A dance macabre reprises each year in late October; the sprightly steps of costumed revelers, cat-eyed or red-iris deviled — leading up to the dawn postlude of bleary patients presenting to clinician’s offices with wicked symptoms. And in cultures, shadowy characters have returned; namely Bacillus cereus, fungi, and Acanthamoeba.
“It doesn’t take long for a rip-roaring infection and for all hell to break loose in your eye when you’re not careful with soft contact lenses — any soft contact lens, not just the colored ones,” said Thomas Steinemann, MD, Professor of Ophthalmology at Case Western Reserve University, and contact lens-related disorder researcher. Dr Steinemann is director, Cornea and External Eye Disease at MetroHealth Medical Center, a teaching hospital in Cleveland, Ohio.
He supports patients who would like to wear costume lenses if they seek education, professional fit, and a prescription, “and if you want to do this for Halloween, forge ahead, but just do it safely and smartly.”
During this season of glowing alien gazes and sports team-printed lenses, clinicians have several tools they can wield to prevent lens injury, mentorship for those who ask about decorative lens wear, and inclusion of lens-specific patient history questions for patients who develop post-costume-party disorders.
Problems Start in the Package
At Wills Eye Hospital, general lens-related issues or injuries average fewer than 10 cases each month; but, near the time of Halloween, the number “approximately doubles,” explained Ann Murchison, MD, MPH, director of the Emergency Department at Wills Eye Hospital, Philadelphia. She also serves as Associate Professor of Ophthalmology at Thomas Jefferson University and a Senior Fellow at Jefferson School of Population Health in Philadelphia.
“It’s a widespread problem, unfortunately, and actually a global problem,” she said. “And the problems that we see range from temporary irritation and discomfort, to infections; some of which can cause long term scarring and vision problems.”
A 2017 case report of 300 CLs examined since 2013 by the Forensic Chemistry Center of the US Food and Drug Administration (FDA) found impurities in many nonprescription CLs and lens solutions in their original packaging. Of the total, 285 were decorative soft lenses, obtained from import seizures, over-the-counter or market purchases, internet sites, and tattoo parlors.1
“Our observations indicate that 60% of the counterfeit lenses and 27% of the unapproved lenses examined were positive for microbial contamination,” according to the report. For 28 brands of unapproved costume CLs, 13 had one or more samples test positive for microbes. Overall, the study found 50 different organisms, including gram-positive and gram-negative bacteria, and several fungi. Of special concern is Bacillus cereus, which can cause endophthalmitis, a pathogen that has also been found in recalled cosmetics.1
Preemptive Patient Education
Preventively, clinicians can advise individuals that costume CLs may be worn more safely with a 3-step approach: step 1 — appropriate fitting; step 2 — safe disinfection and handling; and step 3 — no napping or sleeping overnight in costume contacts, Dr Steinemann explained.
Even before the autumn costume party invitations were sent out, general CL hygiene in the United States proved insufficient, according to the Centers for Disease Control and Prevention (CDC).2 In 2016, the CDC surveyed 4548 adults ≥18 years of age and 1618 adolescents 12-17 years of age. It reports that a considerable number of existing CL wearers took chances that exposed them to eye infections, including 85.3% of teens 12 to 17 years old who admitted to one or more sub-optimal lens-wearing practices, as well as 80.9% of adults 18 to 24 years old, and 87.5% of those 25 years of age or older.2
At Halloween, these figures may be exacerbated by the wide availability of costume lenses via online sites, beauty supply retailers, or novelty shops where novice buyers may guess at their size or receive no safety instruction. In an Eye & Contact Lens study led by Dr Steinemann investigators conducted a survey of patients in a clinical practice setting on their lens wear and care. Of 159 respondents, 23% reported using decorative contacts, obtaining these lenses from an unlicensed party 51% of the time. “Education about lens care and handling was significantly associated with acquiring lenses from licensed providers (R =.74, P <.0001),” according to the investigation.3
Triaging Decorative Contact Lens Injury Patients
Patients may end up with a corneal abrasion from lenses that do not fit properly, or from trying to take out a stuck CL. When there is a break in the protective epithelial barrier, infections can set up. Notably, a study published in Investigative Ophthalmology & Visual Science found that the relative risk (RR) of developing microbial keratitis (MK) was 16.5 times higher in individuals who wore cosmetic CLs compared with other CL wearers.4
At Wills Eye Hospital, the emergency triage process is based on severity of the disorder and amount of vision loss. When it comes to costume-lens-related disorders, “the least serious would probably be an irritation of the conjunctiva, which can be just an abrasion or a small hemorrhage on that covering layer of the conjunctiva of the eye,” Dr Murchison explained. “More severe would be corneal ulcers, which can be very large and lead to significant vision loss, and sometimes there can be permanent problems from that.”
