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LITERATURE REVIEW ME119

Student Name- Lubaba Tasneem Nawar

Student ID- 00000027459

Topic Title-
Contact Lens Associated Pseudomonas Keratitis

Word Count- 1882

Number of References- 15
 Contact Lends Associated Pseudomonas Keratitis
Methodology of Research:
Search Engines Used- PubMed, Science Direct, Clinical Key, Access Science, BMJ,
ProQuest
Inclusion Criteria- Bacterial keratitis, pseudomonas, qualitative data, primary and
secondary data, dissertation, scholarly journals, wire Feeds
Exclusion Criteria- Keratitis by gram positive bacteria, fungi or amoeba,
quantitate data, statistics, unstructured interview
Keywords Used- Keratitis, contact lens, associated, induced, microbial keratitis,
pseudomonas, pathophysiology, epidemiology, risks, complications, medical and
surgical management of ps keratitis
Restrictions Applied- 2014- 2020 (year of publication), English (language of
article)
Introduction
Pseudomonas aeruginosa is a rod shaped gram negative bacteria. It is known to be an
opportunistic human microbe, causing an assortment of infectious diseases. In the eye, P.
aeruginosa is a typical reason of bacterial keratitis, especially in those who wear contact lens.
Being particularly virulent, pseudomonas keratitis is both harder to treat and have worse
prognosis than other forms of bacterial keratitis. P. aeruginosa microbe secretes proteases that
causes liquefactive necrosis of the cornea, resulting in rapid corneal weakening and
perforation.1
Bacterial keratitis is one of the most serious complications of contact lens use. If not
appropriately treated, this ocular problem can lead to undermining sight-threatening intricacies
such as corneal scarring, endophthalmitis, perforation and, finally, blindness. 2 A specific
component of bacterial keratitis is its rapid progression; corneal destruction may be complete
in 24-48 hours with some of the more destructive pathogens. Characteristic features of this
disease includes corneal ulceration, anterior segment inflammation and stromal abscess
formation surrounding corneal edema.3 Hence, early diagnosis and treatment in addition to
follow-up on laboratory data are significant in minimalizing visual impairment.

