- Email: [email protected]
Fusarium “Outbreak”
The Contact Lens/Fusarium “Outbreak” JOEL SUGAR, MD
I
N THIS ISSUE OF THE
JOURNAL,
ALFONSO AND ASSOCI-
ates1 present an expedited report on their experience with an increasing number of fungal keratitis cases in contact lens wearers. At the Bascom Palmer Eye Institute in 2004 and 2005, a total of 26 fungal ulcers were seen in contact lens wearers, and 92% of these (24 of 26) were due to Fusarium species. In 2004 a total of 30 Fusarium ulcers were treated, but only seven (23.3%) were in contact lens wearers. In 2005 a total of 36 Fusarium ulcers were seen, but the proportion of contact lens wearers had doubled to 47.2% (17 ulcers). In the first quarter of 2006, 12 (60%) of 20 Fusarium ulcers were in contact lens wearers (Miller D, personal communication, Apr 14, 2006). Unfortunately, this series from a single institution is not an isolated cluster of patients with an uncommon infection. In recent months, increasing numbers of Fusarium ulcers in contact lens wearers have been reported. The Ministry of Health of Singapore reported 75 cases of Fusarium keratitis in contact lens wearers between July 2005 and mid-April 2006.2 A total of 95% of the 59 patients who were certain of the solution used for cleaning and storing their lenses reported using Bausch & Lomb (Rochester, New York, USA) ReNu®. Closer to home, the Centers for Disease Control and Prevention (CDC) reported, as of April 9, 2006, 109 patients with Fusarium keratitis from 17 states in the United States between June 15, 2005, and March 18, 2006. Of the 30 patients with “complete data” at the time of the report, 93% were soft contact lens wearers, and all of these reported using Bausch & Lomb ReNu®, mostly the MoistureLoc variety.3 What is happening here? There appears to be a surge in cases of Fusarium infection, although 109 cases in 30 million US soft contact lens wearers may well be too few to call it an epidemic. There are, however, many more cases as yet either unreported or still in the process of being accumulated, according to Internet cornea discussion groups. The reasons for these infections are uncertain. The apparent association with ReNu® is disconcerting, although the mechanism is unknown. Investigation by the manufacturer and the US Food and Drug Administration of the Greenville, South Carolina, USA, plant where the ReNu® solution used in the United States and Asia is produced has failed to demonstrate a source for the organism.4 Whether environmental changes, recent changes in water processing regulations, effects of the contact lens solution on Fusarium behavior, or other factors explain this outSee accompanying Brief Report on page 154. Accepted for publication Apr 17, 2006. From the University of Illinois at Chicago, Chicago, Illinois. Inquiries to Joel Sugar, MD, University of Illinois at Chicago, 1855 W Taylor, Chicago, IL 60612-7242; e-mail: [email protected]
146
©
2006 BY
break remains to be elucidated. Increased vigilance and greater recognition and reporting of cases since the initial reports may also magnify the apparent increase in numbers. Perhaps many cofactors have created this unfortunate “perfect storm” situation. The occurrence of these cases of Fusarium keratitis in contact lens wearers, despite many media reports and professional organization e-mails, is not a reason for panicked responses, or even a substantial change in contact lens practice. It does, however, alert eye care practitioners to the need to be able to recognize and treat or refer for treatment patients with the signs or symptoms of possible Fusarium keratitis. We should also advise our contact lens–wearing patients to follow appropriate lens handling, cleaning, replacement, and storage techniques and strongly encourage patients to seek medical attention if they develop redness, pain, or decreased vision. Treating ophthalmologists should carry out appropriate microbiologic evaluation of suspected patients, and when Fusarium is identified, they should institute treatment with natamycin, voriconazole, or other appropriate agents. Until evaluation of these occurrences here and abroad is completed, the recommendation of Bausch & Lomb to switch to another lens care solution should be followed.4 All cases of contact lens–related fungal keratitis should be reported to the CDC. By the time this Editorial is in print, I hope more specific information and recommendations will be available. Update: On May 15, 2006, Bausch & Lomb recalled ReNu® with MoistureLoc suggesting that “under certain unusual circumstances” it “can increase the risk of Fusarium infection.”5
REFERENCES 1. Alfonso EC, Miller D, Cantu-Dibildox J, O’Brien TP, Schein OD. Fungal keratitis associated with non-therapeutic soft contact lenses. Am J Ophthalmol 2006;142:154 –155. 2. Singapore Ministry of Health. Update on contact lens related fungal corneal infections. Press release, April 12, 2006. Available at: http://www.moh.gov.sg/corp/about/newsroom/pressreleases/details.do?id⫽36962317. Accessed: May 15, 2006. 3. Centers for Disease Control and Prevention. Fusarium keratitis—multiple states, 2006. MMWR Morb Mortal Wkly Rep 2006;55:400 – 401. 4. Harris G. Bausch & Lomb ask retailers to remove a lens cleaner. New York Times, April 14, 2006. 5. FDA press office. Bausch & Lomb global recall of ReNu® with MoistureLoc contact lens cleaning solution. FDA statement May 15, 2006.
ELSEVIER INC. ALL
RIGHTS RESERVED.
