Original research

Personal hygiene risk factors for contact

lens-­related microbial keratitis
Anna Stellwagen  ‍ ‍,1,2 Cheryl MacGregor,1 Roger Kung,1,2
Aristides Konstantopoulos,1 Parwez Hossain  ‍ ‍1,2

To cite: Stellwagen A, ABSTRACT

MacGregor C, Kung R, Objective  Microbial keratitis is a sight-­threatening Key messages
et al. Personal hygiene risk complication of contact lens wear, which affects thousands
factors for contact lens-­
of patients and causes a significant burden on healthcare What is already known about this subject?
related microbial keratitis. ►► Contact lens-­
related microbial keratitis (CLMK)
services. This study aims to identify compliance with
BMJ Open Ophthalmology causes significant burden on patients and healthcare
2020;5:e000476. doi:10.1136/ contact lens care recommendations and identify personal
hygiene risk factors in patients who develop contact lens-­ services. Previous papers have identified certain risk
bmjophth-2020-000476
related microbial keratitis. factors for developing CLMK, such as type of contact
Methods and analysis  A case–control study was lenses worn, hand hygiene and overnight wear.
Received 2 April 2020 conducted at the University Hospital Southampton Eye What are the new findings?
Revised 4 August 2020 Casualty from October to December 2015. Two participant ►► Our case–control trial is unique in that it uses face-­
Accepted 15 August 2020 groups were recruited: cases were contact lens wearers to-­face interviews to, not only identify contact lens
presenting with microbial keratitis and controls were hygiene practices, but to also capture patient opin-
contact lens wearers without infection. Participants ions and experiences. We demonstrate for the first
underwent face-­to-­face interviews to identify lens wear time the dose-­dependent effect of showering in con-
practices, including lens type, hours of wear, personal tact lenses. Showering in contact lenses increases
hygiene and sleeping and showering in lenses. Univariate the risk of CLMK (OR 3.1), while showering daily
and multivariate regression models were used to compare in lenses compared with never showering in lens-
groups. es, increases the risk of microbial keratitis by over
Results  37 cases and 41 controls were identified. seven times (OR 7.1). Sleeping in lenses and being
Showering in contact lenses was identified as the greatest aged 25–39 are also significant risks. Our study also
risk factor (OR, 3.1; 95% CI, 1.2 to 8.5; p=0.03), with shows that despite most contact lens wearers buy-
showering daily in lenses compared with never, increasing ing their lenses from opticians and having regular
the risk of microbial keratitis by over seven times (OR, follow-­up appointments, contact lens wearers con-
7.1; 95% CI, 2.1 to 24.6; p=0.002). Other risks included tinue to perform poor hygiene practices.
sleeping in lenses (OR, 3.1; 95% CI, 1.1 to 8.6; p=0.026),
and being aged 25–39 (OR, 6.38; 95% CI, 1.56 to 26.10; How might these results change the focus of
p=0.010) and 40–54 (OR, 4.00; 95% CI 0.96 to 16.61; research or clinical practice?
p=0.056). ►► Focusing attention on improving contact lens edu-
Conclusion  The greatest personal hygiene risk factor cation of infection and retention of information may
for contact lens-­related microbial keratitis was showering help improve compliance with lens wear practices,
while wearing lenses, with an OR of 3.1, which increased which may help reduce incidence of CLMK.
to 7.1 if patients showered daily in lenses. The OR for
sleeping in lenses was 3.1, and the most at-­risk age group
was 25–54.
Despite advances in contact lens tech-
© Author(s) (or their nology, the incidence of CLMK has remained
employer(s)) 2020. Re-­use consistent at around 4 per 10  000 daily
permitted under CC BY-­NC. No
contact lens wearers per annum.5–7 Poor
commercial re-­use. See rights
and permissions. Published by INTRODUCTION contact lens hygiene is a known contributor
BMJ. Contact lenses for visual correction offer to microbial keratitis. In a study by Brewitt et
1
Eye Unit, University Hospital many benefits to the 4 million wearers in the al,8 66% of complications observed in contact
Southampton NHS Foundation UK, yet contact lens-­related microbial kera- lens wearers were attributed to poor hygiene
Trust, Southampton, UK titis (CLMK) is a frequent cause of unilateral practices. There is great variation in contact
2
Eye Unit, Clinical and
visual impairment.1–3 Severe cases can result lens hygiene awareness and recognition of
Experimental Sciences,
University of Southampton, in permanent vision loss, a need for corneal the risks among regular contact lens wearers.
Southampton, UK transplant or loss of the eye. In all healthcare Aftercare practices and demographic trends
systems, CLMK poses a significant healthcare of contact lens wearers have been previ-
Correspondence to
challenge as patients require intensive topical ously investigated to identify risk factors for
Professor Parwez Hossain; ​P.​N.​ antimicrobial therapy and close monitoring microbial keratitis.2 9–12 This study aims to
Hossain@​soton.​ac.​uk of treatment response.2–4 identify patient demographics and current

