corneal ulcer

My 13 year old daughter is recovering from a corneal ulcer that was 1 mm from visual axis. Normally a very healthy, athletic 13 year old. History: frequent ear infections and ear tubes,mild asthma & eczema as a young child.
March 12, 2007 - Dirt in her eyes during golf.  Both eyes were blood red within 2 hours. I immediately re-examined the eye and removed her contacts.  Irrigated the eye with contact lens solution.  By morning, eyes were completely back to normal so I allowed her to put new contacts back in. However, there were 3 or 4 occasions when she had tearing and irritation, but it was always after she had played a few hours of golf.  Weather was dry during this time and the pollen count was high.  Her eyes were back to normal each time she left the contacts out overnight, so I thought it was just allergies.  Had a severe sinus infection earlier in the month.
March 28, 2007 - Woke up with left eye swollen shut, photophobic, tearing.  Right eye was just a little swollen. Local opthamologist who diagnosed a corneal abrasion of her left eye. Prescribed antibiotic eye drops every 2 hours and eye ointment (antibiotic) at night.
March 29, 2007 - I noticed a grayish white blister on her left eye when I was putting the eye drops in.  Local opthamologist who told me to increase the drops to q1h.
April 2, 2007 -  Went back to local opthamologist because I felt the eye wasn't improving fast enough. Right eye now seems normal.  Local opthamologist said she actually had a corneal ulcer & sent her to a corneal specialist.  Saw corneal specialist that day.  Her BCVA in the left eye was 80/20 at this time. Corneal specialist was extremely concerned about her eye and said she might have to have a corneal transplant.  He did cultures (which came back negative) and 4 antibiotic injections subconjuntivally & put her on fortified Vancomycin & Tobramycin drops every 30 minutes while awake and q2hrs @ night. Over the next 7 weeks the eye slowly began to open completely and the BCVA improved to  20/30 with an irregular astigmatism and a 2 mm corneal scar (1-2 o'clock position).  It literally took all of 7 weeks for the eye to completely open.  After she finished the antibiotic drops, they did try a 2 wk course of mild steroid eye drops to improve the scar, but the corneal specialist didn't feel like they were helping.  There were 2 other teens on the school golf team (out of 20) and one other child at her school had corneal ulcers during the Spring.  Also, she had been contact lens solution that was recalled (acanthamoeba).  The company did bacteriology testing only (small sample size), it was negative.  I still have the case and lens, but no one seems interested in culturing them.
August 7, 2007 Currently, the BCVA of the left eye is 20/20 minus 2.  (This is with the glasses she had before the ulcer -3.75).  Dr. says that we could improve it even more if we change the rx just a little, to -4.50 spherical, +0.75 cylinder and 22 axis.  The irregular astigmatism seems to be smoothing out. Tear testing was normal.  Left eye is slightly to mildly irritated looking every single morning, even though she has been using Genteal drops every two hours while awake for the last 2 months.  Occasionally I will notice that the left eye isn't as open as the right and the lid seems a little swollen.  We are told that this is just the cornea healing.  Told that she should avoid contact lens indefinately, & she may be a candidate for PTK when she is in her 20's. Told that the scar might stay the same, disappear or get more dense.  Suggested we look into the possibility of her having Celiac disease as a possible cause of the ulcer.  Told to come back in 5 months.
1.  Is it normal for the eye to still be reddened and sometimes puffy in the mornings?  She hasn't worn a contact in her eyes since March 27th. Or could this be an allergy or infection?  
2.  Is there a chance the scar or astigmatism could get worse again?  
3.  They seem to feel this ulcer was due to a bacterial infection due to the dirt to the eye.  Should we explore other causes?
4.  Will or should she ever wear contacts?
5.  Is PTK an option for the future? Are there other options?  

[John C Hagan III, MD, FACS, FAAO]

1. No its not normal for the eye to be red and puffy in the morning. Yes it could be allergy or irritation or dryness. It's not likely due to infection after all the antibiotics she's had.
2. Yes the scar or astigmatism could get worse but most normally it stabalizes this far after the initial infection. Many scars flatten out, bet more transparent with time. (scar maturation).
3. What would be the advantage of "exploring other causes" and what would you do? The contact lens culture this late would tell you nothing. Mostl likely it was a combination of the contact lens and the dirt.
4. Sure she can wear contacts. They question is is it safe and advisable. Most ophthalmologists including me would recommend not wearing them again.
5. PTK would be a good option. Other options --glasses.

Glad she did okay. Our practice took care of several acanthomeoba infections that are a nightmare.

