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Liu J, Guo X, Wei Z, Zhang Y, Zhang Z, Xu X, Liang Q. Infectious Keratitis After Keratorefractive Surgery: Update and Review of the Literature. Eye Contact Lens 2023; 49:275-282. [PMID: 37166228 PMCID: PMC10281179 DOI: 10.1097/icl.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To summarize the clinical manifestations, microbiological profile, treatment, and prognosis of corneal infections after different keratorefractive surgery. METHODS To obtain relevant studies, English-language databases, including PubMed, Ovid Embase, Web of Science, and CLNAHL, were searched from January 1979 to March 2022. The fundamentals of the literature, clinical characteristics, pathogens, and treatments were retrieved for each included article. RESULTS Eighty-four studies involving 306 infectious eyes were included in this review. Risk factors of potential infection included a history of blepharitis, contact lens usage, and contaminated surgical instruments. The mean onset time was 22.9±38.7 days (range: 1 day to 3 years). The most common organism isolated from infectious keratitis after keratorefractive surgery were Staphylococcus aureus , followed by Mycobacterium and coagulase-negative Staphylococcus . Most of the infections after refractive procedures were sensitive to medical treatment alone, and the ultimate best-corrected visual acuity after medical treatment was as follows: 20/20 or better in 82 cases (37.0%), 20/40 or better in 170 cases (76.5%), and worse than 20/40 in 52 cases (23.5%). Surgical interventions including flap lift, flap amputation, ring removal, and keratoplasty were performed in 120 eyes (44.5%). CONCLUSIONS Most infections after keratorefractive surgery occur within a week, whereas more than half of the cases after laser-assisted in situ keratomileusis happen after about a month. Gram-positive cocci and mycobacterium are the most common isolates. Infections after LASIK, intracorneal ring (ICR) implantation, and small incision lenticule extraction, which primarily occur between the cornea layers, require irrigation of the tunnels or pocket with antibiotics.
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Affiliation(s)
- Jiamin Liu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Xiaoyan Guo
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Zhenyu Wei
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Yuheng Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Zijun Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Xizhan Xu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Qingfeng Liang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
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Afsharpaiman S, Zare M, Yasemi M, Jamialahmadi T, Sahebkar A. The Prevalence of Infectious Keratitis after Keratorefractive Surgery: A Systematic Review and Meta-Analysis Study. J Ophthalmol 2020; 2020:6329321. [PMID: 32774907 PMCID: PMC7407012 DOI: 10.1155/2020/6329321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/24/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The keratorefractive surgeries (KRS) are one of the most common ocular surgeries. One of the dangerous complications of these surgeries is infectious keratitis (IK), which is the second cause of blindness after cataract surgery. The purpose of this study was to estimate the prevalence of IK after KRS in different parts of the world. METHODS In order to obtain relevant studies, all national and international databases including IranMedex, SID, Magiran, IranDoc, Medlib, ScienceDirect, PubMed, Scopus, Cochrane, Embase, Web of Science, and Google Scholar were searched using standard keywords. RESULTS IK prevalence after KRS was 0.000496% (0.000145% for the left eye and 0.000149% for the right eye). IK prevalence after KRS in the United States, Europe, and Asia was 0.000667%, 0.000473%, and 0.000045%, respectively, in all of which the common microorganisms were Staphylococci. Meta-regression showed no significant association between IK after KRS and either sample size or publication year of the studies. IK prevalence after KRS in the right eye was more than that in the left one. Also, the probability of IK incidence after LASIK surgery was more than PRK and LASEK. In the evaluation of continents, IK after KRS in the United States was more frequent compared with Europe and Asia. CONCLUSIONS This study provided data as to the overall prevalence of IK following KRS and its variations according to the types of eye, surgery, pathogenic microorganism, and geographical location.
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Affiliation(s)
- Shahla Afsharpaiman
- Health Research Center, Life Style Institute, Bagiyatallah University of Medical Sciences, Tehran, Iran
| | - Musa Zare
- Department of Ophthalmology, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Masoud Yasemi
- Health Research Center, Life Style Institute, Bagiyatallah University of Medical Sciences, Tehran, Iran
| | - Tannaz Jamialahmadi
- Department of Food Science and Technology, Quchan Branch, Islamic Azad University, Quchan, Iran
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Halal Research Center of IRI, FDA, Tehran, Iran
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Very late-onset flap margin corneal ulcer following laser in situ keratomileusis. Int Ophthalmol 2019; 39:2533-2538. [PMID: 30982142 DOI: 10.1007/s10792-019-01100-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To report and characterize cases of very late onset (5 years or more after surgery) flap margin corneal ulcers after laser in situ keratomileusis (LASIK) procedure. METHODS A retrospective case series of consecutive patients who were diagnosed with very late flap margin corneal ulcers following LASIK, between January 2014 and July 2017. All patients were treated with topical antibiotics and were followed up until complete resolution. RESULTS A total of eight patients, with a mean age of 46.5 ± 11 years, (range 31-64 years), were included in this study. All patients underwent uneventful myopic LASIK 13.3 ± 3 (range 10-20) years before presentation. Patients best corrected visual acuity (BCVA) at presentation was 0.20 ± 0.15 logMAR compared to a final BCVA of 0.10 ± 0.10 logMAR (p = 0.28). The ulcer was located in the bottom two clock hours of the flap margin (5-7 o'clock) in six (75%) patients and superior (11 o'clock) in the remaining two patients (p = 0.048). Seven patients (87.5%) suffered from blepharitis, and only one did not. CONCLUSIONS LASIK may be associated with an increased risk of late-onset corneal ulcer occurring years after the procedure. Instability of the flap margin, blepharitis and dry eye are possible causes of epithelial disturbance and may account for this complication.
