When That Sore Eye Is Something Much Worse
By Erich Mack, ABOAC, LDO, NCLEC
Release Date: July 1, 2014
Expiration Date: May 6, 2019
To update the ECP on changes and adoption practices for a lens material that is capable of being the overall lens platform including:
- Become familiar with some of the more serious eye infections.
- Learn how these eye infections are transmitted and affect patients.
- Know how to recognize "red flag" symptoms and how to handle these patients properly.
Erich Mack, B.S., ABO, NCLE, is a
certified Arizona licensed optician.
At Visions Optique, he assists in
practice management, training and brings his personal
style to everyday
well as creating
new CE courses.
This course is approved for one (1) hour of CE credit by the American Board of Opticianry (ABO). Course STWJH100
This course is approved for one (1) hour of CE credit by the National Contact Lens Examiners. Course CTJHI109-2
1 hour of CE credit by the American Board of Opticianry ~ Valid for credit through May 6, 2019
1 hour of CE credit by the National Contact Lens Examiners ~ Valid for credit through May 6, 2016
Infections can be the most devastating and scary
ocular emergencies we encounter. Infections come
in many forms and can be bacterial, viral, fungal or
parasitic. They strike their victim in a variety of
ways and are indiscriminate. In this article, we will
cover the worst five ranked in order based on my
subjective opinion. To create a hierarchy, a subjective ranking of transmission, symptoms, treatment
options and contagion will be used. It may be possible that some opticians may never encounter
these infections but it is important to note that
these patients are in crisis, and as opticians, it is
important to recognize the warning signs and
direct these patients to the right professional.
Transmission: Transmission methods can vary.
Some infections are non-transmissible and score
low where others transmit easily and therefore
score high. Some invading organisms may live in
your backyard plants or water sources, which also
will score higher.
Symptoms: Symptoms vary with each type of
infection. The symptoms are categorized by
pain level and longevity, which will determine
the score. For example, itching would score
lower than a melting cornea (more about that
later). A recurrent infection would score higher
than an acute infection.
Treatments: Treatments make up the third
scoring category. Multi-drug resistant infections
would score higher than an infection treated
by petroleum jelly. Some infections require a
lifelong treatment plan, which score higher than
a two-week antibiotic regimen.
Contagion: Finally, how contagious the infection
is will be scored. Epidemic capability would
score highest and non-contagious infections
would score the lowest in this category.
The "fearsome five" are the worst five afflictions based on my rankings and starting from
|Number 5: Pthiras Pubis (aka Crabs). The crab louse, also known as the pubic louse, is a tiny insect parasite that lives and breeds exclusively in thick, coarse human hairs. Due to their wide, flat bodies, they don't fit well in regular thin hair areas such as the scalp, although there exists a cousin louse that does indeed survive very well in the scalp. This cousin louse is the embarrassing lice that every grade school kid dreads. The coarse hair folliculaphilic crab louse (Pthiras Pubis) is found in the pubic and eyebrow/lashes in humans.
- Tiny insect parasites usually found in
- Transmission to the eye area is commonly
through sexual intercourse.
- There can be non-sexual transmission
via family and/or roommates sharing
towels, clothes, beds or closets.
- Localized intense itching due to
hypersensitivity to crab saliva.
- The crabs feed exclusively on host
blood four to five times per day.
- Excessive itching can cause corneal
scratching and/or open wounds which
can lead to secondary infections.
- The parasites can only survive a short
time away from the warmth and humidity
of the human body.
- Successful treatment of the eye area
includes applying petroleum jelly to the
infected site twice a day for 10 days.
- The female crabs lay three eggs a day
and sweeps over the host quickly.
- Direct contact with infected persons or
infected items can transmit the crabs to
- Highly contagious to other humans due
to high dwelling density.
- Ranks as number five due to its low pain,
damage levels and ease of treatment.
But it makes the list due to its highly
|Number 4: Adenovirus or viral conjunctivitis (aka viral pink eye) ranks fourth on our fearsome five list. Adenovirus actually consists of a family of virus strains called Adenoviridae. These medium-sized viruses infect a large range of animals and cause a variety of illnesses. For our purposes, we will focus on the notorious pink eye, specifically viral pink eye.
- An Adenovirus is spread easily by accidental inoculation to others via sharing
towels, shaking hands, coughing and
public swimming pools. This is certainly
a red flag for an optician to be aware of,
you don't want to accidentally let your
patient infect you.
- We all have had the unwitting pink-eye
patient walk in and touch the check-in
desk, try on glasses and generally inoculate the whole optical department. Be
aware of the following symptoms.
- Adenovirus causes intense itchy eyes and
usually the eyes are crusted shut after
- Eyes tear excessively and have a red
appearance and giant papillary conjunctivitis (GPC) is present under the lids.