Content
Pseudomonas keratitis refers to microbial invasion of intact corneal epithelium, and in some
cases, abnormal tears, leading to proliferation and ulceration. Inflammation leads to infection
and damage of epithelium, endothelium and stroma. Several adhesins are displayed on
fimbriated and non-fimbriated structures that aid in adhesion to corneal host cells. In initial
phases, area of injury in epithelium and stoma during infection swell up and tend to undergo
necrosis. Acute inflammatory cells, especially neutrophils, enclose the beginnings of ulcer and
result in necrosis of the stromal lamellae.4 Bacterial toxins and different enzymes released
during corneal infection, like elastase and alkaline protease, contribute tot the destruction of
corneal substance.5
55% of Pseudomonas keratitis cases were associated with contact lens wearers. Studies show
that 13.04 cases out of every 10,000 individuals wear contact lens. The epidemiology of this
condition is most frequent in the USA, where 25,000 Americans develop this disease annually.
International incidence considerably varied, where significantly less number of contact users in
less industrialized countries, and as such, much fewer contact-lens bacterial infections. 6
The prognosis of visual activity and mild-to-severe decrease of visual prognosis is influenced by
the following factors:
1. Locations and extent of the corneal ulcer
2. Virulent degree or extent of the bacterial pathogen responsible for the keratitis
3. Ensuing deposition of collagen and vascularization
Rapid onset of pain, visual weakening or loss and photophobia are common symptoms keratitis
patients present with. Accordingly, the type of contact lens, the total wearing time and the type
of disinfection solution or system used are key points to be noted. Furthermore, supplementary
aspects to be counted are if the patients who wear contact lens, particularly for extended wear,
have issues with sensation of foreign body, irritation, hyperemia, plus, if their lens cleaning
solution is sterile to prevent contamination.
The following are physical features in keratitis patients revealed by external physical and
biomicroscopic examination:7
1. Ulcer in corneal epithelium; infiltrate in corneal with insignificant loss of tissue;
indistinctly edged suppurative, dense stromal inflammation; tissue loss in the stroma
and adjacent edema in the stroma.
2. Edema in upper eyelid
3. Hyperemia in the conjunctiva
4. Reaction in the cells and flare of the anterior chamber with or without hypopyon
5. Posterior synechiae
6. Focal or diffuse inflammation surrounding the cornea
7. Folds found in the Descemet membrane
8. Inflammatory plaque in the endothelium
9. Adherent mucopurulent exudate
The most effective physical examination for those with confirmed or even suspected keratitis is
a thorough anterior segment slit lamp examination. It is essential to examine epithelial defects
seen by using fluorescein, whitish opacities and other defects in cornea, thinning or edema in
cornea, and hypopyon, flare or cells in anterior chamber. Seidel examination can detect leak of
the aqueous humor fluid in case of a perforation in the corneal surface.8
Laboratory investigations can be done by obtaining scapings of corneal ulcers using a sterile
blade, spatula or sterile calcium alginate swab. Samples are mounted on slides with Giemsa or
Gram stains. In case of deteriorating conditions, corneal biopsies should be considered to check
for deep stromal infiltrations. Histological studies show necrosis in the epithelium and stroma
of the infected area in the initial stages of inflammation. Corneal vascularization occurs in
chronic conditions of keratitis.
Radiological findings can be obtained by ultrasound (B- scan) of eyes that have severely
ulcerated corneas, with only view of the anterior segment, not posterior segment. Again, the
progression of keratitis can be documented by slit lamp photography. It is also useful in cases
where patients do not respond to antimicrobial therapy, chiefly in chronic and indolent cases. 9
The introduction of hydrogel contact lens has caused the increase of contact lens associated
keratitis, markedly for extended use. Organisms have been detected in the lens case and saline
dispensers used for care of contact lens. As a result, in case for poor lens hygiene, bacteria
transfers from surface of lens to cornea. Glycocalyx formation in pseudomonas is also
augmented by overnight wet storage of hydrogel lens. Lens storage cases washed with tap
water provides an environment for bacterial growth. Risk of infection multiplies not only due to
these physical vectors, but also by overnight lens wear since ocular surface is altered by
increased exposure duration. The probability rises particularly during sleep, as eye surface is in
proinflammatory stage and polymorphonuclear neutrophils are rich in the tears. 10
The morbidity and mortality complications of keratitis occur predominantly when stromal
abscess coalesce with deep ulcers, which consequently result in the thinning of corneal surface
and sloughing of the infected stroma. The most probable complications of bacterial keratitis are
given below in the following:11
1. Corneal Leukoma: Corneal leukoma is a possible complication rooted at formation of
scar tissue from corneal vascularization. The depth of involvement in stroma and
location of the leukoma determines the visual significance and need of corneal surgery,
like penetrating keratoplasty (PK) or phototherapeutic keratectomy (PTK) in order to
improve vision.
2. Irregular Astigmatism: Another such complication is uneven stromal healing, leading to