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Abstract
PURPOSE To report outcomes of post-laser in situ keratomileusis (LASIK) interface filamentous fungal keratitis. METHODS This retrospective interventional case series included 6 eyes of 5 patients with microbiologically proven post-LASIK interface fungal keratitis from August 2008 to August 2013. Patients presenting with concurrent bacterial/viral keratitis, systemic illness, prior ocular pathology, or those without a minimum follow-up of 3 months were excluded. Every case underwent microbiological scrapings from residual bed and undersurface of the flap after flap lift at presentation followed by voriconazole interface wash. Flap amputation was performed when required. The outcome measure was complete resolution of infection. RESULTS The mean age was 24 ± 3.1 years. The male:female ratio was 4:1. The mean interval between LASIK and symptom onset was 4.16 ± 2 days; and the mean interval between symptom onset and patient referral was 3.16 ± 1.16 days. Interface scrapings showed filamentous fungal filaments in KOH wet mount. The culture grew Aspergillus in case 1 and case 5. Infiltrated LASIK flap needed to be amputated in 4 eyes of 3 patients. Voriconazole wash (100 μg/mL) of the stromal bed was performed in all cases. A positive response to therapy with resolution of infection was seen in all cases at a mean of 6.5 ± 4.6 days. No intraoperative or postoperative complications after interface scraping or voriconazole wash were observed. The final best-corrected visual acuity ranged from 20/20 to 20/80 at a mean follow-up of 9.1 ± 6.5 months. CONCLUSIONS Post-LASIK interface fungal filamentous keratitis can present early and gives good outcomes with early microbiological diagnosis and appropriate management. Voriconazole is an efficient and probably safe adjunct in the armamentarium of corneal surgeons to treat such cases.
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Review and Update on the Epidemiology, Clinical Presentation, Diagnosis, and Treatment of Fungal Keratitis. CURRENT FUNGAL INFECTION REPORTS 2013. [DOI: 10.1007/s12281-013-0163-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Labiris G, Troeber L, Gatzioufas Z, Stavridis E, Seitz B. Bilateral Fusarium oxysporum keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2012; 38:2040-4. [DOI: 10.1016/j.jcrs.2012.08.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 05/03/2012] [Accepted: 05/04/2012] [Indexed: 11/27/2022]
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Yeung SN, Lichtinger A, Kim P, Amiran MD, Slomovic AR. Late-onset Klebsiella oxytoca flap-margin–related corneal ulcer following laser in situ keratomileusis. J Cataract Refract Surg 2011; 37:1551-4. [PMID: 21782101 DOI: 10.1016/j.jcrs.2011.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 04/28/2011] [Accepted: 04/28/2011] [Indexed: 11/26/2022]
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Abstract
PURPOSE To report 4 cases of flap margin-related corneal ulcer that developed 5 years after laser in situ keratomileusis (LASIK) procedures. METHODS We retrospectively documented the clinical and laboratory characteristics of all patients between 2004 and 2008 who presented with LASIK-related corneal ulcer that appeared >5 years postoperatively. The 4 patients who had this condition were 25-, 33-, 61-, and 62-year-old males. RESULTS Two patients had cultures positive to Staphylococcus aureus and Streptococcus epidermidis. Two ulcers healed after standard fortified topical antibiotic regimen, 1 ulcer healed after treatment with moxifloxacin, and the fourth healed after treatment with lomefloxacin. All cases presented 5 years after the LASIK procedure. CONCLUSIONS LASIK procedures can be associated with the risk of corneal infection even years later. The mechanism may be flap margin instability causing epithelial defense barrier disturbance.
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Unilateral Candida parapsilosis interface keratitis after laser in situ keratomileusis: case report and review of the literature. Cornea 2009; 28:105-7. [PMID: 19092419 DOI: 10.1097/ico.0b013e318184e69b] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe a rare case of early-onset Candida parapsilosis infection after laser in situ keratomileusis (LASIK) and review the published reports of post-LASIK fungal infections. METHODS A 32-year-old woman presented with interface infiltration in the central interface in the right eye 2 days after LASIK surgery. The right eye flap was lifted, and the opacities were scraped. Two days later, a 3- x 3-mm-dense oval opacity and diffuse hazes were noted. Surgical intervention was arranged because of suspicion of interface infectious keratitis. RESULTS After an apparent post-LASIK keratitis with related interface inflammation failed to respond to medical therapy, corneal culture results were positive for C. parapsilosis 2 weeks 6 days after presentation. The patient was started on topical drops of amphotericin B 0.15% every hour after the smear showed the presence of yeast. The opacities decreased, and the topical antifungal drops were tapered. One month later, her uncorrected visual acuity recovered to 20/20. CONCLUSIONS Candida parapsilosis interface keratitis after LASIK may occur in the early phase. Early diagnosis and proper treatment can result in good outcome.
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Kanavi MR, Foroutan AR, Kamel MR, Afsar N, Javadi MA. Candida interface keratitis after deep anterior lamellar keratoplasty: clinical, microbiologic, histopathologic, and confocal microscopic reports. Cornea 2007; 26:913-6. [PMID: 17721287 DOI: 10.1097/ico.0b013e3180ca9a61] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To report the clinical, histopathologic, microbiologic, and confocal microscopic features of Candida keratitis after deep anterior lamellar keratoplasty (DALK). METHODS We performed clinical, confocal scan, microbiologic and histopathologic examinations on two corneas from 2 young patients who underwent DALK for keratoconus. RESULTS The first patient presented with asymptomatic white to cream-colored interface deposits 2 months after DALK. The confocal scan disclosed clusters of hyperreflective, fine granular deposits at the region of interface, with no evidence of inflammation or hyphaelike structures. The clinical presumption of possible "epithelial downgrowth" was suggested, and because of the progression of these lesions, irrigation of the interface was considered. Finally, penetrating keratoplasty was performed because of a rupture in the Descemet membrane. Histopathologic examination of the cornea disclosed yeastlike structures within the interface area. The microbiologic results of the irrigation fluid showed Candida glabrata. The second patient presented with a symptomatic infiltration of the inferior interface close to the suture site 2.5 months after DALK. The confocal scan showed foci of inflammation with clusters of hyperreflective round-shaped structures that resembled epithelial cells. Clinically, there was a suggestion of epithelial downgrowth, and subsequently, penetrating keratoplasty was performed because of the progression of the lesion. Histopathologic examination of the cornea disclosed an acute and chronic granulomatous keratitis caused by yeastlike structures. The microbiologic results revealed infection with Candida albicans. CONCLUSIONS These are the first reported occurrences of interface Candida keratitis after DALK and with different confocal features. The clinical and the confocal features of interface Candida keratitis may be similar to those seen in epithelial downgrowth, which may postpone correct diagnosis and treatment. Candida keratitis should be considered in cases of interface deposits after any form of lamellar keratoplasty.
