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Original Article
Cosmetic Soft Contact Lens Associated Ulcerative
Keratitis in Southern Saudi Arabia
Almamoun Abdelkader

ABSTRACT

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Purpose: To review the microbiologic profile, clinical course, treatment, and outcome of patients
with cosmetic contact lens(CL)associated ulcerative keratitis.
Materials and Methods: Observational noncomparative case series selected from an ongoing
prospective series. Fortysix subjects examined at a corneal specialty practice in Abha,
southern Saudi Arabia between April 2012 and June 2013, who presented with corneal stromal
infiltrate on slitlamp examination, were included in the study.
Results: All patients were emmetropic, and lenses were worn solely for cosmetic purposes.
Nine(19.5%) of 46 CLwearing patients presented with laboratoryproven infectious keratitis.
Pseudomonas was the most common organism(6/9; 66.6%). Staphylococcus species were the
second most common, occurring in two(22.2%) of the nine cases. Streptococcus viridans in
one case(11%). Laboratorybased medical therapy led to the healing of ulcers in all cases.
Thirtyseven(80.4%) patients had sterile infiltrates.
Conclusions: Overthecounter use of cosmetic lenses is rapidly increasing. The easy
availability of these lenses is resulting in severe sightthreatening complications in some
young emmetropic individuals. Prompt treatment of microbial keratitis is important to
prevent vision loss.

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DOI:
10.4103/0974-9233.134677
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Key words: Corneal Ulcer, Cosmetic Contact Lens, Keratitis

INTRODUCTION

orneal contact lenses(CLs) are worn for cosmetic, visual,

or therapeutic purposes by many patients. Improper use of
CL can cause numerous complications. CLassociated microbial
keratitis remains a serious condition with sightthreatening
complications. Early diagnosis, identification of the responsible
organism, and prompt antimicrobial therapy are mandatory for
effective treatment.
Several studies have reported an increased risk of infectious
keratitis with the use of soft CL. As the CL wearing population
has increased, many studies have been performed on the
complications associated with soft CL use.15 The popularity
of colored CLs has increased among younger generations in
recent years. Abuse of CL wear and failure to follow the specific
instruction when using CL could result in sightthreatening

complications. The risk factors of CLrelated corneal ulcers are:

Overnight wear, extended continuous wear, lower socioeconomic
status, smoking, dry eye, and poor hygiene.6 Other known
factors predisposing to corneal ulcer formation are the lens
material, lens design, lens wearing schedule, lens care patterns,
and immunosuppressive state.7
A corneal ulcer develops when there is a break in the corneal
epithelium. In the normal eye, the surface of the cornea is
constantly lubricated by the tear film. The tears play a major
role in delivering adequate oxygen to the cornea and maintaining
adequate lubrication for the cornea. Studies have shown that
continuous overnight use of CL is a major risk factor for corneal
ulcer formation.8 CL wear during sleep results in reduced
tear flow and oxygen delivery to the cornea. Hence, hypoxia
and hypercapnia of the corneal epithelium occur, resulting
in ischemic necrosis. Astudy found that the relative risk for

Department of Ophthalmology, Faculty of Medicine, AlAzhar University, Cairo, Egypt

Corresponding Author: Dr.Almamoun Abdelkader, Department of Ophthalmology, Abha Private Hospital, 1794 Abha,
Kingdom of SaudiArabia. Email:Mamoun_kader@yahoo.com

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Abdelkader: Cosmetic Contact Lens-associated Ulcerative Keratitis

overnight CL wear(for any lens type) was 5.4times higher than

for nonCL users.7 Superimposed bacterial infections especially
with Pseudomonas aeruginosa can be very severe and can lead to
catastrophic blindness if they are not treated promptly.9

significant. Data were expressed as mean, range, and standard

deviation(SD).

In this study, I evaluate the clinical characteristics, clinical

management, and outcome of CLinduced keratitis(CLIK)
associated with cosmetic CL wear.

Fortysix patients with CLIK due to cosmetic CL wear comprised

the study group. All patients were emmetropic, and lenses were
worn solely for cosmetic purposes. All lenses were purchased
without an eye examination, proper fitting, wear and care
instructions, or followup. Twentyfour lenses were dispensed
without prescription or fitting from an unlicensed optical
shop, nine patients had shared lenses with friends/relatives.
Six patients admitted to sleeping with the lenses on. None
of the patients followed the recommended CL handling and
storage techniques. Twentytwo out of 46patients(47.8%)
had central ulcerative keratitis and 24(52.2%) had peripheral
ulcerative keratitis. The average size of the ulcer was 4.3mm.
No eyes developed anterior chamber reaction or hypopyon.
The mean age of all patients was 26.765.9years, 44 were
female(95.7%) and two males(4.3%). Six(13%) patients used
nondisposable soft CLs and 40(87%) patients used disposable
CLs. Thirtyseven(80.4%) of the total number of patients had
a daily wearing schedule and nine(19.6%) used their CLs for
longer than recommended. Mean wearing time per day was
14.44.8 h. The characteristics of CL wearers examined for
CLIK are summarized in Table1.

