Download A Presentation of Pseudomonas aeruginosa Keratitis Secondary to

A Presentation of Pseudomonas aeruginosa Keratitis Secondary to Contact Lens Overwear
Stephanie M. Sloan, OD
Abstract
Microbial Keratitis due to contact lens overwear can be a serious vision threatening condition.
We present a case involving the central cornea which was found to be secondary to
Pseudomonas aeruginosa.
I. Case History
- 54 y.o. African American female
- Sudden, worsening pain with yellow discharge and extreme photophobia OS x 3 days
- Ocular/Medical Hx: contact lens related red eye – unknown diagnosis, breast cancer
- Meds: ibuprofen, visine; NKDA
- “trial period” for contact lenses, 2 week lens, current pair 3-4 weeks old, sleeps in lenses, h/o
swimming in lenses but hasn’t for over 2 months, using unknown generic contact lens solution
II. Pertinent findings
- BCVA: 20/20 OD, 1/400 – PH: NI OS
- SLE (photos): OS: 3+ lid edema c thickened margins, lashes matted together, 4+ conjunctival
injection, 4+ chemosis, 2.4mmx2.7mm central ulcer c infiltrate, discharge, peripheral corneal
neovascularization 360, 1.8mm hypopyon, 4+ cell, 2+ flare
- IOP: deferred 2’ corneal pathology
- DFE: no view 2’ corneal pathology
- Pt referred same day to Corneal Specialist for corneal culture
- Laboratory studies: eye culture and stain, acanthamoeba culture and stain, eye fungal culture
- Results: moderate Pseudomonas aeruginosa, few Staphylococcus epidermidis
III. Differential diagnosis
- Bacterial keratitis
- Acanthomeba keratitis
- Herpes Simplex Virus keratitis
IV. Diagnosis and discussion:
- Diagnosis: Bacterial Keratitis secondary to Pseudomonas aeruginosa
- Pseudomonas aeruginosa is a virulent and rapidly progressing Gram-negative bacterium that
can be found in soil and water
- Produces proteases which invade or kill corneal cells
- Coordinate expression of virulence factors
- Activate immune system pathways via toll-like receptors (TLRs) which consequently
causes continued destruction
- P. aeruginosa has a more severe presentation when compared to a cohort of microbial keratitis
- Large and deep infiltrate
- Significant decrease in visual acuity
- Suppurative
- Associated hypopyon
- 30,000 cases of microbial keratitis in the US every year
- P. aeruginosa responsible for up to 39% of microbial keratitis cases in the US
- 3-5 per 10,000 contact lens wearers per year affected
- Low Dk contact lenses can cause corneal hypoxia which can be exacerbated under
closed-eye conditions
- Reduced epithelial cell turnover with contact lens wear creates opportunity for
infection
V. Treatment, management
- Vision threatening, severe keratitis
- Deep stromal involvement or infiltrate larger than 2mm with extensive suppuration
- Fluoroquinolone loading dose after obtaining culture
- Every 5-15 minutes for the first 30-60 minutes, then, every 30-60 minutes for
24 hours
- Cycloplegic agent to decrease synechia formation and pain
- Fortified tobramycin or gentamicin (15mg/mL) q1hr altered with fortified cefazolin
(50mg/mL) or vancomycin (25mg/mL) q1hr
- Taper antibiotics as directed, based on clinical situation
- Adjunct corticosteroid recommended when infection is controlled
- Potentially decrease scarring - SCUT trial
- Contact lens wear must be discontinued
- Systemic antibiotics necessary if adjacent tissues become infected or impending or
frank perforation of the cornea is evident
- Follow-up examinations performed daily unless hospitalization is required due to
concern for noncompliance or need for intravenous antibiotics
- This patient was cultured and then empirically treated with tobramycin 1.53% q2hr OS which
was alternated every hour with vancomycin 5% q2hr OS, as well as cyclopentolate 1% BID OS.
- Medications then altered after pathology confirmation of Pseudomonas aeruginosa
- Fortified tobramycin 1.53% q2hr OS, ciprofloxacin gtts q2hr OS and ung qhs
OS, cyclopentolate BID OS
- Antibiotics tapered as infection resolved
- Pred Forte TID OS added 2 weeks after initial onset
VI. Conclusion
- Understanding the array of clinical presentations of microbial keratitis increases
effectiveness of empirical treatment and management
- The incidence of microbial keratitis can be minimized with increased patient education of
risk factors and preventative measures
- Bibliography
- American Academy of Ophthalmology Cornea/External Disease Panel. Preferred
Practice Pattern Guidelines. Bacterial Keratitis. San Francisco, CA: American Academy of
Ophthalmology; 2013. Available at: www.aao.org/prp.
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corticosteroids in the treatment of bacterial keratitis.” JAMA Ophthalmol. 2014
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KC, Oldenburg CE, Lee SM, Zegans ME, McLeod SD, Lietman TM, Acharya NR; Steroids
for Corneal Ulcers Trial Group. “Corticosteroids for bacterial keratitis: the Steroids for
Corneal Ulcers Trial (SCUT).” Arch Ophthalmol. 2012 Feb;130(2):143-50. doi:
10.1001/archophthalmol.2011.315. Epub 2011 Oct 10. PubMed.
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John K. Dart, DM, Garry Brian, and Brien Holden, DSc. "Risk Factors for Moderate and
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