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Yuan M, Ji R, Zhang R. A case of severe diffuse lamellar keratitis after small-incision lenticule extraction operation. Indian J Ophthalmol 2024; 72:1219-1223. [PMID: 39078970 PMCID: PMC11451777 DOI: 10.4103/ijo.ijo_2974_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2024] Open
Affiliation(s)
- Mengxia Yuan
- Joint Shantou International Eye Center of Shantou University and the Chinese University of Hong Kong, Shantou, Guangdong Province, China
| | - Ruifeng Ji
- Joint Shantou International Eye Center of Shantou University and the Chinese University of Hong Kong, Shantou, Guangdong Province, China
| | - Riping Zhang
- Joint Shantou International Eye Center of Shantou University and the Chinese University of Hong Kong, Shantou, Guangdong Province, China
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Sukhanova EV, Pateyuk LS, Ivanova MA. [Pathogenetic aspects of diffuse lamellar keratitis after laser corneal refractive surgery]. Vestn Oftalmol 2024; 140:131-137. [PMID: 39731247 DOI: 10.17116/oftalma2024140061131] [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] [Indexed: 12/29/2024]
Abstract
This review analyzes the primary etiological factors of diffuse lamellar keratitis following various laser corneal refractive surgery techniques. The use of advanced diagnostic methods such as optical coherence tomography, confocal microscopy, and immunohistochemical methods has allowed for the identification of the main pathogenetic mechanisms underlying this condition, which will help improve the prevention, as well as assist with the development of optimal treatment strategies for this complication.
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Affiliation(s)
- E V Sukhanova
- Krasnov Research Institute of Eye Diseases, Moscow, Russia
- OOO Nauchno-prakticheskiy tsentr vosstanovleniya zreniya, Moscow, Russia
| | - L S Pateyuk
- Krasnov Research Institute of Eye Diseases, Moscow, Russia
| | - M A Ivanova
- Pirogov Russian National Research Medical University, Moscow, Russia
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Dan TT, Liu TX, Liao YL, Li ZZ. Delayed diffuse lamellar keratitis after small-incision lenticule extraction related to immunoglobulin A nephropathy: A case report. World J Clin Cases 2022; 10:4131-4136. [PMID: 35665110 PMCID: PMC9131215 DOI: 10.12998/wjcc.v10.i13.4131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 10/09/2021] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diffuse lamellar keratitis (DLK) is a complication of laser-assisted in situ keratomileusis (LASIK). This condition can also develop after small-incision lenticule extraction (SMILE) with a distinctive appearance. We report the case involving a female patient with delayed onset DLK accompanied by immunoglobulin A (IgA) nephropathy.
CASE SUMMARY A 22-year-old woman was referred to our department for DLK and a decline in vision 1 mo after undergoing SMILE. The initial examination showed grade 2 DLK in the flap involving the central visual axis of the right eye. She was immediately administered with a large dose of a topical steroid for 30 d. However, the treatment was ineffective. Her vision deteriorated from 10/20 to 6/20, and DLK gradually worsened from grade 2 to 4. Eventually, interface washout was performed, after which her vision improved. DLK completely disappeared 2 mo after washout. Six months after SMILE, the patient was diagnosed with IgA nephropathy due to a 4-year history of interstitial hematuria.
CONCLUSION DLK is a typical complication of LASIK but can also develop after SMILE. Topical steroid therapy was ineffective in our patient, and interface washout was required. IgA nephropathy could be one of the factors contributing to the development of delayed DLK after SMILE.
