Sir,

An outbreak of Fusarium keratitis has recently resulted in the withdrawal of Bausch & Lomb ReNu MoistureLoc®.1 To our knowledge, no cases of Fusarium keratitis related to contact lens solutions have been reported in Europe. We have treated four cases of Fusarium solani keratitis in soft contact lens wearers, three of whom used ReNu MoistureLoc®, and one used AMO Complete Moisture Plus®.

Figures 1 and 2 describe the clinical details. These cases demonstrate a spectrum of outcomes, ranging from the need for a therapeutic corneal graft (case 1), to a good outcome with a visually insignificant corneal scar (case 4). Two factors contributing to a poor prognosis were delayed the diagnosis and the use of topical steroids.

Figure 1
figure 1

Table describing all four cases of Fusarium keratitis.

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Figure 2
figure 2

Composite illustration of case 1 (a–d) and case 2 (e–f). (a) Fusarium keratitis at the time of presentation, (b) corneal biopsy with periodic acid-schiff (PAS) stain showing septate hyphae in deep stroma (arrow) × 400 (c) worsening clinical course, and (d) following therapeutic keratoplasty. Fusarium keratitis in an 18-year-old contact lens wearer (case 2) before (e) and after (f) treatment.

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Until 2004, fungal keratitis was a rare cause of microbial keratitis among contact lens wearers, even in tropical Florida and South East Asia. A report from London (which includes two of the cases described here) where filamentary fungal keratitis is uncommon, found only nine cases of fungal keratitis in contact lens wearers over 13 years.2 For reasons that are unclear, ReNu-related Fusarium keratitis has not been reported in Europe. Cases may have been diagnosed, but not reported. The temperate climate has also probably played a role.

Although there has been a dramatic decrease in contact lens-related Fusarium keratitis since the withdrawal of ReNu MoistureLoc®, it has not been completely eliminated.3 This raises concern about the antifungal efficacy of multipurpose solutions, and continued case reporting and further investigation into the pathogenesis is needed. Reasons for the selective increase in Fusarium keratitis in contact lens users remain speculative and factors such as alteration in virulence, in addition to the reduced efficacy of some multipurpose solutions,4 may be important.

In conclusion, Fusarium keratitis should be considered in any case of contact lens-related keratitis. Topical steroids are not recommended until the initial laboratory information is available or clinical improvement is observed, given lack of evidence of effect on bacterial keratitis outcomes.5 Practitioners must advise contact lens wearers of recent outbreaks and emphasise strict adherence to the recommended regimes with multipurpose solutions.