MATERIALS AND METHODS

This study adhered to the tenets of the Declaration of Helsinki
and was approved by the Institutional Review Board. Written,
informed consent was obtained from all patients. The study
comprised all consecutive patients presenting with CLIK
between April 2012 and June 2013 at a corneal specialty
practice in Abha(southern Saudi Arabia). The history included
duration of current CL use, initial symptoms, sharing of CLs,
and CL hygiene practices. Extended wear was defined as a
24h use at least once per week, less frequent overnight wear
was defined as daily wear. Based on the clinical characteristics,
patients were assigned according to the location of the ulcer to
one of two categories, namely central keratitis, presenting in a
central, approximately 6mm diameter zone of the cornea, and
peripheral keratitis, manifesting within 2mm of the limbus.
The visual acuity of each eye of the patient was measured using
the standard Snellen projector chart. One drop of topical
anesthesia 0.5% proparacaine hydrochloride(Alcaine, Alcon,
USA) was instilled if the patient could not open the eye due
to blepharospasm or photophobia. The fluorescein strips
were used and the corneal ulcer was examined using a slit
lamp biomicroscope. Both CLs and carrying box were sent to
the laboratory for culture and sensitivity tests. Proparacaine
hydrochloride 0.5% was used to anesthetize the cornea. Corneal
scrapings with Grams stain microscopy and culture with
antibiotic sensitivity tests were performed. The culture specimen
was obtained from the edge and the bed of the ulcer. The
material was inoculated on culture media(blood agar, chocolate
agar, and Sabouraud agar); gram staining was carried out and
subsequently culture and sensitivity tests were performed. The
initial treatment protocol of patients with bacterial keratitis
was either(1) topical ciprofloxacin(Ciloxan; Alcon, Inc., Fort
Worth, TX, USA) and gentamicin(1.4%) every minute for 5min
and then every 30min for the 1st day, to be tapered according
to clinical response; or(2) topical Vigamox(moxifloxacin HCl
0.5%, Alcon Inc., Fort Worth, TX, USA) every minute for 5min
and then every 30min for the 1st day, to be tapered according to
clinical response. Antibiotic therapy was modified as required
based on culture and antibiotic susceptibility reports. Final visual
outcome at the last followup was evaluated.
Statistical analysis was performed using the Students ttest
and a Pvalue less than 0.05 was considered statistically

RESULTS

Nine(19.5%) of 46 CLwearers patients presented with

laboratoryproven infectious keratitis. Pseudomonas aeruginosa was
the most common organism(6/9; 66.6%). Staphylococcusaureus
was the second most common, occurring in two(22.2%) of the
nine cases. Streptococcus viridans was isolated in one case(11%).
Laboratorybased medical therapy led to the healing of ulcers in
all cases. Thirtyseven patients(80.4%) showed sterile infiltrates
with no growth. Table2 presents the isolated microorganisms
that were found in the central and the peripheral CLIK cases.
All patients in this series were managed on an outpatient
basis. Thirtyfive(76.1%) patients were treated with topical
ciloxan(ciprofloxacin 0.3%) and gentamicin(1.4%) eye drops
and nine patients(21.7%) were treated with topical vigamox
(moxifloxacin HCl 0.5%). Two(4.34%) patients were treated
with moxifloxacin and other fortified drugs(fortified vancomycin
(50mg/ml). All cases responded well to topical therapy and none
required surgical intervention.
The mean followup period for all patients was
3.191.16months. Visual acuity was tested in all eyes with
keratitis at the time of presentation and at the last visit. The
predominant symptoms and clinical signs were eye pain, redness,
lacrimation, swollen lids, blepharospasm, and a decrease in
visual acuity. Sixteen(34.8%) eyes of 46patients with keratitis
had visual acuity of<6/60 at the time of presentation and all

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Abdelkader: Cosmetic Contact Lens-associated Ulcerative Keratitis

patients had best spectaclecorrected visual acuity of>6/12 at

the last visit[Table3].

DISCUSSION
The current study illustrates a significant trend that can cause
vision loss in southern Saudi Arabiathe unlicensed sale of
plano colored hydrogel CLs by vendors other than eye care
professionals. Cosmetic CLs are produced using molecular
imprinting and are colored using various methods such as dye
dispersion, vatdye tinting, chemicalbond tinting, and dye
printing.10 Colored lenses were first developed for patients with
abnormalities including aniridia or corneal opacity. However,
healthy people also currently use colored lenses to change the
color or the appearance of their eyes. These lenses are easily
available and are sold as cosmetic accessories by unauthorized
providers without any medical supervision.1113
Table1: Characteristics of contact lens wearers examined for
contact lensinduced keratitis
Mean age( SD)
Sex(females/males)
Nondisposable soft CL
Disposable soft CL
Daily wear
Extended wear
Central keratitis
Peripheral keratitis

Number of eyes

Percentage

44females
2males
6
40
37
9
22
24

95.7
4.3
13
87
80.4
19.6
47.8
52.2

Values are expressed in numbers(percentages), CLIK: Contact lens-induced

keratitis, SD: Standard deviation, CL: Contact lens

Table2: Microbial isolates from corneal scrapings

Isolated
microorganisms

Central
keratitis
(n=22)

