Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Contact Lens and Anterior Eye

journal homepage: www.elsevier.com/locate/clae

Bilateral simultaneous infective keratitis

⁎
Lai Hiu On Anniea, Manotosh Raya,b,
a
Department of Ophthalmology, National University Hospital, Singapore
b
Yong Loo Lin School of Medicine, National University of Singapore, Singapore

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: To analyze the demographics, risk factors, clinical and microbiological characteristics of cases of bilateral
Keratitis simultaneous infective keratitis.
Bilateral Methods: In this retrospective case series, patients with clinical evidence of bilateral simultaneous infective
Infective keratitis were identified from January 1, 2011 to August 31, 2016. Demographics, risk factors, clinical and
microbiological characteristics, and treatment outcomes were analyzed.
Results: Five patients (ten eyes) with bilateral simultaneous infective keratitis were identified. The mean age was
32.8 years (SD, ± 8.8; range, 24–44). All the patients were disposable soft contact lens wearers before
presentation. The average size of the infiltrate was 4.76 mm2 (SD ± 9.0; range, 0.2–31.34). A total of 4 types of
bacteria were isolated, with Pseudomonas aeruginosa being the most frequently isolated bacteria involving 5 eyes
of four patients. Infection resolved with medical treatment in 9 eyes, 1 patient required therapeutic corneal
transplantation for impending corneal perforation. The average time taken for infection to resolve was 6.7 days
(SD ± 4.5; range, 2–16).
Conclusions: In this case series, the most common risk factor of bilateral simultaneous microbial keratitis was use
of soft disposable contact lens and the most commonly isolated bacteria was Pseudomonas aeruginosa. Bilateral
simultaneous infective keratitis is uncommon and is a serious complication of contact lens use in immuno-
competent adult patients.

1. Introduction blurring of vision. Clinical history was recorded in detail. Clinical

diagnosis was made by an experienced corneal surgeon (RM). The
Infective keratitis is a serious ocular infection that can potentially patients were asked about any possible risk factors including contact
lead to severe visual dysfunction and is a major cause of blindness lens use, ocular trauma, use of steroids or any immunocompromised
worldwide [1]. The outcome can be worse if there is bilateral state. Time of onset of symptoms to presentation to hospital was
simultaneous infective keratitis. Bilateral simultaneous infective kera- recorded. We followed the standard protocol for microbiological
titis in immunocompetent, healthy adults with no previous history of isolation [8]. All suspected infectious corneal infiltrates were scraped
ocular surgery is rare and only six isolated cases have been reported in for microbiological studies before any treatment was initiated. Corneal
the literature [2–7]. Therefore, the aim of this study is to identify the smears were prepared for gram and fungal stain (KOH) with a spatula.
demographics, risk factors, and clinical and microbiological character- Corneal samples were directly inoculated to blood and chocolate agar
istics of bilateral simultaneous infective keratitis. media for aerobic isolation, to Robertson cooked meat media for
anaerobic and microaerophilic isolation and to Sabouraud’s agar media
2. Methods for fungal detection. Bacterial isolates were identified by gram staining,
colony characters and motility testing. All bacterial isolates were tested
In this retrospective case series, we identified all patients treated for for their anti-microbial susceptibility by standard disc diffusion method
bilateral simultaneous infective keratitis at the National University against different antibiotics. The results of the susceptibility were
Hospital, Singapore, a tertiary referral center, between January 1, 2011 recorded as resistant or susceptible. Bacterial culture was considered
to August 31, 2016. All patients with clinical evidence of bilateral positive if two media had grown five or more colonies of a particular
simultaneous infective keratitis were included. These patients had isolate or if growth in one media was associated with identification of
presented with symptoms of bilateral pain, redness, photophobia and same organism in gram stain. However, any fungal growth in one solid

⁎
Corresponding author at: Dept. of Ophthalmology, National University Hospital 1E, Kent Ridge Road NUHS Tower block, Level 7, 119228, Singapore.
E-mail address: [email protected] (M. Ray).