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Affiliation(s)
- Mozhgan Rezaei Kanavi
- Labbafinejad Ophthalmic Research Center, Shaheed Beheshti Medical University, Tehran, Iran.
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Affiliation(s)
- Judy I Ou
- F.I. Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, CA 94143, USA
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Patel SR, Hammersmith KM, Rapuano CJ, Cohen EJ. Exophiala dermatitidis keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2006; 32:681-4. [PMID: 16698496 DOI: 10.1016/j.jcrs.2006.01.040] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2005] [Accepted: 08/10/2006] [Indexed: 11/17/2022]
Abstract
A 52-year-old man had laser in situ keratomileusis in March 2002 and 2 weeks later had a corneal infection that was found to be caused by Exophiala dermatitidis. This infection waxed and waned for 9 months despite therapy with natamycin, itraconazole, and fluconazole but eventually responded to topical amphotericin. He recovered good visual acuity in this eye with a rigid gas-permeable lens. This case shows the importance of selecting the appropriate agent in fungal keratitis.
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Affiliation(s)
- Seema R Patel
- Cornea Service, Wills Eye Hospital, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Verma K, Vajpayee RB, Titiyal JS, Sharma N, Nayak N. Post-LASIK Infectious Crystalline Keratopathy Caused by Alternaria. Cornea 2005; 24:1018-20. [PMID: 16227855 DOI: 10.1097/01.ico.0000159735.83295.1c] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe a case of infectious crystalline keratopathy (ICK) after laser in situ keratomileusis (LASIK) caused by Alternaria species. METHODS A case report of a 29-year-old woman who presented with clinical features of ICK 3 weeks after LASIK surgery. RESULTS Medical therapy failed to control and resolve the corneal infection. Penetrating keratoplasty was performed, which controlled the infection and aided in visual recovery of 20/30. The culture of the corneal button revealed the presence of Alternaria species fungus. CONCLUSIONS Alternaria species fungus may cause ICK after LASIK.
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Affiliation(s)
- Kamna Verma
- Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi
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Lifshitz T, Levy J, Raiskup F, Klemperer I, Frucht-Pery J. Two Cases of Pneumococcal Keratitis Following Myopic LASIK. J Refract Surg 2005; 21:498-501. [PMID: 16209450 DOI: 10.3928/1081-597x-20050901-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To report two cases of pneumococcal keratitis after LASIK. METHODS Retrospective interventional small case series of two patients who underwent bilateral LASIK for myopia and developed pneumococcal keratitis after surgery. This complication was encountered 2 days after surgery in one eye in both cases. The corneal flap was lifted, and irrigation and cultures from the stromal bed performed. Topical and subconjunctival antibiotics were started. RESULTS Culture revealed Streptococcus pneumoniae in both cases. The infiltrates responded well to treatment. One year after the procedure, uncorrected visual acuity is > 20/40 in both cases. CONCLUSIONS Pneumococcal keratitis can complicate LASIK. Patients should be informed of this potential complication, as prompt treatment is crucial.
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Affiliation(s)
- Tova Lifshitz
- Department of Ophthalmology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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John T, Velotta E. Nontuberculous (atypical) mycobacterial keratitis after LASIK: current status and clinical implications. Cornea 2005; 24:245-55. [PMID: 15778593 DOI: 10.1097/01.ico.0000151565.63107.64] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Corneal infection with unfamiliar organisms such as nontuberculous (atypical) mycobacteria after laser in situ keratomileusis (LASIK) can be a significant clinical problem, and mismanagement of such corneal infection in an otherwise healthy, young individual can lead to significant medicolegal issues for the refractive surgeon. Because nontuberculous (atypical) mycobacterial keratitis is the most common infection after LASIK, the refractive surgeon should be aware of all aspects of this dreaded infection to be better prepared to manage such cases. METHODS Literature search. RESULTS/CONCLUSIONS This article provides a comprehensive compilation of all reported cases of nontuberculous (atypical) mycobacterial keratitis in the English literature and provides some useful recommendations for the clinical management of such corneal infection after LASIK.
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Affiliation(s)
- Thomas John
- Department of Ophthalmology, Loyola University at Chicago, Maywood, IL, USA.
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Solomon R, Biser SA, Donnenfeld ED, Perry HD, Doshi SJ, Lee CC. Candida parapsilosis keratitis following treatment of epithelial ingrowth after laser in situ keratomileusis. Eye Contact Lens 2004; 30:85-6. [PMID: 15260354 DOI: 10.1097/01.icl.0000116049.80374.1f] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To present a case of Candida parapsilosis following laser in situ keratomileusis (LASIK). METHODS Retrospective chart review. RESULTS A case report of a 51-year-old woman who underwent bilateral LASIK is presented. Two weeks after the procedure, the patient presented with epithelial ingrowth OD. The ingrowth was treated with flap lifting and scraping, followed by postoperative antibiotics. Four weeks later, the patient presented with numerous interface infiltrates. Smears were positive for yeast forms and cultures grew Candida parapsilosis. Administration of topical and systemic antifungal therapy resulted in clearing of the infection with partial visual recovery. CONCLUSIONS To our knowledge, this represents the first reported case of a post-LASIK Candida parapsilosis keratitis. A high degree of suspicion coupled with rapid and appropriate treatment can result in visual recovery.
