Update: Fusarium Keratitis --- United States, 2005--2006

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http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5520a5.htm?s_cid=mm5520a5_e%0A

May 26, 2006 / 55(20);563-564

Update: Fusarium Keratitis --- United States, 2005--2006

On May 19, this report was posted as an MMWR Dispatch on the MMWR

website (http://www.cdc.gov/mmwr).

In April 2006, CDC reported on an ongoing multistate investigation of

Fusarium keratitis occurring predominantly among contact lens wearers

(1). This update summarizes epidemiologic developments in this

investigation, which indicate an association with Bausch & Lomb's ReNu

with MoistureLoc® contact lens solution.

Fusarium keratitis is a fungal infection of the cornea, preceded

usually by trauma to the eye. Although not a notifiable disease, the

infection is thought to be rare among contact lens wearers in

temperate climates (2). Fusarium keratitis is treated with antifungal

medication but can be severe and sometimes result in vision loss and

the need for corneal transplantation (3).

As of May 18, 2006, CDC had received reports of 130 confirmed cases of

Fusarium keratitis infection, defined as clinically consistent fungal

keratitis with symptom onset after June 1, 2005, no history of recent

ocular trauma, and a corneal culture yielding a Fusarium species.

Cases have been reported from 26 states and one territory.* Patients

had a median age of 41 years (range: 12--83 years), and 85 of 127

(67%) were female. As a result of this infection, corneal

transplantation was required in 37 of 120 (31%) cases.

Among the 130 patients with confirmed cases, 125 reported wearing

contact lenses, and 118 were able to identify which contact lens

solution(s) they had used during the month before onset of infection.

Seventy-five (64%) reported using Bausch & Lomb's ReNu with

MoistureLoc alone, 14 (12%) reported using MoistureLoc in combination

with another product, eight (7%) reported using an unspecified Bausch

& Lomb solution, and 21 (18%) reported using only products other than

MoistureLoc, from various manufacturers. Ongoing surveillance

continues to identify persons who used MoistureLoc and had disease

onset after April 13, when Bausch & Lomb withdrew this product from

the market in the United States.

In April, a subset of confirmed case-patients who were soft contact

lens wearers and aged >18 years was enrolled in a matched case-control

investigation to evaluate risk factors for infection. To avoid

potential bias from media coverage on case-patient responses, this

subset was limited to those patients reported to CDC before online

publication of the initial MMWR Dispatch on April 10.

Neighborhood-matched controls were adults reporting soft contact lens

use during March 2006 with no history of fungal keratitis. Information

regarding contact lens types, solutions used, and contact lens hygiene

practices was obtained via telephone interviews conducted by trained

personnel who used standardized questionnaires. Exact conditional

logistic regression was used to estimate odds ratios.

A total of 50 case-patients and 79 controls were enrolled in the

matched case-control investigation. For the most stringent test of

product association, analysis was limited to the matched sets of 25

case-patients and 37 controls who were soft contact lens wearers,

reported using only a single solution type, and provided all the

information requested. In a multivariable model, use of Bausch &

Lomb's ReNu with MoistureLoc during the month before symptom onset was

independently associated with being a case-patient (adjusted odds

ratio: 19.0, 95% confidence interval = 2.4--944.9, p<0.001), when

compared with contact lens solutions other than ReNu with MoistureLoc

or ReNu Multiplus®; 19 case-patients and seven controls reported

this exposure. This association was statistically significant even

after controlling for poor contact lens care (i.e., reported reuse or

topping off of contact lens solution). Use of ReNu Multiplus solution

was not significantly associated with infection (adjusted odds ratio:

3.6, 95% confidence interval = 0.3--189.0, p = 0.5); five

case-patients and 10 controls reported this exposure.

The results of this case-control investigation indicate an increased

risk for Fusarium keratitis associated with use of Bausch & Lomb's

ReNu with MoistureLoc. The cause of this association is not clear;

however, further studies, including environmental and molecular

testing, are ongoing. Although certain patients have reported use of

other contact lens solutions, the analysis does not indicate that

these products are associated with significantly increased risk for

disease. Patients who reported using only products other than

MoistureLoc might not have recalled all the contact lens solutions

they had used, especially if the period between exposure and interview

was lengthy. In addition, extensive surveillance for this infection

might have identified patients whose disease was unrelated to the

outbreak.

