Contact Lenses : Update on the Fusarium (Fungal) Outbreak
I just got back from Salzburg Austria where I attended the International Society of Contact Lens Specialists (ISCLS). Apart from holding conferences in magnificent locations, this great group of practitioners always amazes me with the information that is shared about contact lenses. Some of them were pioneers practicing optometry and prescribing contact lenses from the 1950's and some of them are currently world leaders in contact lenses. It is always a humbling experience to share the same room with them.
The highlight for me at this meeting were the two presentations on the Fusarium outbreak. It is quite clear now that this very rare form of fungal infection is linked to the use of B&L ReNu with Moistureloc.
Severe Fusarium infection More subtle presentation
Fungal keratitis may appear as a greyish white lesion with feathery borders. It may be difficult to differentiate from other forms of microbial keratitis. If fungla infection is suspected laboratory testing is crucial but in many cases one would treat it as a bacterial keratitis using a fluroquinolone until laboratory testing confirms the diagnosis. The treating practitioner would then immediately change to to an antifungal medication such as
natamycin and/or voriconozole.
Many cases needed corneal transplantation. Unfortunately a number of eyes required enucleation.
The presentations finally seemed to explain (to me anyway) why this type of outbreak was possible even though the solution had gone through the normal FDA testing protocol:
Superficial punctate staining (SPK) with the use of ReNu (Moisture Loc) was common. Something new I learnt with this fact was that SPK is most common between 2 to 4 hours after inserting contact lenses. At the beginning and at the end of the day the preservative has either not penetrated the cornea or it has dissipated and the cornea has healed. This is an extremely important clinical finding that requires more study and validation, as contact lens aftercares need to be organised around this time period to pick up cases of preservative toxicity.
- Fungal infections such as Fusarium require a compromised epithelium to proliferate. SPK caused by contact lens solutions creates an ideal environment.
- The effectivity of B&L ReNu with Moisture Loc seems to reduce dramatically after a few days of soaking in the same solution. What was interesting was that this solution seemed to be more effective against Fusarium on the first day of soaking but lost effect with a few days, whereas the comparison solutions seemed to keep their effect over time.
In summary there were a few take home messages for my contact lens practice:
- All solutions are not the same! It is time that we took control of the contact lens market again. We have lazily allowed the commoditisation of these medical devices - myself included.
- It is imperative that we explain to patients that they must stick to the solution that we recommend so that if complications arise we will be able to troubleshoot more effectively, rather than having to deal with waxing and waning non specific symptoms.
- A compromised epithelium is a significant risk factor for microbial keratitis and arranging aftercares between 2 to 4 hours of contact lens insertion will find cases of SPK.
- Most solutions say "NO RUB". I have always asked my patients to rub anecdotally believing that it must be better. I still believe this to be the case and will continue to do so.
- Topping up old solution with new solution rather than cleaning out the case and starting with new solution every time is an important issue.
- I will use this disastrous outbreak as an example of what can happen when patients do not comply.
- Contact lens disinfection and compliance must be revisited during every contact lens aftercare. Apart from having a huge impact on our patients well-being it will also have a huge impact on our bottom line. Compliance means more profitability!
- Even though severe microbial keratitis is not that common, if you are the person that is being affected the fact it is rare all of a sudden is irrelevent. Let's take control of contact lenses again. It is our responsibility.
Therapeutic Tip: Ocular complications of eyelid malpositions
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