphenicol, trimethoprim,
vancomycin, and cefazolin. Hence, we suggest these antibiotics should not be included in any
empirical antibiotic regimen against P. aeruginosa. Resistance to chloramphenicol has been
previously reorted.
11

Even with optimal contact lens care and hygiene, keratitis seems to be inevitable in patients
who wear contact lenses. The problem might be more common in patients who wear cosmetic
contact lenses in comparison to patients who wear lenses for therapeutic reasons. In the
current study, 45 (86%) of the subjects had corneal ulcers after wearing cosmetic lenses. One
reason for this large discrepancy might be that contact lens dispensers spend less in teaching
cosmetic lens wearers about contact lens hygiene compared to patients who were therapeutic
contact lens wearers. Additionally, follow-up visits are usually absent for cosmetic lens
wearer. Hence, once cosmetic lens wearer is symptomatic, there is an increased tendency to
use topical steroids without the consultation from an ophthalmologist which may finally lead
to a well-established corneal ulcer.
A group of cosmetic colored contact lenses which can be purchased via non-professional
suppliers were the major source of corneal ulcers in the current study. In most countries, a
person who is not a medical practitioner or registered optician should not sell the contact
lenses; however this act does not include the purchase of the cosmetic Plano (or Afocal)
contact lenses, which have no optical power. Recent reports of equal potential complications
in both types of contact lenses (therapeutic or cosmetic)
12
indicates that all types of contact
lenses should be fit only by a registered medical practitioner or registered opticians. We
concur with this position due to the high prevalence of corneal ulcers in this group of patients
in our study. All the patients wearing contact lenses and especially cosmetic lens wearers
should be familiar with simple preventive hygiene such as hand washing prior to handling the
lenses and using disinfection agents.
In conclusion, prompt diagnosis of keratitis and corneal ulcers and treatment with appropriate
antibiotics prevent blindness and devastating visual disability. Patients wearing cosmetic
lenses are at an increased risk due to lower patient education and the absence of follow-up
visits.
Multidrug resistance might be a significant concern in cases of keratitis and corneal ulcer. In
the referral centers dealing with corneal ulcers, the initial antibiotic regimens should be
changed from time to time to prevent this phenomenon. Resistance to antibiotics such as
chloramphenicol, cefazolin, and trimethoprim is very common and these antibiotics should
not be considered for empirical treatment. Our outcomes indicate ceftazidime or
ciprofloxacin in combination with amikacin is the most effective regimen for the initial
treatment of keratitis and corneal ulcers.
Footnotes
Source of Support: Nil,
Conflict of Interest: None declared.
REFERENCES
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in Pseudomonas aeruginosa strains isolated from contact lens-associated corneal
ulcers. Cornea. 2008;27:3206. [PubMed]
2. OBrien TP. Management of bacterial keratitis: Beyond exorcism towards consideration of
organism and host factors. Eye. 2003;17:95774. [PubMed]
3. Willcox MD, Holden BA. Contact lens related corneal infections. Biosci
Rep. 2001;21:44561. [PubMed]
4. Upadahyay Murthy GV. Epidemiologic characteristics, predisposing factors and etiologic
diagnosis of corneal ulceration in Nepal. Am J Ophthalmol. 1991;111:929. [PubMed]
5. Ormerod LD, Hertzmark E. Epidemiology of microbial keratitis in Southern California A
multivarate analysis.Ophthalmology. 1987;94:13223. [PubMed]
6. Liesegang TJ. Contact lens-related microbial keratitis: Part I:
Epidemiology. Cornea. 1997;16:12531.[PubMed]
7. Matthews TD, Frazer DD, Minassian DC. Risks factors of keratitis and patterns of
disposable contact lenses.Arch Ophthalmol. 1992;110:155962. [PubMed]
8. Stapleton F. Contact lens-related microbial keratitis: What can epidemiologic studies tell
us? Eye Contact Lens.2003;9:S859. [PubMed]
9. Willcox MD. New strategies to prevent Pseudomonas keratitis. Eye Contact
Lens. 2007;33:4013. [PubMed]
10. Ly CN, Pham JN, Badenoch PR, Bell SM, Hawkins G, Rafferty DL, McClellan KA.
Bacteria commonly isolated from keratitis specimens retain antibiotic susceptibility to
fluoroquinolones and gentamicin plus cephalothin.Clin Experiment Ophthalmol. 2006;34:44
50. [PubMed]
11. Tan DT, Lee CP, Lim AS. Corneal ulcers in two institutions in Singapore: Analysis of
causative factors,organisms and antibiotic resistance. Ann Acad Med
Singapore. 1995;24:8239. [PubMed]
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 Lenses. 2003;29:196200. [PubMed]




Sultan Qaboos Univ Med J. Nov 2008; 8(3): 283290.
PMCID: PMC3074844
Contact Lens Induced Corneal Ulcer Management in a Tertiary Eye Unit in
Oman - A descriptive study
Rikin Shah,
1
Manali Shah,
1
Rajiv Khandekar,
2,*
and Abdulatif Al-Raisi
1