Stellwagen A, et al. BMJ Open Ophth 2020;5:e000476. doi:10.1136/bmjophth-2020-000476 1

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compliance with contact lens care recommendations by relating to contact lens wear and aftercare. Patients with
contact lens wearers in the UK. The study also aims to CLMK were asked additional questions relating to their
identify modifiable risk factors for patients who develop infection. This is summarised in table 1. Participants were
CLMK, including, types of lenses worn, lens wearing able to withdraw from the study at any time.
habits, aftercare habits and water exposure. Further aims
included analysing patient opinions and experience on Definitions of categories
contact lens wear and microbial keratitis. Our study is Frequency of wear and frequency of performing a certain
unique in that we used face-­to-­face interviews, to be able hygiene practice was categorised into daily (7 days a
to accurately capture patient hygiene practices and expe- week), few times a week (between once to six times a
riences of CLMK. week), few times a month (less than once per week, but
more than once a month) and few times a year (less than
METHODS once in a month to once in a month).
In this study, we interviewed contact lens wearers to Data analysis
compare contact lens hygiene practices in lens wearers Data analysis was done using SPSS V.22. Mann-­Whitney U
with CLMK (cases) and lens wearers without infection and Pearson χ2 test were used to compare demographic
(controls). Ethics committee approval was obtained from data. Risk factors were first analysed individually using
University of Southampton Ethics and Research Gover- simple binomial logistic regression to determine ORs,
nance Online (ERGO reference: 14394). 95% CIs and p values. Risk factors with a significance
p<0.2 were considered in the multivariate model using
Participant recruitment
stepwise multiple logistic regression. Only risk factors
Contact lens wearers attending University Hospital
with significance p<0.05 were included in the final model.
Southampton Eye Casualty between October 2015 and
December 2015 were identified. A convenience sampling Patient and public involvement
method was adopted, whereby patients who were identi- Patients were involved in the study design. The ques-
fied to be contact lens wearers at triage were approached tionnaire was designed by the research team and was
to take part. Participants were included if they were aged trialled in a pilot study with patients with CLMK. The
18–75 and had worn refractive or cosmetic contact lenses questionnaire was further improved based on the patient
for the last 30 days before attendance. Participants with priorities and experiences of CLMK identified during the
therapeutic lenses, other ocular surface disease, herpes pilot study. Our study was designed to be conducted via
simplex keratitis, significant mental illness or learning face-­to-­face interviews, due to patient preference.
disability were excluded.
Cases of CLMK were defined as contact lens wearers RESULTS
having a diagnosis of microbial keratitis made by an Demographics and contact lens types
ophthalmologist for the first time or within the preceding Seventy-­eight participants were recruited into the study
1 month prior to interview. Only patients with active infec- (41 controls, 37 cases of CLMK), and no participants
tion, and who were still being treated or followed up for dropped out. Patient demographics and baseline char-
CLMK were included. Microbial keratitis was defined as acteristics are shown in table 2. Soft monthly disposable
1. a positive culture from a corneal scrape or contact lenses were the most commonly worn (43%)
2. a corneal infiltrate and overlying epithelial defect as- contact lens type in our cohort. Table 2 also shows the
sociated with either breakdown of contact lens type and frequency of wear.
i. the lesion being within central 4 mm of the cor-
nea, or Univariate analysis
ii. uveitis. Univariate analysis was used to calculate risk factors for
Controls were defined as contact lens wearers attending CLMK, as shown in table 3. Showering in lenses was the
Eye Casualty for non-­ contact lens-­
related problems, greatest modifiable risk factor (OR, 3.1; 95% CI, 1.2 to
and who had no previous history of corneal or infective 8.5; p=0.025), with a dose-­ dependent effect. The OR
complications from contact lens wear. for showering in lenses daily, compared with never, was
7.1 (OR, 7.1; 95% CI, 2.1 to 24.6; p=0.002). Sleeping in
Data collection and questionnaires contact lenses also increased the risk of microbial kera-
Participants were given a patient information sheet and titis (OR, 3.1; 95% CI, 1.1 to 8.6; p=0.026), as did being
consent was obtained. A single trained researcher who aged 25–39, when compared with being aged >55 (OR,
had a medical background but was external to the eye 6.38; 95% CI, 1.56 to 26.10; p=0.010).
department, conducted face-­ to-­
face interviews in a
private room using a standardised questionnaire. The Multivariate analysis
questionnaire was internally validated13 by the research The multivariate analysis model showed that age, contact
team, after trialling it in a pilot study with patients. lens type and showering in lenses were risk factors
Both patient groups (CLMK and controls) were asked which reached statistical significance (table 4). The OR
the same questions about demographics, and risk factors for being aged 25–39 was 8.16 (95% CI, 1.45 to 46.05;

