1. Keratitis Related to a Multipurpose Contact Lens Solution Jules Winokur, MD Michelle Lee, OD Mohamed Osman, BS Sid Mandelbaum, MD Authors have no financial interest

2. Purpose To describe a non-infectious corneal condition associated with use of contact lenses disinfected with a multipurpose contact lens solution (MPS) Methods Observational case series Private corneal practice Retrospective chart review

3. Clinical Findings Symptoms included: –Ocular redness –Irritation –Decreased lens tolerance –Decreased visual acuity Signs included some combination of: –Punctate corneal fluorescein staining (SPK) –Pinpoint white epithelial opacities, only some of which stain with fluorescein –Conjunctival injection –Epithelial microcysts –Small sub-epithelial opacities –Limbal thickening –Whorl-like epitheliopathy

4. Pinpoint white epithelial opacities, only some of which stain with fluorescein Microcysts, fluorescein stainSub-epithelial opacity

5. Findings 26 patients over three year period All patients used Opti- free solutions Most patients had more than one finding

6. Treatment Many of the patients had already used topical antibiotics and topical steroids without apparent improvement Cessation of contact lenses and elimination of Opti-free solution was effective treatment Resolution of signs and symptoms ranged from 3 days to > 6 months Patients with more severe findings at presentation took longer to resolve No patient had recognizable permanent sequelae

7. Outcomes All patients with long-term follow-up returned to CL use Many patients successfully resumed CL use with the same lens parameters, but with hydrogen peroxide disinfection Some patients switched to daily disposable contact lenses Several patients who returned to Opti-free solution disinfection had recurrence of clinical picture

8. Background In 2002, 32,000,000 people using lenses in US 1, 87% using soft lenses Opti-free is the most commonly used solution for soft lens disinfection Figure 1: Type of soft CL use in US 2 Figure 2: Market share of disinfecting solutions 3

9. Antimicrobials in MPS Polyhexamethylene biguanide (PHMB) –Renu Multiplus (0.00005%) [B&L] –AQuify (0.0001%) [Ciba] Myristamidopropyl dimethylamine (Aldox) –Opti-free* (0.0005%) [Alcon] Polyquaternium-1 (Polyquad) –Opti-free* (0.001%) [Alcon] * Opti-free solutions contain both Aldox and Polyquad

10. Possible Relationships Aldox and Polyquad are proprietary disinfectants used only in Opti-free In vitro studies show cytotoxicity and decreased corneal epithelial cell viability after exposure to Opti-free 4,5,6 Study in rats did not show toxicity from Polyquad 7,8 Combination of factors likely responsible for clinical condition

11. Discussion Opti-free multipurpose contact lens solution may be associated with a particular pattern of corneal findings Corneal abnormalities slowly resolve with discontinuation of contact lens use These patients were able to resume use of contact lenses with a daily disposable lens or peroxide-based disinfecting system

12. Notes 1.Barr, Joseph. "Contact Lenses 2002: Annual Report." Contact Lens Spectrum Jan. 2003: 24-31. 2.Nichols, JJ. http://www.clspectrum.com/article.aspx?article=103778 Diagram reproduced with permission from author. 3.Ibid 2. 4.Mowrey-McKee M, Sills A, Wright A, CIBA Vision Corporation. Comparative cytotoxicity potential of soft contact lens care regimens. CLAO J. 2002 Jul;28(3):160- 4. 5.Wright A, Mowrey-McKee M. Comparative cytotoxicity potential of soft contact lens care products. Cutan Ocul Toxicol. 2005;24(1):53-64. 6.Cavet ME, Harrington KL, VanDerMeid KR, Ward KW, Zhang JZ. Comparison of the effect of multipurpose contact lens solutions on the viability of cultured corneal epithelial cells. Cont Lens Anterior Eye. 2009 Aug;32(4):171-5. Epub 2009 Jun 21. 7.Tripathi BJ, Tripathi RC, Kolli SP. Cytotoxicity of ophthalmic preservatives on human corneal epithelium. Lens Eye Toxic Res. 1992;9(3-4):361-75. 8.Labbé A, Pauly A, Liang H, Brignole-Baudouin F, Martin C, Warnet JM, Baudouin C. Comparison of toxicological profiles of benzalkonium chloride and polyquaternium-1: an experimental study. J Ocul Pharmacol Ther. 2006 Aug;22(4):267-78.