Author information Article notes Copyright and License information
This article has been cited by other articles in PMC.
Abstract
Advances in Knowledge
CL induced keratitis is not included in the World Health Organisations Vision 2020
initiative to eliminate all causes of avoidable blindness by 2020.
The CL from an eye with keratitis should be sent to the laboratory in order to isolate
the organisms.
Proper and timely management can reduce long term visual disabilities in patients
with corneal ulcer due to CL wear.
Pseudomonas organisms were mainly responsible for corneal ulcer in our patients.
Corneal ulcer due to acanthomoeba was not found in our series.
Application to Patient Care
Materials should be collected from corneal scraping and CLs for culture and
sensitivity tests before starting antibiotic treatment.
Until the report of culture and sensitivity is available, one should assume that keratitis
is due to pseudomonas and antibiotics should be given accordingly.
Proper records of the extent of keratitis and visual acuity are useful to evaluate the
response to treatment.
BACTERIAL KERATITIS, ALTHOUGH RARE, IS potentially the most devastating complication of
contact lens (CL) wear. The occurrence is more common in soft lens wearers and extended
wear of CLs increases the incidence 10 to 15 fold.1 The causes of severe keratitis could be: 1.
low knowledge and skills among CL providers; 2. poor quality of the product and/or 3.
misuse of lenses by the user. Whatever the cause, the sufferer is certainly the cornea and the
patient. Prompt treatment is essential and, even after proper treatment, sequelae may
compromise the quality of vision.
Conflicting reports suggest trends both of rising and declining incidence of CL induced
keratitis.2, 3 The popularity of coloured CLs has increased among younger generations in
recent years. Carelessness and abuse of CL wear could result in catastrophic blindness if
proper steps are not taken; hence, the American Academy of Optometry has stressed the need
to impart knowledge both about the advantages of CL system and about the risks if the care
of CLs is neglected.4
In Oman, CL practice is the domain of private sector opticians and ophthalmologists. The
National Eye Health Care Committee recently introduced a programme approach to minimise
adverse events related to CL wear.5
We did not find any literature on CL related complications in Middle Eastern countries. In
Oman, like other Gulf countries, the climate is not conducive to sustained and healthy tear
film and, at the same time, the use of the CLs is on the increase. Hence, we reviewed the
cases of CL induced severe keratitis that were admitted in the cornea unit of Al Nahdha
Hospital, a tertiary hospital in Oman. The profile, clinical presentation, modalities of
treatment and visual status are here presented.
METHODS
This study was a retrospective descriptive study in which ophthalmological hospital records
were reviewed. It was approved by the ethical and research committee of Al-Nahdha
Hospital. In this series, we included patients that were admitted in the cornea unit of the
hospital between January 2005 and December 2006. Three senior ophthalmologists of the
cornea unit were our investigators.
The computerised case records of these patients were used to generate relevant information.
An agreed protocol is used by ophthalmologists of the cornea unit in all cases of corneal
ulcer. The history included duration of using the present CLs, initial symptoms, treatment
before admission, sharing of CLs and CL hygiene practices. Eyes with acute onset of
keratitis, involving the visual axis or with hypopyon, were considered to suffer from sight
threatening condition and such patients were admitted into the hospital.
The visual acuity of each eye of the patient was noted using Snellens illiterate E chart, held
at a six metre distance from the patient. If the patient could not open the eye due to
blepharospasm or photophobia, one drop of 0.4% oxybuprocaine hydrochloride (minims) was
instilled. If the person could not identify the E in the top line, the test was repeated at a
three metre distance. The projection of light and perception of light rays were tested in all
four quadrants for those who could not be tested for visual acuity even at 3 metre distance.
The fluorescein minims were used and the corneal ulcer was observed using a slit lamp
biomicroscope. The size of the ulcer was measured using a grid. The ulcer was graded as
less than 3 mm, 3 to 5 mm and more than 5 mm in size. The location of the ulcer was
designated central if it covered the pupil, para-central if it partly covered the pupil or
peripheral if the central cornea that covers the pupil was not affected. The presence of
hypopyon was grouped according to its level in the anterior chamber, the categories being:
<1/3, between 1/3 and and more than half of the anterior chamber.
The CLs were sent to the laboratory for culture and sensitivity tests. Minims of
oxybuprocaine hydrochloride 0.4% were used to anaesthetise the cornea. 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, Sabrauds agar, MacConkey agar, brain-heart-
infusion broth); gram and potassium hydroxide staining was carried out and subsequently
culture and sensitivity tests were performed.
The patients with severe keratitis were treated with wide spectrum antibiotics. In the presence
of hypopyon, 1% atropine eye drop was instilled for cycloplegia and oral acetazolamide (250
mg four times a day) was given if the intraocular pressure was raised. The antibiotic was
changed subsequently according to the culture and sensitivity report. When staining was
negative and the ulcer was healed, the person was discharged. Information on the status of
vision and the cornea were noted before sending patients home and during the follow up at
one and six weeks. The eye examination methods were similar on admission and follow up.
The patient was advised not to use CLs for the next 3 to 6 months depending upon size and
severity of the ulcer. Health education was given for the care of CLs. All details were
recorded in computerised case records.
A pre-tested data collection form was used to gather information from the case records.
Personal logbooks of corneal specialists of the unit were also referred to. The data was then
entered into a Microsoft XL spreadsheet. It was converted to the Statistical Package for
Social Studies (SPSS-12) and a univariate parametric type of analysis was carried out to
calculate frequencies and percentage proportions. For statistical validation, we used 95%
confidence intervals (95% CI) of percentage proportions.
All patients with severe keratitis were treated free of cost. Their identities were de-linked
from the results at the time of analysis. The authors presented the outcomes of this study in a
national ophthalmic meeting to increase the awareness and knowledge among the CL
practitioners and ophthalmologists of Oman.
RESULTS
Fifty-two patients had corneal ulcers in their eyes (18 in the right eye, 27 in the left eye and 7
in both eyes). The profile of the patients with keratitis is shown in Table 1. Thirteen (25%)
patients had approached a cornea clinic within 24 hours and 17 (32.7%) patients had used
antibiotics before visiting our institution. Twenty-six (50%) patients had not used antibiotics,
while in nine (17.3%) patients, this information was not available.