2 Stellwagen A, et al. BMJ Open Ophth 2020;5:e000476. doi:10.1136/bmjophth-2020-000476

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Table 1  Data collected for cases and controls in standardised face-­to-­face questionnaire
Collected data Description

Data collected for Demographics Age, sex

cases and controls Lens type RGP, SDD, STWD, SMD or SEW
Wear habits and water exposure Wear frequency, wear duration
Sleeping in lenses
Showering/bathing in lenses
Swimming in lenses
Hygiene practices Hand washing before handling lenses
Lens case use, storage location and replacement frequency
Contact lens soaking duration
Lens purchasing history and follow-­up Frequency of contact lens aftercare appointment with
contact lens practitioner
Where lenses are purchased
Were lens infections/complications explained when lenses
first prescribed?
Who should be responsible for providing information about
risks of contact lens wear?
How lens care advice should be given
Additional data Subjective vision loss after infection None, mild, moderate or severe
collected for cases of
Thoughts of giving up contact lenses Concerns over recurrence, vision loss, memories of
CLMK
after infection symptoms
Quality of life after infection Affecting work, sight, sports, daily activities, physical
appearance
Additional data were collected for cases of CLMK regarding patient experiences following infection.
CLMK, contact lens-­related microbial keratitis; RGP, rigid gas permeable; SDD, soft daily disposable; SEW, soft extended wear; SMD, soft
monthly disposable; STWD, soft 2-­week disposable.

p=0.017), and the OR for being aged 40–54 was 7.78 responded with either ‘no’ or ‘not sure’. The responses
(95% CI, 1.31 to 36.28; p=0.024), when compared with were not statistically different between controls and
being aged >55. The OR for showering daily in lenses was patients with CLMK (figure 1C). Participants were asked
13.73 (95% CI, 2.35 to 80.07; p=0.004), when compared whom they felt was responsible for providing education
with never showering in lenses. The OR for wearing about contact lens-­ related complications. Ninety-­ two
soft daily disposable was 16.76 (95% CI, 1.09 to 257.56; (n=71) per cent of respondents felt that contact lens
p=0.043) and soft 2-­week disposable was 26.07 (95% CI, education was the responsibility of the ‘optician’, 13.0%
1.18 to 577.16; p=0.039). (n=10) stated ‘self’ and 1.3% (n=1) stated ‘doctor’ (with
some participants choosing more than one option).
Visual outcomes and attitudes towards contact lenses after Participants were asked how they thought advice and
CLMK instructions about contact lens wear should be given.
In our cohort, the majority of patients felt that their About 54.5% (n=42) of participants felt written informa-
infective episode had not resulted in significant visual tion, 68% (n=52) felt verbal information and 48% (n=37)
loss. About 55.6% of patients with CLMK (n=20) felt that felt demonstrations (48.1 %, n=37) would help improve
their infective episode had affected their quality of life, education.
and of these patients, the breakdown of how their life was
affected is shown in figure 1A. Figure 1B shows subjective Compliance with annual contact lens aftercare appointments
visual outcomes following CLMK. Most patients (86.5%, with optician
n=32) had not considered discontinuing contact lens About 80.8% (n=63) of all participants in the study were
wear after an infective episode of microbial keratitis. compliant with attending appointments at least annually.
Of the few patients who wished to discontinue contact About 83.7% (n=31) of patients with microbial keratitis,
lens wear (13.5 %, n=5), the greatest reason was fear of and 78% (n=32) of controls reported that they were
having another infection (n=3), fear of permanent sight attending appointments at least annually.
loss (n=1) and recurrent memories of symptoms (n=1).

