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Rafael A. Oechsler, MD Rafael A. Oechsler, MD 1,21,2

Alfonso Iovieno, MD Alfonso Iovieno, MD 11

Darlene Miller, DHSc, MPH Darlene Miller, DHSc, MPH 11

Eduardo Alfonso, MD Eduardo Alfonso, MD 11

Update on Infectious Keratitis after Refractive Surgery

1 - Bascom Palmer Eye Institute – Miller School of Medicine – University of Miami1 - Bascom Palmer Eye Institute – Miller School of Medicine – University of Miami2 - Ophthalmology Department - Federal University of Sao Paulo - Brazil2 - Ophthalmology Department - Federal University of Sao Paulo - Brazil

None of the authors has any financial interest on the contents of this study

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IntroductionIntroduction

• Infectious keratitis after Infectious keratitis after refractive surgery procedures, refractive surgery procedures, is a rare (less than 1/1000 is a rare (less than 1/1000 surgeries), but sight-surgeries), but sight-threatening condition. threatening condition.

• Risk factors include lack of Risk factors include lack of sterility during the procedure sterility during the procedure and predisposing factors and predisposing factors inherent of each patient, such inherent of each patient, such as dry eye, blepharitis and as dry eye, blepharitis and delayed epithelial healing.delayed epithelial healing.

Trichosporon spp infection post-LASIK

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To report clinical aspects and outcomes of culture-To report clinical aspects and outcomes of culture-proven post-refractive surgery infectious keratitis proven post-refractive surgery infectious keratitis in patients treated at the Bascom Palmer Eye in patients treated at the Bascom Palmer Eye Institute from July 2001 through December 2007Institute from July 2001 through December 2007

PurposePurpose

Mycobacteria (MOTT) infection post-LASIK

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MethodsMethods

Review of the medical records from all Review of the medical records from all patients with culture-proven post-patients with culture-proven post-refractive surgery infectious keratitis and refractive surgery infectious keratitis and treated at the Bascom Palmer Eye treated at the Bascom Palmer Eye Institute from July 2001 through Institute from July 2001 through December 2007 was performedDecember 2007 was performed

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Results: Demographics

• 12 eyes in 10 patients12 eyes in 10 patients

• 7 males (70%) and 3 females (30%)7 males (70%) and 3 females (30%)

• Mean age Mean age 42 years (range: 23-65 years)42 years (range: 23-65 years)

• Mean follow-up time was 22 months Mean follow-up time was 22 months (range: 2-45 months)(range: 2-45 months)

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Results: main clinical outcomes

BCVA

Initial: LogMAR 1.0 (20/200)

Final: LogMAR 0.55 (20/70)

Infiltrate size 4mm Range 1-8mm

Time to cure 74 days Range 25-170 days

Therapeutic keratoplasty

6 eyes (50%) 4 in MOTT infections

2 in mold infections

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Results: Pathogens

Nontuberculous Mycobacteria (MOTT) (42%)

5 eyes

Yeasts (25%) 2 Candida spp

1 Trichosporon spp

Molds (17%) 1 Aspergillus spp

1 Acremonium spp

S. aureus (17%) 1 MSSA

1 MRSA MRSA infection post-LASIK

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Results: Medications

• Topical medications when seen:• 5 eyes on 4th generation fluoroquinolones

(Moxifloxacin, Gatifloxacin)• 4 eyes on 2nd generation fluoroquinolones

(Ciprofloxacin, Oxifloxacin)• 2 eyes on Vancomycin 5% +Tobramycin 1.4%• 1 eye on Natamycin 5% + Vanco 5% + Tobra

1.4%

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Results: Risk Factors

• 3 eyes – trauma (foreign body)

• 1 eye – enhancement

• 1 eye – previous Radial Keratotomy (RK)

• 7 eyes – none

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ConclusionsConclusions

• Even after the start of use of 4Even after the start of use of 4thth generation generation fluoroquinolones, fluoroquinolones, Mycobacteria Mycobacteria continue continue to be the most frequent pathogen to be the most frequent pathogen associated with post-refractive surgery associated with post-refractive surgery infections.infections.

• Fungi had an increased incidence (42%) Fungi had an increased incidence (42%) when compared with our last study (20%)when compared with our last study (20%)

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Conclusions

The rate of therapeutic therapeutic The rate of therapeutic therapeutic keratoplasties is very high (50%) among keratoplasties is very high (50%) among these patients.these patients.

• All molds (2 out of 2) and 80% of the MOTT All molds (2 out of 2) and 80% of the MOTT (4 out of 5) required a therapeutic PK(4 out of 5) required a therapeutic PK

• None of the yeasts or None of the yeasts or S. aureus S. aureus cases cases required a PKrequired a PK