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Affiliation(s)
- Ting-Ting Dan
- Department of Ophthalmology, The Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Tai-Xiang Liu
- Department of Ophthalmology, The Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Yi-Lu Liao
- Department of Ophthalmology, The Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Zong-Ze Li
- Department of Ophthalmology, The Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
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Rippon MG, Westgate S, Rogers AA. Implications of endotoxins in wound healing: a narrative review. J Wound Care 2022; 31:380-392. [PMID: 35579309 DOI: 10.12968/jowc.2022.31.5.380] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bacterial toxins are thought to play a role in delayed wound healing in critically colonised and infected wounds. Endotoxins are released from Gram-negative bacteria when they are lysed by host phagocytic cells during an immune response, or by antimicrobial agents, potentially leading to a detrimental effect on the host tissues. Endotoxins can affect all aspects of the wound healing process, leading to delayed healing and contributing to wound chronicity. Release of endotoxins by bacteria can also have serious systemic effects (for example, septic shock) that can lead to high levels of patient mortality. This review summarises the role and implications on wound healing of bacterial endotoxins, describing the impact of endotoxins on the various phases of the wound healing response. There is a paucity of in vivo/clinical evidence linking endotoxins attributed to a wound (via antibiotic treatment) or their release from infecting bacteria with parameters of delayed wound healing. Future work should investigate if this link is apparent and determine the mechanism(s) by which such detrimental effects occur, offering an opportunity to identify possible treatment pathways. This paper describes the phenomenon of antimicrobial-induced endotoxin release and summarises the use of wound dressings to reduce wound bioburden without inducing microbial death and subsequent release of endotoxins, thus limiting their detrimental effects.
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Affiliation(s)
- Mark G Rippon
- University of Huddersfield, Queensgate, Huddersfield, UK
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Miura M, Toshida H. Burkholderia Cepacia-Induced Bilateral Microbial Keratitis in a Wearer of Colored Cosmetic Contact Lenses. Cureus 2022; 14:e22840. [PMID: 35382181 PMCID: PMC8977052 DOI: 10.7759/cureus.22840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 11/05/2022] Open
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Five-Year Incidence, Management, and Visual Outcomes of Diffuse Lamellar Keratitis after Femtosecond-Assisted LASIK. J Clin Med 2021; 10:jcm10143067. [PMID: 34300233 PMCID: PMC8304683 DOI: 10.3390/jcm10143067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/26/2021] [Accepted: 07/01/2021] [Indexed: 01/01/2023] Open
Abstract
Femtosecond (FS) lasers initially had a higher incidence of diffuse lamellar keratitis (DLK) compared with microkeratome flap creation. It has been theorized that higher-frequency lower-energy (HFLE) FS lasers would reduce the incidence of DLK. Our study sought to evaluate the incidence of newer HFLE FS lasers with pulse frequencies above 60 kHz. It was a retrospective case-control study evaluating the incidence of DLK following flap creation with one of three FS lasers (AMO iFs, WaveLight FS200, Zeiss VisuMax). Uncomplicated LASIK cases were included as the control group (14,348 eyes) and cases of DLK were recorded in the study group (637 eyes). Of the 637 cases of DLK, 76 developed stage II, 25 progressed to stage III, and only three developed stage IV DLK. The overall incidence rate of DLK was 4.3%; it has fallen with the invention of newer HFLE FS lasers and is approaching the DLK incidence rates of DLK with microkeratome.
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Das S, Garg P, Mullick R, Annavajjhala S. Keratitis following laser refractive surgery: Clinical spectrum, prevention and management. Indian J Ophthalmol 2021; 68:2813-2818. [PMID: 33229656 PMCID: PMC7856934 DOI: 10.4103/ijo.ijo_2479_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Laser refractive surgery (LRS) is one of the most demanding areas of ophthalmic surgery and high level of precision is required to meet outcome expectations of patients. Post-operative recovery is of vital importance. Keratitis occurring after LRS can delay visual recovery. Both surface ablations [Photorefractive keratectomy (PRK)] as well as flap procedures [Laser in-situ keratomileusis (LASIK)/Small incision lenticule extraction] are prone to this complication. Reported incidence of post-LRS infectious keratitis is between 0% and 1.5%. The rate of infections after PRK seems to be higher than that after LASIK. Staphylococci, streptococci, and mycobacteria are the common etiological organisms. About 50–60% of patients present within the first week of surgery. Of the non-infectious keratitis, diffuse lamellar keratitis (DLK) is the most common with reported rates between 0.4% and 4.38%. The incidence of DLK seems to be higher with femtosecond LASIK than with microkeratome LASIK. A lot of stress is laid on prevention of this complication through proper case selection, asepsis, and use of improved protocols. Once keratitis develops, the right approach can help resolve this condition quickly. In cases of suspected microbial keratitis, laboratory identification of the organism is important. Most lesions resolve with medical management alone. Interface irrigation, flap amputation, collagen cross-linking and therapeutic penetrating keratoplasty (TPK) are reserved for severe/non-resolving cases. About 50–75% of all infectious keratitis cases post LRS resolve with a final vision of 20/40 or greater. Improved awareness, early diagnosis, and appropriate intervention can help limit the damage to cornea and preserve vision.