http://dx.doi.org/10.1016/j.clae.2017.03.011
Received 3 October 2016; Received in revised form 9 March 2017; Accepted 13 March 2017
1367-0484/ © 2017 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Hiu, L., Contact Lens and Anterior Eye (2017), http://dx.doi.org/10.1016/j.clae.2017.03.011
L.H. On Annie, M. Ray Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx

media was considered positive. Hypopyon was present in 3 eyes of 3 patients (Fig. 1). LogMAR visual
The study was approved by the institution’s ethics committee acuity at presentation ranged from 0.12 to 2.3, with the mean being 1.0
(Domain Specific Review Boards, National Healthcare Group, (SD, ± 0.9). All patients were initially treated empirically with the
Singapore). The research protocol adhered to the tenets of the standard protocol of topical cefazolin and gentamicin, and then
Declaration of Helsinki for clinical research. subsequently the choice of antibiotic was dependent upon the culture
Demographics, presdisposing factors, and clinical and microbiolo- results and susceptibilities. All patients were treated inpatient, and the
gical characteristic were reviewed from medical records. Clinical average time taken for the infection to resolve was 6.7 days (SD, ±
characteristics reviewed included the size and location of corneal 4.5; range, 2–16). The LogMAR visual acuity after treatment ranged
infiltrate, presence of hypopyon, pre- and post-treatment best-corrected from 0.12-1.9, with the mean being 0.47 (SD, ± 0.6).
visual acuity, antibiotic regimen, duration of infection, and treatment Two patients were bilaterally culture positive while 3 patients were
outcomes. The size of infiltrate was measured in square millimeters at positive in one eye. A total of 9 organisms belonging to 4 species of
presentation, and the location was classified as central or peripheral. bacteria were isolated (Table 2). Pseudomonas aeruginosa was isolated in
The central zone was defined as the central 3 mm in diameter, whereas 4 patients. All of the isolated bacteria were gram-negative bacilli. The
peripheral zone refers to corneal infiltrate lying outside the central Gram and culture positivity rate was 50% and 70% respectively in our
zone. Visual acuity was recorded using Snellen's visual acuity chart and series. All the isolated bacteria were tested against a number of
converted into logMAR (logarithm of the minimum angle of resolution) antibiotics and sensitivity results are shown in Table 4. All P. aeruginosa
acuity. All patients were initially treated empirically with topical were susceptible to ceftazidime, gentamicin, ciprofloxacin, levofloxacin
cefazolin (50 mg/mL) and gentamicin (14 mg/mL), which were subse- and piperacillin (Table 3). All other gram-negative bacteria were
quently changed according to culture and sensitivity results if required. susceptible to cotrimoxazole. Medical treatment was successful in all
Microbiological characteristics reviewed included the types of isolated except one eye that required therapeutic corneal transplantation due to
pathogens and their susceptibility to common antibiotics such as impending corneal perforation (Fig. 2). The patient who underwent
cefazolin, gentamicin, ciprofloxacin, and piperacillin. For statistical therapeutic corneal transplantation had presented late and grew
analysis, we used descriptive statistics using SPSS version 16.0 for MS Pseudomonas aeruginosa in that eye.
Windows (SPSS Inc, Chicago, IL) software.
4. Discussion
3. Results
Bilateral simultaneous infective keratitis is rare in immunocompe-
From January 1, 2011 to August 31, 2016, a total of 430 cases of tent adults with no previous ocular surgery or trauma. There have been
infective keratitis were seen. There were 5 patients (10 eyes) with sporadic case reports of bilateral infective keratitis in the literature
bilateral simultaneous infective keratitis. Demographics, clinical and mostly after various refractive surgeries and to the best of our knowl-
microbiological characteristics are summarized in Table 1. The mean edge; our case series is the largest one reported in the literature to date.
age was 32.8 years (SD, ± 8.8; range, 24–44). There were 2 males and Chehaibou I et al. reported a case of bilateral simultaneous infective
3 females. Most of the patients were Chinese (n = 4). All patients wore keratitis two days after bilateral small-incision lenticule extraction
soft disposable contact lenses. None of the patients had any significant (SMILE) procedure [9]. The causative organism was Steptococcus
past medical condition predisposing them to be immunocompromised pneumonia. Ali N A et al. reported a rare case of bilateral polymicrobial
nor any ocular trauma, surgery or use of immunosuppressive medica- infection with poor visual outcome in a young contact lens wearer
tion. involving three organisms [10]. Karimian F et al. published a case series
The mean size of corneal infiltrate was 4.76 mm2 (SD, ± 9.0; of three patients who had developed bilateral keratitis after photore-
range, 0.2–31.34). Infiltrates were located centrally in 8 eyes. fractive keratectomy (PRK). Staphylococcus aureus was isolated in two
patients while the third patient had grown Steptococcus pneumonia [11].
Table 1 All patients were contact lens user before presentation and this
Demographics, Risk Factors and Clinical Features in Bilateral Bacterial Keratitis. could be the possible risk factor in this series. A high prevalence of
myopia in Singapore [12] has led to an increase in the number of
n
contact lens wearers. The risk of keratitis is significantly higher in
Gender contact lens users due to various factors such as poor hygiene, type of
Male 2 lens care solution and poor compliances [13]. In our series four patients
Female 3 used monthly disposable while one patient used bi-weekly disposable
Race/ethnicity lenses. These lenses were silicone hydrogel lenses. Compliance was one
Chinese 4 of the major issues as majority of the patients used contact lenses for
Indonesian 1 long hours and even admitted to have slept with them occasionally.
Mean age 32.8 years (SD, ± 8.8; range, 24–44)
In previous case reports of bilateral simultaneous infective keratitis,
Risk factors P. aeruginosa, Flavobacterium meningosepticum, Alkaligenes species were
Disposable contact lens 10
also isolated. In our case series, 2 patients (2 eyes) had polymicrobial
Trauma 0
Ocular surface disorder 0 infection: one eye had P. aeruginosa and S. maltophilia and the other
Use of steroids 0 grew Serratia marcescens and Bukholderia cepacia.
Clinical characteristics P. aeruginosa was the most frequently isolated bacteria in our case
Mean size of corneal infiltrate 4.76 mm2 (SD, ± 9.0; range, 0.2–31.34) series. It is the most common organism worldwide in contact-lens
Location of infiltrate
related keratitis [14] and the most common bacteria found in corneal
Central 8 ulcers among Singaporean patients [15]. In a recent study from Taiwan,
Paracentral 2 Hsiao et al. had noted a shifting trend in bacterial keratitis when more
Hypopyon 3 gram-positive bacteria were isolated. However, Pseudomonas aeruginosa
Mean visual acuity (logMAR) still remained commonest isolated bacteria in this study [16].
At presentation 1.0 (SD, ± 0.9; range, 0.12–2.3) The limitations of our study include its retrospective design and
After treatment 0.47 (SD, ± 0.6; range, 0.12–1.9)
small sample size. Nevertheless, our study is the largest cases series
Mean duration for resolution of 6.7 days (SD, ± 4.5; range, 2–16)
infection reported in the literature of bilateral simultaneous infective keratitis
and highlights its demographics, risk factor and clinical features.