Table 1:
Profile of patients with contact lens induced severe keratitis
In our institute during the same period, 177 patients with corneal ulcers were admitted. The
proportion of CL induced corneal ulcer to the total cases of corneal ulcer was 29.4%.
Daily wear is common and extended wear soft lenses and disposable CLs are extensively
used in Oman compared to hard CLs which are rarely used. Therefore, we can safely assume
that all the patients with keratitis in our series wear soft lenses.
The salient features of the corneal ulcers in our series are given in Table 2. One fourth of
patients had peripheral ulcers. Only 35 (67.3%) patients had brought their CLs with them to
be tested for bacterial growth and antibiotic sensitivity. Thirty-seven (71.2%) patients were
treated with fortified gentamycin (14mg/ml) and fortified cefuroxime (50mg/ml) eye drops,
while in twelve (23%) patients ofloxacilline eye drops were used. Three (6%) patients were
treated with ofloxacilline and other fortified drugs (fortified gentamycin/fortified amikacin).
Fourteen (30%) patients were admitted for three days, nineteen (36.5%) patients were
admitted for one week and nine (17.3%) patients were in the hospital for two weeks. Six
(11.5%) patients left hospital against medical advice before completing the treatment.

Table 2:
Characteristics of ulcers in eyes of patients with contact lens induced severe keratitis
Visual acuity was tested in the eye with keratitis on admission and at the time of discharge.
Twelve (23%) eyes of 52 patients with severe keratitis had visual acuity of <6/60 (legally
blind) at the time of admission. In contrast, only five (9.6%) eyes of 52 patients had visual
acuity of less than 6/60 following the management of severe keratitis. A percentage
scattergram comparing pre- and post-treatment vision is given in Table 3. In one eye only, the
vision deteriorated following treatment. After leaving the hospital, 13 (25%) of patients did
not return for follow up. Only 16 (30.7%) patients had been followed up after 3 months.
Twenty-eight (53.8%) patients were advised to continue ofloxacillin eye drops even after
leaving the hospital. Another 18 (34.6%) patients were given the gentamycin eye drops in
addition to the ofloxacillin eye drops. Twenty-one (40.4%) patients were also given lubricant
eye drops. Topical steroids were used in treatment of only 8 (15.4%) patients. The status of
the corneas following treatment is given in Table 4. Nearly half of the patients treated for
severe keratitis were advised to use spectacles to correct their refractive error.

Table 3:
Percentage Scatter gram: Initial and final visual acuity in eyes treated for contact lens
induced severe keratitis