Peripheral
keratitis
(n=24)

Numbers
of eyes
(n=46)

Percentages

Pseudomonas
aeruginosa
Staphylococcus
aureus
Streptococcus
viridans
No growth

13

4.35

2.17

15

22

37

80.4

Values are expressed in numbers(percentages)

Table3: Distribution of patients by visual acuity

Range of visual acuity
<3/60PL
<6/60-3/60
6/60
6/36-6/12
6/9-6/6
Total numbers
PL: Perception of light

234

Patients status(number)
At presentation

At last visit

9
7
10
14
6
46

0
0
0
0
46
46

Cosmetic lenses, like any other lenses, can induce epithelial

erosion, corneal neovascularization, and infectious keratitis.12,13
The color pigments used in these lenses can also induce allergic
reactions or toxic keratopathy and render roughness to the lens
surface, thereby causing trauma to the corneal epithelium.14
The most serious and sightthreatening complication associated
with CL use is ulcerative keratitis. Disposable CLs were
introduced in the expectation that their use would decrease
the risks of severe CLrelated complications. 15 However, we
found that disposable soft CLs seem to be a risk factor for
developing CLIK. In the current study, 87% of the patients
with keratitis used this type of CL. Pseudomonas aeruginosa has
been reported to be the main organism in all studies reporting
substantial numbers of CL wearers.1619 However, Staphylococcus
and gram negative organisms other than Pseudomonas are also
important.17,19,20 This is consistent with that observed in our
series where Pseudomonas aeruginosa was the most common cause
of microbial keratitis and Staphylococcus was the second most
common among laboratoryproven infectious keratitis.
Interestingly enough, 37(80.4%) of the 46patients with CLIK
were culturenegative. Only four of these patients received
topical antimicrobial treatment prior to the time of presentation.
These patients had sterile corneal infiltrates. These infiltrates are
suggested to be due to immunological or toxic reactions to CL
material, CL color pigments, or to the disinfecting systems.18 In
our series, all cases that were culturenegative responded well
to antibiotic therapy. It was encouraging to find good visual
recovery in the patients treated in the current study. At the end
of the study period all ulcers had healed and visual outcome was
stable. All patients had best spectaclecorrected visual acuity
of>6/12 at the last visit with no residual corneal scarring.
Overthecounter use of cosmetic lenses is rapidly increasing.
The easy availability of these lenses is followed by severe
sightthreatening complications in young emmetropic individuals.
Early diagnosis and treatment is paramount to prevent permanent
visual impairment. All cases of suspected corneal ulcers seen
in the primary care clinic should be promptly referred to an
ophthalmologist for confirmation and timely treatment to
prevent permanent visual loss. In October 2002, the Food
and Drug Administration(FDA) issued a warning against the
use of noncorrective, decorative lenses without a prescription
or professional fitting. The FDA announced that it would
aggressively move to prevent the distribution of decorative CLs
directly to consumers. The organization further emphasized that
it would seize products that are being marketed and distributed
without a prescription and without proper fitting by an eye
care professional. Many noneye care retailers contacted by the
FDA voluntarily withdrew these products.2123 We do not wish
to discourage the use of CL, but would advise the appropriate
authorities that adaptation of CLs needs to be supervised by a

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Abdelkader: Cosmetic Contact Lens-associated Ulcerative Keratitis

specialist who can counsel the wearer on the best available options
and encourage patient compliance through regular followup.
The development of symptoms of pain or redness in a patient
with previously comfortable lens should cause the clinician to
suspect the presence of bacterial keratitis. The patient must be
instructed to seek immediate ophthalmic attention to confirm
the presence or absence of this serious complication and initiate
appropriate therapy. Wearers of CLs that do not correct their
vision may erroneously assume that because a decorative lens
is not used to correct a refractive error, they do not need a
proper lens fitting, evaluation, or followup by a licensed eye
care professional. Cosmetic lenses should be properly fitted
by a qualified professional and ongoing care must be provided.
The single best way to avoid eye infections is to follow proper
lens care guidelines as prescribed by the eye care professional.
Compliance with recommended hygiene procedures for cleaning
and disinfecting lenses is fundamental to safe CL users and hence
the prevention of infection. Several types of CL solutions may
be ineffective in eradicating some resistant organisms. The two
most common methods of CL disinfection are the multipurpose
solutions in which a single solution is used for disinfecting,
cleaning, and storing lenses and hydrogen peroxidebased
systems. Hydrogen peroxide is an effective microbial disinfectant,
destroying pathogens by oxidation.24 Hydrogen peroxide is
active against many microbes including the resistant cyst form
of Acanthamoeba when used at a concentration of 3% with an
exposure time of at least 9 h (overnight).25

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Cite this article as: Abdelkader A. Cosmetic soft contact lens associated
ulcerative keratitis in Southern Saudi Arabia. Middle East Afr J Ophthalmol
2014;21:232-5.
Source of Support: Nil, Conflict of Interest: None declared.

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