Responsibility of contact lens education DISCUSSION

Participants were asked if they were told the risks of infec- Risk factors for CLMK
tions when first prescribed contact lenses, and nearly Our study is unique in that, not only does it investigate
half of both patients with CLMK and control groups risk factors for microbial keratitis, but it also analyses the

Stellwagen A, et al. BMJ Open Ophth 2020;5:e000476. doi:10.1136/bmjophth-2020-000476 3

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Table 2  Demographic information for participants and information regarding contact lens types and contact lens wear
frequency
  Controls n=41 Cases n=37 Total n=78 P value

Patient demographics
Male, n (%) 12 (32) 17 (46) 0.128*
Mean age, years (range) 41.0 (20–73) 39.5 (19–69) 0.764†
Age categories
 <24, n (%) 12 (29) 4 (11)
 25–39, n (%) 8 (20) 17 (46)
 40–54, n (%) 9 (22) 12 (32)
 >55, n (%) 12 (29) 4 (11)
  Controls n=40 (%)‡ Cases n=36 (%)‡ Total n=76 (%)‡

Contact lens type and wear frequency

SDD wear frequency n=25 (33%)
 Daily wear 5 (36) 8 (73) 13 (52)
 Few times a week 6 (43) 1 (9) 7 (28)
 Few times a month to few times a year 3 (21) 2 (18.2) 5 (20)
SMD wear frequency n=33 (43%)
 Daily wear 11 (69) 13 (77) 24 (73)
 Few times a week 5 (31) 4 (24) 9 (27)
 Few times a month to few times a year 0 0 0
STWD wear frequency n=9 (12%)
 Daily wear 2 (67) 4 (67) 6 (67)
 Few times a week 1 (33) 2 (33) 3 (33)
 Few times a month to few times a year 0 0 0
 SEW frequency n=3 (4%)
 Daily wear 1 (50) 1 (100) 2 (67)
 Few times a week 1 (50) 0 1 (33)
 Few times a month to few times a year 0 0 0
 RGP wear frequency n=6 (8%)
 Daily wear 3 (60) 1 (100) 4 (67)
 Few times a week 2 (40) 0 2 (33)
 Few times a month to few times a year 0 0 0

*Not significantly different (Pearson χ2).

†Not significantly different (Mann-­Whitney U test).
‡Two contact lens types unknown (one each from control and case group) and excluded in this analysis.
RGP, rigid gas permeable; SDD, soft daily disposable; SEW, soft extended wear; SMD, soft monthly disposable; STWD, soft 2-­week
disposable.

opinions of patients after corneal infection. This gives Monthly contact lenses were the most frequently
useful insight into how contact lens practitioners can used contact lens type in our patient cohort. All forms
improve patient education and compliance. This was of contact lens wear increase the risk of microbial kera-
only possible with face-­to-­face interviews as it allowed titis but monthly and extended wear contact lenses have
for a lot of detail to be gathered from participants, previously been shown to increase risk of sight loss.1–3
and also ensured full completion of the questionnaire. Although monthly disposable lenses also increase the risk
Completing the questionnaire did not lengthen waiting of infection, this did not reach statistical significance. In
times, which meant that no patients dropped out of the our patient group, 10.8% of patients reported significant
study. Our most significant risk factors for CLMK iden- sight loss, while 56.8% reported no change in their vision.
tified included showering in contact lenses, being aged Pseudomonas aeruginosa is the most commonly identi-
25–54 and wearing certain soft contact lenses. fied pathogen among contact lens wearers followed by