Given the association between Fusarium keratitis and MoistureLoc,

Bausch & Lomb (Rochester, New York) announced its decision to

voluntarily recall and permanently remove this contact lens solution

from the worldwide market on May 15, 2006. Contact lens wearers should

immediately discontinue use of this solution and consult an eye-care

professional regarding use of an appropriate alternative product for

cleaning or disinfecting lenses. Contact lens wearers also should

practice good hygiene, including hand washing and drying before

handling lenses, avoiding reuse of contact lens solutions, and

following the specific instructions of manufacturers of contact lenses

and contact lens solutions. Clinicians evaluating contact lens wearers

with signs or symptoms of keratitis (e.g., unusual redness of the

eyes, eye pain, tearing, discharge, or light sensitivity) should

consider fungal keratitis and refer the patient to an ophthalmologist

if appropriate. Eye-care professionals should continue to be vigilant

in the diagnosis and treatment of Fusarium keratitis, and should

report possible cases to state health departments or to CDC at

telephone, 800-893-0485. Reports should also be submitted to the FDA

via MedWatch at telephone, 800-FDA-1088; fax, 800-FDA-0178; or mail,

MedWatch, Food and Drug Administration, 5600 Fishers Lane, Rockville,

MD 20857-9787; or online at http://www.fda.gov/medwatch/report.htm.

Reported by: MA Barry, MD, J Pendarvis, MPH, Boston Public Health

Commission, Massachusetts. P Mshar, MPH, Connecticut Dept of Public

Health. K Ritger, MD, Illinois Dept of Public Health. P Dixon,

Kentucky State Dept for Public Health. E Alfonso, MD, Bascom-Palmer

Eye Institute, Miami; F Leguen, MD, Miami-Dade County Health Dept,

Florida. K Signs, DVM, Michigan Dept of Community Health. A Fine, MD,

B Nivin, MPH, New York City Dept of Health and Mental Hygiene; M

Anand, MPH, P , MD, New York State Dept of Health. E Salehi, MPH,

Ohio Dept of Health. K DeMarco, MPH, Monmouth County Health Dept; E

Sison, MPH, Newark Dept of Health and Human Svcs; C Genese, MBA, C

on, MD, C Tan, MD, E Bresnitz, MD, New Jersey Dept of Health

and Senior Svcs. MA Kainer, MBBS, MPH, Tennessee Dept of Health. NL

Thayer, Vermont Dept of Health. DB , MD, Cullen Eye Institute,

Baylor College of Medicine, Texas. K O'Donnell, PhD, US Dept of

Agriculture. BJ Park, MD, K Wannemuehler, MS, L son, C Crowell, M

Gerhart, M Brandt, PhD, S Fridkin, MD, National Center for Zoonotic,

Vector-Borne and Enteric Diseases (proposed); A Srinivasan, MD, M

Arduino, PhD, J Noble-Wang, PhD, National Center for Preparedness,

Detection, and Control of Infectious Diseases (proposed); D Chang, MD,

G Grant, MD, L Burwell, MD, C Rao, PhD, LR Carpenter, DVM, M Gershman,

MD, A Huang, MD, FM , MD, G Mirchandani, PhD, L Sosa, MD, EIS

officers, CDC.

References

1. CDC. Fusarium keratitis---multiple states, 2006. MMWR 2006;55:400--1.

2. PA. Fungal infections of the cornea. Eye 2003;17:852--62.

3. Dursun D, Fernandez V, D, Alfonso EC. Advanced Fusarium

keratitis progressing to endophthalmitis. Cornea 2003;22:300--3.

* Arizona (one case), Arkansas (one), California (seven), Connecticut

(three), Florida (26), Georgia (two), Illinois (eight), Iowa (one),

Kansas (one), Kentucky (five), Louisiana (one), land (one),

Massachusetts (one), Michigan (three), Missouri (three), Nevada (one),

New Jersey (four), New York (six), North Carolina (two), Ohio (seven),

Oklahoma (one), Oregon (one), Pennsylvania (12), Tennessee (eight),

Texas (seven), Vermont (two), and Puerto Rico (15).