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Affiliation(s)
- Shilpa Das
- Cornea and Refractive Services, Narayana Nethralaya Eye Hospital, Bengaluru, Karnataka, India
| | - Prashant Garg
- Paul Dubord Chair of Cornea, L.V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Ritika Mullick
- Cornea and Refractive Services, Narayana Nethralaya Eye Hospital, Bengaluru, Karnataka, India
| | - Sriram Annavajjhala
- Cornea and Refractive Services, Narayana Nethralaya Eye Hospital, Bengaluru, Karnataka, India
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Buxey K. Delayed onset diffuse lamellar keratitis following enhancement LASIK surgery. Clin Exp Optom 2021; 87:102-6. [PMID: 15040777 DOI: 10.1111/j.1444-0938.2004.tb03156.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2003] [Revised: 01/06/2004] [Accepted: 01/10/2004] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Diffuse lamellar keratitis (DLK) is a relatively uncommon complication of the refractive procedure, laser-assisted in situ keratomileusis (LASIK). If detected and diagnosed in a timely fashion, it can be treated and should resolve with minimal sequelae. If untreated, or misdiagnosed and treated incorrectly, there may be loss of visual acuity. Optometrists should be familiar with this condition, its signs, symptoms and correct treatment protocol. CASE HISTORY A 58-year-old male Caucasian developed delayed onset diffuse lamellar keratitis, seemingly in the absence of an epithelial defect, 25 days following an enhancement LASIK procedure to his right eye. The DLK in this patient is delayed longer than typically reported in the literature. Subsequent management with topical steroids was complicated as the patient was a steroid responder and developed a markedly raised intraocular pressure that was managed with a topical anti-glaucoma agent. The diagnosis, pathogenesis and issues relevant to the treatment of this condition are discussed. CONCLUSION Optometrists, particularly those actively participating in the shared care of refractive surgery patients, must be familiar with diffuse lamellar keratitis so that diagnosis is not delayed. As the number of cases of refractive surgery in Australia increases, optometrists will encounter this condition more frequently.
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André C, Durand ML, Buckley T, Cadorette J, Gilmore MS, Ciolino JB, Bispo PJM. A Cluster of Corneal Donor Rim Cultures Positive for Achromobacter Species Associated With Contaminated Eye Solution. Cornea 2021; 40:223-227. [PMID: 33395117 PMCID: PMC8551930 DOI: 10.1097/ico.0000000000002473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/16/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate a cluster of corneoscleral rim cultures positive for Achromobacter species over a 6-month period at Massachusetts Eye and Ear. METHODS An increased rate of positive corneal donor rim cultures was noted at Massachusetts Eye and Ear between July and December 2017. Positive cultures were subjected to identification and antimicrobial susceptibility testing by phenotypic (MicroScan WalkAway) and genotypic (16S rDNA sequencing) methods. Samples of the eye wash solution (GeriCare) used in the eye bank were also evaluated. Antimicrobial activity of Optical-GS against Achromobacter spp. at 4°C and 37°C was assessed by time-kill kinetics assay. RESULTS Of 99 donor rims cultured, 14 (14.1%) grew bacteria with 11 (78.6%) due to uncommon nonfermenting Gram-negative bacilli. These had been identified by standard automated methods as Achromobacter (n = 3), Alcaligenes (n = 3), Ralstonia (n = 2), Pseudomonas (n = 2), and Stenotrophomonas (n = 1). Eight of these 11 isolates were subsequently available for molecular identification, and all were identified as Achromobacter spp. Six bottles of eyewash solution were evaluated and were positive for abundant Achromobacter spp. (3.4 × 105 ± 1.1 CFU/mL). Optisol-GS had no bactericidal activity against Achromobacter spp. at 4°C after 24-hour incubation but was bactericidal at 37°C. None of the patients who had received the contaminated corneas developed postoperative infection. CONCLUSIONS An eyewash solution arising from a single lot was implicated in the contamination of donor rims by Achromobacter spp. The isolates were able to survive in the Optisol-GS medium at the recommended storage temperature. This highlights the need to continue improving protocols for tissue preparation and storage.