Table 4:
Corneal status and suggested correction following treatment of contact lens induced
severe keratitis
DISCUSSION
Our study highlights the importance of reviewing CL induced severe keratitis. Eighty percent
of our patients were less than 30 years of age. It is known that even after successful treatment
of severe keratitis, corneal opacities will be unavoidable thus causing visual impairment,
which could be a social and economic disaster at such a young age. Fortunately, vision
improved in all except in one case in our study. Thus, prompt and standard treatment of
severe keratitis is crucial to prevent visual disabilities.
Pseudomonas was the main organism found in CLs used in the eyes of patients with corneal
ulcer in our study. Surprisingly, we did not come across keratitis due to acanthomoeba, but
the fact that nearly 50% of the sample were without growth after laboratory tests in our
study is worthy to note. The ulcers were mainly in the visual axis and were of < 3 mm
diameter. The main characteristics of the patients in our series were: a majority of female
patients; age range from 20 to 30 years; coming for treatment in the early hours of the day 24
hours after symptoms appeared.
Unfortunately, a large number of cases were lost to followup and therefore we could not
compare visual recovery in nearly 48% of cases. Loss of data and patients in follow up visits
are known limitations of a study based on data review.6 Therefore, correlation of visual
impairment to the categories like causative organisms or age group could not be attempted.
Further studies of a prospective nature with a larger sample are recommended.
To the best of our knowledge, this study was the first of its kind in the Gulf countries. Since
complication due to CL wear is a problem of the young generation, the loss of DALYS
(disability adjusted life years) will be high. In spite of treatment, it could cause unilateral
blindness and/or low vision. In these circumstances, the outcomes of our study would be
important not only to Oman but also to many other countries having a similar CL delivery
system.
Oman has prioritised corneal diseases within its Vision 2020 initiative.7 Corneal
complications contributed to 14% of blindness in the population aged >40 years in 2005. The
majority of them were due to corneal complications of trachoma. Trachomatous trichaisis has
declined in the last decade.8, 9 However, the cornea is now at a higher risk due to the
increased use of CLs in Oman. The scope for using CLs is large in Oman since the
prevalence of myopia in 16 to 17 years old school children is as high as 12% and the
compliance of spectacle wear is only 70%.10, 11 In industrialized countries, it has also been
noted that the proportion of severe keratitis due to CL wear has increased the total number of
cases of corneal ulcer needing admission by up to 50%.12 Thus, awareness campaigns
targeting these potential patients could use the information of our study to warn them of the
consequences of abusing CLs.
CL induced keratitis was 30% of total admissions in our institute. This rate was close to the
33% reported by Keay et al.13 Pseudomonas was the main organism responsible for severe
keratitis. Many other researchers have also noted these organisms as the main culprit of
keratitis.14, 15 We found bacteria both in the sample collected from the corneal ulcer and
from the CL. Mela et al., in their study, demonstrated the importance of sending both the
material from corneal scraping and from the CLs for culture.16 Hence, it is important to
inform the family physician or optician referring the case to ensure that the patient is sent
with the CLs when the case is referred for admission and care. We found four cases with
gram negative bacilli and one case of gram positive cocci. But, we could not carry out culture
and sensitivity tests for them as we could not culture them on artificial media and test for
sensitivity. Inoue et al. noted gram positive and gram negative bacteria and fungi and
acanthamoeba in their specimen.17 A study in Belgium, reported pseudomonas as the main
culprit of CL induced severe keratitis.18
Only 25% of our patients had consulted an ophthalmologist within 24 hours of development
of symptoms showing that further strengthening of the reference system is therefore urgently
needed. Opticians and family physicians should be educated about the problems related to CL
use and need for prompt treatment by experts to avoid sight-threatening complications. Under
the guidance of cornea specialists, a standard management protocol should be prepared to be
followed by all ophthalmologists and CL practitioners. A large number of samples with no
growth after laboratory tests could be due to the use of antibiotics before the collection of the
sample. The referring practitioners should be aware of the need to collect the sample both
from the cornea and the lenses before commencing antibiotic treatment. Central corneal
ulcers and peripheral ulcers can be due to different causes and organisms.19 In our study
also, we noted that central ulcers of more than 5 mm in size were due
topseudomonas organisms. However, gram negative organisms were noted in samples from
both paracentral and peripheral keratitis. Twenty eight (53.8%) of laboratory tests reported
no growth, hence associating the site of ulcer to the type of organisms should be done with
caution in our study.
We could avoid perforation and its sequelae by good treatment; however, the vision remained
< 6/60 due to corneal opacities in five (19%) patients. Visual acuity following successful
treatment of CL induced corneal ulcer in another study was < 20/200 in two out of nine cases
in a group of myopic persons using soft CLs.20 Adam et al. studied complications in persons
using cosmetic CLs and found that one out of six eyes were blind after treatment.21 A study
with a larger sample is recommended to confirm these observations.
A limitation of our study is that patients presenting with mild corneal ulcers that were treated
in clinics and not admitted into hospital were not included in our study. Although
computerised case records were useful, a switch from manual to computer records co-incided
with our study period. This could have affected our study as the learning curve of the
ophthalmologists in using the computerised system may have resulted in incomplete data.
Our study was retrospective in nature; hence, the attrition of cases following discharge and
loss of data were inherent limitations.6 Thus, the results of our study are limited to CL
induced severe keratitis that needed treatment under supervision. Therefore, any attempt to
extrapolate the result of our study should be undertaken with due caution.
CONCLUSION
Our study suggests that vision improves following prompt and standard treatment of CL
induced severe keratitis. Prompt referral, standard management, regular follow up and proper
case records are essential. In view of the high rate of corneal ulcers in CL wearers, CL
dispensing practice in Oman should be monitored. Ophthalmologists, CL providers and CL
users should work jointly to solve this issue.
Acknowledgments
We thank the staff of the Ophthalmology Department at Al Nahdha Hospital for all their
assistance and care of the patients. We also thank the staff of the health record section there.
The hospital administrators gave their permission for this study and we appreciate their
cooperation. We thank the patients and their relatives who in spite of their suffering gave
their consent to use the information for improving eye care. We are grateful for their
cooperation and support.
The authors did not have any conflicts of interest (financial or other) in conducting this study.
The subject was presented in International Ophthalmology Conference in February 2007 in
Muscat, Oman.

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JAMA Ophthalmol. Author manuscript; available in PMC Feb 1, 2014.
Published in final edited form as:
JAMA Ophthalmol. Feb 2013; 131(2): 147153.
doi: 10.1001/jamaophthalmol.2013.778
PMCID: PMC3796098
NIHMSID: NIHMS516798
Association between Cytotoxic and Invasive Pseudomonas aeruginosa and Clinical
Outcomes in Bacterial Keratitis
Durga S. Borkar, BA,
1
Suzanne M. J. Fleiszig, PhD,
2,3,4
Chelsia Leong, BA,
2
Prajna Lalitha,
MD,
5
Muthiah Srinivasan, MD,
5
Avanti A. Ghanekar, OD,
2
Connie Tam, PhD,
2
Wing Y. Li,
OD,
2
Michael E. Zegans, MD,
6,7
Stephen D. McLeod, MD,
1,8
Thomas M. Lietman,
MD,
1,8,9
and Nisha R. Acharya, MD
1,8

