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Corneal Infiltrative Events (CIE) and Contact Lenses: Avoidable
or Not?
Lyndon Jones PhD DSc FCAHS FCOptom FAAO FIACLE FBCLAProfessor
& University Research ChairSchool of Optometry & Vision
Science
Director, Centre for Ocular Research & Education
(CORE)University of Waterloo, Ontario, Canada
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Over the past three years, members of CORE have received
research funding and/or honoraria from the following 15 companies
& 3 funding agencies:
Lyndon Jones PhD, DSc, FCAHS, FCOptom, FAAO Financial
Disclosures
• Alcon• Allergan• Contamac• CooperVision• GL Chemtec
• Inflamax Research• Johnson & Johnson Vision• Menicon•
Nature’s Way• Novartis
• Safilens• Santen • Shire • SightGlass• Visioneering
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3
Corneal Infiltrates vs Microbial Keratitis
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• An infiltrate is a collection of inflammatory cells (usually
polymorphonuclear leucocytes) located within the cornea
• located within the epithelium or subepithelial layers
• Self-limiting inflammatory response
Definition
1. Efron N: Contact Lens Complications. 3rd ed. 2012, Oxford:
Elsevier.2. Steele & Szczotka-Flynn: Epidemiology of contact
lens-induced infiltrates: an updated review. Clin Exp Optom 2017;
100;5: 473-481.
Stroma
Epithelium
Tears
Bowman’s
Stroma
Epithelium
Tears
Bowman’s
Intraepithelial infiltrates Subepithelial infiltrates (SEI)
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• Infiltrates appear as small, hazy whitish areas often
surrounded by edema • Can be single or diffuse
Appearance
1. Dumbleton: Adverse events with silicone hydrogel continuous
wear. Cont Lens Anterior Eye 2002; 25;3: 137-46.2. Sweeney et al.:
Clinical characterization of corneal infiltrative events observed
with soft contact lens wear. Cornea 2003; 22;5: 435-42.3. Steele
& Szczotka-Flynn: Epidemiology of contact lens-induced
infiltrates: an updated review. Clin Exp Optom 2017; 100;5:
473-481.
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Contact Lens Peripheral Ulcer (CLPU)
1. Grant et al.: Contact lens induced peripheral ulcers during
hydrogel contact lens wear. CLAO J 1998; 24;3: 145-51.2. Holden et
al.: Contact lens-induced peripheral ulcers with EW of disposable
hydrogel lenses: histopathologic observations on the nature and
type of corneal infiltrate. Cornea 1999; 18;5: 538-43.3. Hume et
al.: Contact lens induced peripheral ulcers (CLPU) are produced by
an alpha-toxin deficient mutant of Staph aureus. Investigative
Ophthalmology & Visual Science 2001; 42;4: S593-S593.4.
Dumbleton: Adverse events with silicone hydrogel continuous wear.
Cont Lens Anterior Eye 2002; 25;3: 137-46.5. Wu et al.: The causes
of and cures for contact lens-induced peripheral ulcer. Eye Contact
Lens 2003; 29;1 Suppl: S63-6; discussion S83-4, S192-4.
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Microbial Keratitis
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• Infection of the cornea with pathogenic organism• most
typically bacteria• associated inflammation and destruction of the
cornea
• Sight-threatening ocular emergency• Variety of terms
• corneal ulcer• infectious keratitis• ulcerative keratitis•
bacterial keratitis
Microbial Keratitis (MK)
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• CL Wearers• 70% Pseudomonas aeruginosa (gram –ve)
• Non CL wearers• 50% Staph aureus (gram +ve)
• Emerging gram –ve pathogens 1,2• Achromobacter xylosoxidans•
Delftia acidovorans• Stenotrophomonas maltophilia
Major microbial types in MK
1. Wiley et al., Bacterial biofilm diversity in contact
lens-related disease: emerging role of Achromobacter,
Stenotrophomonas, and Delftia. IOVS 2012. 53(7): p. 3896-905.2.
Willcox et al., Contact lens case contamination during daily wear
of silicone hydrogels. Optom Vis Sci, 2010. 87(7): p. 456-64.
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• Acutely painful• increasing pain despite CL removal
• Patient may notice “white spot” on cornea• Redness• Discharge
/ tearing• Photophobia• Reduced vision• Swollen lid
Symptoms of MK
Sweeney et al.: Clinical characterization of corneal
infiltrative events observed with soft contact lens wear. Cornea
2003; 22;5: 435-42.