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Affiliation(s)
- Camille André
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA. Dr. André is now with Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, Ecole Normale Supérieure de Lyon, Lyon, France
| | - Marlene L. Durand
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA. Dr. André is now with Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, Ecole Normale Supérieure de Lyon, Lyon, France
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | - James Cadorette
- Henry Whittier Porter Bacteriology Laboratory, Massachusetts Eye and Ear, Boston, MA
| | - Michael S. Gilmore
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA. Dr. André is now with Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, Ecole Normale Supérieure de Lyon, Lyon, France
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA
| | - Joseph B. Ciolino
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA. Dr. André is now with Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, Ecole Normale Supérieure de Lyon, Lyon, France
| | - Paulo J. M. Bispo
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA. Dr. André is now with Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, Ecole Normale Supérieure de Lyon, Lyon, France
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10
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Wilson SE, de Oliveira RC. Pathophysiology and Treatment of Diffuse Lamellar Keratitis. J Refract Surg 2020; 36:124-130. [PMID: 32032434 DOI: 10.3928/1081597x-20200114-01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 01/14/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE To review cytokine- and chemokine-mediated mechanisms of diffuse lamellar keratitis (DLK) after lamellar corneal surgical procedures. METHODS Review of the basic science and clinical literature. RESULTS DLK can occur early or late (months to decades) after all lamellar corneal surgeries, including laser in situ keratomileusis, small incision lenticule extraction, anterior lamellar keratoplasty, and Descemet's stripping automated endothelial keratoplasty. It is most commonly triggered by epithelial injury during or after lamellar surgery, which leads to the release of interleukin (IL)-1α, IL-1β, and tumor necrosis factor (TNF)-α from the epithelium and into the stroma. These chemokines directly attract inflammatory cells into the cornea from the limbal blood vessels and also bind to receptors on keratocytes and corneal fibroblasts where myriad chemokines are upregulated that also chemotactically attract monocytes, macrophages, granulocytes, lymphocytes, and other bone marrow-derived cells into the corneal stroma. Other factors that can trigger DLK include retained blood in the interface, endotoxins and other toxins, and excessive keratocyte necrosis caused by femtosecond lasers. Infiltrating cells show a preference to enter any lamellar interface in the cornea, regardless of the time since surgery, because of the ease of movement toward the chemotactic attractants relative to the surrounding stroma with intact collagen lamellae and stromal cells that serve as relative barriers impeding motility. The mainstay of treatment is topical corticosteroids, but severe cases may also be treated with flap lift irrigation and systemic corticosteroids. CONCLUSIONS DLK can occur early or late after any lamellar corneal surgical procedure and is most commonly triggered by epithelial-stromal-bone marrow-derived cellular interactions mediated by corneal cytokines and chemokines. [J Refract Surg. 2020;36(2):124-130.].