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Affiliation(s)
- Renée Solomon
- Ophthalmic Consultants of Long Island, Rockville Centre, NY 11570, USA
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Chang MA, Jain S, Azar DT. Infections following laser in situ keratomileusis: an integration of the published literature. Surv Ophthalmol 2004; 49:269-80. [PMID: 15110665 DOI: 10.1016/j.survophthal.2004.02.007] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Infections occurring after laser in situ keratomileusis (LASIK) surgery are uncommon, but the number of reports have steadily increased in recent years. This systematic, comprehensive review and analysis of the published literature has been performed in order to develop an integrative perspective on these infections. We have stratified the data by potential associations, microbiology, treatment, and the degree of visual loss, using Fisher's exact tests and Student's t-tests for analysis. In this review, we found that Gram-positive bacteria and mycobacterium were the most common causative organisms. Type of postoperative antibiotic and steroid use was not associated with particular infecting organisms or severity of visual loss. Gram-positive infections were more likely to present less than 7 days after LASIK, and they were associated with pain, discharge, epithelial defects, and anterior chamber reactions. Fungal infections were associated with redness and tearing on presentation. Mycobacterial infections were more likely to present 10 or more days after LASIK surgery. Moderate or severe visual reductions in visual acuity occurred in 49.4% of eyes. Severe reductions in visual acuity were significantly more associated with fungal infections. Flap lift and repositioning preformed within 3 days of symptom onset may be associated with better visual outcome.
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Affiliation(s)
- Margaret A Chang
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Alfonso JF, Baamonde MB, Santos MJ, Astudillo A, Fernández-Vega L. Acremonium fungal infection in 4 patients after laser in situ keratomileusis. J Cataract Refract Surg 2004; 30:262-7. [PMID: 14967302 DOI: 10.1016/s0886-3350(03)00646-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2003] [Indexed: 11/24/2022]
Abstract
We present 4 patients who had laser in situ keratomileusis and were referred to our clinic with a diagnosis of infectious keratitis. Laser in situ keratomileusis was performed in all cases in the same operating room by different surgeons between April and May 2002. A partial penetrating keratoplasty was performed in all patients to control the process. A study of the corneas demonstrated the presence of the fungus Acremonium in all cases. Rigid asepsis during the surgical procedure is important to prevent this serious complication.
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Affiliation(s)
- José F Alfonso
- Instituto Oftalmológico Dres Fernández-Vega, Oviedo, Asturias, Spain.
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Jabbarvand M, Hashemian MR, Abedinifar Z, Amini A. Nattrassia mangiferae keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2004; 30:268-72. [PMID: 14967303 DOI: 10.1016/j.jcrs.2003.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2003] [Indexed: 11/16/2022]
Abstract
A 32-year-old man had photophobia and blurred vision 2 weeks after uneventful laser in situ keratomileusis to correct myopia. He was treated with steroids for suspected diffuse lamellar keratitis, antiherpetics, and antibiotic eyedrops, but the condition worsened and the patient developed further blurred vision, an inflamed eye, and pain. When referred to us, the patient had an extensive corneal ulcer with hypopyon and mycelia were reported in scrapings of the ulcer bed. Nattrassia mangiferae (Hendersonula toruloidea) was cultured from the specimen. The patient was treated with antifungal agents and 2 penetrating keratoplasties. At the last examination, the uncorrected visual acuity was 20/200.
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Affiliation(s)
- Mahmood Jabbarvand
- Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Solomon R, Donnenfeld ED, Azar DT, Holland EJ, Palmon FR, Pflugfelder SC, Rubenstein JB. Infectious keratitis after laser in situ keratomileusis: Results of an ASCRS survey. J Cataract Refract Surg 2003; 29:2001-6. [PMID: 14604725 DOI: 10.1016/s0886-3350(03)00512-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To investigate the incidence, culture results, treatment, and visual outcomes of infectious keratitis after laser in situ keratomileusis (LASIK) worldwide, the Cornea Clinical Committee of the American Society of Cataract and Refractive Surgery (ASCRS) contacted 8600 United States and international ASCRS members by e-mail and asked them to respond to a questionnaire about post-LASIK infectious keratitis. One hundred sixteen infections were reported by 56 LASIK surgeons who had performed an estimated 338 550 procedures. Seventy-six cases presented in the first week after surgery, 7 during the second week, 17 between the second and fourth weeks, and 16 after 1 month. Forty-seven cases were not diagnosed on initial presentation. The most common organisms cultured were atypical mycobacteria and staphylococci. Empiric therapy is not recommended as most of the organisms are opportunistic and not responsive to conventional therapy. Flap elevation and culturing should be performed when post-LASIK infectious keratitis is suspected.
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Affiliation(s)
- Renée Solomon
- Ophthalmic Consultants of Long Island, Rockville Centre, East Meadow, New York, USA
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Abstract
Fungi may infect the cornea, orbit and other ocular structures. Species of Fusarium, Aspergillus, Candida, dematiaceous fungi, and Scedosporium predominate. Diagnosis is aided by recognition of typical clinical features and by direct microscopic detection of fungi in scrapes, biopsy specimens, and other samples. Culture confirms the diagnosis. Histopathological, immunohistochemical, or DNA-based tests may also be needed. Pathogenesis involves agent (invasiveness, toxigenicity) and host factors. Specific antifungal therapy is instituted as soon as the diagnosis is made. Amphotericin B by various routes is the mainstay of treatment for life-threatening and severe ophthalmic mycoses. Topical natamycin is usually the first choice for filamentous fungal keratitis, and topical amphotericin B is the first choice for yeast keratitis. Increasingly, the triazoles itraconazole and fluconazole are being evaluated as therapeutic options in ophthalmic mycoses. Medical therapy alone does not usually suffice for invasive fungal orbital infections, scleritis, and keratitis due to Fusarium spp., Lasiodiplodia theobromae, and Pythium insidiosum. Surgical debridement is essential in orbital infections, while various surgical procedures may be required for other infections not responding to medical therapy. Corticosteroids are contraindicated in most ophthalmic mycoses; therefore, other methods are being sought to control inflammatory tissue damage. Fungal infections following ophthalmic surgical procedures, in patients with AIDS, and due to use of various ocular biomaterials are unique subsets of ophthalmic mycoses. Future research needs to focus on the development of rapid, species-specific diagnostic aids, broad-spectrum fungicidal compounds that are active by various routes, and therapeutic modalities which curtail the harmful effects of fungus- and host tissue-derived factors.