Some key factors to remember — patients with conjunctivitis present with redness, but not severe pain, although eyes with keratitis typically are red, painful, with considerable light sensitivity, and they may have drainage, according to Dr Steinemann. There may be excessive tearing with a corneal scratch, or a watery drainage upon the start of bacterial infection, later becoming purulent. Presentations with blindness can occur; some pathogens can act that fast.
In a 2019 literature review of decorative CL-related infections published in Eye, investigators list the most common species of bacteria found in prior studies, including Pseudomonas, Staphylococcus and Streptococcus species. The most common is Pseudomonas aeruginosa. Biofilms by Pseudomonas aeruginosa, Staphylococcus aureus, and Elizabethkingia species were also prevalent.5
Bacteria More Common, But Acanthamoeba on the Rise
Dr Murchison sees a variety of infections including bacteria, a mix of bacteria, and Acanthamoeba. “And it can be severe enough if they have a keratitis or a corneal ulcer that they can get inflammation in the front of the eye where they’ll have iritis or uveitis, even layering to a hypopyon beyond where you can see all those inflammatory cells layering in the front of the eye,” she explained.
Dr Steinemann added that, “bacterial infections are urgent and a very acute presentation, but that’s not to ignore some of the other bad actors, and one of the worst bad actors of infection that you worry about, particularly with soft lenses, is something that doesn’t come on as acutely as a bacterial infection, and it’s called Acanthamoeba.”
Naïve wearers may not suspect fresh tap water as a problem and wash their lens case without drying it, or wear contacts in the shower. In the 2019 literature review published in Eye, several studies showed increasing occurrence of decorative CL-related Acanthamoeba keratitis in the United States, Korea, and New Zealand.5
Acanthamoeba keratitis pain can be intense, along with redness, blurry vision, and severe photophobia. “Acanthamoeba keratitis is not as common, but we worry about it because if it’s not recognized early in the game, you won’t have any chance of a medical treatment cure,” Dr Steinemann said. “So a lot of these people do very poorly in terms of not only their eyesight, but in terms of pain control and chronic trips back and forth (to the clinic).” Some may need corneal transplants.
For corneal scratches that are caused by improperly fitting CLs, the lenses can act as a kind of band-aid, camouflaging perception of the scratch. The wearer may be unaware there is a problem as long as the contact is in place, and infection can worsen underneath the lens. Multiple studies have reported that decorative CL wearers who experience uncomfortable symptoms put off calling an eye care provider longer than those who customarily wear lenses.5
Many patients will own up to wearing decorative contacts and not knowing the proper care instructions. However, sometimes the patient may not want to admit they’ve been wearing costume CLs, especially if he or she is a child or teen.
“The youngest patient I’ve ever seen was a 12-year-old, and in her case, she’d gotten them from a family member,” Dr Steinemann said. “I saw a 14-year-old that went out with her friends to a party and basically got them sold to her without her mom’s consent. So a lot of times, you know the kids, they might be afraid to even tell you, particularly if mom or dad are there, but they’ve done something that is dangerous or hurting their eyes. And so you have to kind of figure it out by looking at it.” He added that it’s crucial to take a good history.
When patients present to Wills’ Emergency Department, history-taking includes questions about the lens product. “We’d like to know if they had a prescription for their contact lenses, because certainly you can get a prescription for contact lenses that are not for improving your vision,” Dr Murchison said. “And then sometimes knowing the type of contact lens can be helpful as well.”
So they ask about lens hygiene and how patients wear their CLs. “So how long they’re worn, or if they sleep in them, what types of solution they may use, for how often they clean them, and if they’re using homemade or store-bought solutions for cleaning and making sure that the contact lenses are their own contact lenses and not being shared between people,” she added.
Another question may be to ask the patient about costume makeup around the eye. Individuals wearing costumes may use eye liners or share make-up. Previous studies have shown that products such as lotions, mascara, and make-up removers may stick to the surface, “and alter lens properties” even after cleaning.5
The “sleeping in lenses” question is crucial. In a case series of 6 patients with lens-related corneal infections for which the main risk factor was sleeping in soft lenses, 3 of the participants obtained contacts without a prescription. The cases occurred from 2016 to 2018, and were reported by ophthalmologists at 4 academic medical centers.
For example: a male patient, 18 years of age, wore decorative soft lenses for 1 year prior to reporting to the emergency department after a 3-day history of redness, pain, tearing, and photophobia in his left eye. Upon examination, his eye “showed moderate injection with a central ulcer, edema, and moderate inflammatory reaction.” Cultures of his lenses, eye, and lens case grew Klebsiella pneumoniae and Pseudomonas aeruginosa. Fortified cephalosporin and aminoglycoside eye drop treatment worked to resolve the infection, and vision improved to 20/25, but the patient was left with a stromal scar.6
One teaching point for patients wearing colored CLs is that they should not wear them for as long as they would wear clear refractive lenses. Color is simply another layer that slows the free flow of oxygen. “The second thing people need to be aware of is the way that the dye is introduced, sometimes probably most safely, the dye is introduced internally into what they call ‘the matrix of the lens,’” Dr Steinemann described. “Those are probably a little more expensive, but that’s the safest way because the dyes are not on the surface of the contact right next to your eye and to your eyelid.” This is important because when the pigment is roughing up the surface or rubbing the cornea or conjunctiva, microbes find spaces to collect.