4 Stellwagen A, et al. BMJ Open Ophth 2020;5:e000476. doi:10.1136/bmjophth-2020-000476

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Table 3  Independent risk factors for CLMK identified by Table 3  Continued

univariate analysis, including patient demographics, contact Risk factor OR 95% CI P value
lens wear habits, water exposure, hygiene practices and
purchasing and aftercare follow-­up history Frequency of swimming in contact lenses
Risk factor OR 95% CI P value  Never 1.00 (referent)
 Few times a year 0.92 0.34 to 2.46 0.580
Demographics
Age  Few times a month 0.58 0.043 to 5.874 0.229

 >55 1.00 (referent) Personal hygiene factors

 <24 1.00 0.20 to 4.96 1.000 Compliance with hand washing prior to handling contact lenses

 25–39 6.38 1.56 to 26.10 0.010**  Always 1.00 (referent)

 40–54 4.00 0.96 to 16.61 0.056  Most of the time 0.39 0.14 to 1.10 0.075

Gender  Occasionally 0.41 0.04 to 4.85 0.482

 Female 1.00 (referent) How hands are washed

 Male 2.05 0.81 to 5.22 0.131  Soap and water 1.00 (referent)

Contact lens wear habits  Water only 1.27 0.48 to 3.34 0.628

Contact lens type† Use of contact lens case

 RGP 1.00 (referent)  Do not use case 1.00 (referent)

 SDD 3.93 0.34 to 38.70 0.241  Use case 1.07 0.42 to 0.27 0.894

 STWD 10.00 0.78 to 128.78 0.077 Contact lens case storage location

 SMD 5.31 0.56 to 50.55 0.146  Bedroom 1.00 (referent)

 SEW 2.50 0.10 to 62.61 0.577  Bathroom 0.53 0.16 to 1.82 0.314

Frequency of wear Frequency of replacing contact lens case

 Few times a month 1.00 (referent)  Monthly 1.00 (referent)

 Few times a week 0.70 0.10 to 5.18 0.727  1–3 months 0.46 0.10 to 2.17 0.328

 Daily 1.83 0.28 to 11.88 0.528  3+ months 1.94 0.51 to 7.32 0.329

Hours of contact lens wear Purchasing lenses and follow-­up history

 1–8  hours 1.00 (referent) Where contact lenses are purchased

 8–12  hours 2.25 0.39 to 13.17 0.368  Optician 1.00 (referent)

 12–18  hours 3.53 0.63 to 19.8 0.152  Internet 0.55 0.09 to 3.18 0.500

 Continuous wear 4.50 0.41 to 49.63 0.219  Other 2.18 0.19 to 25.2 0.532

Sleeping in contact lenses Were risks of infections explained when lenses were first
prescribed?
 No 1.00 (referent)
 Yes 1.00 (referent)
 Yes 3.14 1.15 to 8.63 0.026*
 No 1.26 0.39 to 4.15 0.700
Frequency of sleeping in contact lenses
 Not sure 0.85 0.30 to 2.39 0.758
 Never 1.00 (referent)
Compliance with follow-­up appointments (at least annually)
 Few times a year 2.33 0.67 to 8.06 0.183
 Yes 1.00 (referent)
 Few times a month 1.46 0.19 to 11.12 0.718
 No 1.20 0.47 to 3.07 0.700
 Daily 2.18 0.34 to 14.15 0.413
Frequency of contact lens aftercare appointments with optician
Showering in contact lenses
 Every 3–6 months 1.00 (referent)
 No 1.00 (referent)
 Every 6–12 months 1.60 0.58 to 4.41 0.360
 Yes 3.13 1.16 to 8.47 0.025*
 Less than annually 0.68 0.11 to 4.41 0.688
Frequency of showering in contact lenses
 Never 1.09 0.24 to 4.03 0.911
 Never 1.00 (referent)
**p<0.05. **p<0.01.
 Few times a year 0.59 0.06 to 6.18 0.663
†Two contact lens types unknown and excluded in this analysis.
 Few times a month 2.38 0.54 to 10.53 0.255 RGP, rigid gas permeable; SDD, soft daily disposable; SEW, soft
extended wear; SMD, soft monthly disposable; STWD, soft 2-­week
 Few times a week 1.70 0.41 to 6.98 0.464
disposable.
 Daily 7.13 2.06 to 24.61 0.002**
Swimming in contact lenses
Gram-­positive organisms.3 P. aeruginosa is able to adhere
 No 1.00 (referent)
and colonise contact lens materials during lens wear,
 Yes 0.85 0.34 to 2.13 0.723 survive in contact lens storage cases and has resistance to
Continued contact lens disinfectants.14 Acanthamoebae are free-­living

