June 15, 2006

Serious fungal infections of the eye on the rise

NEW YORK (Reuters Health) - Investigators in Miami and San
Francisco describe clusters of a serious eye infection called
ulcerative keratitis, an ulceration of the cornea, among soft
contact lens wearers caused by the fungus Fusarium, which until
this year had been considered an unusual condition in the U.S.
Reports of both clusters are published in the Archives of

An editorial note preceding the articles refers to the
recent withdrawal by Bausch & Lomb of its ReNu MoistureLoc
contact lens cleaner, because of an association with these
infections. The note says those cases "appear to be part of a
more global emergence of Fusarium as a vision-threatening
organism in otherwise healthy patients."

In the first paper, Dr. Eduardo C. Alfonso and colleagues
at the Bascom Palmer Eye Institute in Miami, report that their
group treated 10 cases of soft contact lens-associated
keratomycosis between 1969 and 1992. But between January 2004
and April 2006, they treated 34 cases attributed to Fusarium

The average age of the patients was 34.9 years (range 13 to
92). Medical histories and evaluations failed to turn up any
active disease that would predispose the patients to infectious

Thirty-one patients (91 percent) were initially treated
with antibiotics for presumed bacterial keratitis; four
patients were treated with antiviral medications; and only two
received antifungal therapy before the final diagnosis was

The average time from onset of symptoms to diagnosis was
9.1 days (range 0 to 140 days). At the initial examination, the
size of the infiltrates ranged from 1 to 8 mm.

Once the fungus was identified, patients were usually
treated with topical natamycin 5 percent and oral voriconazole
200 mg per day was prescribed to three patients. The length of
treatment ranged from 21 to 138 days

One case required placement of tissue adhesive glue, and
another required a surgical procedure. Most patients needed
corneal scraping to remove dead tissue.

Alfonso's team cautions: "Based on the present report,
ophthalmic clinicians should have a heightened clinical
suspicion for possible Fusarium and other fungal pathogens as
causative agents in cosmetic soft contact lens patients with
ulcerative keratitis."

They note that cultures and microscopy are valuable
diagnostic tools, and early treatment leads to rapid cure with
good outcomes. They recommend a polyene antifungal agent, such
as natamycin or amphotericin, applied every hour initially.

Meanwhile, in a small case series reported by Dr. David G.
Hwang and associates at the University of California, San
Francisco, there were four patients with contact
lens-associated Fusarium keratitis during a 5-week span in
early 2006. Previously, the department had treated eight cases
of Fusarium keratitis between 1976 and 2005, only two of which
were associated with contact lens use.

Three of the patients -- ages 19 to 24 years -- had no risk
factors for fungal keratitis, whereas a fourth woman, 56 years
old, was undergoing chemotherapy for non-Hodgkin lymphoma,
which may have lowered her resistance to infection.

Initially two of the patients were misdiagnosed with
herpes-related keratitis and the other two with bacterial
keratitis. One patient whose diagnosis was not made for at
least 4 weeks after symptom onset ended up requiring corneal
transplant surgery. Seven weeks later, her visual acuity was
still poor.

The other three patients recovered with visual acuity of
20/40 or better after treatment with topical antifungal

In many of the cases, but not all, patients recalled having
used Bausch and Lomb contact lens solutions, which have been
pulled from the market.

Hwang's team adds that clusters of cases have been reported
in other areas of the U.S. and in Singapore.

SOURCE: Archives of Ophthalmology, June 12, 2006.