0002-9394/06/$32.00 doi:10.1016/j.ajo.2006.04.026
I
N THIS ISSUE OF THE
JOURNAL,
ALFONSO AND ASSOCI-
ates1 present an expedited report on their experience with an increasing number of fungal keratitis cases in contact lens wearers. At the Bascom Palmer Eye Institute in 2004 and 2005, a total of 26 fungal ulcers were seen in contact lens wearers, and 92% of these (24 of 26) were due to Fusarium species. In 2004 a total of 30 Fusarium ulcers were treated, but only seven (23.3%) were in contact lens wearers. In 2005 a total of 36 Fusarium ulcers were seen, but the proportion of contact lens wearers had doubled to 47.2% (17 ulcers). In the first quarter of 2006, 12 (60%) of 20 Fusarium ulcers were in contact lens wearers (Miller D, personal communication, Apr 14, 2006). Unfortunately, this series from a single institution is not an isolated cluster of patients with an uncommon infection. In recent months, increasing numbers of Fusarium ulcers in contact lens wearers have been reported. The Ministry of Health of Singapore reported 75 cases of Fusarium keratitis in contact lens wearers between July 2005 and mid-April 2006.2 A total of 95% of the 59 patients who were certain of the solution used for cleaning and storing their lenses reported using Bausch & Lomb (Rochester, New York, USA) ReNu®. Closer to home, the Centers for Disease Control and Prevention (CDC) reported, as of April 9, 2006, 109 patients with Fusarium keratitis from 17 states in the United States between June 15, 2005, and March 18, 2006. Of the 30 patients with “complete data” at the time of the report, 93% were soft contact lens wearers, and all of these reported using Bausch & Lomb ReNu®, mostly the MoistureLoc variety.3 What is happening here? There appears to be a surge in cases of Fusarium infection, although 109 cases in 30 million US soft contact lens wearers may well be too few to call it an epidemic. There are, however, many more cases as yet either unreported or still in the process of being accumulated, according to Internet cornea discussion groups. The reasons for these infections are uncertain. The apparent association with ReNu® is disconcerting, although the mechanism is unknown. Investigation by the manufacturer and the US Food and Drug Administration of the Greenville, South Carolina, USA, plant where the ReNu® solution used in the United States and Asia is produced has failed to demonstrate a source for the organism.4 Whether environmental changes, recent changes in water processing regulations, effects of the contact lens solution on Fusarium behavior, or other factors explain this outSee accompanying Brief Report on page 154. Accepted for publication Apr 17, 2006. From the University of Illinois at Chicago, Chicago, Illinois. Inquiries to Joel Sugar, MD, University of Illinois at Chicago, 1855 W Taylor, Chicago, IL 60612-7242; e-mail: [email protected]
146
©
2006 BY
break remains to be elucidated. Increased vigilance and greater recognition and reporting of cases since the initial reports may also magnify the apparent increase in numbers. Perhaps many cofactors have created this unfortunate “perfect storm” situation. The occurrence of these cases of Fusarium keratitis in contact lens wearers, despite many media reports and professional organization e-mails, is not a reason for panicked responses, or even a substantial change in contact lens practice. It does, however, alert eye care practitioners to the need to be able to recognize and treat or refer for treatment patients with the signs or symptoms of possible Fusarium keratitis. We should also advise our contact lens–wearing patients to follow appropriate lens handling, cleaning, replacement, and storage techniques and strongly encourage patients to seek medical attention if they develop redness, pain, or decreased vision. Treating ophthalmologists should carry out appropriate microbiologic evaluation of suspected patients, and when Fusarium is identified, they should institute treatment with natamycin, voriconazole, or other appropriate agents. Until evaluation of these occurrences here and abroad is completed, the recommendation of Bausch & Lomb to switch to another lens care solution should be followed.4 All cases of contact lens–related fungal keratitis should be reported to the CDC. By the time this Editorial is in print, I hope more specific information and recommendations will be available. Update: On May 15, 2006, Bausch & Lomb recalled ReNu® with MoistureLoc suggesting that “under certain unusual circumstances” it “can increase the risk of Fusarium infection.”5
REFERENCES 1. Alfonso EC, Miller D, Cantu-Dibildox J, O’Brien TP, Schein OD. Fungal keratitis associated with non-therapeutic soft contact lenses. Am J Ophthalmol 2006;142:154 –155. 2. Singapore Ministry of Health. Update on contact lens related fungal corneal infections. Press release, April 12, 2006. Available at: http://www.moh.gov.sg/corp/about/newsroom/pressreleases/details.do?id⫽36962317. Accessed: May 15, 2006. 3. Centers for Disease Control and Prevention. Fusarium keratitis—multiple states, 2006. MMWR Morb Mortal Wkly Rep 2006;55:400 – 401. 4. Harris G. Bausch & Lomb ask retailers to remove a lens cleaner. New York Times, April 14, 2006. 5. FDA press office. Bausch & Lomb global recall of ReNu® with MoistureLoc contact lens cleaning solution. FDA statement May 15, 2006.
ELSEVIER INC. ALL
RIGHTS RESERVED.
0002-9394/06/$32.00 doi:10.1016/j.ajo.2006.04.026