corneal ulcer from high-permeability contacts?

I've been wearing contacts for 11 years, and had a corneal ulcer a
number of years ago due to poor use in college (when a 'permanent' soft
lens was what they give you now as 2 week or 1-month disposables)

But for the past 4+ years, I've been wearing regular Bausch and Lomb
Optima soft lenses without any issues. I just went to the optometrist,
who said I had a lot of blood vessels growing toward the center of my
eye, indicating insufficient oxygen, and I told her I probably need
Bausch and Lomb brand because the Acuvue lens' area of vision
correction is too small for my pupil. So she gave me these Bausch and
Lomb PureVision extra-permeable ones that were more thick and rigid
than I'm used to, and clearly a different material. I wore them for 2
weeks, they weren't as comfortable as the regular lenses and dried out
easily (and I work for a few hours per day in a 'dry lab' that has
about 1 ppm water vapor in the air, the dryest environment on earth
other than better dry labs).

So I go in for my follow-up visit, and a different optometrist suddenly
finds white blood cells accumulating in my eye, but she says there's no
infection yet. They didn't note this on my first visit. So I've been
wearing glasses and taking a fluoroquinolone antibiotic 4x daily for
the past 36 hours now. There was originally no pain, but now I can see
a small white spot, definitely an ulcer, forming in my right eye, and
there is increasing level of pain right at that spot when my eyelid
crosses it. I haven't worn the contacts for 36 hours. It seems to be
getting worse and to have turned into a full-blown infection while I'm
taking the antibiotics (and yes, if it's significantly worse tomorrow
I'll go back to the optometrist!). Is this normal for the infection to
develop and worsen 36 hours after starting antibiotic use? I'm afraid
of resistance but don't know the timeframes involved. Antibiotics
usually seem to act quite fast...

Also, she said I was her first customer using this type of contacts,
and that they had been discontinued for a number of years and are just
now being manufactured again. I'm a little ****ed off that to correct
a minor problem, I was given contacts that have now created a much more
major problem that has the potential to impair my vision. Is this
common to have *increased* risk of infection with high permeability
lenses? Is it possible that these lenses were originally discontinued
because of patients having problems like this with them? I'll never
use them again (at this rate I'll never use contacts again)

Thanks for any advice.

The rule of thumb with corneal ulcers is that after 24 hours on
antibiotics "no worse is better." After 36 hours, yours seems to be
getting worse.

On the other hand, you may not be having an infectious ulcer, but a
non-infectious ulcer. Those are typically located peripherally, and do
not involve much, if any tissue necrosis. They are thought to be more
of an immune reaction. The treatment for those involves adding a
steroid.

The Purevision lens is an excellent lens, but no lens is absolutely
safe. You need to go back to your practitioner tomorrow, or else get a
second opinion -- tomorrow.

DrG

Thanks for your fast reply, I'll try to be seen tomorrow instead of on
my Friday appointment. The ulcer is located peripherally near the edge
of the iris, accompanied with a small area of clouding, which seems to
be where irritation usually occurs where the edge of the lens rubs
against the inflection in curvature. Especially from these thick
PureVisions that were drying out on me. Can a non-infectious ulcer
become visible and more painful over 24 hours after stopping contact
lens use? I was really taken aback that there was a problem in the
first place, because there was originally no pain whatsoever. I'll ask
about getting a steroid-containing treatment.

My previous ulcer was much worse to start off, but I don't recall it
getting any worse after starting treatment with Ciproflaxin. It left
this opaque spot at the edge of my iris that could be seen at certain
angles in natural light for well over a year. But that was blatant
neglect (and poverty). I'm going to ask to go back to the Optimas,
with the stipulation of wearing them 6 hours/day or less. At least
this has been a wake-up call that I need to use contacts more
conservatively and treat them as a luxury rather than rely on them to
see, and just in time, since I just got my glasses prescription updated
for the first time in years.

Thanks for your reply, I'll be sure to ask about the potential for it
to be fungal or protozoan. At least those shouldn't replicate nearly
as fast as bacteria, but it sounds like a good deal of damage comes
from your own immune response anyway.

I think I oughta stick with what worked for me (other than the oxygen
issue, which should be solved by wearing them infrequently instead of
16 hours/day). The change in thickness and rigidity combined with
drying out is too much, especially for the ridiculously abnormal
environment of the lab I work in.

When I tried on Acuvues, I experienced large blurry areas all around my
peripheral vision. They seem to go cheap on the optical correction
area in the center compared to B&L (and they are cheaper after all).
Not sure if it's the same in all their lenses, but you usually don't
have the luxury of trying on several different pairs.

With all your problems due to contacts, why not stick to glasses? Its
completely safe and if your pescription isnt very high, youll quickly
get used to them. Some people would be thinking about lasik but that
isnt a safe option either. Only glasses is. I very rarely wear contacts
and I view it as a luxury since they arent comfortable for long and dry
my eyes. I know ill be asking for problems if I wear them more than
occasionally.

In article <(E-Mail Removed) .com>,
(E-Mail Removed) wrote:

> Thanks for your fast reply, I'll try to be seen tomorrow instead of on
> my Friday appointment. The ulcer is located peripherally near the edge
> of the iris, accompanied with a small area of clouding, which seems to
> be where irritation usually occurs where the edge of the lens rubs
> against the inflection in curvature. Especially from these thick
> PureVisions that were drying out on me. Can a non-infectious ulcer
> become visible and more painful over 24 hours after stopping contact
> lens use?

