Contact Lens-Induced Peripheral Corneal Ulcer

Contact lens-induced peripheral infiltration or sterile ulceration is a type of marginal keratitis.  

It is an acute, non-infectious inflammatory condition that is usually associated with overnight contact lens wear, wearing old disposable lenses, poor lens hygiene, anoxia and idiopathic factors. 

Contact lens-induced peripheral ulcer (CLPU) or sterile infiltrates are characterized by the following abnormal signs and symptoms: 

• Pain upon awakening
• Foreign body sensation
• Increased tearing
• Increased ocular redness
• Photophobia
• Blepharospasm
• Intermittent decreased vision

Case Report

• A 24-year-old Black woman presented with a chief complaint of eye pain
• Case history described a subjective decrease in comfort over the past 24 hours
• The patient routinely slept in her contact lenses for 1-2 weeks at a time 

Conclusion

This presentation presents the common diagnostic dilemma of pure inflammation versus inflammatory disease progressing toward infection versus true corneal infection.  Because the clinical signs and symptoms of all three diseases are similar, accurate differential diagnosis is the key to proper treatment.

History of Present Illness

• Associated Signs and Symptoms: decreased vision in the right eye
• Location: right eye
• Duration: this morning (approx 2 hours)
• Quality: deep ocular pain
• Context: sensitive to bright light
• Severity: severe
• Timing: pain is getting worse over time
• Modifiers: none 

Review of Systems

• The patient reported that she was in good health and taking no medications
  
  

Past, Family and Social History

• Non-contributory

Best Corrected Distance Visual Acuity

• 20/30 in the right eye
• 20/20 in the left eye 

Normal Examination Findings

• Mental status
• General medical observation
• Pupils  
• Adnexal examination
• Ophthalmoscopy   

Not Performed on Today’s Examination

• Gross visual fields
• Basic sensorimotor examination

General Medical Observation

• A well-nourished female in moderate distress secondary to eye pain

Intraocular Pressure Measurements

• 15 mm Hg in the right eye
• 7 mm Hg in the left eye

External Ocular Examination with Biomicroscopy

• Begin the biomicroscopic examination with an overview of the cornea using low magnification
• Use a diffuse illumination technique for the initial assessment
• Evaluate corneal infiltrates using high magnification views with direct and indirect illumination techniques as well as vital dye staining techniques

Clinical Appearance of the Cornea and Conjunctiva Sub-epithelial corneal infiltrate separated from the limbus by a clear zone Lesion is small, round, and dense Associated corneal neovascularization Associated focal corneal edema Associated limbal hyperemia Negative fluorescein staining over lesion with surrounding positive staining

Clinical Diagnosis

The clinical diagnosis is a determination based on the knowledge obtained from the patient’s medical history and from the results of the eye examination alone, without the benefit of diagnostic tests or procedures.

The patient’s clinical diagnosis is contact lens-induced peripheral corneal ulcer based on the following clinical findings:

• History of overnight contact lens wear
• Clinical appearance of the involved eye
• Nature of the presenting problem

Treatment Plan

To gather the clinical information required to treat contact lens-induced peripheral corneal micro-ulcer, a diagnostic and treatment program is initiated.

• Determination of different types of diagnoses
• Selection of one or more treatment options

After a clinical diagnosis has been determined, the diagnostic process continues with a process that involves the identification and exclusion of differential diagnoses.  The differential diagnosis process allows the doctor to distinguish between two or more diseases with similar signs and symptoms by systematically comparing their signs and symptoms.