Author information Copyright and License information
The publisher's final edited version of this article is available at JAMA Ophthalmol
See other articles in PMC that cite the published article.
Abstract
Go to:
Introduction
Pseudomonas aeruginosa is a significant cause of bacterial keratitis in both the United States
and South India, accounting for between 829% and 1148% of cases, respectively.
1
7
However, not all P. aeruginosa strains impact host cells in the same manner. Two important
virulence determinants are invasiveness and cytotoxicity.
812
Invasive strains encode exoS,
and therefore can sequester themselves intracellularly, replicating and stimulating membrane
bleb formation within host cells.
1315
Cytotoxic strains lack exoS, and instead encode the
acute cytotoxin exoU, which can quickly kill cells.
16
Both ExoS and ExoU are effectors of
the P. aeruginosa type III secretion system (T3SS). Effector proteins are injected into
eukaryotic cells via the T3SS apparatus, activated within the targeted cell, and then trafficked
to specific organelles, where they mediate a variety of phenotypic changes that ultimately
result in cell death.
17

Studies in cultured cells and in mouse models have compared invasive and cytotoxic strains.
Cell culture studies show an inverse relationship between capacity for cell killing and
capacity for invasion, while mouse models show different effects on pathology, immune
responses, and response to antibiotics.
810, 12, 18, 19
Although there have been some studies
showing differences in ulcer presentation between these two subtypes of P. aeruginosa, a
larger study in humans investigating differences in functional outcomes and therapeutic
response is lacking.
11,2024

The Steroids for Corneal Ulcers Trial (SCUT) was an NIH-funded, randomized, placebo-
controlled trial investigating the effect of topical corticosteroids as adjunctive treatment to
antibiotics for bacterial keratitis.
25
The use of topical corticosteroids for bacterial keratitis has
been controversial, and prior to this trial, there was insufficient evidence to guide clinical
practice. The SCUT found no overall benefit or harm with adjunctive topical corticosteroid
treatment across all types of bacterial corneal ulcers but suggested a benefit for patients with
the most severe ulcers. The large sample size from the SCUT allows for further investigation
by subgroup, including by organism type. The purpose of this pre-specified study was to
determine whether the invasive and cytotoxic subtypes of P. aeruginosa have different
clinical signs at baseline and result in a different response to therapy, which may allow for a
more tailored treatment approach.
Go to:
Methods
In the SCUT, patients with culture-confirmed bacterial keratitis were randomized to receive
adjunctive treatment with either topical 1% prednisolone phosphate or placebo after 48 hours
of topical 0.5% moxifloxacin treatment. Specific methods of the trial, including inclusion and
exclusion criteria as well as examination and treatment protocol, are described in detail
elsewhere.
26

Patients were evaluated at enrollment, three weeks, and three months by certified
refractionists and ophthalmologists who performed visual acuity and slit-lamp examinations,
respectively. Best spectacle-corrected visual acuity (BSCVA) was measured in logMAR units
using a tumbling E chart at four meters, with 0.1 logMAR being approximately one line of
acuity. Slit lamp examination was used to measure infiltrate/scar size, epithelial defect size,
depth of the ulcer, and size of hypopyon, if present, as well as to assess for ocular adverse
events. Infiltrate/scar size and epithelial defect size were evaluated to the nearest 0.1
millimeter by taking the geometric mean of the longest diameter and the longest
perpendicular to the first measurement. Re-epithelialization was defined as the absence of an
epithelial defect with administration of fluorescein. Depth of the ulcer was measured in thirds
(>033%, >3367%, or >67100%). Size of hypopyon was measured to the nearest 0.5 mm.
Ulcer location was assessed using photographs with an artificial 4mm pupil superimposed by
cornea-specific software. Location was graded as completely central, partially central, or
peripheral. Further details of how these assessments were done have been previously
described.
26

Microbiological Methods
All corneal isolates from the SCUT with growth morphology and Gram stain characteristics
consistent with P. aeruginosa were strain typed after confirming speciation by growth on
centrimide agar. Lab personnel were masked to clinical data, both baseline data and treatment
outcomes, until strain typing was completed. Bacteria were grown on Trypticase soy agar
overnight, and rabbit corneal epithelial cells were exposed to bacterial strain suspensions.
Corneal epithelial cells were washed and treated with gentamicin to kill extracellular bacteria.
Isolates which were resistant to gentamicin were also treated with amikacin. Rabbit corneal
epithelial cells were washed and lysed. Lysate was plated on MacConkey agar and incubated.
Percent invasiveness was determined by comparing growth from the intracellular lysate of
each isolate to growth from P. aeruginosa clinical isolate 6294, which was used as a positive
control. Since the assay for invasion depends on sensitivity to either gentamicin or amikacin,
percent invasiveness was not measured for gentamicin and amikacin resistant strains.
However, P. aeruginosa speciation was confirmed for these strains with an Analytical Profile
Index kit.
Percent cytotoxicity for each corneal isolate was determined by measuring the amount of
lactate dehydrogenase released into the media by dead or dying host cells after bacterial
exposure using a cytotoxicity detection kit (Roche Diagnostics, Indianapolis, IN). Values
were compared to a positive control, P. aeruginosa clinical isolate 6206. In some
experiments, invasive control 6294 had slightly lower LDH values than the media (baseline)
control. Negative values for percent cytotoxicity corresponded to strains that were not
cytotoxic and had negative LDH values after the media control had been included in the
calculation. Values greater than one corresponded to invasiveness or cytotoxicity greater than
the respective positive control.
Each bacterial isolate was genotyped using polymerase chain reaction (PCR). PCR was
specifically performed on target loci for the four effectors, exoU, S, T, and Y, of the type III
secretion system for P. aeruginosa. Strains 6206 and 6294 were used as positive controls
for exoU and exoS amplification, respectively. Both strains were used as positive controls
for exoY and exoT amplification. Negative controls were also used for amplification of each
effector protein sequence. Strains which were positive for either exoU or exoS, but not both,
were considered typical strains. Within this group, exoU
+
/exoS

