Bilateral peripheral corneal infiltrates after simultaneous myopic laser in situ keratomileusis

Three cases of non-infectious necrotizing stromal keratitis after corneal refractive surgery

We reported three cases of aseptic necrotizing stromal keratinitis after corneal refractive surgery (two with small incision lenticule extraction and one with femtosecond laser-laser-assisted insitu keratomileusis). There were three young women who had undergone corneal refractive surgery had white aseptic infiltrating foci along or away from the stroma in both eyes or one eye on regular review, all of whom denied systemic disease or chronic ocular disease. Two patients were diagnosed with aseptic necrotizing corneal stromal inflammation, and one patient was diagnosed with delayed necrotizing corneal stromal inflammation. In our opinion, before corneal refractive surgery, medical history inquiry is very important. More attention should be paid to patients with vaccination history and foreign travel history. In addition, the possibility of delayed corneal stromal inflammation should be considered for patients with poor binocular corrected vision.

Wessely corneal ring phenomenon: An unsolved pathophysiological dilemma

The cornea is a densely innervated, avascular tissue showing exceptional inflammatory and immune responses. The cornea is a site of lymphangiogenic and angiogenic privilege devoid of blood and lymphatic vessels that limits the entry of inflammatory cells from the adjacent and highly immunoreactive conjunctiva. Immunological and anatomical differences between the central and peripheral cornea are also necessary to sustain passive immune privilege. The lower density of antigen-presenting cells in the central cornea and the 5:1 peripheral-to-central corneal ratio of C1 are 2 main features conferring passive immune privilege. C1 activates the complement system by antigen-antibody complexes more effectively in the peripheral cornea and, thus, protects the central corneas' transparency from immune-driven and inflammatory reactions. Wessely rings, also known as corneal immune rings, are non-infectious ring-shaped stromal infiltrates usually formed in the peripheral cornea. They result from a hypersensitivity reaction to foreign antigens, including those of microorganism origin. Thus, they are thought to be composed of inflammatory cells and antigen-antibody complexes. Corneal immune rings have been associated with various infectious and non-infectious causes, including foreign bodies, contact lens wear, refractive procedures, and drugs. We describe the anatomical and immunologic basis underlying Wessely ring formation, its causes, clinical presentation, and management.

Visual outcomes of sterile corneal infiltrates after photorefractive keratectomy

Purpose:

Sterile infiltrates following laser refractive surgery is an uncommon complication. This study was undertaken to analyze the visual outcomes of sterile infiltrates following photorefractive keratectomy (PRK).

Methods:

This retrospective study included 14 eyes that developed sterile infiltrates following PRK out of a total of 6280 eyes that underwent PRK between 2014 and 2017. Medical records of these patients, including patient demographics, characteristics of the infiltrate, presenting visual acuity, and treatment outcomes were recorded and analyzed.

Results:

The incidence of sterile corneal infiltrates post-PRK in our study was 0.22% (14/6280). The mean age of the patients was 27.42 ± 4.87 years. The uncorrected visual acuity (UCVA) at presentation was 0.49 ± 0.13 log MAR units. The mean size of the infiltrate was 3.22 ± 2.85 mm². All cases were successfully managed medically with topical steroids. The mean UCVA and best-corrected visual acuity (BCVA) at the last follow-up visit were 0.08 ± 0.08 and 0.05 ± 0.07 log MAR units, respectively. The mean time taken for resolution of the infiltrate was 8.91 ± 4.57 days.

Conclusion:

Sterile infiltrates following PRK can be effectively treated with aggressive topical steroids. The outcome is generally favorable and does not require surgical intervention if treatment is instituted early.

Hypersensitivity reactions after femtosecond laser small incision lenticule extraction: a case report of corneal infiltrates

BACKGROUND

Femtosecond laser corneal refractive surgery is generally considered safe and effective; however, this procedure is rarely associated with severe allergic reactions. We reported a rare case of hypersensitivity reactions which caused bilateral peripheral corneal infiltrates after femtosecond laser small incision lenticule (SMILE) surgery in a man with a history of fruits allergy.

CASE PRESENTATION

Here we report the case of a young man who developed white, ring-shaped bilateral peripheral infiltrates that appeared 1 day after an uneventful SMILE surgery. The overlying corneal epithelium was intact; the infiltrate was negative for bacterial culture, but high titers of immunoglobulin E was demonstrated in the blood. Symptomatically, a clinical diagnosis of sterile corneal infiltrates was made, and the patient was treated with topical and systemic steroids. The infiltrates were immunogenic in origin, which may be caused by the contact lenses used for suction duration in surgery. It resolved without corneal scarring in the subsequent months following steroid treatment. The patient's visual acuity improved.

CONCLUSIONS

When patients with a history of allergy who aim to perform corneal refractive surgery, surgeons must consider possible hypersensitivity reactions after treatment. More studies are needed to clarify the relationship between contact glass used in femtosecond laser corneal refractive surgery and IgE mediated hypersensitivity reactions.