In a 2015 study published in Eye & Contact Lens, investigators scrutinized 5 cosmetically tinted CLs available without a prescription.7 Energy-dispersive x-ray spectroscopy identified chemical elements found in the samples. In regions of pigmentation; chlorine, iron, and titanium were found. Although dye was embedded 8 to 14 μm from the anterior surface of one product, pigment was only 1 μm from the posterior lens surface in another. In 1 lens, color was located on the anterior surface, and 2 had dye deposited on the posterior surface. In one of the lenses with posterior side colorant, “chlorine is exuded and spread.”7 And these substances may continue to escape, “so you could have a toxic reaction to these chemicals leaching out while the contact lens is actually on the eye,” Dr Murchison added.
In another study, researchers used a standardized rub-off test on 15 brands of colored contacts. Gentle rubbing to a maximum of 20 rubs with a moistened “cotton bud” was performed, and each bud’s tip was examined for detached pigment, according to data published in Contact Lens & Anterior Eye. Also, 5 new lenses of each brand were incubated in Pseudomonas aeruginosa. Of the 15 brands, only 2 showed dye permanence. The 2 brands with permanent pigment also demonstrated ≥6 times less bacterial adhesion than the 13 which exhibited rubbed-off dye.8
Clinicians can also mentor patients about their cornea needing oxygen. Dr Steinemann has seen hypoxic keratitis many times. Dr Murchison added that hypoxia of the cornea can result from lenses not approved by the FDA that are made of a thicker plastic that is also less permeable.
Provider reporting may help
All soft contacts are considered medical devices, regulated by the FDA. Consumers or vision providers who suspect an online retailer of illegally selling CLs without a prescription can report it to the FDA.9
Voluntary reporting is a start, but not enough to inform clinicians of the issue’s prevalence, Dr Steinemann explained. He is working with the nonprofit Prevent Blindness’s newly launched Contact Lens Safety Month (October) to help create more awareness for lens safety.
“We’ve got a lot of work to do to try to understand how often people are putting themselves in harm’s way when it comes to wearing costume lenses,” he added. “Probably it would be helpful if there was a registry, a national registry for ophthalmologists and optometrists who see people who have been injured.”
Dr Murchison sums up the discussion perceptively, “I always think that, you know, everybody’s vision is worth the price of a prescription.”
1. Land AD, Penno KL, Brzezinski JL. Identification of microorganisms isolated from counterfeit and unapproved decorative contact lenses. J Forensic Sci. 2017; 63(2):635-639. doi:10.1111/1556-4029.13553
2. Cope JR, Collier SA, Nethercut H, et al. Risk behaviors for contact lens-related eye infections among adults and adolescents — United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(32):841–845. doi:10.15585/mmwr.mm6632a2
3. Steinemann, TL, Fletcher M, Bonny AE, et al. Over-the-counter decorative contact lenses: cosmetic or medical devices? A case series. Eye Contact Lens. 2005;31(5):194–200. doi:10.1097/01.icl.0000175654.79591.03
4. Bourcier T, Sauer A, for the French Study Group of Contact Lenses-related Microbial Keratitis. Cosmetic contact lenses related microbial keratitis as a foreseeable disaster: a prospective study. Invest Ophthalmol Vis Sci. 2010;51(13):2884. doi:10.1111/j.1755-3768.2011.02120
5. Lim CHL, Stapleton F, Mehta JS. A review of cosmetic contact lens infections. Eye. 2019;33(1):78–86. doi:10.1038/s41433-018-0257-2
6. Cope JR, Konne NM, Jacobs DS, et al. Corneal infections associated with sleeping in contact lenses – six cases, United States, 2016-2018. MMWR Morb Mortal Wkly Rep. 2018;67(32):877-881. Published online August 17 2018. doi:10.15585/mmwr.mm6732a2
7. Hotta F, Eguchi H, Imai S, et al. Scanning electron microscopy findings with energy-dispersive x-ray investigations of cosmetically tinted contact lenses. Eye & Contact Lens. 2015;41(5):291–296. doi:10.1097/ICL.0000000000000122
8. Chan KY, Cho P, Boost M. Microbial adherence to cosmetic contact lenses. Cont Lens Anterior Eye. 2014;37(4):267–72. doi:10.1016/j.clae.2013.12.002
9. Reporting unlawful sales of medical products on the internet. FDA’s MedWatch Reporting Form. FDA.gov. https://www.fda.gov/safety/report-problem-fda/reporting-unlawful-sales-medical-products-internet. Accessed Oct. 12, 2021.