Our case began in clinic with a referral for a new corneal ulcer. The patient was a 64-year-old male with no previous ophthalmic history other than refractive error. One week prior to presentation in our clinic, he went to an outside provider for a trial of contact lenses. He had never worn contact lenses before and was interested in getting out of glasses. Contact lenses were placed in both eyes and he was taught appropriate insertion and removal techniques.
However, soon after that visit, he was unable to get the contact lens out of the right eye. He left it in for two days before returning to the original provider’s office where it was removed for him. At this point, he said his vision had decreased and the eye was painful. The patient said he received an ointment in the clinic and referred to a local ophthalmologist. He saw that ophthalmologist two days later, who noted an opaque right cornea and referred him to our clinic the next day.
FROM BAD TO WORSE
Upon presentation to our clinic, the patient had light perception vision in the right eye, with a completely white opaque cornea. Inferiorly, there was an area of significant thinning but was Seidel negative (Figure 1). As there was no view posteriorly, we performed a B-scan ultrasound, which showed a normal posterior segment. His left eye was normal with 20/20 vision. Cultures were taken and the patient was started on fortified vancomycin 25 mg/ml and tobramycin 15 mg/ml every hour around the clock.
Over the next few days he was watched closely. His cultures returned positive for pan-sensitive pseudomonas. Unfortunately, his thinning progressed, and at his one-week follow-up, his cornea had a perforation in the area of previous thinning. The patient underwent an in-clinic corneal gluing; it was noted that his chamber was flat and he had a white cataract. His glue was holding temporally, but his nasal cornea had also thinned with a new perforation that was plugged by iris (Figure 2). At this point, we discussed the timing and need for a penetrating keratoplasty. As his cornea was still Seidel negative and his eye still acutely infected, we decided to delay the procedure until after the eye was quieter.
By week three, his cornea had reperforated and was Seidel positive, requiring a second corneal gluing; additionally, his pain increased. A repeat B-scan ultrasound showed increased vitreous opacities; he was subsequently seen by a retina specialist and diagnosed with endophthalmitis. The consulting retina physician performed a tap-and-inject with moxifloxacin and ceftazidime. The tap was culture negative.
THE PK SOLUTION
Due to his progressive corneal thinning, multiple perforations and subsequent endophthalmitis, the decision was made to perform a penetrating keratoplasty despite his persistent infection. By this time, it was clear that the entirety of his cornea was infected limbus-to-limbus. There was no clear scleral involvement, but he still needed a large diameter trephination. Twenty-five days after initial presentation to our clinic, and one month after trying on contact lenses for the first time, the patient underwent a penetrating keratoplasty; we performed the procedure using a 13-mm graft into an 11-mm trephination. We also did an open-sky intracapsular cataract extraction and limited vitrectomy. We carefully peeled his iris off his cornea and preserved it. He was left aphakic due to the endophthalmitis. The corneal-scleral graft was sutured to the remaining host scleral with 26 interrupted 10-0 nylon sutures.
By postoperative week one, the patient’s vision had improved to 2/200 and his pain substantially improved. He was again evaluated by a retina specialist, who felt that his endophthalmitis was largely resolved with no obvious indications of extreme retinal damage. However, by week two he started to develop signs of early endothelial graft failure with edema and keratic precipitates. The remainder of his graft was intact, and the integrity of his globe was no longer threatened.
While we are actively treating him aggressive steroids at this time, the likely plan is to perform a lamellar graft under his existing PK and scleral fixation IOL placement once his eye is less acutely inflamed.
Two salient discussion points arose from this case. The first is that contact lenses are not nearly as innocuous as the public believes them to be. The second is the unique two-part staged transplant approach to both save his eye and eventually restore some level of vision.
Contact lenses are the most commonly used medical devices on the planet with over 30 million people using them in United States alone.1 This familiarity with contact lenses among the general public has led to some level of apathy towards the potential devastating complications of improper contact lens use. Despite the fact that overnight use and poor contact lens hygiene can increase the risk of moderate to severe microbial keratitis 6-7 fold, 2 only approximately 30% of contact lens users endorse following all recommended cleaning and use guidelines.3 This case in particular highlights the extreme damage that can be done by contact lens misuse. Our patient developed this severe ulcer and subsequent endophthalmitis the first time he put in a contact lens! We must be vigilant of poor contact lens hygiene and stress upon our patients the importance of proper contact lens wear to help avoid a devastating infection such as this.
The second interesting teaching point about this case is the planned two-stage approach to his transplant. At the time of penetrating keratoplasty, the patient’s eye was still extremely inflamed. However, due to the progressive corneal destruction and repeated perforations caused by the infection, he needed the transplant to restore the structural integrity of the globe. This graft required an extremely large trephination as nearly the entire cornea was affected limbus-to-limbus. While the hope was that the graft would survive, the expectation was that it would fail. The main objective of this transplant was not visual rehabilitation, but instead to buy time to allow the eye to further heal without worrying about perforations or corneal melt. In that sense, the graft has been a success as his globe is structurally intact. The visual rehabilitation portion of his care will come in the future once the eye is quieter. At that time, we plan to perform a sutured IOL placement and DSAEK.
As ophthalmologists, we are attuned to surgeries that restore both structure and function simultaneously. This case, however, highlights an instance when those two objectives could not be achieved with a single procedure. In situations like this, saving the structure of the eye needs to be triaged to the top priority, and function can be addressed with subsequent surgeries. OM
- Clayton-Jeter H. Looking good: safe use and care of contact lenses. FDA. FDA news for health professionals. 2010.
- Stapleton F, Edwards K, Keay L, et al. Risk factors for moderate and severe microbial keratitis in daily wear contact lens users. Ophthalmology. 2012;119:1516-1521.
- Bui TH, Cavanagh HD, Robertson DM. Patient compliance during contact lens wear: perceptions, awareness, and behavior. Eye Contact Lens. 2010;36:334.