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• 23 year-old male• SCL wearer• Non compliant with care regimen•
Red eye (OD) for 1 day• Significant pain & photophobia•
Significant epiphora• Significant hyperemia• VA 6/12 OD, 6/5 OS
My 1st MK Case: 1986
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Slit Lamp Appearance: 1986
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My Last MK Case: 2016
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Management: Scleral Lens Fit
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• Lower risk than bacterial keratitis • 5-10% of all CL-related
MK
• Acanthamoeba 1-4• Non-sterile water exposure (including
swimming in CLs)• Poor compliance• CL solutions (US 2007; UK
2018)
• Fungal keratitis (mainly Fusarium) 5-7• Poor compliance• CL
solution (global 2004-2006)
• formulation and storage conditions
Acanthamoeba & Fungal Keratitis
1. Szentmary et al.: Acanthamoeba keratitis - Clinical signs,
differential diagnosis and treatment. J Curr Ophthalmol 2019; 31;1:
16-23.2. Arshad et al.: Water Exposure and the Risk of Contact
Lens-Related Disease. Cornea 2019.3. Joslin et al.: The association
of contact lens solution use and Acanthamoeba keratitis. Am J
Ophthalmol 2007; 144;2: 169-180.4. Carnt et al.: Acanthamoeba
keratitis in 194 patients: risk factors for bad outcomes and severe
inflammatory complications. Br J Ophthalmol 2018; 102;10:
1431-1435. 5. Chang et al.: Multistate outbreak of Fusarium
keratitis associated with use of a contact lens solution. JAMA
2006; 296;8: 953-63.6. Saw et al.: Risk factors for contact
lens-related fusarium keratitis: a case-control study in Singapore.
Arch Ophthalmol 2007; 125;5: 611-7.7. Bullock et al.: Effects of
time, temperature, and storage container on the growth of Fusarium
species: implications for the worldwide Fusarium keratitis epidemic
of 2004-2006. Arch Ophthalmol 2011; 129;2: 133-6.
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Incidence
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MK Rates for All CL Types(modern lenses)
DW RGP DW SCL DD SCL DW SH EW SCL EW SH0
20
40
60
80
100
120
Ann
ual I
ncid
ence
(per
10,
000)
2.96.4 4.9
0
96.4
19.8
1.2 1.9 2
11.9
19.525.4
Morgan 2005 Stapleton, 2008
Lowest for RGPHighest for EW
Severe keratitis and MK
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MK Rates for EW SCL
Hydrogel ~ SiHy
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MK Rates for DW SCL
No change over 25 years!
Willcox: Microbiology and CL wear. CL Spectrum April 2011
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Incidence of MK with OK in Children• 1317 patients• 640 adults
(49%) and 677 children
(51%) • 2599 patient-years of wear • Incidence
– 13.9 per 10,000 px years• Risk of MK with overnight
corneal
reshaping contact lenses is similar to that with other overnight
modalities
Bullimore et al.: The risk of microbial keratitis with overnight
corneal reshaping lenses. Optom Vis Sci 2013; 90;9: 937-44.
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• Difficult• depends upon criteria used for classification, lens
type worn, frequency of visits and
quality of the observers in the study• Daily wear
• symptomatic• 0.5-3%
• asymptomatic• 3-5%
• Extended wear• symptomatic
• 2-6%• asymptomatic
• 20-25%
Annualised Incidence for IK
Steele & Szczotka-Flynn: Epidemiology of contact
lens-induced infiltrates: an updated review. Clin Exp Optom 2017;
100;5: 473-481.
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Risk Factors
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Relative Risk Factors For CIEFactor Relative Risk
Non-modifiable
Age (18-29) 2.2xYoung age (50) 2xMales 1.4xRefractive error >
± 5 D 1.2-1.6xPrevious history of CIE 2.5-6.1x
Modifiable
Smoking 1.4-2.7xOvernight wear 2.4-7xMultipurpose solutions
2.9-3.8xBacterial bioburden 5x (lids); 8x (lens)
Modified from Steele & Szczotka-Flynn: Epidemiology of
contact lens-induced infiltrates: an updated review. Clin Exp Optom
2017; 100;5: 473-481
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Question• Which soft lens material has been shown to provide
the lowest risk for the development of corneal infiltrates in
reusable lenses?
a) Hydrogels b) Silicone hydrogelsc) No difference
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Infiltrative Keratitis: Reusable CL• Consistently ~2X higher
rate with
reusable SiHy 1-4
1. Szczotka-Flynn & Diaz: Risk of corneal inflammatory
events with silicone hydrogel and low dk hydrogel extended contact
lens wear: a meta-analysis. Optom Vis Sci 2007; 84;4: 247-56.2.
