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 Table of Contents    
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 106-108  

Corneal ring infiltration in contact lens wearers


Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran

Date of Web Publication29-Jun-2017

Correspondence Address:
Mohammad Soleimani
Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, South Kargar Street, Qazvin Square, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-620X.209109

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   Abstract 


To report a case of atypical sterile ring infiltrates during wearing soft silicone hydrogel contact lens due to poor lens care. A 29-year-old woman presented with complaints of pain, redness, and morning discharge. She was wearing soft silicone hydrogel contact lens previously; her current symptoms began 1 week before presentation. On examination, best-corrected visual acuity was 20/40 in that eye. Slit-lamp examination revealed dense, ring-shaped infiltrate involving both the superficial and deep stromal layers with lucid interval to the limbus, edema of the epithelium, epithelial defect, and vascularization of the superior limbus. Cornea-specific in vivo laser confocal microscopy (Heidelberg Retina Tomograph 2 Rostock Cornea Module, HRT 2-RCM, Heidelberg Engineering GmbH, Dossenheim, Germany) revealed Langerhans cells and no sign of Acanthamoeba or fungal features, using lid scraping and anti-inflammatory drops; her vision completely recovered. We reported an atypical case of a sterile corneal ring infiltrate associated with soft contact lens wearing; smear, culture, and confocal microscopy confirmed a sterile inflammatory reaction.

Keywords: Contact lens, keratitis, ring infiltration


How to cite this article:
Tabatabaei SA, Soleimani M, Johari M. Corneal ring infiltration in contact lens wearers. Oman J Ophthalmol 2017;10:106-8

How to cite this URL:
Tabatabaei SA, Soleimani M, Johari M. Corneal ring infiltration in contact lens wearers. Oman J Ophthalmol [serial online] 2017 [cited 2019 Dec 8];10:106-8. Available from: http://www.ojoonline.org/text.asp?2017/10/2/106/209109




   Introduction Top


A number of different inflammatory stimuli such as microbial infection, mechanical, or thermal injury, and an immune hypersensitivity response can produce corneal infiltration; corneal infiltrates are serious complications associated with contact lens wear. They can range from a small infiltrate with or without an associated epithelial defect to a large corneal ulcer with active microbial involvement.[1] Distinguishing noninfectious sterile infiltrates from infected microbial keratitis is often difficult.[2] The most common symptoms related to sterile infiltrates are redness, foreign body sensation, discomfort rather than pain, photophobia, and lacrimation. Furthermore, there is no purulent discharge.[3] Corneal ring infiltrates have been reported to occur in infections with a variety of organisms. These include Acanthamoeba, Gram-negative Bacilli like Pseudomonas aeruginosa or  Moraxella More Details, herpes simplex virus, varicella-zoster virus, and fungi as well as immunity-related conditions such as rheumatoid arthritis. Corneal ring infiltrates are most consistently associated with Acanthamoeba keratitis, especially in contact lens wearers.[4]

Herein, we are reporting a case with noninfectious ring infiltration, emphasizing the importance of thinking about sterile infiltrations in contact lens wearers.


   Case Report Top


A 29-year-old woman presented to the emergency ward with complaints of left eye pain, redness, and morning discharge. Her medical history was significant for wearing soft silicone hydrogel contact lens previously; her current symptoms began 1 week before presentation. On examination, best-corrected visual acuity was 20/20 in the right eye and reduced to 20/40 in the left eye. Slit-lamp examination in the left eye revealed dense; ring-shaped infiltrates involving both the superficial and deep stromal layers with lucid interval to the limbus and edema of the epithelium and vascularization of the superior limbus. There was moderate cilliary injection for 360° peripherally around the affected area, and there was an epithelial defect, which over coated the infiltration [Figure 1]. The right eye examination showed 2 mm × 2 mm marginal corneal stromal infiltration with lucid interval to the limbus. There was no hypopyon in the anterior chamber, but fine diffuse keratic precipitations on the cornea; other ocular and systemic examinations were normal. Contact lens wearing was promptly discontinued. The corneal smear and culture of the both eyes were negative for bacteria and fungi. Cornea-specific in vivo laser confocal microscopy (Heidelberg Retina Tomograph 2 Rostock Cornea Module, HRT 2-RCM, Heidelberg Engineering GmbH, Dossenheim, Germany) was done for both eyes; confocal microscopy revealed brightly, finely branching reflective structures with cell bodies at the epithelial and stromal level which were characteristic for Langerhans cells, and no sign of Acanthamoeba or fungal features was seen [Figure 2].
Figure 1: The left eye slit photograph during early examination

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Figure 2: Confocal scanning of the eye

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Preservative-free artificial tears were prescribed once an hour, topical preservative-free levofloxacin six times a day and eyelid scraping were also prescribed; she was scheduled for daily outpatient follow-up appointments. After a week, the patient's condition was stable, mucopurulent discharge and ocular pain were completely improved but stromal ring infiltration remained the same, so loteprednol etabonate eye drop applied four times daily was added to control the inflammatory component then the patient was seen weekly. At the 4-week follow-up visit, stromal deep infiltration in both eyes was decreased and started to fade-out. Best-corrected visual acuity improved to 20/20 in both eyes.


