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Bennie H. Jeng, MD; Gerri S. Hall, PhD; Lynn Schoenfield, MD; David M. Meisler, MD

Arch Ophthalmol. 2007;125(7):981-983.

In February 2006, several clusters of patients with Fusarium keratitis were reported in Singapore¹ and in Hong Kong.² Because initial findings suggested an association between the use of Bausch & Lomb's ReNu with MoistureLoc solution (Rochester, New York) and the development of this infection, the manufacturer voluntarily suspended all sales of the product in these locations. One month later, the Centers for Disease Control and Prevention (CDC) received a report of 3 cases of Fusarium keratitis in New Jersey³ and, subsequently, several clusters of contact lens–related Fusarium keratitis were reported in the literature, including cases in unlikely temperate-climate locations such as San Francisco, California.^4-5 After preliminary findings suggested a link between the infections and the ReNu with MoistureLoc product, on May 15, 2006, Bausch & Lomb withdrew this product from the world market.

The CDC has subsequently published a summary of the multistate outbreak of Fusarium keratitis associated with contact lens use in the United States, and they concluded that the Bausch & Lomb ReNu product was indeed associated with the outbreak. In this study, only 2 of the 164 patients with confirmed Fusarium keratitis used a non–Bausch & Lomb solution.³

After the withdrawal of the ReNu with MoistureLoc product, there was a dramatic decrease in the number of cases of contact lens–related Fusarium keratitis that were reported to the CDC,³ and it appeared that the Fusarium keratitis outbreak was finished. In this study, we report 4 cases of Fusarium keratitis that presented to us between July 1, 2006, and November 1, 2006, after the withdrawal of Bausch & Lomb's ReNu with MoistureLoc from the world market. In all cases, cultures from the cornea yielded Fusarium species, and none of the patients were using Bausch & Lomb's ReNu with MoistureLoc product.

Institutional review board approval was obtained to perform this retrospective study, and the patients' clinical data are shown in Table 1. All patients were female and ranged in age from 12 to 42 years. The patients were initially treated for 2 to 21 days for a bacterial or herpetic keratitis in 3 of the 4 cases, and for a corneal abrasion in 1 case. All patients started receiving topical natamycin drops every hour after they were examined at our institution, and topical amphotericin B drops were started on an hourly basis after corneal scraping cultures confirmed the presence of Fusarium species. Three patients were also given oral voriconazole twice daily (the fourth patient was nursing her young child, and therefore the use of voriconazole was contraindicated). Two patients required therapeutic penetrating keratoplasties for progressive keratomycoses (Figure 1 and Figure 2). All patients had a best corrected visual acuity of 20/40 or better at last follow-up visit. Although interpretive breakpoints for resistance of Fusarium species to antifungal medications do not exist, the minimum inhibitory concentrations of the various tested antifungal medications to the organisms were very high (except for amphotericin B to the specimen from patient 4), which suggested resistance (Table 2).

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table 1. Clinical Summaries of All 4 Patients With Contact Lens–Related Fusarium Keratitis After the Recall

View larger version (51K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 1. High-magnification slit-beam view of the left cornea of patient 1 demonstrating a 2.5 x 2.5-mm feathery central corneal infiltrate.

View larger version (60K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 2. Low-magnification slit-beam view of the left cornea of patient 2 demonstrating a feathery infiltrate with satellite lesions involving the superior and central portions of the cornea.

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table 2. Minimum Inhibitory Concentrationsa of Various Antifungal Medications to the Fusarium species Found in Each Patient's Corneal Culture

In the 8 years from January 1, 1997, through June 30, 2005, we saw 2 cases of Fusarium keratitis at our institution, and neither was associated with contact lens wear. From July 1, 2005, through June 30, 2006, the period encompassing the time of the Fusarium keratitis outbreak, we saw 3 cases of contact lens–related Fusarium keratitis, all associated with the use of Bausch & Lomb's ReNu with MoistureLoc product. Since the withdrawal of this product from the world market, we have seen these 4 additional cases of contact lens–related Fusarium keratitis, and none were associated with the recalled product. This suggests that the Fusarium keratitis outbreak may not yet be over. Indeed, at the 2006 Federated Societies Scientific Session, in Las Vegas, Nevada, an informal poll revealed that, since the recall of Bausch & Lomb's ReNu with MoistureLoc, many in attendance had seen cases of contact lens–related Fusarium keratitis that were not associated with the recalled product.

Several theories have been proposed to explain the sudden increased incidence of Fusarium keratitis in contact lens wearers, and these were discussed at the 2006 American Academy of Ophthalmology annual meeting. These theories included the possible loss of antimicrobial activity during contact lens storage,⁶ and the selective growth of Fusarium in globules of partially dried deposits of ReNu with MoistureLoc.⁷ In addition, because the contact lens solutions on the market are composed of different disinfectants and antimicrobial agents, it is possible that there is a generalized decreased effectiveness of all-in-1 solutions to kill Fusarium compared with previous disinfecting systems. It is also possible that Fusarium has a propensity to bind to different contact lens materials. Further research is needed, especially into theories involving other possible contact lens solutions besides ReNu with MoistureLoc, so that this outbreak can be better understood and controlled.

In summary, it appears that the Fusarium keratitis outbreak may not be finished, and that this condition may be associated with other contact lens cleaning solutions. Ophthalmologists should be aware of this and must therefore continue to be vigilant in suspecting this infection. Any suspicious infiltrate should be scraped for culture, and prompt appropriate antifungal therapy should be instituted.

AUTHOR INFORMATION
Correspondence: Dr Jeng, The Cole Eye Institute, Cleveland Clinic, 9500 Euclid Ave, Building i-32, Cleveland, OH 44195 (jengb{at}ccf.org).

Financial Disclosure: None reported.

Funding/Support: Supported in part by a Research to Prevent Blindness Challenge Grant (Drs Jeng and Meisler).

Previous Presentation: Presented in part at the Federated Societies Scientific Session; November 10, 2006; Las Vegas, Nevada.

REFERENCES
1. Khor WB, Aung T, Saw SM; et al. An outbreak of Fusarium keratitis associated with contact lens wear in Singapore. JAMA. 2006;295(24):2867-2873. FREE FULL TEXT 2. Tsang T. Fungal keratitis among contact lens users. Commun Dis Watch. February 5-18, 2006;3(4):15. http://www.chp.gov.hk/files/pdf/CDW_V3_4.pdf. Accessed November 1, 2006.3. Chang DC, Grant GB, O’Donnell K; et al. Multistate outbreak of Fusarium keratitis associated with use of a contact lens solution. JAMA. 2006;296(8):953-963. FREE FULL TEXT 4. Alfonso EC, Cantu-Dibildox J, Munir WM; et al. Insurgence of Fusarium keratitis associated with contact lens wear. Arch Ophthalmol. 2006;124(7):941-947. FREE FULL TEXT 5. Bernal MD, Acharya NR, Lietman TM, Strauss EC, McLeod SD, Hwang DG. Outbreak of Fusarium keratitis in soft contact lens wearers in San Francisco. Arch Ophthalmol. 2006;124(7):1051-1053. FREE FULL TEXT 6. Rosenthal RA. Loss of antimicrobial activity during contact lens storage. Paper presented at: American Academy of Ophthalmology Annual Meeting; November 13, 2006; Las Vegas, NV.7. Stulting RD. Microbiology of environmental specimens and a hypothesis to explain contact lens-related Fusarium keratitis. Paper presented at: Federated Societies Scientific Session; November 10, 2006; Las Vegas, NV.

SECTION EDITOR: W. RICHARD GREEN, MD

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