JCH III MD

[double l's mom]

Thank you so much for taking the time to respond with such clarity; it is quite helpful.  
As far as the irritated eye in the morning, is there anything we can do other that the Genteal drops during the day and the ointment at night?  Is this a normal part of the healing process?  Will this eventually go away?
I am also still a little concerned that this might have been VKC, and that this may have been a shield ulcer and will be nervous as spring approaches.  
The contact lens issue is still a struggle; she is an athlete and would like to at least wear them for her basketball games.  I have bought her some very nice (and very expensive) sports glasses, but they tend to fog up and are hot.  Between the glasses and the sometimes unequal eye opening due to a puffy lid, it has really affected her self image & confidence.  She doesn't understand why all the other kids who got corneal ulcers are allowed to wear contacts now.  I'm trying to explain to her that her situation is different.  Is it because her risk of the contact causing another infection higher because she has a corneal corneal scar?  It would really be helpful to be able to rationalize this with her; any help you can provide in this area would be appreciated!

Thank You,
Double L's mom

[John C Hagan III, MD, FACS, FAAO]

Hi mom, I know its tough for you and her. I've been through this a lot of times with young people.

1. You might try other types of lubricants they're not all the same. Other good choices to try Soothe, Opteve, Systane, Hypotears. Be sure she's not sleeping under a fan or having air conditioning blowing across her face at night. You can also try Refresh PM ointment at bedtime.

2. In most people the eye does return to feeling normal and is pain free. How long? I would say between 3 to 6 months post ulcer. If the scar is near the pupil center the eye may remain more sensitive to light than before the ulcer.

3. Did you mean EKC  (epidemic kerato-conjunctivis?). VKC is not ringing a bell for me now.  Do you mean vernal conjunctivitis? If so that doesn't look too much like an infected ulcer and usually doesn't leave a scar like an infection.

4. There are any number of college and professional basketball players that play in glasses and/or goggles. I would talk to the optician where you bought your expensive sports glasses. You may need an anti-fog liquid to put on the glasses before a sporting event. I played highschool and college basketball in sports glasses and it was not a problem.

5. You would have to get clearance for sporting events or special special social events to wear the contact lens from your ophthalmologist.

6. The biggest risk is another infection, a bigger scar. If the contact was well fit and she was taking proper care of it then she may be unable to wear contacts any longer. Happens all the time.

JCH MD

[double l's mom]

You have been very helpful!  She does sleep under a ceiling fan, so that will stop tonight!  She hasn't had any pain in a lonnng time, just this mildly irritated (sometimes puffy) eye every morning....it seems like any little thing irritates it (playing outside, etc)....but hopefully within the next month or so things will be back to normal.  And I will try to look into some of the anti fog liquids for her sports glasses.  

Yes, I was talking about vernal conjuntivitis.....I've had a hard time understanding why the eye suddenly swelled shut 2 weeks after the dirt to the eye and the cultures were neg....I just don't want to miss anything....but you've provided reassurance.

I did have a question about #6.....I'm not clear on that last sentence.  Are you talking about not being able to tolerate a lens or get it to fit correctly due to the scar /irregular astigmatism?  I'm thinking that might be the case especially as sensitive as her eye is now.

We are blessed that she has recovered so much of her vision despite such a severe ulcer....now to deal with the emotional issues.

Thanks again for your kindness and thorough/quick response!

Double L's Mom

[John C Hagan III, MD, FACS, FAAO]

The point I was making is that sometimes "out of the blue" and "for no good reason" people lose the ability to wear contacts. This is more common in women due to the effects of hormones and that dry eyes is more common in women. Also the percentage of people that can wear contacts declines over time, that's why you don't see many sixty year olds wearing contacts but a lot of 16 year olds are.

One study in the medical literature on corneal ulcers found that about 20% of people that got infected corneal uclers didn't do anything wrong. They had no trauma, were wearing and cleaning the contacts properly, etc.

In our large refractive surgery practice about 10-15% of our LASIK patients are having the surgery because they couldn't wear their contacts anymore.

JCH III MD   Eye Physician & Surgeon

[double l's mom]

Thanks for the clarification!  Hopefully her eye will get better soon as well as her feelings about having to wear glasses.  She's been a real trooper through all this, she's just getting a bit weary of all of it recently.  Thank you for your help.