   Discussion Top


The estimated number of contact lens wearers exceeds 34 million in the United States and 140 million worldwide. Silicone hydrogel lenses are among the most commonly used lenses as they are relatively inexpensive and more broadly tolerated than hard lenses. However, silicone hydrogel use also increases the risk for sterile corneal infiltrates, including contact lens peripheral ulcers and contact-lens-associated red eye.[4],[5],[6] Contact lens-associated corneal infiltrates have been correlated with the presence of bacteria, extended lens wear, noncompliance to lens replacement or care schedules, and hypersensitivity to lens material or solution preservatives.[7] Hypoxia, primarily as a result of overnight wear, has been linked to infiltrate formation, central and infectious infiltrates.[8] There is a migration of inflammatory cells including polymorphonuclear leukocytes and mononuclear cells into the cornea, forming the infiltrate. The limbal arcade and the precorneal tear film are the likely origins of these inflammatory cells.[1],[2],[3] In general, contact lens use has been shown to induce a number of physiological and morphological changes in the cornea, which are manifested as cellular responses that can lead to the development of infiltrates.[1],[2],[9] Damage to epithelial cells due to lens-associated trauma increases the release of inflammatory cytokines, leading to infiltrate formation. The lens itself can trap bacteria, which may also adhere more readily to damaged epithelium.

Corneal ring infiltrates have been reported to occur in infections with a variety of organisms. These include Acanthamoeba, Gram-negative Bacilli like P. aeruginosa or Moraxella, herpes simplex virus, varicella-zoster virus and fungi as well as immunity-related conditions such as rheumatoid arthritis.[4] Corneal ring infiltrates are most consistently associated with Acanthamoeba keratitis, especially in contact lens wearers. Ring infiltration has been reported after a corneal collagen cross-linking procedure with the postoperative use of a contact lens because of a polymicrobial infection caused by Streptococcus salivarius, Streptococcus oralis, and a coagulase negative Staphylococcus sp.[10] It may be difficult using clinical signs to distinguish between the corneal infiltrate caused by infection and an infiltrate caused by a hypersensitivity response, although the treatment differs significantly. Pain, suppurative discharge, an epithelial defect of >2 mm, and an anterior chamber reaction are suggestive of a infective keratitis [7] while a marginal corneal infiltration or stromal infiltration with only a minimal epithelial defect and no anterior chamber reaction are typical of the sterile keratitis associated with staphylococcal blepharitis or early stage of anesthetic keratopathy.[8] Several studies reported that corneal ring infiltrations to occur after contact lens wearing specially with Acanthamoeba or Bacillus cereus keratitis.[6] Although the pathophysiology of corneal infiltrates is not completely understood, it is likely that it is an immunologically mediated reaction,[2] in contact lens wearers many agents may present as an antigenic load like lens material itself, lens care solutions and preservatives and bacteria or toxins adherent to the lens.[1] We reported an atypical case of a sterile corneal ring infiltrate associated with soft contact lens wearing, culture and staining of all samples were negative, and confocal microscopy confirmed inflammatory reaction.


   Conclusion Top


It seems that multiple peripheral sterile infiltrations with lucid intervals formed a ring infiltration in this case with lower central corneal edema and mucopurulent discharge, differentiating this sterile infiltration from infectious one.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Chan TC, Li EY, Wong VW, Jhanji V. Orthokeratology-associated infectious keratitis in a tertiary care eye hospital in Hong Kong. Am J Ophthalmol 2014;158:1130-5.  Back to cited text no. 1
[PUBMED]    
2.
Keenan JD, Fram NR, McLeod SD, Strauss EC, Margolis TP. Perifosine-related rapidly progressive corneal ring infiltrate. Cornea 2010;29:583-5.  Back to cited text no. 2
[PUBMED]    
3.
Ghanem RC, Netto MV, Ghanem VC, Santhiago MR, Wilson SE. Peripheral sterile corneal ring infiltrate after riboflavin-UVA collagen cross-linking in keratoconus. Cornea 2012;31:702-5.  Back to cited text no. 3
[PUBMED]    
4.
Chin J, Young AL, Hui M, Jhanji V. Acanthamoeba keratitis: 10-year study at a tertiary eye care center in Hong Kong. Cont Lens Anterior Eye 2015;38:99-103.  Back to cited text no. 4
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5.
Kurna SA, Sengor T, Aki S, Agirman Y. Ring keratitis due to topical anaesthetic abuse in a contact lens wearer. Clin Exp Optom 2012;95:457-9.  Back to cited text no. 5
[PUBMED]    
6.
Basak SK, Deolekar SS, Mohanta A, Banerjee S, Saha S. Bacillus cereus infection after Descemet stripping endothelial keratoplasty. Cornea 2012;31:1068-70.  Back to cited text no. 6
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7.
Wallang BS, Das S, Sharma S, Sahu SK, Mittal R. Ring infiltrate in staphylococcal keratitis. J Clin Microbiol 2013;51:354-5.  Back to cited text no. 7
[PUBMED]    
8.
Yagci A, Bozkurt B, Egrilmez S, Palamar M, Ozturk BT, Pekel H. Topical anesthetic abuse keratopathy: A commonly overlooked health care problem. Cornea 2011;30:571-5.  Back to cited text no. 8
[PUBMED]    
9.
Cao X, Ursea R, Shen D, Ramkumar HL, Chan CC. Hypocellular scar formation or aberrant fibrosis induced by an intrastromal corneal ring: A case report. J Med Case Rep 2011;5:398.  Back to cited text no. 9
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10.
Mascarenhas J, Lalitha P, Prajna NV, Srinivasan M, Das M, D'Silva SS, et al. Acanthamoeba, fungal, and bacterial keratitis: A comparison of risk factors and clinical features. Am J Ophthalmol 2014;157:56-62.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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