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Affiliation(s)
- Philip A Thomas
- Department of Ocular Microbiology, Institute of Ophthalmology, Joseph Eye Hospital, Tiruchirapalli 620001, India.
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Muallem MS, Alfonso EC, Romano AC, Miller D, Kurstin J, Marangon FB, Culbertson WW, Yoo SH. Bilateral Candida parapsilosis interface keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2003; 29:2022-5. [PMID: 14604730 DOI: 10.1016/s0886-3350(03)00217-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a case of Candida infection after laser in situ keratomileusis (LASIK) and review the literature for reports of post-LASIK fungal infections. Risk factors may include postoperative surgical intervention and extended use of topical steroids.
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Affiliation(s)
- Marcus S Muallem
- Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida, USA
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23
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Tessari G, Forni A, Ferretto R, Solbiati M, Faggian G, Mazzucco A, Barba A. Lethal systemic dissemination from a cutaneous infection due to Curvularia lunata in a heart transplant recipient. J Eur Acad Dermatol Venereol 2003; 17:440-2. [PMID: 12834456 DOI: 10.1046/j.1468-3083.2003.00674.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 69-year-old male heart transplant recipient, being treated with Cell Cept, FK 506 and methylprednisolone had multiple deep brown skin nodules and nodes, on the upper right arm. Skin biopsy and culture detected a strain of Curvularia lunata. The infection disseminated to the whole skin surface, oral mucosa, upper third of the oesophagus and to the lungs. Therapy with antibiotics and antifungal drugs was ineffective. The patient died of sepsis. We did not find any other case of systemic dissemination from a skin infection due to C. lunata among heart transplant recipients. We feel that heart transplant recipients need adequate education to prevent situations that would put them at risk for infection and to seek medical advice immediately for an early diagnosis and an effective therapy.
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Affiliation(s)
- G Tessari
- Department of Biomedical and Surgical Sciences, Section of Dermatology and Venereal Disease, Institute of Cardiac Surgery, University of Verona, Verona Italy.
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24
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Tuli SS, Yoo SH. Curvularia keratitis after laser in situ keratomileusis from a feline source. J Cataract Refract Surg 2003; 29:1019-21. [PMID: 12781293 DOI: 10.1016/s0886-3350(02)01608-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Fungal keratitis following laser in situ keratomileusis (LASIK) is extremely rare. Except in cases that follow trauma, the source of fungal organisms is unknown in published reports. We report a case of keratitis following LASIK that could be directly traced to a fungal skin infection of the patient's pet cat.
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Affiliation(s)
- Sonal S Tuli
- Division of Cornea and External Disease, University of Florida, Gainesville, FL, USA
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25
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Donnenfeld ED, O'Brien TP, Solomon R, Perry HD, Speaker MG, Wittpenn J. Infectious keratitis after photorefractive keratectomy. Ophthalmology 2003; 110:743-7. [PMID: 12689896 DOI: 10.1016/s0161-6420(02)01936-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To elucidate risk factors, microbial culture results, and visual outcomes for infectious keratitis after photorefractive keratectomy (PRK). DESIGN Multicenter, retrospective chart review, case report, and literature review. METHODS The records of 12 patients with infectious keratitis after PRK were reviewed. MAIN OUTCOME MEASURES Causative organism, response to medical treatment, and visual outcome. RESULTS Infectious keratitis developed in 13 eyes of 12 patients after PRK. Organisms cultured were Staphylococcus aureus (n = 5), including a bilateral case of methicillin-resistant Staphylococcus aureus; Staphylococcus epidermidis (n = 4); Streptococcus pneumoniae (n = 3); and Streptococcus viridans (n = 1). Four patients manipulated their contact lenses, and 2 patients were exposed to nosocomial organisms while working in a hospital environment. Prophylactic antibiotics used were tobramycin (nine cases), polymyxin B-trimethoprim (three cases), and ciprofloxacin (one case). Final best spectacle-corrected visual acuity ranged from 20/20 to 20/100. CONCLUSIONS Infectious corneal ulceration is a serious potential complication of PRK. Gram-positive organisms are the most common pathogens. Antibiotic prophylaxis should be broad spectrum and should include gram-positive coverage.
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Affiliation(s)
- Eric D Donnenfeld
- Department of Ophthalmology, Nassau University Medical Center, East Meadow, New York, USA
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Karp CL, Tuli SS, Yoo SH, Vroman DT, Alfonso EC, Huang AH, Pflugfelder SC, Culbertson WW. Infectious keratitis after LASIK. Ophthalmology 2003; 110:503-10. [PMID: 12623812 DOI: 10.1016/s0161-6420(02)01760-8] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To report the clinical course, management, and outcomes of culture-proven infectious keratitis in 15 eyes of 13 subjects after LASIK. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Fifteen eyes of 13 subjects who underwent LASIK and developed culture-positive keratitis. INTERVENTION Infectious keratitis was encountered in the operative eyes between 1 day and 450 days. Cultures were obtained, and topical antibiotic therapy was administered in all cases. Some cases required flap lifting, irrigation, and soaking of the bed with antibiotics, flap amputation, or further surgical intervention. MAIN OUTCOME MEASURES Time periods from onset to diagnosis, from clinical diagnosis to clinical resolution, final acuities, microbiologic profiles, and medical and surgical interventions were reviewed. RESULTS Onset of symptoms of infection varied, depending on the infectious organism. Bacterial organisms tended to present earlier, whereas mycobacterial and fungal organisms had a later mean onset of presentation. Furthermore, the atypical organisms such as mycobacteria, fungus, and acanthamoeba also had a more delayed diagnosis, resulting in a prolonged disease course. CONCLUSIONS Infectious keratitis after LASIK is a potentially vision-threatening complication. Onset of symptoms varies depending on causative agents. Furthermore, atypical organisms in the interface or beneath the flap can pose both diagnostic and therapeutic dilemmas. Location in the interface can make it more difficult to culture the organisms and prevent adequate penetration of topical antibiotics.
