Early Post-LASIK Flap Amputation in the Treatment of Aggressive Fungal Keratitis

in Association With Construction of the

Refractive Suite

John Au MD - no financial disclosures

William Dupps Jr MD, PhD – Avedro Consultant

Karolinne Rocha MD, PhD - No financial disclosures

Ronald Krueger MD, MSE - Alcon, Clarity Medical

Systems and LensAR Consultant

Post Laser Vision Correction Infectious Keratitis

• Infectious keratitis following laser vision correction

as reported by the 2008 American Society of

Cataract and Refractive Surgery (ASCRS) survey was

19 of 20,941 eyes or 0.09%.

• The most commonly cultured organism in this series

was methicillin-resistant Staphylococcus aureus

(MRSA).

• One case definitively resulted from a fungal infectionSolomon R, Donnenfeld E, Holland E, Yoo S, Daya S, Guel J, Mah F, Scoper S, Kim T. Microbial keratitis trends following refractive surgery: Results of the ASCRS Infectious keratitis survey and comparisons with prior ASCRS surveys of infectious keratitis following keratorefractive procedures. J Cataract Refract Surg 2011;37:1343-1350

Case Presentation• 24-year old female -1.25D sphere in both eyes

• Her exam, pachymetry and corneal tomography were normal

• Her history included prior right V1 dermatome herpes zoster

without ophthalmic involvement

• Treated with wavefront-optimized femtosecond-LASIK on the

WaveLight FS-200 and Allegretto Eye-Q laser platform (Alcon, Fort

Worth, TX, USA)

• She had an uneventful procedure and was started on ciprofloxacin

0.3% (Ciloxan®) and dexamethasone 0.1% drops four times daily

each.

• On post-op day one, UDVA was 20/15 in each eye. Her exam was

unremarkable

Case Presentation

• During the week prior to this case, a new wall was

built within the refractive suite waiting area, which

was not directly continuous with the laser suite

• However, the day prior to the case, construction

workers had removed some ceiling tiles in the

laser suite in preparation for the upcoming

construction and removal of an internal wall

Postoperative Day 2• Patient presents with pain and

decreased vision• UDVA OD 20/50

Clinical Plan• Clinical suspicion for fungal keratitis was high

• The flap was lifted and a gelatinous branching infiltrate was seen,

extending superficially into the flap and posteriorly into the stromal bed

• Cultures were obtained and the interface was irrigated extensively

• Because the infiltrate penetrated into the flap stroma, and due to the

rapid progression (< 24 hours) of a presumed of fungal keratitis, a

decision was made to amputate the flap

• Hourly topical fortified tobramycin (13.5mg/ml), vancomycin (25mg/ml)

and voriconazole 1% were begun immediately

• Although the infiltrate was clearly in the flap interface and not involving

the overlying epithelium, a 10 day course of of oral valacyclovir 1 gram

TID was given due to the patient’s history of right V1 herpes zoster

• Prednisolone was discontinued

Postoperative Course

• Post-flap amputation Day 4

• UDVA 20/100-

• Infiltrate was improving and the epithelium was

approximately 85% healed over the stromal bed

Postoperative Course• Fungal cultures grew Aspergillus flavus, all other cultures

were negative

• Pathology of the flap showed fungal elements (black arrows)

PAS stain

Postoperative Course• Post-flap amputation day 11 UDVA 20/40; MRx -0.50 SPH with BCVA 20/20-

• Post-flap amputation month 5 UDVA 20/15, but having double image

• Epithelial thickness is variable (40-59 um) due to irregular stromal surface

Post-flap amputation day 11

Post-flap amputation month 8planned PTK/PRK ENH

• VisX S4 PTK OD• 6.5 mm OZ, 0.2 TZ• 71 um depth• H-PRK OD, +1.0 D

Pre PTK

1 Month Post PTKUCVA 20/40MR -1.00 (20/25+)…still healing!

Factors That Allowed For Good Visual Outcome Post Flap

Amputation 1. Penetration of the antibiotics and antifungal medication

to the infiltrate were optimized

2. The patient had a low myopic correction with robust

residual stromal bed thickness for possible future

refractive treatment

3. The flap was created with a femtosecond laser, and,

therefore, had a uniform planar shape, allowing for

minimal refractive change when compared to a

meniscus shaped microkeratome flap, when amputated

ConclusionAlthough we cannot not definitively

link this infection to the preceding

construction work, it is reasonable to

conclude one should avoid performing

Laser Vision Correction following

recent construction work in the

refractive suite