[double l's mom]

An update and a question:
My daugter's eye hasn't been irritated looking for the last 2 mornings, so we have started to taper back on the Genteal drops.  However, I have come to realize what I thought was a mild puffiness of the eyelid in the morning may actually be a mild ptosis.  Most of the time, her left eye is not as open as the right, by about 2 - 3 mm's.  There are times when it looks almost normal, but it looks like a "weak eye" most of the time, especially if she is tired.  Most noticeable in photographs.  What is the likelihood that this will return to normal....especially this far out from the onset of the infection (3/28)?   Is it a result of the swelling due to the infection, the injections, the strong eye drops or all of the above? Is there anything we can do to help strengthen/tone the muscles of her eyelid?  She is pretty self conscious about it and is worried that it might be a permanent thing.
Thanks again,
DoubleL's Mom

[John C Hagan III, MD, FACS, FAAO]

Corneal ulcers rarely cause ptosis. Antibiotic drops rarely cause ptosis. Injections can cause ptosis but usually the injections are given through the lower lid to prevent ptosis. Probably your daughter was injected inferiorly? Steroid drops can cause occassional ptosis but clear in the weeks after drops are stopped.

If an eye is painful or sensitive to light the eyelid often partially closes to reduce light and protect the eye. This is called "guarding ptosis"  it goes away when the eye is no longer sensitive to light or painful.

People have rubbed the eye so hard they disinsert the muscle that holds the eyelid up. This is very rare in young people not uncommon in 80+ people. Even tight eye patch can cause same.

Exercises will not help ptosis.  No one will likely consider surgery without 4-6 months observation to see if it gets better with time.

Sometimes drops like Visine will stimulate the Mueller muscle that is a helper muscle on holding the lid up.

Hope this clears with time.

JCH III MD

[double l's mom]

Well, she did receive injections in the upper conjunctiva.  I thought she did and I just checked with her to be sure.  She had a total of 4 injections (2 in the lower, 2 in the upper.  Vancomycin (25mg/ml)  & Tobramycin (40mg/ml).  If the ptosis is the result of injections into this area, would it be because the volume of the medication, the irritating effects of the medication or the needle?  If this is the cause, is it likely to go away?  Would the visine help?
Thank You,
Double L's Mom

[John C Hagan III, MD, FACS, FAAO]

Visine will not help. Time may. The injections could be the cause. It's something I've published 3 papers on:

82. “Diplopia and Ptosis Following Injection of local Anesthesia Without Hyaluronidase”, Jehan FS, Hagan III JC, Whittaker T, Subramanian M. Journal of Cataract & Refractive Surgery, 27:1876-1879, 2001

90. “Permanent Diplopia Following Cataract Surgery”, Journal of Cataract & Refractive Surgery, 27: 341-342, 2001

JCH III MD

[Diamondeyes]

Hi mom! I have a few other suggestions for your daughter's comfort both on & off the golf course. Incidentally, I'm a woman golfer who had cataract surgery two years ago and I've been contending with dry eyes ever since. In addition to turning off the ceiling fan have her make sure that the air vents in the car are directed away from her when she rides in the front seat. Nothing dries my eyes out as quickly as having the heat or AC blow in my face. I have read that shopping malls are in fact more arid than the Sahara. I find that big box stores are comparable. I carry an aerosol product called Nature's Tears for just such environments. No fuss, no muss - more inconspicuous than drops. You can Google the name and find out more from their web site. Increasing one's intake of Omega 3 fatty acids seems to help many people, myself included. I take Thera Tears capsules. They are OTC & you'll find them near the Genteel in the store. At home you might try putting a room size humidifier in her bedroom. They say that for eye comfort the humidity should be at least 47%. I can vouch for that. For about $4.00 you can buy a combo thermometer/humidity gage at your nearest discount store.

Now about the sport goggles - I hope the good doctor won't be offended, but I have a much better understanding of how a 13 year old girl feels about such things. I would not be back on the course at my age (60) if it weren't for someone having put me wise to Panoptx glasses. (I'm eternally grateful to that person whom, being a man, doesn't seem to quite comprehend my effusive expressions of gratitude.) The glasses look like glasses rather than goggles. They offer men's and women's styles designed for motorcycling fashionistas. There's another brand that's very similar - WileyX. Both companies can fit their glasses with prescription lenses. Most styles are at least shatter resistant if not shatter proof. Mine are plano sunglasses as I have multifocal IOL's. They offer clear lenses, sunglasses in different tints and photo sensitive lenses. Here's the part you're going to love, mom - some styles come with removable foam padding around the edges that keeps the wind and DIRT out of your eyes! The foam easily snaps in & out and is far less noticeable than sport goggles. Even without the foam mine fit closely to my face cutting down a great deal on the wind. With the foam I've been perfectly comfortable when other golfers (without eye problems) have been miserable. I wear mine for all manner of outdoor activity. Again a Google search will take you to their web sites for more info. If you are interested you can see at least some of these glasses first hand at most Harley-Davidson dealerships. Pardon a little maternal advice from a mother & grandmother of girls - since they aren't cheap & she's only 13, I suggest taking her to check them out.

The only thing I have to gain from telling you all this is the satisfaction I will feel if it helps to keep your daughter in the game and feeling better. Good luck to both of you.