Peripheral Ulcerative Keratitis following Laser in situ Keratomileusis

Purpose

We report a case of a patient with a history of glomerulonephropathy, not disclosed prior to laser in situ keratomileusis (LASIK), who developed severe postoperative peripheral ulcerative keratitis (PUK) soon after surgery.

Method

Case report.

Results

Within a week of surgery, the patient, who had no blepharitis or ocular surface disease, also developed diffuse lamellar keratitis (DLK) that was not contiguous with the PUK. Microbiologic evaluation of the flap interface disclosed no organisms, and no epithelial ingrowth was found. Both PUK and DLK resolved with topical and oral steroid therapy, and the patient's induced refractive error improved over the 12 months following LASIK.

Conclusions

Necrotizing keratitis has been described after LASIK surgery in patients with or without autoimmune disease. However, to our knowledge, there has been no case of PUK following LASIK. As shown by our patient's clinical course and the typical association of PUK with systemic conditions, patients with a history of atypical postinfectious sequelae may require additional preoperative counseling, vigilant postoperative monitoring, and possibly additional intervention. Because patients do not always divulge medical details, especially if an extraocular site was involved or illness occurred many years prior, this case demonstrates the importance of performing a diligent history that excludes autoimmune disorders or atypical postinfectious sequelae prior to proceeding with keratorefractive intervention.

Peripheral sterile corneal infiltrate in two brothers after photorefractive keratectomy

This is a report of two brothers who underwent bilateral photorefractive keratectomy and developed bilateral peripheral corneal infiltrate on the third day following surgery. The patients were treated with antibiotics and low concentration steroid until negative culture was reported 48 h later, when intensive topical steroid was started. The infiltrate resolved by day 10 with residual subepithelial haze that was apparent 8 months after surgery. Sterile infiltrate has been reported as complication of photorefractive keratectomy and can be managed successfully with excellent outcome. The fact that it happened in two brothers may raise the possibility of genetic predisposition.

Peripheral sterile corneal infiltrates after refractive surgery

PURPOSE

To report 5 eyes of peripheral sterile corneal infiltrates after refractive surgery.

SETTING

Department of Ophthalmology, Soroka University Medical Center, Beer-Sheva, Israel, and Enaim Ophthalmological Center, Jerusalem, Israel.

METHODS

Three patients had bilateral refractive procedures for correcting myopia. The procedures included laser epithelial keratectomy in 2 eyes, laser in situ keratomileusis (LASIK) in 2 eyes using a keratome, and LASIK in 1 eye using femtosecond laser.

RESULTS

All the patients complained of ocular pain between 1 and 3 days after the procedure. A ring stromal infiltrate peripheral to the flap edge with intact epithelium and an intervening clear zone between the peripheral corneal infiltrates and the limbus was observed in 5 eyes without anterior chamber reaction. All cases improved after several days of topical steroid and antibiotic treatment and systemic steroid. Final visual acuity was 20/25 or better in all cases.

CONCLUSIONS

The exact mechanism of this complication is still unknown, which can be confused with infectious keratitis. It is important to maintain a high degree of suspicion for infectious keratitis because the management is very different. The potential outcome can be much worse if the keratitis is due to an infectious etiology which can appear after all types of refractive laser procedures.

Delayed Reactivation of Presumed Adenoviral Subepithelial Infiltrates After Laser In Situ Keratomileusis

OBJECTIVE

To report the reactivation of presumed adenoviral keratitis after laser in situ keratomileusis (LASIK).

METHODS

Case report and literature review.

RESULTS

The patient underwent uneventful LASIK more than 5 years after an episode of adenoviral keratitis that left subepithelial corneal scarring. Three months after LASIK, new subepithelial infiltrates appeared in the right eye. These lesions resolved without sequelae during treatment with topical steroids. The patient's uncorrected and best-corrected visual acuity returned to her postoperative baseline.

CONCLUSION

LASIK may cause delayed exacerbation of subepithelial infiltrates caused by adenoviral keratitis. However, good visual outcomes can be achieved with recognition of this reactivation and treatment with topical corticosteroids.

Peripheral Keratitis Following Laser in situ Keratomileusis

PURPOSE

To report two different cases of sterile, peripheral keratitis following laser in situ keratomileusis (LASIK).

METHODS

A report of two cases (two eyes of two patients).

RESULTS

In two patients, peripheral infiltrates appeared 1 day after LASIK. One patient had a history of rheumatoid arthritis and both had peripheral corneal changes that may have represented prior inflammatory events. The presentations were quite different, with one occurring in association with an epithelial defect at the edge of the flap and the other occurring without an epithelial defect peripheral to the microkeratome cut. In the second case a similar infiltrate showed up in the unoperated fellow eye. Both patients were treated with aggressive antibiotic and corticosteroid therapy. Both patients recovered well with no loss of best spectacle-corrected visual acuity.

CONCLUSION

Peripheral keratitis can occur in patients following LASIK; preoperative evidence of previous inflammation may be a marker for patients at higher risk. Rheumatoid arthritis patients may be at increased risk for this complication. With careful and aggressive management excellent visual outcomes are still possible.