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1 Manchester Royal Eye Hospital, Manchester, UK
2 Eurolens Research, The University of Manchester, Manchester, UK
3 Manchester Royal Infirmary, Manchester, UK
Keywords: Pseudomonas aeruginosa; microbial keratitis; contact lens wear
Cosmetic coloured contact lenses are worn to give the appearance of a different or unusual eye colour and about 60 000 people in the United Kingdom obtain these types of contact lenses through eye care professionals.1 A subset of these lenses—those with no optical power ("plano" coloured lenses)—falls outside legislation designed to restrict the sale of contact lenses to suitably qualified professionals. We report a severe case of microbial keratitis caused by Pseudomonas aeruginosa which has resulted in lasting visual impairment in a patient obtaining cosmetic coloured contact lenses from a fashion shop rather than through an eye care practitioner.
CASE REPORT
An 18 year old south Asian male student presented in December 2003 with a 2 day history of a foreign body sensation in his left eye. One day before presentation the eye had become slightly red. He had commenced the use of Brolene eye drops which had been purchased from a large chain supermarket. The eye then became painful with eyelid swelling and he presented to the local district general hospital the following day. He was diagnosed with a corneal ulcer and referred to our institution.
He reported a 12 month history of cosmetic coloured plano contact lens wear, having purchased the lenses from a fashion shop rather than through an eye care professional. No counselling was provided at the point of purchase regarding a hygiene routine, care of lenses, or possible complications associated with their use. He wore the lenses 12 hours per day, 7 days per week without any overnight use. The lenses were designed to make the eye appear grey or blue (patient’s natural eye colour was brown). There was no past medical or ocular history of note including amblyopia.
On examination the unaided vision was 6/6 in the right eye and 6/36 in the left eye. The left eye demonstrated a mid-peripheral corneal infiltrate in the 4 o’clock position with overlying 2.4 mm diameter ulcer, and surrounding stromal swelling (fig 1). There was a 0.5 mm height hypopyon. The intraocular pressure was within the normal range. The right cornea demonstrated a very small peripheral infiltrate with no significant anterior chamber reaction. Both posterior segments were unremarkable. A corneal scrape was performed with the Gram stain demonstrating a small quantity of neutrophils and Gram negative bacilli. Ofloxacin 0.3% drops were commenced every hour to the left eye. The peripheral infiltrate resolved with the corneal epithelial healed by day 10. Topical prednisolone 0.5% was commenced on day 4. A more central mid stromal corneal infiltrate encroaching on the visual axis developed on day 1 after admission and has gradually become less prominent during follow up over 3 months (fig 2) although the visual acuity remains reduced at 6/36. Pseudomonas aeruginosa was grown from the corneal scrape, sensitive to ciprofloxacin, ofloxacin, gentamicin, and ceftazadine. The right eye was not scraped, responded well to topical ciprofloxacin drops, and did not develop any scarring. The contact lenses and their cases were also investigated as there was a high degree of suspicion that clinically they would be contaminated. All grew Pseudomonas aeruginosa with a sensitivity profile identical to the corneal scrape specimen. Mixed coliform growth was also noted also in one of the contact lens cleaning solutions.
Figure 1 Large corneal infiltrate with overlying area of ulceration on presentation.
Figure 2 Residual central corneal infiltrate at 1 month after presentation.
COMMENT
The use of cosmetic coloured plano contact lenses, sourced via non-professional suppliers is becoming increasingly common and fashionable. Their use over the past 12 months has increased fourfold and stores have reportedly sold more than one million pairs.2 Their purchase is currently possible from non-eye care professional retailers without any ocular assessment, customised fitting, or verbal counselling regarding a hygiene routine, care of the lenses, or possible complications associated with their use. In addition, there is often no plan for follow up.
Potential complications are the same as those for all contact lenses and have been documented in a recent case series in the United States.3Pseudomonas aeruginosa microbial keratitis with vision loss requiring elective penetrating keratoplasty, presumed herpes simplex related corneal scarring causing legal blindness, acute iridocyclitis, corneal hypoxia, microcystic oedema, punctuate keratopathy, corneal abrasions, and giant papillary conjunctivitis were all documented.
In the United Kingdom, the Opticians Act 1989 states that a person who is not a registered medical practitioner or registered optician shall not fit contact lenses. Plano (or "afocal") contact lenses are not included in this act because they have no optical power. The General Optical Council has received reports of these lenses being shared and exchanged between wearers and of sales staff demonstrating fitting on themselves before offering the lens to the purchaser.4 In November 2000 the General Optical Council submitted recommendations to the Department of Health arguing that primary legislation should be passed stipulating that the fitting and sale of plano contact lenses should also fall within the terms of the act. On 28 October 2003 Mr John Robertson, MP for Anniesland, Glasgow, moved a bill to amend the Opticians Act 1989 to include plano contact lenses in the restrictions already placed on the sale of other contact lenses.5
This case report highlights the potential complications of these lenses and supports legislation restricting their sale.
References
Morgan PB. Healthcheck on the contact lens market. Optician 2003;226:32–33.
McKie R . ‘Alien’ lenses put young eyes at risk. The Observer. 2003 November 9.
Steinemann TL, Pinninti U, Szczotka, et al. Ocular complications associated with the use of cosmetic contact lenses from unlicensed vendors. Eye Contact Lenses 2003;29:196–200.
Cosmetic contact lenses draft explanatory notes.
The United Kingdom Parliament. Bill moved by Mr John Robertson (Glasgow, Anniesland): Non-Prescription Contact Lenses. 28 October 2003: Column 176, 1.21 pm.