Case Rep Ophthalmol 2016;7:21–24
DOI: 10.1159/000443325 © 2016 The Author(s)
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Rhizopus Keratitis Associated with
Poor Contact Lens Hygiene
David B. Warnera Hugh E. Wright IIIa Eric R. Rosenbaum b
a b
Departments of Ophthalmology and Microbiology, University of Arkansas for Medical
Sciences, Little Rock, Ark., USA
Key Words
Rhizopus keratitis · Contact lens hygiene
Abstract
We report a case of Rhizopus keratitis in a young woman with poor contact lens hygiene. The
mold was highly sensitive to treatment with amphotericin 0.15% drops, after a relatively
prompt diagnosis. Obtaining cultures of both corneal infiltrates and presumably infected
contact lenses may help to avoid a delay in proper treatment. © 2016 The Author(s)
Published by S. Karger AG, Basel
Case Report
A 27-year-old white female with a history of poor contact lens hygiene, including con-
tinuous wear, presented to our clinic with left eye pain, redness, and worsening vision for 2
days. Visual acuity was initially recorded as counting fingers at 3 feet. Intraocular pressures
were within normal limits. Examination revealed severe conjunctival injection with ciliary
flush, and a <1 × 1 mm central corneal ulcer with mild stromal thinning. Other findings in-
cluded a diffuse lymphocytic stromal infiltrate, microcystic edema, and 360° limbal neovas-
cularization. Scattered small scars were also present indicating previous infection. The ante-
rior chamber was quiescent, and the pupil was round and reactive. Corneal scrapings were
sent to the microbiology laboratory for Gram stain and were cultured on blood, chocolate,
and potato dextrose agars. Moxifloxacin (Vigamox; Alcon Laboratories, Fort Worth, Tex.,
USA) 0.5% drops were initiated hourly. The scrapings grew 5 colonies of a coagulase-
negative staphylococcus, which was thought to be a contaminant.
After 48 h of treatment, the patient developed a 2.5 × 2.5 mm feathery, stromal infiltrate
around the original 1 × 1 mm ulcer and two small satellite lesions in the mid-periphery.
Symptoms persisted, and the presumptively contaminated contact lens was brought to the
David B. Warner, MD
Department of Ophthalmology, University of Arkansas for Medical Sciences
4301 W. Markham Street, Slot 523
Little Rock, AR 72205 (USA)
E-Mail dbwarner @ uams.edu
Case Rep Ophthalmol 2016;7:21–24
DOI: 10.1159/000443325 © 2016 The Author(s). Published by S. Karger AG, Basel 22
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Warner et al.: Rhizopus Keratitis Associated with Poor Contact Lens Hygiene
clinic and cultured for microorganisms. The laboratory identified a rapidly growing mold, of
the order Mucorales (class Zygomycetes), which was further characterized as Rhizopus spp.
(fig. 1). Hourly amphotericin B 0.15% drops were initiated with rapid initial clinical im-
provement of the corneal infiltrate over the next 2 days.
The patient was lost to follow-up and returned approximately 1 month later. The stro-
mal infiltrate had partially resolved with scarring at the periphery and now contained fine
intrastromal crystals (fig. 2). Her vision remained stable, and amphotericin drops were de-
creased to every 2 h. For the next 2.5 months, she failed to return for subsequent appoint-
ments due to financial constraints. At her next visit, the infiltrate had completely scarred,
and the best spectacle corrected visual acuity was 20/60. She was referred for contact lens
fitting and achieved 20/25 vision with a scleral lens.
Discussion
Molds, or filamentous fungi, can be divided into septate and nonseptate forms. Septate
filamentous fungi, specifically Fusarium and Aspergillus, are the most frequent causes of my-
cotic keratitis, as high as 16–40 and 17–59%, respectively [1]. For treatment of filamentous
fungal keratitis, natamycin provides superior clinical outcomes compared to voriconazole,
including best corrected visual acuity, lesser chance of corneal perforation, and reduced
need for penetrating keratoplasty [2]. Within the order Mucorales, there are four notable
genera pathogenic to humans. These include Rhizopus, Mucor, Rhizomucor, and Absidia, all of
which are found widely in the environment. These molds typically have broad, nonseptate
hyphae and grow rapidly in laboratory conditions. Clinically, they are not commonly encoun-
tered in ophthalmologic practice; however, they can present as rhinocerebral and extraocu-
lar infections in the immunocompromised, and much less commonly as ocular infections
(e.g. keratitis) [3].
We are aware of only two reported cases of Rhizopus keratitis. Schwartz et al. [4] re-
ported the first case in 1978, a 24-year-old male presenting with a perforating injury from a
soil-contaminated screw driver. The open globe, initially repaired and treated with steroids
and broad-spectrum intravenous antibiotics, presented 1.5 months later as a fulminant kera-
titis and anterior uveitis. The patient required a penetrating keratoplasty after failing treat-
ment with natamycin drops and oral flucytosine. Intravenous amphotericin B was initiated
and provided eventual clinical improvement. In 2013, Azari et al. [5] reported a case of Rhi-
zopus keratitis in a 48-year-old male presenting after trauma from a metal wire. The patient
was treated successfully with oral and topical voriconazole.
To our knowledge, our case is the first patient reported to have Rhizopus keratitis asso-
ciated with contact lens wear. Although Gram stain of the corneal scraping and culture were
negative for fungi, these tests are the least sensitive for fungal keratitis [6], and clinical
presentation coupled with contact lens culture and response to antifungal therapy confirm
the diagnosis. While Rhizopus is known to cause rapid and severe destruction of the extraoc-
ular and rhinocerebral soft tissues, our observation is that it behaves less aggressively in the
cornea, perhaps due to the avascularity of this tissue. In our patient, the mold was highly
sensitive to topical amphotericin when administered following a relatively prompt diagno-
sis.
We recognize that the culture came from a contact lens rather than a corneal scraping,
and that we cannot be certain that the organism from the lens we cultured corresponds to
the corneal infection. However, it is compelling that the patient’s rapid clinical response
strongly coincided with the appropriate treatment based on the contact lens culture.
Case Rep Ophthalmol 2016;7:21–24
DOI: 10.1159/000443325 © 2016 The Author(s). Published by S. Karger AG, Basel 23
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Warner et al.: Rhizopus Keratitis Associated with Poor Contact Lens Hygiene
This case underscores the importance of considering fungi in the differential diagnosis
for patients with contact lens-related infiltrates who demonstrate an insufficient clinical
response to empiric antibiotic therapy. We recommend obtaining cultures of both the con-
tact lens and cornea early in the course of treatment to avoid delay in proper treatment.
Empiric antifungal treatment may also be indicated depending on presentation, individual
laboratory capabilities, and laboratory turnaround times.
Statement of Ethics
The authors have no ethical conflicts to disclose.
Disclosure Statement
The authors have no conflicts of interest.
References
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Case Rep Ophthalmol 2016;7:21–24
DOI: 10.1159/000443325 © 2016 The Author(s). Published by S. Karger AG, Basel 24
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Warner et al.: Rhizopus Keratitis Associated with Poor Contact Lens Hygiene
Fig. 1. Contact lens culture. Lactophenol cotton blue slide preparation, ×1,000. Rhizopus spp. demonstrat-
ing rhizoids (arrow head) emerging characteristically at the base of a sporangiophore.
Fig. 2. Slit-lamp photograph of resolving corneal infiltrate and satellite lesions after 1 month of treatment,
using the Apple iPhone 4.