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Following an episode of CLMK, very few of our patients

Table 4  Independent risk factors for CLMK identified by
multiple logistic regression analysis considered discontinuing contact lens wear. Of those
whose quality of life or vision had been affected by
Risk factor OR 95% CI P value
the infection, 80% (n=20) wished to continue wearing
Age their lenses, demonstrating the benefits that contact
 >55 1.00 (referent) lens wear provide but also the importance of instilling
 <24 1.78 0.28 to 11.26 0.541 good contact lens hygiene awareness and reinforcing
 25–39 8.16 1.45 to 46.05 0.017* this information when attending eye casualty. A large
number of our participants (92.2%, n=72) identified the
 40–54 7.78 1.31 to 46.28 0.024*
optician as being responsible for providing information
Contact lens type†
about contact lens-­related complications. Nearly half of
 RGP 1.00 (referent) all participants in both control and CLMK groups could
 SDD 16.76 1.09 to 257.56 0.043* not recall or were unsure if they were told specifically
 STWD 26.07 1.17 to 577.16 0.039* about the risks of contact lens-­related infections when
 SMD 10.33 0.72 to 148.27 0.086 first prescribed their contact lenses (figure 1c).
Under guidance from College of Optometrists UK,
 SEW 1.58 0.04 to 71.50 0.813
contact lenses can only be fitted and prescribed by optom-
Frequency of showering in contact lenses
etrists, doctors and contact lens opticians. Dispensers of
 Never 1.00 (referent) contact lenses are required to give training and informa-
 Few times a year 0.38 0.03 to 4.89 0.454 tion about lens care, hygiene and wear schedules before
 Few times a month 1.55 0.27 to 8.90 0.626 lenses can be dispensed. About 89.2% (n=33) of the
 Few times a week 3.24 0.58 to 18.05 0.181 patients who developed microbial keratitis, stated that
 Daily 13.73 2.35 to 80.07 0.004**
an optician supplies them with their contact lenses. The
British Contact Lens Association (BCLA) recommends
*p<0.05. **p<0.01. contact lens aftercare appointments at least annually.
†Two contact lens types unknown and excluded in this analysis. As shown in table 3, non-­compliance with annual after-
RGP, rigid gas permeable; SDD, soft daily disposable; SEW, soft
extended wear; SMD, soft monthly disposable; STWD, soft 2-­
care appointments was not found to be a risk factor for
week disposable. microbial keratitis. There was a high level of reported
compliance in attending annual follow-­up appointments,
in both cases and control group. A 2010 Australian study18
cysts, forming ubiquitous protozoa found in air, dust, looking at contact lens compliance found similar results.
soil and fresh water. They are highly resistant to disin- These findings are rather confusing, as despite regular
fection with chlorine and are thus not eradicated from follow-­up with opticians and perceived good concordance
tap water.15 16 For this reason, showering, swimming or with BCLA recommendations, patients’ understanding
washing contact lenses in fresh water can be considered and retention of contact lens hygiene and risk behaviour
risk behaviours. In our study, showering while wearing remains low. As patients are likely to want to continue
lenses was identified as a significant independent risk wear lenses even after an infective episode, contact lens
factor for CLMK. The univariate regression model practitioners should focus efforts on improving patient
retention of information about infections and aftercare
showed the OR for showering in lenses was 3.1 (95% CI,
practices, because persuading patients to stop wearing
1.2 to 8.5; p=0.025), with a dose-­dependent effect. The
contact lenses may be ineffective.
OR for showering in lenses daily, compared with never,
Our study demonstrated that all three forms of infor-
was 7.1 (95% CI, 2.1 to 24.6; p=0.002). The OR for show-
mation—verbal, demonstrations and written—were
ering daily in lenses in the multiple regression model was
important for contact lens wearers to improve educa-
13.73 (95% CI, 2.35 to 80.07; p=0.004). tion about lens wear and complications. A possible way
Equally, our study showed that sleeping in contact to increase awareness may be to supply printed material
lenses increased the risk of microbial keratitis (OR, 3.1; with each contact lens box to remind them about risks
95% CI, 1.1 to 8.6; p=0.026) in the univariate model but and aftercare practices.
this was not significant in the multivariate model. The A limitation of the study was that controls were also eye
effect of sleeping in lenses was replicated from previous casualty attendees, presenting with other ocular prob-
studies,9 10 12 but these studies looked at overnight lems, which could have introduced bias into the control
wear, whereas our study looked at sleeping in lenses for group. These patients, however, presented with non-­
different amounts of time. The effects of contact lens-­ ocular surface problems and non-­ contact lens-­related
related hypoxia are likely increased in sleeping patients issues, which were typical for any person attending the
as oxygen diffusion is compromised when eyes are shut department. To limit recall bias in the CLMK cases group,
for a long time. Studies have shown that hypoxia can lead only patients who were newly diagnosed with CLMK and
to increased binding of Pseudomonas to the cornea when still had active infection were included in the study. The
a contact lens is present.17 questionnaire used was developed and validated by the

