Unusual PresentationsUnusual Presentationsof of

Post-LASIK Sterile Post-LASIK Sterile KeratitisKeratitis

Farid Karimian, MD

2002

Case no. 1Case 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°

Case no. 1… cont.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

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

Case no. 1… cont.Case no. 1… cont.

Post-op Course….cont.Day 3: OU(OD>OS): 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

Pros and ConsPros and ConsPros 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

Case no. 1Case no. 1

Peripheral circumferential

Post-LASIK sterile keratitis

Case no. 2Case 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 > 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°

Intraoperative eventsIntraoperative 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

Postop CoursePostop CourseDay 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

Post-op CoursePost-op CourseDay 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 CED’s

- infiltration involved all over interface

(gradeII)

RX: - prednisolone 75mg (1.5mg/kg)

- Ciprofloxacin OU q6h

- Beta OU q4h started

Post-op CoursePost-op Course2 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

Epithelial Erosions: Epithelial Erosions: are not benign complications are not benign complications associated with:associated with:

Increase risk of epithelial ingrowth

Induced astigmatism

Flap edema

Over or undercorrection

DLK

Flap melt

Epithelial erosion: Epithelial erosion: CausesCauses 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

Case no. 2Case no. 2

Post-LASIK interface keratitis

mimicking infectious cause

Case no. 3 Case no. 3 “Refractory DLK”“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 (OS>OD) Intensive and aggressive steroid therapy: Beta

OU q1h, prednisolone 100mg PO qd

Case no 3…cont.Case no 3…cont.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

Case no 3..cont.Case no 3..cont.

Management:Management:Steroids: topical; was DC

Systemic: rapid tapering and

discontinuedAntiglaucoma: timolol OU q12h

Acetazolamide 250mg PO q6h

Case no. 3… cont Case no. 3… cont

Follow up course After 1 wk: IOP OU decreased to Mid 20’s

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

Case no 3… cont 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

Case no. 3Case no. 3

“Refractory DLK “

or

“ Pseudo – DLK”

Was in fact secondary to very high interaocular pressures due to

“ steroid – responsiveness”