corneal ulcer from high-permeability contacts?

Discussion in 'Contact Lenses' started by rekuci, Feb 23, 2006.

  1. rekuci

    rekuci Guest

    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 pissed 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.
     
    rekuci, Feb 23, 2006
    #1
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  2. rekuci

    Dr. Leukoma Guest

    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
     
    Dr. Leukoma, Feb 23, 2006
    #2
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  3. rekuci

    rekuci Guest

    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.
     
    rekuci, Feb 23, 2006
    #3
  4. rekuci

    rekuci Guest

    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.
     
    rekuci, Feb 23, 2006
    #4
  5. rekuci

    acemanvx Guest

    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.
     
    acemanvx, Feb 23, 2006
    #5
  6. rekuci

    LarryDoc Guest

    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.
     
    LarryDoc, Feb 23, 2006
    #6
  7. rekuci

    CatmanX Guest

    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
     
    CatmanX, Feb 23, 2006
    #7
  8. rekuci

    Dr. Leukoma Guest

    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
     
    Dr. Leukoma, Feb 23, 2006
    #8
  9. rekuci

    rekuci Guest

    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)."
     
    rekuci, Feb 23, 2006
    #9
  10. rekuci

    Dr. Leukoma Guest

    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
     
    Dr. Leukoma, Feb 23, 2006
    #10
  11. rekuci

    rekuci Guest

    I'm leaving for my appointment in half an hour, had to at least wait
    til the office was open to call. In all fairness, it wasn't yet an
    ulcer when they saw me. They saw white blood cell accumulation but no
    other sign of infection, and said the antibiotic was a precaution.
    It's hard to find any level of competence in doctors or otherwise where
    I live - I still don't have a general practice doctor because every one
    that I try out is worthless, most seem more like a drug sample vending
    machines than doctors. Some degree of diagnosing or at least educating
    yourself is therefore necessary. You need to know what to ask for, or
    else you don't get it. I definitely never had any culturing or
    staining done for the last ulcer, but don't remember how soon the
    follow-up was. That was already a full-blown infection when he saw me.
    I agree, and I intend to never wear contacts at work again. It's a
    little pointless to wear them anyway, since I just have to wear safety
    glasses in place of prescription glasses. On the other hand, my
    glasses don't really adequately protect my eyes given the nature of the
    chemicals I work with. Employers are required to provide prescription
    safety glasses, but it'll probably be a serious hassle to obtain.
     
    rekuci, Feb 23, 2006
    #11
  12. rekuci

    Dr. Leukoma Guest


    Well, I bet odds that there was an epithelial defect in the center of
    those white blood cells such that it would have shown a little bit of
    fluorescein dye uptake.

    DrG
     
    Dr. Leukoma, Feb 23, 2006
    #12
  13. rekuci

    JohnR66 Guest

    I was a long term contact wearer (17 years). I too started to have problems
    in the latter few years. I always cleaned them at night. I decided to ditch
    the contacts for good. You only have one set of eyes. Why put them in
    jeopardy.

    John
     
    JohnR66, Mar 2, 2006
    #13
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