- Puss-like, ropey discharge is often
noticed with adenovirus.
- Painful photophobia can also occur in
- In rare cases, patients may be susceptible
to a secondary bacterial infection which
leads to a very painful and difficult to
treat super infection.
- Adenovirus usually can resolve itself within
two to four weeks.
- There are support treatments to help
alleviate the symptoms and prevent
bacterial super infection.
- Cold compress, artificial tears and
NSAID pain relievers are also commonly
- Adenovirus is the most contagious of the
fearsome five ocular infections.
- It is extremely contagious, and as with
most viruses, it is very durable inside and
outside the human body.
- It is so contagious that it can cause epidemics
of the infection, called epidemic keratocon-junctivis (EKC), which are tracked by the
Centers for Disease Control.
- Adenovirus ranks at number 4 due to its
extremely contagious nature, even reaching epidemic levels.
- The pain is high and the symptoms are
extremely unpleasant but damage levels
are low. However, it is short-lived and
|Number 3: Herpes Zoster Ophthalmicus (aka Zoster) weighs in at a strong third on the fearsome five list. Zoster is caused by the virus varicellazoster. It is the same virus we love to hate that causes chickenpox and the painful shingles disease. It should be noted that Zoster is not the same virus that causes genital herpes, and therefore it is not sexually transmitted. Zoster outbreaks occur when the virus, which lives around nerve fibers, decides to replicate and/or move to another body part. This outbreak is very unpleasant in appearance and usually strikes when the victim has a weakened immune system.
- Since Zoster is a second unique type of
outbreak from chickenpox, it isn't directly
- Only someone who never had chickenpox or a chickenpox vaccine would be
susceptible. A person would need to
have an open wound come in direct
contact with a victim's Zoster outbreak.
Even then only the chickenpox virus is
transmitted with no guarantee of getting
a Zoster outbreak.
- Zoster is a very painful condition since
it directly attacks sensory nerves and can
last for weeks, months and sometimes
years. Hospitalization is considered for
- The severe pain is spread around the
eyes and the side of the face. The pain
continues to persist for several days
after the visible signs have disappeared.
- A very unpleasant-looking rash appears on
the eyes, forehead and sometimes nose.
- It causes open wounds and when a crust
forms, called crusting, the outbreak is
beginning to resolve itself.
- Swelling and cloudiness of the cornea
occurs during the outbreak as well as an
increased intraocular pressure (IOP).
- Zoster is a virus and antibiotics are
- There are some antiviral eye drops, and
pills that may shorten outbreak length
but they must be administered as soon as
possible (72 hours).
- Zoster is not directly contagious, it's the
least dangerous for public contamination
of the fearsome five.
- Zoster is number 3 due to its extreme pain
level and long-term effects. The physical
symptoms are extreme as well. It is difficult to treat, and all treatments must start
quickly to have any effect. Zoster scores
low in the contagion factor as it does not
spread from person to person, and there
is no guarantee of an outbreak even if you
|Number 2: The terrifying infection by Pseudomonas (aka The Cornea Melter) is number two on the fearsome five list—and for good reason. Pseudomonas is a ubiquitous bacteria that is commonly found in soil, water and plants. Normally Pseudomonas is harmless to humans, however in certain situations, an extremely dangerous and nightmarish infection can occur. To add to the risk factor, all non-disposable contact lens wearers are at the most risk for a Pseudomonas infection.
- Pseudomonas is ubiquitous, and you
probably have a few of the bacteria
on you as you read this. However, the
danger occurs when it forms a colony
in the solution or case of contact lens
- A person that decides to create their own
saline solution for contacts runs at risk of
Pseudomonas infection since Pseudomonas
is found naturally in water. Also if the saline
solution isn't fully sterilized, Pseudomonas
- A person that doesn't follow cleaning
protocol in regards to their contact lens
case is also at risk of allowing Pseudomonas
to grow inside the case.
- Pseudomonas infection to the eyes is devastating, often resulting in a melted cornea.
Thus the moniker "The Cornea Melter."
- The infection is extremely painful due to
nerve exposure associated with the melting
of the epithelial and stromal cell layers.
- The wound is also susceptible to
secondary super infection.
- If the Pseudomonas infection is not
treated properly, and even in some
cases of quick medical intervention,
the victim's infected eye has to be
- If the infection is successfully stopped,
often severe vision loss occurs. Severe
being equated to no light perception
(NLP), or 5/200 VA.
- There are no vaccines for Pseudomonas,
and it is notoriously resistant to
- Even if diagnosed and treated on
day one of the infection, outcomes
are grim, resulting in blindness or
- With such a narrow window of treatment, finding an effective antibiotic is
- Most often the only successful method is
removing the infected tissue.
- Since Pseudomonas is usually harmless,
it is not very contagious.