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Affiliation(s)
- Carol L Karp
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida
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Freitas D, Alvarenga L, Sampaio J, Mannis M, Sato E, Sousa L, Vieira L, Yu MC, Martins MC, Hoffling-Lima A, Belfort R. An outbreak of Mycobacterium chelonae infection after LASIK. Ophthalmology 2003; 110:276-85. [PMID: 12578767 DOI: 10.1016/s0161-6420(02)01643-3] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe an outbreak of mycobacterial keratitis after laser in situ keratomileusis (LASIK), including the microbiologic investigation, clinical findings, treatment response, and outcome. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Patients (n = 10) who underwent LASIK surgery between August 22 and September 4, 2000, and developed mycobacterial infection. METHODS Patients were prospectively followed in relation to microbiologic investigation, clinical findings, treatment response, and outcome. MAIN OUTCOME MEASURES Most patients underwent bilateral simultaneous LASIK. Postoperative infection was signaled by the appearance of corneal infiltrates in the third postoperative week. The microbiologic workup was performed on cultures obtained either by direct scraping of the cornea or by lifting the flap. Medical therapy was instituted based on drug susceptibility testing. Surgical interventions such as corneal debridement and flap removal were performed during recurrences or when there was no satisfactory clinical response. RESULTS Cultures revealed Mycobacterium subspecies chelonae. Patients were treated with topical clarithromycin (1%), tobramycin (1.4%), and ofloxacin (0.3%). Oral clarithromycin (500 mg twice a day) was prescribed for those patients who did not respond clinically to topical treatment. Four eyes healed on this regimen. Flap removal was necessary in seven eyes. CONCLUSIONS This report highlights mycobacteria as an etiologic infectious agent after LASIK. Diagnosis can be difficult and is often delayed. The treatment mainstay is prolonged antibiotic therapy. Surgical debridement and flap removal may shorten the disease course.
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Affiliation(s)
- Denise Freitas
- Ophthalmology Department, Federal University of São Paulo, Paulista School of Medicine, São Paulo Hospital, Rua Botucatu 822, 04023-062 São Paulo, Brazil.
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28
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Pache M, Schipper I, Flammer J, Meyer P. Unilateral fungal and mycobacterial keratitis after simultaneous laser in situ keratomileusis. Cornea 2003; 22:72-5. [PMID: 12502955 DOI: 10.1097/00003226-200301000-00018] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To report a case of unilateral fungal and mycobacterial keratitis after simultaneous laser in situ keratomileusis (LASIK). METHODS Case report of a 37-year-old woman who developed corneal infiltrates located at the flap-stroma interface in her left eye 3 weeks after LASIK for myopia. The infiltration progressed despite topical antibiotic therapy; therefore, the flap was lifted and irrigated with antibiotic solution. Parallel corneal scrapings were taken. The patient's condition deteriorated, prompting a lamellar keratoplasty. RESULTS Corneal scrapings demonstrated no growth. Microbiologic cultures of the corneal specimen were reported as negative, whereas histopathologic examination disclosed fungal filaments. Two months later, the patient presented corneal infiltrates of the left eye again. Because the situation worsened despite therapy, a penetrating keratoplasty was performed. Histopathologic examination of the host cornea revealed no pathogenic species; microbiologic cultures, however, demonstrated Mycobacterium chelonae. CONCLUSION Fungi and M. chelonae are rare and insidious causes of infectious keratitis after LASIK. Our case emphasizes the possible difficulties in diagnosing and treating a combined or subsequent infection with both species.
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MESH Headings
- Antifungal Agents/therapeutic use
- Corneal Stroma/microbiology
- Eye Infections, Bacterial/diagnosis
- Eye Infections, Bacterial/etiology
- Eye Infections, Bacterial/surgery
- Eye Infections, Fungal/diagnosis
- Eye Infections, Fungal/etiology
- Eye Infections, Fungal/surgery
- Female
- Humans
- Keratitis/diagnosis
- Keratitis/microbiology
- Keratitis/surgery
- Keratomileusis, Laser In Situ/adverse effects
- Keratoplasty, Penetrating
- Middle Aged
- Mycobacterium Infections, Nontuberculous/diagnosis
- Mycobacterium Infections, Nontuberculous/etiology
- Mycobacterium Infections, Nontuberculous/surgery
- Mycobacterium chelonae/isolation & purification
- Postoperative Complications
- Surgical Flaps/microbiology
- Treatment Outcome
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Affiliation(s)
- Mona Pache
- University Eye Clinic, P.O. Box, CH-4012 Basel, Switzerland
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30
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Abstract
PURPOSE To describe the time course, diagnosis, clinical features, and treatment of seven patients with Mycobacterium szulgai keratitis that developed from 7 to 24 weeks after laser in situ keratomileusis (LASIK). METHODS Seven of 30 eyes of 18 patients were identified with keratitis after LASIK. The first two patients presented 12 to 14 weeks after LASIK; nontuberculous mycobacteria were identified 1 month after the flaps were cultured. Patient recall identified three additional cases by culture and two cases by clinical features alone. Pulsed-field gel electrophoresis (PFGE) was used to type the isolates, and treatment was modified based on susceptibilities. RESULTS M. szulgai was identified in five patients for whom cultures were performed, but response to empiric therapy based on cultures proved unsatisfactory. The keratitis resolved in all patients with treatment including clarithromycin based on susceptibilities. Medical therapy was sufficient, although one patient required flap amputation. Six of seven patients recovered best-corrected visual acuity (BCVA), while one patient lost one line of BCVA. Two patients lost one line of postoperative uncorrected visual acuity (UCVA), two patients gained one line of UCVA, and three patients recovered postoperative UCVA. PFGE analysis revealed that the M. szulgai strains were identical, and the infection source was contaminated ice used to chill syringes for saline lavage. CONCLUSIONS Nontuberculous mycobacterial keratitis after LASIK is a diagnostic and management challenge, but outcomes can be preserved with treatment based on susceptibilities. This cluster underscores the importance of adherence to sterile protocol during LASIK.