Yes.

> I was really taken aback that there was a problem in the
> first place, because there was originally no pain whatsoever. I'll ask
> about getting a steroid-containing treatment.
>
> My previous ulcer was much worse to start off, but I don't recall it
> getting any worse after starting treatment with Ciproflaxin. It left
> this opaque spot at the edge of my iris that could be seen at certain
> angles in natural light for well over a year. But that was blatant
> neglect (and poverty). I'm going to ask to go back to the Optimas,
> with the stipulation of wearing them 6 hours/day or less.

The Optima is very low on the oxygen permeability list and you mentioned
you have neovascularization. That would make Optima a poor choice for
any use at all. As you've read, you should be looking at a silicone
hydrogel lens, perhaps a Proclear brand lens or no lens at all.

Do let us know what you learn following your doctor visit tomorrow.

LB, O.D.

First things first. The problem is an autoimmune problem at this point.
The major culprit are toxins from bacteria and the first line of
treatment is antibiotics. Whether the lens is the problem is not
determined. PureVision lenses are surface treated and just don't build
up deposits or bacterial adhesions such as your old lenses did. They
also will dehydrate much less than your Optima's did for most people.

Once the infiltrates have subsided, a change of design is warranted,
try Acuvue Oasys or Advance, Ciba Night and Day as alternatives. Forget
about optic zone, it is of little relevance to most people.

dr grant

With conventional soft hydrogel lenses, the oxygen permeability is
directly related to the water content. In a low humidity environment,
the water in the lens is evaporating, which drives the growth of blood
vessels into oyour corneas. With silicone-hydrogel lenses, the oxygen
permeability is inversely related to the water content -- with pure
silicone being the most permeable. I have not noticed any issues with
Purevision, as I sell all brands of silicone-hydrogels.

I have been doing research on the dehydration characteristics of
various types of contact lenses, both in the lab and on the eyes of
patients. So far, what I have found agrees with most of the
literature, which is that FDA Group 1 lenses show the least amount of
drying, while Group 2 exhibits the most. Groups 3 and 4 are
intermediate. Purevision is classified as a Group 3 lens. Focus N&D
and Acuvue Oasys are Group 1 lenses.

Silicone-hydrogel lenses have shown a lower rate of infectious
keratitis than conventional hydrogel lenses. However, non-infectious
sterile corneal infiltrates are still occurring. At this point, we
don't really know if your ulcer is sterile, bacterial, or protozoan.
Unfortunately, it is very difficult to obtain a viable culture,
especially after antibiotic treatment.

DrG

It's hard to tell if the ulcer is any worse this morning. It's
definitely no better in terms of pain. And I'm starting to get redness
now. This seems quite bad if this is bacterial in nature and it's not
responding to a fluoroquinolone. The antibiotic information sheet says
that up to 10% of patients experience side-effects including things
like keratitis, extra irritation and inflammation etc...keratitis is
basically a corneal ulcer so how can one tell if the antibiotic is
working if there is a fairly large chance it could *cause* one? I tend
to doubt the Wal-Mart vision center is going to culture my eye
(although they seem as much if not more competent than any other
optometrist office I've been to, which is why I go there), but I'll
ask. It does hurt for a few seconds after putting the antibiotic in but
goes away pretty quickly.

Perhaps the silicone hydrogels would be ok so long as I don't wear them
to work, but after this I'm afraid to risk it. Interesting paragraph:

"While the precise etiology of the hyperopic shifts with silicone
hydrogel lens wear is not clear, it is likely that both increased
oxygen supply compared to their previous hydrogel lenses and an
"orthokeratology-like" effect are involved. A study of patients who
wore low-Dk hydrogels on an extended wear basis when refitted with
silicone hydrogel lenses (also worn on an extended wear basis)
exhibited a mean hyperopic shift of 0.37D within a month (1).
Initially, this change in refractive error was attributed to recovery
from the myopic shift commonly reported to occur following chronic
corneal hypoxia (2-4). However a subsequent study found similar but
smaller hyperopic shifts in silicone hydrogel lens wearers who had no
previous lens wear experience (5). This finding suggests that silicone
hydrogels, which are relatively stiff compared to conventional soft
lens materials, may flatten the central cornea leading to an
"orthokeratology-like" effect and two studies have reported central
corneal flattening during silicone hydrogel wear (1,5)."

I hate to say this, but the standard of care involving a corneal ulcer
is professional follow-up within 24 hours. You need to go back to the
doctor regardless, as you are not in a position to diagnose yourself.

My opinion is that you should not be wearing contact lenses at all in
your current working environment. Regarding the article you quoted,
research on the effects of overnight wear of silicone-hydrogel lenses
on the corneal epithelium indicates little or no adverse effects on the
epithelium when viewed under high magnification confocal microscopy.
On the other hand, overnight wear of conventional low-DK soft lenses
does lead to significant epithelial compromise.

The silicone-hydrogel market is growing exponentially. Consumers have
also spoken loudly regarding their preference for low cost, no frills
eye care, abbreviated eye exams, and cheap contact lenses.

DrG