Severe bacterial keratitis after photorefractive keratectomy (PRK) is a rare postoperative complication. To our knowledge, no case of methicillin-resistant Staphylococcus aureus (MRSA) infection after PRK has been reported in the literature. Some reports describe early bacterial ulcers after PRK related to bandage contact lenses.1–5 All the patients had severe bacterial ulcers 2 to 3 days after surgery. A case report describing later bacterial infections after PRK was not associated with bandage contact lenses.6
A 43-year-old nurse had PRK in the left eye in June 2000 outside our hospital. The preoperative best corrected visual acuity was 20/20 with −1.75 −2.00 × 55. Three weeks earlier, she had had PRK in the right eye without any severe complications. Postoperatively, she wore a bandage contact lens and applied ofloxacin eyedrops. At 1 day, there were no signs of corneal inflammation. At 3 days, the original surgeon referred her to our hospital. The bandage contact lens was removed the same day, and a deep, central, infected corneal ulcer with marked anterior chamber reaction and hypopyon was diagnosed in the left eye. There was severe lid and conjunctival edema and a significant purulent discharge (Figure 1). The visual acuity was light perception.
The patient did not report pain but felt very uncomfortable. Cultures were sent out immediately, and thermocautery was performed (Figure 2). Intensive topical treatment included gentamicin and cefotaxime eyedrops every 30 minutes; systemic antibiotic treatment consisted of gentamicin and cefotaxime. The next day, because of continuous thinning of the corneal stroma, full-thickness penetrating keratoplasty (PKP) was performed. Culture results revealed MRSA. The topical and systemic antibiotic treatment was changed to systemic gentamicin and clindamycin and topical erythromycin.
None of the microbiological tests showed that the otherwise healthy woman was a carrier of MRSA. Histological examination revealed an acute, ulcerative-phlegmonous keratitis. The cornea was deepithelialized with destruction of Bowman's membrane in a very deep central defect surrounded by a dense, superficially accentuated inflammatory infiltrate and detachment of Descemet's membrane. Three months after surgery, the corneal transplant presented clear with a refraction of +4.0 –1.0 × 35.
Severe infectious keratitis is a serious complication of refractive corneal surgery. In spite of the large epithelial defect after PRK, infections are rare. We found 2 case reports describing a Staphylococcus aureus (but not MRSA) infection after PRK3,4 and 1 after laser in situ keratomileusis (LASIK).7 The conditions of the PRK patients were almost the same as those in our case. Two days after uneventful PRK, the patient developed a corneal ulcer. Postoperatively, a bandage contact lens was placed on the eye. After bandage contact lens removal and intensive antibiotic treatment, the defect healed, with a visual acuity of finger counting in 1 patient3 and 20/20 in the other.4 The photographs of these infections did not show as severe an infection as in our case.
To our knowledge, all reported early corneal infections after PRK are related to bandage contact lens application.1–5 Therefore, the use of bandage contact lenses after PRK should be discussed, although we do not dispute their possible effect on pain relief and influence on epithelial healing. A staphylococcal infection after LASIK7 has also been reported. The patient recovered good visual acuity after antibiotic treatment.
The prevalence of MRSA varies geographically. An increasing prevalence has been reported in German hospitals in the past decade.8 Because of the local rigid control management, the University Hospital of Münster has a low rate of nasal MRSA colonization (5.8%).9 Concerning MRSA colonization of health care workers, most studies suggest that the incidence of MRSA is approximately 2%.10
In severely infected corneal ulcers, we generally achieved good results using thermocautery as a first step in addition to intensive systemic and topical antibiotic treatment. In this case, we subsequently had to perform a full-thickness keratoplasty because of progressive thinning of the cornea.
The need to perform PKP after refractive surgery is extremely disappointing for the patient since the surgery was performed to free the patient of glasses or contact lenses.
1. Derse M, Holschbach A. Corneal ulcer following PRK; early postoperative complication of the therapeutic contact lens? Abstract P222. Ger J Ophthalmol 1995; 4(suppl):S57
2. Faschinger C, Faulborn J, Ganser K. Infektiöse Hornhautgeschwüre—einmal mit Endophthalmitis—nach PRK mit Einmalkontaktlinse. Klin Monatsbl Augenheilkd 1995; 206:96-102
3. Hill VE, Brownstein S, Jackson WB, Mintsioulis G. Infectious keratopathy complicating photorefractive keratectomy. (letter) Arch Ophthalmol 1998; 116:1382-1384
4. Lim-Bon-Siong R, Valluri S, Gordon ME, Pepose JS. Efficacy and safety of the ProTek (Vifilicon A) therapeutic soft contact lens after photorefractive keratectomy. Am J Ophthalmol 1998; 125:169-176
5. Malling S. Keratitis with loss of useful vision after photorefractive keratectomy. J Cataract Refract Surg 1999; 25:137-139
6. Sampath R, Ridgway AEA, Leatherbarrow B. Bacterial keratitis following excimer laser photorefractive keratectomy: a case report. (letter) Eye 1994; 8:481-482
7. Webber SK, Lawless MA, Sutton GL, Rogers CM. Staphylococcal infection under a LASIK flap. Cornea 1999; 18:361-365
8. Kresken M, Hafner D, die Studiengruppe. Resistenzsituation bei klinisch wichtigen Infektionserregern gegenüber Chemotherapeutika in Mitteleuropa. Ergebnisse einer multizentrischen Studie der Arbeitsgemeinschaft ‘Resistenz’ in der Paul-Ehrlich-Gesellschaft für Chemotherapie eV aus dem Jahre 1998. Chemother J 2000; 9(2):51-86
9. von Eiff C, Becker K, Machka K, et al. Nasal carriage as a source of Staphylococcus aureus bacteremia. N Engl J Med 2001; 344:11-16
10. Allen KD, Anson JJ, Parsons LA, Frost NG. Staff carriage of methicillin-resistant Staphylococcus aureus (EMRSA 15) and the home environment: a case report. J Hosp Infect 1997; 35:307-311