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  • P. aeruginosa Keratitis Caused by Artificial Tears: Case Report

    By Lynda Seminara
    Selected and reviewed by Neil M. Bressler, MD, and Deputy Editors
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    Journal Highlights

    JAMA Ophthalmology, May 2023

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    Pseudomonas aeruginosa, a rare bac­terium that resists treatment, had not been detected in the United States until 2022, when it caused multidrug-resis­tant (MDR) keratitis in dozens of users of EzriCare Artificial Tears, leading to enucleation in some cases. Shoji et al. shared a case study to highlight the gravity of this phenomenon and the importance of culturing corneal infil­trates, as well as contact lenses, their storage cases, and drop bottles contain­ing eye- and lens-care solutions.

    Case Report. A 72-year-old man arrived at Bascom Palmer Eye Institute in Miami, having experienced pain and reduced vision in his right eye for the past day. His medical history included diabetes, coronary artery disease, and chronic obstructive pulmonary disease. He reportedly wore contact lenses but did not sleep in them or overuse them. He had not undergone ocular surgery or been exposed to vegetation, but he was using EzriCare Artificial Tears for eye dryness. At presentation, his BCVA was hand motion in the right eye and 20/20 in the left eye. IOP was 29 mm Hg in the right eye and 14 mm Hg in the left eye. Slit-lamp examination of the right eye showed diffuse conjunc­tival hyperemia, a 6- × 5-mm corneal infiltrate with an overlying epithelial defect, and a 2-mm hypopyon. Ultra­sound findings were normal. In light of recent concerns about contaminated eyedrops, the patient received hourly treatment (when awake) of topical fortified vancomycin, fortified tobra­mycin, and trimethoprim-polymyxin drops. His corneal infiltrate culture was positive for P. aeruginosa, which resisted fluoroquinolones, amino­glycosides (including amikacin and tobramycin), and cephalosporins. Re­sistance to carbapenem was moderate (minimum inhibitory concentration [MIC] = 4). The EzriCare solution also was positive for P. aeruginosa, which did not respond to fluoroquinolones, aminoglycosides, and cephalosporins. Resistance to carbapenem was higher than in the cornea (MIC = 8). Based on these findings, trimethoprim-polymyx­in was continued hourly, and imipe­nem-cilastatin was given every two hours. At the most recent follow-up visit, the infection and visual loss per­sisted. Treatment and close monitoring were continued.

    Risk factors for MDR P. aeruginosa include eye lubricants, compromised ocular surface, and bandage contact lenses. Contaminated products can cause severe infections. Until recently, artificial tears were considered relatively benign. Per the CDC, at least 10 brands of artificial tears have been implicated.

    The authors hope to raise awareness of this vision-threatening contamina­tion so that potentially blinding sources of infection can be eliminated. They concluded that “concern for contami­nation ideally should lead to prompt reporting to the CDC and U.S. Food and Drug Administration.” (Also see related commentary by Christina R. Prescott, MD, PhD; and Kathryn A. Colby, MD, PhD; in the same issue.)

    The original article can be found here.