2
L.H. On Annie, M. Ray Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx

Fig. 1. Bilateral Keratitis; Right eye central keratitis with hypopyon and small corneal infiltrate in the left eye.

Table 2
Microbiological characteristics of Bilateral Infective Keratitis.

Microbiological Characteristics

Right Eye Left Eye

Gm Stain Organism Gm Stain Organism

Patient 1 Gram P aeruginosa Gram-ve P aeruginosa

−ve rods rods
Patient 2 Nil P aeruginosa Nil Nil
Patient 3 Gram 1. Serratia marcescens Gram Serratia
−ve rods 2. Burkholderia cepacia −ve rods marcescens
Patient 4 Gram 1. P aeruginosa Nil Nil
−ve rods 2. Stenotrophomonas
maltophilia Fig. 2. The eye with severe corneal infection with Pseudomonas aeruginosa that required
Patient 5 Nil Nil Nil P aeruginosa a therapeutic keratoplasty.

be considered if there is poor response to the standard empirical

5. Conclusions
antibiotic protocol, with the treatment being guided by culture and
sensitivity.
In our case series, the most common risk factor of bilateral
simultaneous infective keratitis was use of contact lens and the most
commonly isolated bacteria was P. aeruginosa. Bilateral simultaneous
Conflict of interest
infective keratitis is rare and may be associated with contact lens use.
This should be urgently and adequately managed to avoid blinding
The authors have no proprietary or commercial interest in any
complications. Although P. aeruginosa is the most common cause of
materials discussed in this article.
contact lens-related infective keratitis, polymicrobial infection should

Table 3
Culture and Antibiotic Sensitivity Pattern of Bilateral Bacterial Keratitis.