- The transmission vehicle is dirty contact
lens solution and cases, so avoiding and
disposing of them will eliminate any
- Pseudomonas is a close number 2.
- It ranks high because it is extremely
painful and has horrifying corneal
melting symptoms. It also ranks high
due to its grim outcomes, even after
immediate treatment, often resulting
in loss of an eye or total blindness.
It is not very easy to contract except
for noncompliant contact lens wearers
and is uncommon so it scores low in
|Number 1: The near invincible Acanthamoeba tops off the list as the infamous number 1. Like Pseudomonas, Acanthameoba is a microorganism that is ubiquitous. It is found in soil, water and many other everyday locales. Infection is rare, similar to Pseudomonas, but when infection does occur, it is extremely dangerous and devastating. And thanks to some high profile cases involving corporate quality control negligence, it edges out Pseudomonas in the list. It is a true free-living monster that can infiltrate and lay waste to a victim's cornea.
- Acanthameoba is a very tough organism
to kill as it can transform itself into a cyst.
- While in this dormant defensive form, it
becomes resistant to temperature changes,
pH changes and resistant to immune
- The transmission vehicle is identical to
Pseudomonas. Contact lens wearers are
the main target for ocular Acanthameoba
infection. People with recent agricultural
inflicted eye trauma would be the second
most common victims.
- A person that decides to create his or her
own saline solution for contacts runs a
risk of Acanthameoba infection. Since
Acanthameoba is found naturally in water,
if the saline solution isn't fully sterilized,
Acanthameoba can thrive.
- A person who doesn't follow cleaning
protocol in regard to their contact lens case
is also at risk of allowing Acanthameoba to
growing inside the case.
- Contaminated commercial contact lens solution can also cause Acanthameoba infection.
- In 2006, Bausch & Lomb recalled its contact
lens solution due to Acanthameoba contamination. Also, a 2007 recall occurred for the
same reason by the AMO corporation.
- Initial symptoms appear as epithelial irregularities and ring-shaped infiltrates which
mimic other much more common ocular
problems. This makes it difficult to diagnose.
- A clue to Acanthameoba presence is an
extraordinary amount of pain in what appears
to be a minor low pain corneal problem.
- Exquisitely high photophobia is another
symptom. People often come to their exam
with two pairs of sunglasses on and a jacket
pulled over their head to block out light.
- Super infection with bacteria is common,
making treatment and diagnosis even more
- Damage to the cornea is severe, leading to
total vision loss and/or corneal transplant.
- There are no FDA-approved medications
for treating Acanthameoba infection.
- Aggressive surgical and antimicrobial
treatments need to occur immediately.
Even then the treatments last from three
months to over a year with grim outcomes.
Many patients still end up requiring
- Treatment with high levels of steroids is
common; however, it often then leads to
super infection with bacteria further
complicating the problem.
- When Acanthameoba forms a cyst, it is
nearly impossible to kill.
- Like Pseudomonas, Acanthameoba is not
- Sharing contaminated products like solution
and/or cases can spread the infection.
- Acanthameoba is number 1 in the fearsome
five. It ranks high due to its extreme pain, damage and photophobia. It also is nearly
impossible to treat and requires immediate
aggressive surgeries. Even so, the aggressive
treatments continue for up to over a year
with grim outcomes, often resulting in
corneal destruction and transplants.
Acanthameoba ranks high for its extreme
toughness. However, it ranks low in the
contagious area, as it is usually limited to
contaminated contact lens solution and cases
or agricultural caused eye injuries. It edges
out Pseudomonas in this area due to the
high profile contaminated product recalls.
What can an optician do when faced with the
infected patient? It is important to recognize
red flag symptoms. Recognition is important in
order for precautionary measures to happen.
Of course, every patient must be treated with
the utmost respect and professionalism. Keep
in mind the protocols of HIPAA and patient
treatment when the patient is in the exam
room with the doctor. Never speak ill of a
patient or discuss the patient's conditions in
front of other patients/customers. After the
patient has left, have a discussion with the doctor about biohazard disinfection.
It is important to be aware of the fearsome
five and other infections to which your patients
can fall victim. Having knowledge of these
ocular infection emergencies can be an indication of your office professionalism and make
your patient/customers feel that they are in
good hands. As opticians, we of course do not
treat these patients, but having the basic
knowledge can help you help a walk-in case
and avoid giving poor advice. Parents that have
their children go through contact lens training
will certainly appreciate the preventative care
training. Pseudomonas and Acanthameoba are
great examples of how an optician can help
keep their patients healthy. Proper education
of contact cleaning protocols, replacement
schedule or recommending daily disposables
all help reduce Pseudomonas and Acan-thameoba infection risk. After all, giving sound
preventative advice is giving superior care to