strains were classified as

classically cytotoxic whileexoU

/exoS
+
strains were classified classically invasive on the
basis of genotype. Strains which were either positive or negative for
both exoU and exoS were classified as atypical strains. More detailed methodology for the
invasion and cytotoxicity assays as well as the PCR protocol with specific primers are
described elsewhere.
9, 24,27

Statistical Methods
Univariate analyses for genotype were performed using either Fishers exact test or a two-
mean-comparison t-test for categorical and continuous variables, respectively. Multivariate
analyses were performed using Huber robust regression to assess the relationship between
strain type, either genotype or phenotype, and clinical outcome. In these models, strain
genotype was used as a dichotomous predictor variable, either classically invasive or
classically cytotoxic. Strains with atypical genotypes were not used. Phenotype was used as a
continuous predictor variable, measured as either percent invasiveness or percent
cytotoxicity. All confirmed isolates were used in phenotype analyses except when percent
invasiveness could not be measured. Baseline characteristics used were BSCVA enrollment,
location of ulcer, epithelial defect size at presentation, infiltrate/scar size at enrollment, depth
of ulcer at enrollment, size of hypopyon, age, and contact lens wear. Clinical outcome was
measured using change in BSCVA at 3 months. Ulcer location was added as a covariate in
analyses involving BSCVA to control for possible confounding. Additionally, treatment arm
was added as a covariate to control for the possible effect of steroids on change in visual
acuity at 3 months. An interaction term (treatment armstrain genotype) was added to the
model assessing genotype and clinical outcome to test if a differential effect of steroids on
vision was present for cytotoxic versus invasive P. aeruginosa ulcers. Analyses were
performed using STATA 11.0 (StataCorp, College Station, TX). P-values reported for all
analyses are nominal values and have not been adjusted for multiple comparisons.
Informed consent was obtained for all subjects enrolled in the SCUT. Institutional Review
Board approval was granted by the Aravind Eye Care System Institutional Review Board, the
University of California, San Francisco Committee on Human Research, and the Dartmouth-
Hitchcock Medical Center Committee for Protection of Human Subjects.
Go to:
Results
Of the 500 patients in the SCUT enrolled between September 1, 2006 and February 22, 2010,
111 corneal bacterial isolates were strain typed based on growth morphology and Gram stain
characteristics consistent with P. aeruginosa. One hundred one of these isolates were
confirmed P. aeruginosa based on the methodology described above. Of the 101
confirmed P. aeruginosa isolates, 27 were determined to have atypical genotypes defined
as exoU
+
/exoS
+
or exoU

/exoS

. The remaining 74 isolates had typical genotypes; 56 were

classically invasive and 18 were classically cytotoxic. Percent invasiveness, expressed as a
decimal, ranged from 0.03 to 3.32. Percent cytotoxicity ranged from 0.72 to 2.94. A
significant difference was present between the genotypically cytotoxic and invasive strains
for both percent invasiveness and percent cytotoxicity (Figure 1).

Figure 1
Percent Invasiveness and Percent Cytotoxicity by Strain Type for Genotypically
Classically Cytotoxic and Invasive P. aeruginosaStrains
Baseline demographic features and clinical exam findings were compared between the two
genotype groups (Table 1). The mean infiltrate/scar sizes of 4.66 and 3.61 mm for invasive
and cytotoxic isolates, respectively, were significantly different (p=0.049, Table 1). The
difference in enrollment BSCVA between the two genotype groups was not statistically
significant (p=0.80, Table 1). Phenotypically, there was no significant association between
percent cytotoxicity and enrollment BSCVA (0.10 logMAR, 95% CI 0.18 to 0.38 p=0.47).
However, there was a statistically significant correlation between percent invasiveness and
enrollment BSCVA; regression analysis showed that one hundred percent invasiveness was
associated with an approximately two and a half line better visual acuity at enrollment
compared zero percent invasiveness (0.26 logMAR, 95%CI 0.51 to 0.01 p=0.04).

Table 1
Baseline Characteristics: Comparison Between Cytotoxic and Invasive Strains
When controlling for location, P. aeruginosa ulcers caused by genotypically invasive strains
had significantly better visual acuity at enrollment, approximately three and a half lines, than
those caused by genotypically cytotoxic strains (0.36 logMAR, 95%CI 0.63 to
0.10 p=0.008, Table 2). Phenotypically, increasing percent invasiveness was associated with
a significantly better visual acuity at enrollment when controlling for location. One hundred
percent invasiveness was associated with an approximately three line better visual acuity at
enrollment than zero percent invasiveness (0.32 logMAR, 95%CI 0.49 to
0.15 p<0.001, Table 2). Increasing percent cytotoxicity was associated with worse visual
acuity at enrollment; however, this relationship was not significant (0.19 logMAR, 95%CI
0.002 to 0.39 p=0.052, Table 2).