Antibiotic sensitivity Pseudomonas aeruginosa (n = 4) Serratia marcescens (n = 2) Burkholderia cepacia (n = 1) Stenotrophomonas maltophilia
(n = 1)

Cefazolin – – R
Gentamicin S4 S2 – R
Ceftazidime S4 S1 R R
Meropenem – R R
Cotrimoxazole S2 S S
Minocycline – S
Ampicillin R2 –
Co-amoxiclav R2 –
Cefepime S2 –
Ceftriaxone S1
Levofloxacin S1 S
Piperacillin/Tazobactam S1
Ciprofloxacin S2

S = Susceptibility, R = Resistant, Number next to S or R depicts no. of patients.

3
L.H. On Annie, M. Ray Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx

Source of funding 33 (6) (2007) 338–340.

[8] J.G. Collee, R.S. Miles, Tests for isolation of bacteria, 13th ed., in: J.G. Collee,
J.P. Duguid, A.G. Fraser, et al. (Eds.), Mackie and MacCartney Practical Medical
No funding was required for this study. Microbiolog, vol. 2, Churchill Livingstone, New York, 1989, pp. 456–481.
[9] I. Chehaibou, O. Sandali, B. Ameline, et al., Bilateral infectious keratitis after small-
incision lenticule extraction, J. Cataract Refract. Surg. 42 (4) (2016) 626–630.
References [10] N.A. Ali, S.C. Reddy, Bilateral simultaneous infectious keratitis secondary to contact
lens wear: an unusual case report with rare organisms, Eye Contact Lens 33 (6)
[1] J.P. Whitcher, M. Srinivasan, M.P. Upadhyay, Corneal blindness: a global (2007) 338–340.
perspective, Bull. World Health Organ. 79 (2001) 214–221. [11] F. Karimian, A. Baradaran-Rafii, M.A. Javadi, et al., Bilateral bacterial keratitis in
[2] P. Payrau, G. Perdriel, Bilateral hypopyon ulcer of the cornea following the three patients following photorefractive keratectomy, J. Refract. Surg. 23 (3)
continuous wearing of contact lenses, Bull. Soc. Ophtalmol. Fr. 9 (1956) 852–854. (2007) 215–312.
[3] I.A. Shivitz, Bilateral simultaneous Pseudomonas keratitis with myopic extended- [12] B. Seet, T.Y. Wong, D.T.H. Tan, et al., Myopia in Singapore: taking a public health
wear contact lenses, Ann. Ophthalmol. 19 (1987) 204–206. approach, Br. J. Ophthalmol. 85 (2001) 521–526.
[4] C.P. Lin, Y.H. Wang, C.H. Chang, et al., A simultaneous bilateral attack of infectious [13] Ch. Lim, N.A. Carnt, M. Farook, et al., Risk factors for contact lens related microbial
corneal ulcer in an extended-wear soft contact lens wearer: a case report, Gaoxiong keratitis is Singapore, Eye (Lond) 30 (3) (2016) 447–455.
Yi Xue Ke Xue Za Zhi 8 (1992) 628–631. [14] J.H. Mah-Sadorra, S.G. Yavuz, D.M. Najjar, et al., Trends in contact lens-related
[5] C. Lipener, A.L. Ribeiro, Bilateral Pseudomonas corneal ulcer in a disposable contact corneal ulcers, Cornea 24 (2005) 51–58.
lens wearer, CLAO J. 25 (1999) 123–124. [15] S.H.J. Lam, G. Tan, D.T. Tan, et al., Demographics and behavior of patients with
[6] J. Colin, F. Aitali, F. Malet, et al., Bilateral infectious keratitis in a patient wearing contact lens related infectious keratitis in Singapore, Ann. Acad. Med. Singapore 42
cosmetic soft contact lenses, J. Fr. Ophtalmol. 29 (2006) 665–667. (2013) 499–506.
[7] N.A. Mohamed Ali, S.C. Reddy, Bilateral simultaneous infectious keratitis secondary [16] C.H. Hsiao, C.C. Sun, L.K. Yeh, et al., Shifting trends in bacterial keratitis in Taiwan:
to contact lens wear: an unusual case report with rare organisms, Eye Contact Lens A 10 year review in a tertiary-care hospital, Cornea 35 (3) (2016) 313–317.