Conditions presenting with similar presentations include:

Sterile, peripheral corneal infiltrate

• Presentation similar to ulceration but epithelium predominantly intact with negative staining
• Not specifically associated with contact lens wear
• Marginal keratitis
• Lesion typically more widespread
• Mucopurulent discharge
• Concurrent eyelid disease
• Immune compromise

Bacterial Keratitis

• Typically focal involvement but more toward central or midperipheral cornea
• Common to have tissue ulceration with extensive infiltration that spreads away from the lesion
• Significant corneal edema

		Microbial Keratitis Microbial keratitis with associated hypopyon  Characterized by an epithelial defect with stromal infiltration Can be cause by contact lens wear, particularly overnight soft contact lens wear Associated with corneal trauma from surgery or agricultural injury Associated with concurrent ocular surface disease Systemic immunosuppression is a risk factor Diabetes is a risk factor Nutritional deficiency is a risk factor
Marginal Keratitis Bacterial hypersensitivity-mediated immune reaction  Associated with eyelid margin disease Previous corneal inflammation is a risk factor Systemic immunosuppression is a risk Most often at inferior limbus but sometimes 3/9 position Generally, no history of contact lens wear

• External ocular photography
• Laboratory analysis

The decision to order and perform additional testing is totally based on the concept of medical necessity which can only be determined by the examining optometrist or ophthalmologist.

Anterior Segment Photography

Any case of compromised tissue that could pose a threat to function could justify the medical necessity of photodocumentation.  In this case, the compromised cornea tissue posed risks of infection, true ulceration, and loss of vision.  Photodocumentation of the tissue provides a baseline to monitor disease regression and efficacy of treatment.

Laboratory Testing

When there is significant suspicion of true corneal infection, cultures of the suspected pathogen can be considered.  Laboratory testing can also be indicated when the presentation does not respond to treatment as expected.  In the case of this patient, true infection was not suspected and laboratory analysis not considered medically necessary.

Physical Diagnosis

Completion of the differential diagnosis process either returns you to the original clinical diagnosis or it produces a more substantiated physical diagnosis.  This component of the diagnostic and treatment program, the determination of a physical diagnosis, is accomplished by studying the physical manifestations of health and illness revealed in the eye examination, the patient’s complete medical history, and supported by various diagnostic tests and procedures.

According to Current Procedural Terminology, when eye doctors perform ophthalmological examinations, the complexity of medical decision-making is not separated from the examining techniques used.  However, as a tool to assist eye doctors in enhancing their medical decision-making skills, consider that the complexity of medical decision-making in this case report involves three components.

Diagnosis Guidelines

The first component concerns the number of possible diagnoses and treatment options that must be considered.  The diagnosis and treatment of a potential corneal ulcer is predicated on making the proper diagnosis and on understanding the natural history of corneal ulceration.

The second component concerns the amount and complexity of medical records and diagnostic tests that have to be obtained, reviewed and analyzed.  In addition to an eye examination, this visit required the review and analysis of external photodocumentation.

Third, the complexity of medical decision-making is affected by the risk of significant complications and/or morbidity associated with a potential corneal ulcer and the risks involved in any treatment options.  True corneal ulcers are a sight and even eye threatening presentation.  Even corneal infiltrates pose a signficant risk of scarring and conversion to a more serious ulcerative or infection process. 

Treatment Options

To begin the treatment of a corneal infiltrate, the eye doctor must consider the risk of the presenting lesion converting to an infectious process.  This is a difficult and sometimes impossible process of clinical guess work.  It can be considered conservative if not prudent to consider all corneal lesions as infectious until proven otherwise.  This is even more of a factor in a contact lens patient, much less one who abuses lens wear.  To this end, aggressive treatment could be recommended initially until the risk of secondary infection is minimized.  In 24 hours, a non-infectious lesion with antibiotic cover often does not appear any better but is no worse.  Ultimately, sterile infiltrates are a pure inflammatory response and should be treated as such. 

Moxeza ophthalmic solution was prescribed q2h and the patient scheduled for a follow-up evaluation the next day.   The next day there was a slight reduction in inflammation and no change in the staining pattern.  Omnipred ophthalmic solution was prescribed qid, the Moxeza dosage was reduced to tid and the patient asked to return in two days.  At that visit there was significant reduction in inflammation and patient symptoms.  The corneal lesion was reduced in size.  The Moxeza was discontinued, Omnipred continued and the patient scheduled to return in five days.  Strong counseling was provided regarding safe wear of contact lenses and any overnight wear of lenses discouraged.