Unusual%20Presentations%20of%20%20Post-LASIK%20Sterile%20Keratitis

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Unusual Presentationsof Post-LASIK Sterile
Keratitis

• Farid Karimian, MD
• 2002

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Case no. 1

• S.H., 26 year old engineer referred for
• correction of his refractive error
• Glasses refraction were stable for
• over 3years
• There was no h/o contact lens wearing
• nor any positive attitude to its use
• Past medical history negative for any
• systemic disease
• Pre-op Refraction OD- 4.00-0.50x 180
• OS-
  4.25-0.25x180

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Case no. 1 cont.

• Pre-op Topography OU unremarkable
• Sim K OD 43.5/43.0
• OS 43.0/43.0
• Central pachy OD 560µ
• OS 545µ
• Operation Data Standard LASIK procedure
• Excimer machine Nidek EC-5000
• Microkeratome Moria CB
• Complication None

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Case no. 1 cont.

• Post-op Course
• Day 1 CC No pain, No photophobia,
• SLE OU Trace interface infiltration
  at
• periphery (GradeI)
• OU Mid-stromal infiltration
• peripheral to flap Trace AC
  reaction
• RX Beta OU q4h Chloramphenicol OU q6h
• Day 2 OU Peripheral infiltration increased,
• No CED, stable interface
  infiltrates
• RX- ? Beta OU q2h
• - ? Chramphenicol OU q2h

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• Post-op Course.cont.
• Day 3 OU(ODgtOS) Peripheral circumferential
• infiltration, became dense,
  No CED
• RX ? Beta OU q1h
• Prednisolone 75mg PO qd
  started
• Day 5 Peripheral infiltrations markedly
  decreased
• Day 7 Tapering topical and systemic steroid
• started
• 1rst month Faintly visible peripheral
  infiltration
• Clean interface and flap
• UCVA OU 20/20 with
  non-significant
• refractive error

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Pros and ConsPros Cons

• Short interval after LASIK
• Minimal discomfort
• Intact epithelium
• Appropriate response to steroid treatment
• bilaterality

• Unusual pattern of infiltration
• Not present peripheral to hinge are

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Case no. 1

• Peripheral circumferential
• Post-LASIK sterile keratitis

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Case no. 2

• R.C., 38 year old female seeking refractive
  surgery for correction of her refractive error
• Positive history of contact lens wearing
  discontinued years ago
• Stable glasses and refraction gt 10 years
• Negative history of any systemic disease
• Cormeal and ophthalmic exam unremarkable
• Refraction OD-2.00-5.00 x 170
• OS 1.50-5.00 x 10

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Intraoperative events

• OD operated first developed inferior
• paracentral 3mm CED during
• microkeratome pass, she was proposed
• to postpone 2nd eye surgery
• OS Tetracaine epithelial toxicity?
• supposed ? LASIK performed with
• only one drop
• Intraoperative epithelial loosening
• occurred no CED

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Postop Course

• Day 1 CC pain, photophobia OU
• SLE OU - Bilateral inferior
  paracentral CED
• - minimal
  infilteration under CED
• RX - Beta OU bid
• - Chloramphenicol OU q6h
• Day 2 CC ? pain and photopobia
• Exam - OU stable CED
• -? infiltration, confined
  to area of CED
• - mild AC reaction
• RX - Beta was D/C
• - Ciprofloxacin OU q2h
  started

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Post-op Course

• Day 3 CC, Mild ? pain
• Exam OU - CED began to improve
• - infiltration
  spread outward ? DLK?!
• RX - prednisolone 50mg (1mg/kg)
  started
• - ? ciprofloxacin OU q4h
• Day 5 CC, marked improvement
• Exam OU - pseudodendrite, no
  CEDs
• - infiltration
  involved all over interface
• (gradeII)
• RX - ?prednisolone
  75mg (1.5mg/kg)
• - ?
  Ciprofloxacin OU q6h
• - Beta OU q4h
  started

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Post-op Course

• 2 weeks - completely improved CED
• - resolved interface
  infiltration
• - improved flap edema
• RX topical and systemic steroids
  tapered and
• discontinued
• 1 month UCVA OD 20/25 OS 20/25
• Refraction OD 0.25-0.75 x 180
• OS 0.50-0.50
  x 180
• SLE OU no CED
• - OS small 1x1mm epithelial
  pearl at interface
• - Up to 6 months follow-up, condition unstable

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Epithelial Erosions are not benign
complications associated with

• ? Increase risk of epithelial ingrowth
• ? Induced astigmatism
• ? Flap edema
• ? Over or undercorrection
• ? DLK
• ? Flap melt

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Epithelial erosion Causes

• Tangential shearing effect of friction on the
  epithelium
• Excessive topical anesthetic
• Improper draping
• Rough corneal marking
• Poor blade edge quality
• Epithelial basement membrane dystrophy
• aging

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Case no. 2

• Post-LASIK interface keratitis
• mimicking infectious cause

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Case no. 3 Refractory DLK

• M.M., 48 year old gentleman was operated for his
  myopia about 2 months ago
• Pre-operative history and evaluations were
  unremarkable except 7.00 D myopia in both eyes
• LASIK bilateral simultaneous,
• uncomplicated
• Early postop developed DLK Grade II in
• both eyes (OSgtOD)
• Intensive and aggressive steroid therapy Beta
  OU q1h, prednisolone 100mg PO qd

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Case no 3cont.

• In September 2001, he was referred due to poor
  contolled DLK since surgery
• Medications Beta OU q2h,
• Prednisolone 50mg PO qd
• CC blurred vision and ocular pain OU
• UCVA OD 20/60/ OS 20/50 with 4.00 D hyperopia in
  refraction
• SLE OU limbus- to-limbus microcystic coreal
  epithelial edema (ground-glass appearance)
• minimal flap interface infiltration with haziness
• TA OD 68 mmHg/ OS 54 mmHg
• Fundus OU pink discs with 0.5C/D ratio

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Case no 3..cont. Management

• Steroids topical was DC
• Systemic rapid tapering and
• 
  discontinued
• Antiglaucoma timolol OU q12h
• Acetazolamide 250mg PO
  q6h

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Case no. 3 cont

• Follow up course
• After 1 wk IOP OU decreased to Mid 20s
• After 1 mo
• UCVA OU 20/30 with 0.50 D hyperopia
• IOP OD 20 mmHg / OS 18 mm Hg with
• antiglaucoma medication
• - Acetazolamide was D/ C

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Case no 3 cont

• After 3 mo - UCVA OU 20/30 with 0.5
• hyperopia
• IOP OU 18 mm Hg with timolol OU q12h
• Automated VF OU borderline GHT
• Timolol was discontinued
• After 6 mo - condition was the same
• - Follow up with IOP and VF

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Case no. 3

• Refractory DLK
• or
• Pseudo DLK
• Was in fact secondary to very high interaocular
  pressures due to
• steroid responsiveness