Table 2
Multivariate Linear Regressi on Models Predicting Enrollment Visual Acuity (logMAR
BSCVA)
Change in BSCVA at three months was compared between patients with ulcers caused by
invasive and cytotoxicP. aeruginosa strains. Genotypically invasive strains were associated
with an approximately three and a half line less improvement in visual acuity compared to
genotypically cytotoxic strains (0.35 logMAR, 95%CI 0.04 to 0.66p=0.027, Table 3). When
controlling for the effect of location on change in BSCVA at three months, genotypically
invasive strains were associated with an approximately four line less improvement in visual
acuity compared to genotypically cytotoxic strains (0.40 logMAR, 95%CI 0.09 to
0.70 p=0.013, Table 4). Sensitivity analyses demonstrated that treatment arm, either
corticosteroid or placebo, did not affect these results; the corticosteroid treatment difference,
approximately one line, was not significant (0.09 logMAR, 95%CI 0.36 to 0.17 p=0.49).
However, an interaction term between treatment arm and strain type added to the model was
significant (p=0.005,Table 5), suggesting a differential effect of corticosteroids on ulcers
caused by invasive and cytotoxic P. aeruginosa strains. (Figure 2)

Figure 2
Change in logMAR BSCVA at 3 months by treatment arm (placebo vs. steroid) for
each P. aeruginosa strain type

Table 3
Univariate analyses predicting change in BSCVA (logMAR) at 3 months

Table 4
Multivariate analyses predicting change in BSCVA (logMAR) at 3 months, controlling for
location of ulcer

Table 5
Multivariate analyses predicting change in BSCVA (logMAR) at 3 months, controlling for
treatment arm
Analyses of phenotypic properties of each corneal isolate supported these findings. One
hundred percent invasiveness was associated with an approximately two line smaller
improvement in BSCVA at three months versus zero percent invasiveness (0.22 logMAR,
95%CI 0.03 to 0.41 p=0.023, Table 3). Similarly, one hundred percent cytotoxicity was
associated with an approximately three greater improvement in BSCVA at three months
compared to zero percent cytotoxicity(0.29 logMAR, 95%CI 0.50 to 0.08 p=0.007, Table
3). Treatment arm was added to these models as a covariate, was not significant. However, an
interaction term between percent invasiveness and treatment significant (0.37 logMAR,
95% CI 0.74 to 0.004 p=0.047, Table 5), supporting a differential effect corticosteroids on
change in visual acuity as percent invasiveness varied.
Go to:
Discussion
Several studies have compared the effect of cytotoxicity and invasiveness of P.
aeruginosa the cornea in mouse models and have shown a difference in
pathogenesis.
8, 9, 19
The few studies done in humans with corneal infection have demonstrated
an association between strain type and age, as contact lens wear, but the effect on clinical
correlates, such as visual acuity, is unknown.
20, 23
In this study, we found that ulcers caused
by invasive strains presented with better visual acuity than caused by cytotoxic strains, but
they showed less improvement at three months compared to cytotoxic strain ulcers.
Additionally, ulcers in the corticosteroid treatment arm improved more than those placebo
arm within the invasive subgroup but not within the cytotoxic subgroup.
At presentation, we found that patients with genotypically invasive strain ulcers had
significantly better visual acuity compared to patients with genotypically cytotoxic ulcers
when controlling for ulcer location. Similarly, analyses based on phenotypic rather than
genotypic characteristics, i.e. percent invasiveness and percent cytotoxicity, supported these
findings. In a mouse model, cytotoxic P. aeruginosa strains have been previously associated
with more may be severe corneal edema, which may be expected to cause decreased visual
acuity.
19