irregular astigmatism, which may necessitate PTK or gas-permeable contact lens for
visual rehabilitation.
3. Endophthalmitis: When pseudomonas bacteria penetrate the epithelium and infiltrate
the cornea, the internal contents of eyes get infected. Hence, antibiotics in the form of
intravitreal injection or surgical correction for treatment may potentially be required.
 4. Corneal perforation: The most dangerous complication of pseudomonas keratitis is
corneal perforation. This may lead to secondary endophthalmitis and even cause loss of
an eye.
Precautionary measures to prevent biofilm related pseudomonas keratitis in contact lens
consist of good hygiene in additional to proper removal of proteinaceous deposits in contact
lens. Next, adherent organisms should be removed by surfactants or cleaning solutions or
disinfectant multipurpose solutions containing polyquat or polyhexamethylene biguanide that
leaves minimal residue of activity of toxins. Moreover, home made saline solutions should be
strictly avoided. Hydrogen peroxide is an effective microbicide against pseudomonas and other
bacteria within 10 minutes, and against filamentous fungi within 60 minutes. 3% hydrogen
peroxide is the gold standard for overnight soft lens along with neutralization in the morning by
a catalase or thiosulfate solutions made up in tablet form. Hydrogen peroxide neutralization by
catalytic solution cannot prevent contamination by microbes and thereby, is not recommended
for use.
Medical care for pseudomonas keratitis traditionally follows the therapy with fortified
antibiotics, for example, 1 drop of tobramycin along with vancomycin or fortified cefazolin
every hour. This is also the initial therapy recommended for severe stromal ulcers. 12 As healing
of infection occurs, it is best to taper off the antibiotics and gradually stop, since they can be
toxic with extended use to the epithelium and obstruct healing of cornea. The typical
parameter for tapering antibiotics administration frequency are as listed below:
1. When edges of stromal infiltrate blunt from the irregular perimeter and decreases in
density
2. When inflammatory plaque in endothelium and edema in stroma reduces
3. Reduction of inflammation in anterior chamber and epithelialization of defect in
epithelium
4. When painful symptoms improve.
With the improvement of keratitis and decrease of antibiotics, topical corticosteroids can be
increased. Prednisolone acetate 1% suppresses the migration of polymorphonuclear leukocytes
and so, decreases inflammation by reversing permeability of the capillary.
At present, for monotherapy for mild cases of keratitis, fourth generation fluoroquinolones are
being used increasingly.13 Moxifloxacin and gatifloxacin are such ophthalmic fourth generation
fluoroquinolones have better in vitro activity against bacteria than some antibiotics, managing
to penetrate into ocular tissue and prevent mutant characteristics better than older
fluoroquinolones. Hence, they are progressively becoming the favored alternative for first line
monotherapy to ciprofloxacin. The typical dosage is every hour. Besifloxacin ophthalmic
suspension is a new fluoroquinolone developed as an ocular topical preparation with high
potency against gram negative bacteria and decreased dosing frequency.
Surgical treatment is necessary in case or corneal perforation in pseudomonas keratitis
infection. Sclerocorneal patch, PK or penetrating keratoplasty, or the application of
cyanobacterial adhesive may be required in case of perforation or imminent perforation of the
cornea. Some guidelines to be followed in these instances are as indicated in the following:
1. Use of general anaesthesia during surgery
2. Starting ciprofloxacin or systemic intravenous antibiotics from duration of perforation to
3 days after the keratoplasty surgery
3. Irrigation of anterior chamber of eye so as to remove inflammatory or necrotic debris
4. Cataract removal is to be a later procedure in order to prevent endophthalmitis and
expulsive hemorrhage.
5. Moreover, securing of donor cornea should be performed with uninterrupted nylon
sutures and the size of the transplant should be small enough to incorporate into the
site of perforation and any possible ulcerated or inflamed border.
Postoperative procedure includes frequently using topical fortified antibiotics in addition to
topical corticosteroids immediately after operation for 4 times a day. This acute period of
postoperative care is when it is supposed the pseudomonas infection has been completely
excised.14

Conclusion
Contact lens associated keratitis caused by Pseudomonas aeruginosa is the most common form,
seconded by Staphylococcus aureus and coagulase negative staphylococci. Negative strain
bacteria resist disinfection and adhere to biomaterials more effectively than amoeba or fungal
causative organisms. Poor lens hygiene and care is the most common cause of keratitis
infection. The polymer matrix of contacts lens, particularly, hydrophilic lens, are very suited for
adherence of pseudomonas bacteria organism.15 Contamination can be prevented by using
sterile contact lens solution and disinfectant. Topical steroids and antibiotics are also used after
corneal surgery after traumatic corneal injury to inhibit infection. Risk of infection grows with
corneal injury or trauma, extended contact lens wear which facilitates prolonged accumulation
and entrapment of debris. Due to threatening of vision, careful observation of the healing is
needed even after treatment in order to monitor proper lens wear and inhibit further infection.

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