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Case report

Bilateral infectious keratitis after a laser in situ keratomileusis enhancement procedure

Suresh, Palanisamy S. MS, FRCS (Ed)a; Rootman, David S. MD, FRCSC*,a

Author Information
Journal of Cataract & Refractive Surgery: April 2002 - Volume 28 - Issue 4 - p 720-721
doi: 10.1016/S0886-3350(01)01232-9
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Abstract

Infectious keratitis is a well-known complication of LASIK.1–4 However, bilateral infections are rare.5–7 We report a case of simultaneous bilateral infectious keratitis occurring as a complication of a laser in situ keratomileusis (LASIK) enhancement procedure. To our knowledge, bilateral infectious keratitis after flap-lift enhancement procedures has not been reported.

Case Report

A 29-year-old woman had LASIK in both eyes on May 12, 2000, at a commercial laser center. Her preoperative refractive error was −4.25 diopters (D) in the right eye and −4.50 D in the left eye. Regression was noted, and bilateral flap lift and enhancement were done on September 13, 2000. Her uncorrected visual acuity (UCVA) was 20/30 in the right eye and 20/40 in the left eye 1 day after the enhancement. The patient developed pain, redness, and photophobia 24 hours after the enhancement procedure and was examined on September 29, 2000. She was told that she was allergic to the eyedrops. However, her symptoms worsened and she noticed white dots on both eyes.

On October 6, 2000, the patient went to the emergency department of a local hospital because of worsening of the pain and swollen eyelids. There was no associated discharge. The patient had paracentral corneal infiltrates at the interface in both eyes for which she had bilateral flap lift for scraping and culturing of the infiltrates. She was admitted to hospital and treated with fortified cefazolin, fortified gentamicin, and ciprofloxacin eyedrops every hour. The bacterial culture of both eyes grew Staphylococcus aureus. Her symptoms slowly improved with continued antibiotic treatment.

The patient was referred to the Cornea Service at Toronto Western Hospital, University Health Network, on November 4, 2000, for a second opinion. Examination showed a UCVA of 20/50 in the right eye and 20/30 in the left eye. There were bilateral paracentral scars measuring 1.0 mm in diameter (Figures 1 and 2). Also, vertical striae were noted in the flaps of both eyes. The patient had flap smoothing in the right eye on November 14, 2000, that improved the UCVA to 20/30 at the latest follow-up on December 4, 2000.

Figure 1.
Figure 1.:
(Suresh) Appearance of the corneal scar in the right eye.
Figure 2.
Figure 2.:
(Suresh) Appearance of the corneal scar in the left eye.

Discussion

Our patient had simultaneous, bilateral interface infiltrates that grew S aureus from both the eyes. It is apparent from the sequence of events that the flap-lift procedure was directly linked to the development of keratitis. To our knowledge, this is the first reported case of bilateral keratitis after enhancement surgery. The flap-lift procedure involves lifting the flap with a sterile instrument and performing laser treatment on the stromal bed. The exposed interface is at risk of microbial contamination from the ocular adnexa, instruments, and atmosphere.

Watanabe et al.5 report the first case of bilateral keratitis after a LASIK procedure. In their case, cultures from both eyes grew S aureus. After treatment, the patient achieved a best spectacle-corrected visual acuity of 20/40 in both eyes as a result of scar-induced irregular astigmatism. Hovanesian et al.6 report a case of bilateral keratitis in an HIV-positive patient after LASIK. Staphylococcus aureus was isolated in the left eye, and both eyes were treated successfully with cefazolin eyedrops. The patient had penetrating keratoplasty (PKP) in the left eye and achieved a final best corrected visual acuity of 20/25 in both eyes. In 2001, Garg and coauthors7 reported bilateral Mycobacterium keratitis after LASIK. The right eye required corneal glue for thinning, which finally healed with a scar. The left eye required PKP. Karp and coauthors8 report a case of unilateral delayed keratitis 3 months after a LASIK enhancement procedure that did not grow bacteria. However, the patient was successfully treated with antibiotic drops and was left with a small peripheral corneal scar. The UCVA was 20/20.

Infectious keratitis is a rare but an unfortunate complication of LASIK enhancement procedures that may result in flap striae, irregular astigmatism, and visually significant corneal scarring that occasionally necessitate PKP. All patients are at risk of bilateral infection while having bilateral surgery, and every effort should be taken to minimize its occurrence. It is also important to advise patients to seek prompt medical attention if there is undue or persistent pain after an enhancement procedure. In this case, the patient's reported symptoms did not result in prompt attention to her problems and may have contributed to the eventual scarring and irregular astigmatism. In this time of developing the techniques of LASIK and enhancement surgery, it is important to monitor the occurrence of complications and report them to the medical community so that a more realistic view of the possible complications can be compiled.

References

1. Reviglio V, Rodriguez ML, Picotti GS, et al. Mycobacterium chelonae keratitis following laser in situ keratomileusis. J Refract Surg 1998; 14:357-360
2. Nascimento EG, Carvalho MJ, de Freitas D, Campos M. Nocardial keratitis following myopic keratomileusis. J Refract Surg 1995; 11:210-211
3. Dada T, Sharma N, Dada VK, Vajpayee RB. Pneumococcal keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2000; 26:460-461
4. Sridhar MS, Garg P, Bansal AK, Sharma S. Fungal keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2000; 26:613-615
5. Watanabe H, Sato S, Maeda N, et al. Bilateral corneal infection as a complication of laser in situ keratomileusis. Arch Ophthalmol 1997; 115:1593-1594
6. Hovanesian JA, Faktorovich EG, Hoffbauer JD, et al. Bilateral bacterial keratitis after laser in situ keratomileusis in a patient with human immunodeficiency virus infection. Arch Ophthalmol 1999; 117:968-970
7. Garg P, Bansal AK, Sharma S, Vemuganti GK. Bilateral infectious keratitis after laser in situ keratomileusis; a case report and review of the literature. Ophthalmology 2001; 108:121-125
8. Karp KO, Hersh PS, Epstein RJ. Delayed keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2000; 26:925-928
© 2002 by Lippincott Williams & Wilkins, Inc.