Transcript Post-operative # 13

Late Diffuse Lamellar
Keratitis in Post-LASIK
Infective Keratitis
Dr. Umang Mathur
Dr. Amit Agrawal
Dr. Manisha Acharya
The authors have no financial interest in the
subject of this poster
History
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23-year-old female underwent uneventful Bilateral
Myopic LASIK, elsewhere, on 22nd January 2008
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Post-operative # 3
Patient presents to the doctor with Bilateral Infective
Keratitis
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Pain, Photophobia, Redness, Watering/Discharge
Vision: CF 1/2m, both eyes
Central infiltrates, both eyes
New Delhi, India
Management
Flap lifted in both eyes and scraping sent for Bacterial and
Fungal smears and culture
No organisms grown
Empirical treatment
 Moxifloxacin eye drops q1h
 Tobramycin eye drops q1h
 Natamycin eye drops q1h
 Cyclopentolate eye drops tid
New Delhi, India
Post-operative # 7
Patient responds to treatment
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↓ Pain, watering, photophobia
↓ size of infiltration
Improvement in Vision, RE>LE
Impression: Healing Keratitis
New Delhi, India
Post-operative # 13
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↑ ↑ Pain, watering, photophobia
↑ Congestion
↑ signs of inflammation
Referred to us for opinion and management
New Delhi, India
Post-operative # 13
OD
BCVA: CF 50cm
OS
New Delhi, India
BCVA: CF 50cm
What are we dealing with?
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Unresolved infection?
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Immunocompromised patient…HIV?
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RA factor, ANA, CRP, ESR: WNL
Clinically: WNL
Blepharokeratoconjunctivitis?
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Blood reports WNL
Collagen vascular disease?
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Why recurrence after good initial response?
Atypical infection
Clinically: WNL
HSV Keratitis?
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No history of recurrence
?Bilateral and simultaneous- very rare
New Delhi, India
Review
OD
OS
DLK?
Stromal
Edema
Prednisolone acetate eye drops tid, added
New Delhi, India
Post-operative # 20
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Symptomatic relief
↓ Congestion, Infiltrate, Stromal edema
Topical steroids frequency increased
New Delhi, India
Post-operative # 30
OD: 20/20p (-1D cyl x 20)
OS: 20/100
( 20/20p with RGP Contacts)
New Delhi, India
B/L DLK, Post-LASIK Infective Keratitis
OD
OS
New Delhi, India
Discussion
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Diffuse lamellar keratitis (DLK) is an inflammatory
infiltrate occurring at the keratectomy interface after
laser in situ keratomileusis (LASIK)
Endotoxins released from bacteria and inflammatory
bi-products may be the causative agents for producing
DLK in our case
While the infection was controlled by the Antibiotic
treatment, endotoxins released from the bacteria
continued to produce an inflammatory reaction
Holland SP, Mathias RG, et.al. Diffuse lamellar keratitis related to endotoxins released from sterlizer
reservoir biofilms. Ophthalmology. 2000 Jul;107(7):1227-33
Peters NT, Iskander NG,et.al. Diffuse lamellar keratitis: isolation of endotoxin and demonstartion of the
inflammatory potential in a rabbit laser in situ New
keratomileusis
model. J Cataract Refract Surg. 2001
Delhi, India
Jun;27(6):917-23