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Affiliation(s)
- Samuel F A Fulcher
- Division of Ophthalmology, Scott & White Memorial Hospital and Clinic, 2401 South 31st Street, Temple, TX 76508, USA.
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31
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Pushker N, Dada T, Sony P, Ray M, Agarwal T, Vajpayee RB. Microbial Keratitis After Laser in situ Keratomileusis. J Refract Surg 2002; 18:280-6. [PMID: 12051385 DOI: 10.3928/1081-597x-20020501-12] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE AND METHOD To review the literature on microbial keratitis reported after laser in situ keratomileusis (LASIK). RESULTS Forty-one eyes have been reported to have microbial keratitis after LASIK. The causative organisms vary from gram positive bacteria to atypical mycobacteria, fungal, and viral pathogens. The infection is usually acquired intraoperatively, but may also be caused by postoperative contamination. A majority of the patients present within 72 hours of the surgery with an acute onset of symptoms. Management of microbial keratitis after LASIK includes aggressive topical fortified antibiotic therapy, irrigation of stromal bed with antibiotic solution after lifting the flap, and sending the scraping of the infiltrate for microbiological evaluation. The keratitis heals with scarring and a best spectacle-corrected visual acuity of 20/40 or better can be obtained in the majority of the patients. CONCLUSION Microbial keratitis is a sight-threatening complication of LASIK.
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Affiliation(s)
- Neelam Pushker
- R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Ritterband D, Kelly J, McNamara T, Kresloff M, Koplin R, Seedor J. Delayed-onset multifocal polymicrobial keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2002; 28:898-9. [PMID: 11978476 DOI: 10.1016/s0886-3350(01)01015-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report a case of mixed Aspergillus fumigatus and coagulase-negative Staphylococcus stromal keratitis in a 43-year-old man who developed discomfort and swelling in his right eye 20 days after uneventful bilateral laser in situ keratomileusis (LASIK). Clinical examination revealed 2 distinct corneal infiltrates beneath the LASIK flap. Corneal scrapings were taken for microscopic examination and culture. Both infiltrates initially improved on topical antibiotic therapy, but over the next 18 days, 1 infiltrate worsened and repeat cultures were performed, which demonstrated A fumigatus. Natamycin 5% and amphotericin 0.1% were started and continued for 8 weeks with resolution of the infiltrate and return of the best corrected visual acuity. Delayed-onset multifocal keratitis is a rare complication of LASIK. Fungal entities should be considered in the differential diagnosis.
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Affiliation(s)
- David Ritterband
- Department of Ophthalmology, The New York Eye and Ear Infirmary, New York, New York, USA.
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33
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Holmes GP, Bond GB, Fader RC, Fulcher SF. A Cluster of cases of Mycobacterium szulgai keratitis that occurred after laser-assisted in situ keratomileusis. Clin Infect Dis 2002; 34:1039-46. [PMID: 11914991 DOI: 10.1086/339487] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2001] [Revised: 11/19/2001] [Indexed: 11/04/2022] Open
Abstract
Laser-assisted in situ keratomileusis (LASIK) is a recently developed ophthalmic procedure. When 2 patients developed keratitis caused by Mycobacterium szulgai after they underwent LASIK surgery, we conducted a retrospective cohort study of all LASIK procedures performed at Scott & White Clinic (Temple, Texas) during a 4.5-month period. Seven patients had compatible symptoms and signs, 5 of whom had confirmed M. szulgai keratitis. Five cases occurred among 30 procedures performed by doctor A, and there were no cases among 62 procedures performed by doctor B (approximate relative risk, 12.0; 95% confidence interval, 1.6-679.0; P=.0029). Doctor A had chilled syringes of saline solution in ice for intraoperative lavage-the only factor that differentiated the procedures of the 2 surgeons. Cultures of samples from the source ice machine's drain identified M. szulgai; the strain was identical to isolates recovered from all confirmed cases and differed from 4 standard M. szulgai strains, as determined by pulsed-field gel electrophoresis. Intraoperative contamination from ice water apparently led to M. szulgai keratitis in these patients.
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Affiliation(s)
- Gary P Holmes
- Division of Infectious Diseases, Department of Medicine, Scott & White Memorial Hospital and Clinic, Temple, TX, 76508, USA.