Radford et al.: Risk factors for nonulcerative contact lens
complications in an ophthalmic accident and emergency department: a
case-control study. Ophthalmology 2009; 116;3: 385-92.3. Chalmers
et al.: Age and other risk factors for corneal infiltrative and
inflammatory events in young soft contact lens wearers from the
Contact Lens Assessment in Youth (CLAY) study. Invest Ophthalmol
Vis Sci 2011; 52;9: 6690-6.4. Chalmers et al.: Multicenter
case-control study of the role of lens materials and care products
on the development of corneal infiltrates. Optom Vis Sci 2012;
89;3: 316-25.
Study Rate with SiHy compared with hydrogel
1. Szczotka-Flynn & Diaz 2007 2.18 – 2.23x2. Radford et al
2009 2x3. Chalmers et al 2011 1.85x4. Chalmers et al 2012 1.84x
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Reducing CIE risk
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Question• How much lower is the risk of developing corneal
infiltrates if a patient switches to daily disposable lenses
from reusable lenses?
a) 2x b) 6xc) 12x
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Infiltrative Keratitis & DD Contact Lenses
1. Chalmers et al.: Age and other risk factors for corneal
infiltrative and inflammatory events in young soft contact lens
wearers from the Contact Lens Assessment in Youth (CLAY) study.
Invest Ophthalmol Vis Sci 2011; 52;9: 6690-6.
2. Chalmers et al.: Multicenter case-control study of the role
of lens materials and care products on the development of corneal
infiltrates. Optom Vis Sci 2012; 89;3: 316-25.
“12x lower risk of IK with DD lenses”
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Infiltrative Keratitis & DD: Hydrogel vs SiHy• 1171 subjects
(960 years of wear)
– 489 years of SiHyDD (1-Day Acuvue TruEye)– 471 years of HydDD
(1-Day Acuvue Moist)
• Adverse events recorded and practice records reviewed• Only 1%
had SCL complications that prompted visits to ECP• SiHy DD = HydDD•
Risk factors associated with recorded events
– overnight wear = 30%– storage & reuse = 21%– >5.0D =
22%– Age
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Summary
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Hydrogels vs SiHy• CIEs are a potential issue for CL wearers•
Need to be able to differentiate between MK & IK
– careful slit lamp examination required• Be aware of the risk
factors
– be careful of lens choice and modality with those who have
higher risk factors
• Infiltrates lower with reusable hydrogels compared with
reusable SiHy
• Infiltrates lowest with DD lenses
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• Stop sleeping in lenses• Be wary of
• smokers• those in the age group 18-29• non-compliant males•
previous inflammatory response• those exhibiting blepharitis or
meibomian gland dysfunction
• higher levels of gram +ve bioburden on the lids
• Switch to peroxide• Switch to daily disposables• Improve
compliance with respect to
• Water exposure• hand washing• case replacement & case
cleaning
Reducing CIE Risk
Steele & Szczotka-Flynn: Epidemiology of contact
lens-induced infiltrates: an updated review. Clin Exp Optom 2017;
100;5: 473-481.
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THANK YOU
Foliennummer 1Lyndon Jones PhD, DSc, FCAHS, FCOptom, FAAO
�Financial DisclosuresFoliennummer 3DefinitionAppearanceContact
Lens Peripheral Ulcer (CLPU)Microbial KeratitisMicrobial Keratitis
(MK)Major microbial types in MKSymptoms of MKMy 1st MK Case:
1986Slit Lamp Appearance: 1986My Last MK Case: 2016Management:
Scleral Lens FitAcanthamoeba & Fungal KeratitisFoliennummer
19MK Rates for All CL Types�(modern lenses)MK Rates for EW SCLMK
Rates for DW SCLIncidence of MK with OK in ChildrenAnnualised
Incidence for IKFoliennummer 25Relative Risk Factors For
CIEQuestionInfiltrative Keratitis: Reusable CLFoliennummer
29QuestionInfiltrative Keratitis & DD Contact
LensesInfiltrative Keratitis & DD: Hydrogel vs SiHyFoliennummer
33Hydrogels vs SiHyReducing CIE RiskFoliennummer 36THANK YOU