The SCUT demonstrated no overall difference in visual acuity at three months with
adjunctive topical corticosteroid treatment.
25
Analysis of the data from all patients with
confirmed P. aeruginosa infection demonstrated the same result.
28
In the current study, we
found a statistically significant difference between the two treatment arms in the invasive P.
aeruginosa subgroup. On average, patients with invasive ulcers in the steroid treatment arm
had a two and a half line greater improvement in BSCVA from enrollment to three month
follow-up compared to the placebo treatment arm. Phenotypic analyses supported this
finding; increasing percent invasiveness was associated with a greater difference in visual
acuity improvement between the steroid and placebo arms.
Prior studies have showed that neutrophilic infiltration into the center of the cornea, not just
damage caused by bacteria, is the hallmark of a pathologic response to invasive P.
aeruginosa corneal infection in mouse models.
9,19, 29
In contrast, cytotoxic strains suppress
neutrophil infiltration as a direct result of exoU expression.
29
The improved outcomes we
observed in the steroid treatment arm of the invasive subgroup may reflect the local inhibition
of PMN infiltration due to topical corticosteroid exposure. However, modification of other
host responses may also play a role in the effect of topical corticosteroids on P.
aeruginosa corneal ulcers. We found that patients with cytotoxic ulcers in the corticosteroid
arm had approximately five and a half lines less improvement in visual acuity at three month
follow-up compared to those in the placebo arm; however, this result did not quite reach
significance. One prior study showed delayed clearance of cytotoxic, but not invasive, P.
aeruginosa strains from the ocular surface in mice deficient in surfactant protein D, an
immunologic protein present in the tear film.
30
Systemic literature has shown that inhaled
corticosteroids decrease serum surfactant protein D levels.
31
This raises the question of
whether there is a negative effect of topical corticosteroids on immunologic proteins, such as
surfactant protein D, that are important for clearance of cytotoxic P. aeruginosa at the level
of the ocular surface.
We examined differences in several other clinical characteristics between these two P.
aeruginosa subtypes. Specifically, we found that cytotoxic ulcers presented with an
approximately one millimeter smaller infiltrate size on average compared to invasive ulcers
in our sample. While previous studies have found that ulcers caused by cytotoxic strains are
more common in patients younger than 50 years old, we did not find a significant difference
in the age of patients with cytotoxic and invasive ulcers.
20, 24
However, the relatively young
age of patients in our sample may have made it hard to assess the association between strain
type and older age. Additionally, one prior study found that corneal isolates from contact lens
wearers were more likely to be cytotoxic.
23
We were not able to find this relationship, but
there were only five contact lens wearers included in the study.
There are a few potential limitations to consider. This study focused on two specific pathogen
virulence determinants of P. aeruginosa without considering differences in host factors or
other pathogen virulence determinants that might also impact corneal ulcer healing.
29
For
instance, factors such as tear film composition and presence of specific surfactant proteins at
the ocular surface have been shown to affect the capacity to recover from P.
aeruginosa keratitis.
27, 3234
Additionally, almost of the patients in the sample studied were
enrolled at the Aravind Eye Care System in India. Differences in demographics, contact lens
wear, and mechanism of injury may affect the generalizability of the findings to other
populations. It is also possible that geographic location may have had an effect on pathogen
genotype distribution. For example, there were 27 atypical isolates, which were neither
genotypically classically invasive nor cytotoxic. In comparison, a study of 55 human
corneal P. aeruginosaisolates from Australia reported only two atypical
genotypes.
23
Moreover, previous studies reported an approximately even distribution between
the cytotoxic and invasive genotypes.
2022
In this study, only 18 of the 74 corneal isolates
with typical genotypes were cytotoxic. This difference in distribution may be attributed to the
fact that cytotoxic strains have been reported more commonly among infections associated
with contact lens wear, which was rare among the SCUT patient population.
23
Of interest is
the finding that the proportion of cytotoxic strains isolated from the SCUT study participants
resembled the distribution found among canines with P. aeruginosa keratitis.
24
Additionally,
a large sample of clinical nonocular P. aeruginosa isolates had a similar proportion of
cytotoxic strains.
35
While the small sample of cytotoxic strains could have affected the
findings, particularly for subgroup analyses of the cytotoxic strains, the clinical data was
collected prospectively a standardized manner at set time points, increasing the ability to
detect relationships.
Currently, the microbiological methods used in this study have been performed in a basic
science laboratory setting. However, the distinction between cytotoxic and invasive P.
aeruginosa genotypes can be made using PCR, which is inexpensive and available in many
clinical microbiology laboratory settings. Additionally, the time needed to obtain PCR results
may be acceptable given that corticosteroid treatment could be added after 48 hours of
antibiotic treatment, as was done in SCUT.
In summary, the results of this study showed that P. aeruginosa bacterial keratitis caused by
genotypically invasive strains presented with significantly better visual acuity than
genotypically cytotoxic ulcers but had less improvement in visual acuity at three months.
They also revealed that adjunctive treatment with topical corticosteroids had a differential
effect on invasive and cytotoxic ulcers. The results of this study suggest the potential to guide
management decisions using existing therapies, such as corticosteroid treatment, based on
these specific virulence determinants. Additionally, they illustrate the concept that not all
infections caused by pathogens of a single species present or respond to treatment similarly.
Further studies to elucidate differences in clinical presentation and therapeutic response based
on specific virulence determinants for other pathogens may be warranted.
Go to:
Acknowledgements
The Steroids for Corneal Ulcers Trial was funded by National Eye Institute grant U10
EY015114. Dr. Acharya is supported by National Eye Institute grant K23 EY017897 and a
Research to Prevent Blindness Career Development Award. The UCSF Department of
Ophthalmology is supported by National Eye Institute core grant, EY02162, an unrestricted
grant from Research to Prevent Blindness, the South Asia Research Fund, and That Man May
See, Inc. Dr. Fleiszig is supported by National Institutes of Health grants RO1 EY011221 and
RO1 AI079192. Dr. Ghanekar, Dr. Li, and Chelsia Leong were supported by National
Institutes of Health grant T35 EY07139-18. Alcon provided moxifloxacin (Vigamox) for the
trial but did not play a role in the design and conduct of the study, in the collection, analysis,
and interpretation of the data, or in the preparation, review, and approval of this manuscript.
Dr. Acharya had full access to all the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Go to:
Footnotes
Conflicts of Interest: None of the authors have any financial or personal disclosures to
report.
Go to:
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