6 Stellwagen A, et al. BMJ Open Ophth 2020;5:e000476. doi:10.1136/bmjophth-2020-000476

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Figure 1  Graphs showing how the recent CLMK episode (A) subjectively affected patients’ vision (B) and quality of life (more
than one option could be chosen for this question) and (C) Responses for question: ‘Were risks of infections explained when
lenses first prescribed?’ CLMK, contact lens-­related microbial keratitis.

research team, and face-­to-­face interviews were chosen to continue to perform poor hygiene practices and risk
accurately obtain data. To limit interviewer bias and limit developing microbial keratitis. Focusing attention on
influencing participant responses, only one researcher improving education of infection and retention of
who was not involved in patient care, conducted the inter- information may help improve compliance with lens
views in a standardised manner. A limitation was that the wear practices, which may help reduce incidence of
OR and CI ranges in the multivariate model were large. CLMK and associated sight loss.
A larger sample size would be needed to calculate a more
precise estimate of effect. Contributors  AS assisted in study design, collected and analysed the data and
Risk factors that could be investigated further include: is first author. CM assisted with writing the report and mentoring. RK conducted
preliminary work in the pilot study. AK assisted with data collection and mentoring.
overall duration (eg, in years) of contact lens wear, PH led and designed the study.
smoking history, socioeconomic status, ethnicity and
Funding  The authors have not declared a specific grant for this research from any
reason for contact lens wear (hyperopia, myopia, pres- funding agency in the public, commercial or not-­for-­profit sectors.
byopia or cosmetic). A multicentre study with a larger
Competing interests  None declared.
sample size could reduce sample bias, help evaluate risks
Patient and public involvement  Patients and/or the public were involved in the
and demographics further, and could show trends on design, or conduct, or reporting or dissemination plans of this research. Refer to
regional and national levels. Precision and the number of the Methods section for further details.
significant results may also be improved. An interesting Patient consent for publication  Not required.
area for future work would be to further investigate the
Provenance and peer review  Not commissioned; externally peer reviewed.
effect of showering in contact lenses, and to identify
Data availability statement  Data are available upon request.
which organisms are isolated in patients with CLMK who
shower in lenses. Open access  This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
The major personal hygiene risk factors for CLMK permits others to distribute, remix, adapt, build upon this work non-­commercially,
include showering, especially daily, in contact lenses and license their derivative works on different terms, provided the original work is
and sleeping in lenses. Patients aged 25–54 are the properly cited, appropriate credit is given, any changes made indicated, and the
most at-­r isk group. Despite most contact lens wearers use is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
buying their lenses from opticians and having ORCID iDs
regular follow-­u p appointments, contact lens wearers Anna Stellwagen http://​orcid.​org/​0000-​0001-​6246-​6680

Stellwagen A, et al. BMJ Open Ophth 2020;5:e000476. doi:10.1136/bmjophth-2020-000476 7

 Open access

Parwez Hossain http://​orcid.​org/​0000-​0002-​3131-​2395 10 Lim CHL, Carnt NA, Farook M, et al. Risk factors for contact lens-­
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11 Radford CF, Bacon AS, Dart JK, et al. Risk factors for Acanthamoeba
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8 Stellwagen A, et al. BMJ Open Ophth 2020;5:e000476. doi:10.1136/bmjophth-2020-000476