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34
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Chandra NS, Torres MF, Winthrop KL, Bruckner DA, Heidemann DG, Calvet HM, Yakrus M, Mondino BJ, Holland GN. Cluster of Mycobacterium chelonae keratitis cases following laser in-situ keratomileusis. Am J Ophthalmol 2001; 132:819-30. [PMID: 11730644 DOI: 10.1016/s0002-9394(01)01267-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To describe a cluster of Mycobacterium chelonae keratitis cases involving patients who underwent laser in-situ keratomileusis (LASIK) at a single refractive surgery center. DESIGN Descriptive case series of four patients and cohort study to identify disease associations. METHODS Examination schedules, diagnostic tests, and therapy were based on best medical judgment. Isolates from three patients were compared by pulsed-field gel electrophoresis. Epidemiologic studies were performed to identify the source of infection. RESULTS Seven of eight eyes developed M. chelonae keratitis following bilateral simultaneous LASIK. Each patient was thought to have diffuse lamellar keratitis initially, but all seven eyes were noted to have opacities suggestive of infectious keratitis by 13 to 21 days after surgery. All eyes had undergone hyperopic LASIK over four days in April 2001 by one surgeon in a community-based refractive surgery center. A cohort study of all patients undergoing LASIK at the same center in April 2001 revealed that M. chelonae keratitis occurred only in persons undergoing correction of hyperopia (seven of 14 eyes vs. none of 217 eyes undergoing myopic LASIK, P <.001). The only difference identified between procedures was use of masks created from a soft contact lens in hyperopic LASIK. Three isolates (three patients) were indistinguishable by pulsed-field gel electrophoresis. Eyes were treated with a combination of antimicrobial agents, including topical azithromycin in three patients, with resolution of infection in all eyes over 6 to 14 weeks. The source of infection was not identified on environmental cultures. CONCLUSION Postoperative nontuberculous mycobacterial keratitis can occur in an epidemic fashion following LASIK. Topical amikacin, azithromycin, clarithromycin, ciprofloxacin, or a combination of these agents, appears to be effective treatment for these infections.
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MESH Headings
- Anti-Bacterial Agents
- Bacterial Proteins/analysis
- California
- Cluster Analysis
- Cohort Studies
- Cornea/microbiology
- Cornea/surgery
- Drug Therapy, Combination/therapeutic use
- Electrophoresis, Gel, Pulsed-Field
- Eye Infections, Bacterial/drug therapy
- Eye Infections, Bacterial/epidemiology
- Eye Infections, Bacterial/etiology
- Eye Infections, Bacterial/microbiology
- Female
- Humans
- Hyperopia/surgery
- Keratitis/drug therapy
- Keratitis/epidemiology
- Keratitis/etiology
- Keratitis/microbiology
- Keratomileusis, Laser In Situ/adverse effects
- Middle Aged
- Mycobacterium Infections, Nontuberculous/drug therapy
- Mycobacterium Infections, Nontuberculous/epidemiology
- Mycobacterium Infections, Nontuberculous/etiology
- Mycobacterium Infections, Nontuberculous/microbiology
- Mycobacterium chelonae/isolation & purification
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Affiliation(s)
- N S Chandra
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, Department of Ophthalmology, UCLA School of Medicine, Los Angeles, CA, USA
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Abstract
Laser in situ keratomileusis (LASIK) is a rapidly evolving ophthalmic surgical procedure. Several anatomic and refractive complications have been identified. Anatomic complications include corneal flap abnormalities, epithelial ingrowth, and corneal ectasia. Refractive complications include unexpected refractive outcomes, irregular astigmatism, decentration, visual aberrations, and loss of vision. Infectious keratitis, dry eyes, and diffuse lamellar keratitis may also occur following LASIK. By examining the etiology, management, and prevention of these complications, the refractive surgeon may be able to improve visual outcomes and prevent vision-threatening problems. Reporting outcomes and mishaps of LASIK surgery will help refine our approach to the management of emerging complications.
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Affiliation(s)
- S A Melki
- Cornea and Refractive Surgery Service, Massachusetts Eye & Ear Infirmary, Boston, MA 02114, USA
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Ambrósio R, Wilson SE. Complications of Laser in situ Keratomileusis: Etiology, Prevention, and Treatment. J Refract Surg 2001; 17:350-79. [PMID: 11383767 DOI: 10.3928/1081-597x-20010501-09] [Citation(s) in RCA: 155] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To review the etiology, prevention, and management of laser in situ keratomileusis (LASIK) complications. METHODS Review of literature and the experience of the authors. RESULTS Careful preoperative screening is critical to prevention of many potential complications of LASIK. Flap complications that occur during surgery are typically managed by replacement of the flap and repeating the surgery or applying special methods such as transepithelial photorefractive keratectomy weeks to months following the initial procedure. A common source of serious complications is the use of a microkeratome that functions after improper assembly. Timely treatment of postoperative complications such as diffuse lamellar keratitis, flap striae, and infection is critical to an optimal outcome. CONCLUSION Most complications of LASIK can be treated effectively and have minimal effect on the final outcome after surgery, if appropriate methods are used for management.
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Affiliation(s)
- R Ambrósio
- Department of Ophthalmology, University of Sao Paulo, Brazil
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Abstract
PURPOSE To report a case of Aspergillus fumigatus keratitis after a laser in situ keratomileusis (LASIK) enhancement procedure. METHOD Case report. RESULTS A 56-year-old woman developed an ulcer in the flap 13 days after LASIK enhancement. A 4-week course of fortified antibiotics for a presumed bacterial infection followed. The ulcer progressed, causing 60% thinning of the corneal stroma. A biopsy was performed 5 weeks after onset of symptoms, and antifungal agents were initiated. Cultures showed A. fumigatus. Her cornea perforated after the biopsy, requiring cyanoacrylate and lamellar overlay sutures, but the infiltrate resolved on antifungal agents. CONCLUSION This report is the first description of Aspergillus keratitis after LASIK. We hypothesize that the infection became established on the stromal bed during surgery and led to melting, anteriorly through the flap and posteriorly through the stroma. Diagnosis was made by a corneal biopsy and inoculation of a wide array of media. This case demonstrates the need to consider atypical organisms, including fungi, in the differential diagnosis of post-LASIK infections when there is no response to therapy and highlights the role of corneal biopsy and flap lifting in the diagnosis of this condition.
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Affiliation(s)
- I C Kuo
- Cornea and Refractive Surgery Service of the Department of Ophthalmology, University of California, San Francisco 94143, USA
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