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Kanduri V, Madduri B, Mohan N, Fernandes M. Multi-drug resistant Burkholderia cepacia keratitis following laser in situ keratomileusis complicated by interface fluid syndrome. Indian J Ophthalmol 2020; 68:1443-1444. [PMID: 32587186 PMCID: PMC7574062 DOI: 10.4103/ijo.ijo_1633_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Vaibhav Kanduri
- Cornea and Anterior Segment, LV Prasad Eye Institute, GMR Varalakshmi Campus, Visakhapatnam, Andhra Pradesh, India
| | - Bhagyashree Madduri
- Ocular Microbiology Service, LV Prasad Eye Institute, GMR Varalakshmi Campus, Visakhapatnam, Andhra Pradesh, India
| | - Nitin Mohan
- Ocular Microbiology Service, LV Prasad Eye Institute, GMR Varalakshmi Campus, Visakhapatnam, Andhra Pradesh, India
| | - Merle Fernandes
- Cornea and Anterior Segment, LV Prasad Eye Institute, GMR Varalakshmi Campus, Visakhapatnam, Andhra Pradesh, India
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Abstract
PURPOSE OF REVIEW Autoimmune and immune-mediated diseases are considered contraindications for laser refractive surgeries according to the US Food and Drug Administration's guideline. This guideline, however, is based on limited case reports or complications reported during other intraocular procedures. There have been only a handful of new clinical studies that evaluate the efficacy and safety of refractive surgery in this specific patient population. The aim of this article is to review currently available research and offer updated recommendations for the evaluation and management of laser refractive surgery (LRS) in patients with autoimmune diseases. RECENT FINDINGS More recent retrospective studies have reported good refractive outcomes in patients with well controlled autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, seronegative spondyloarthropathy, among others. No severe sight-threatening complications have been reported in these reports. Although postoperative complications occur, the risk of refractive surgery is comparable with those without autoimmune diseases. SUMMARY With the exception of primary Sjogren's syndrome, patients with autoimmune diseases may be good candidates for LRS if diseases are well controlled and have minimal ophthalmic manifestation. Patients should be made aware of the potential surgical complications and be informed of the currently available data. More multicenter and larger prospective studies are needed to compare the refractive outcomes and surgical complications in patients with and without autoimmune diseases. This will help patients make better informed medical decisions.
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Srinivasan S. Biofilms and post-surgical ocular inflammation. J Cataract Refract Surg 2020; 46:331-332. [DOI: 10.1097/j.jcrs.0000000000000147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Diffuse lamellar keratitis associated with tabletop autoclave biofilms: case series and review. J Cataract Refract Surg 2020; 46:340-349. [DOI: 10.1097/j.jcrs.0000000000000070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Lorenzo D. Chloramphenicol Resurrected: A Journey from Antibiotic Resistance in Eye Infections to Biofilm and Ocular Microbiota. Microorganisms 2019; 7:microorganisms7090278. [PMID: 31438629 PMCID: PMC6780676 DOI: 10.3390/microorganisms7090278] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/18/2019] [Accepted: 08/20/2019] [Indexed: 01/13/2023] Open
Abstract
The advent of multidrug resistance among pathogenic bacteria is devastating the worth of antibiotics and changing the way of their administration, as well as the approach to use new or old drugs. The crisis of antimicrobial resistance is also due to the unavailability of newer drugs, attributable to exigent regulatory requirements and reduced financial inducements. The emerging resistance to antibiotics worldwide has led to renewed interest in old drugs that have fallen into disuse because of toxic side effects. Thus, comprehensive efforts are needed to minimize the pace of resistance by studying emergent microorganisms and optimize the use of old antimicrobial agents able to maintain their profile of susceptibility. Chloramphenicol is experiencing its renaissance because it is widely used in the treatment and prevention of superficial eye infections due to its broad spectrum of activity and other useful antimicrobial peculiarities, such as the antibiofilm properties. Concerns have been raised in the past for the risk of aplastic anemia when chloramphenicol is given intravenously. Chloramphenicol seems suitable to be used as topical eye formulation for the limited rate of resistance compared to fluoroquinolones, for its scarce induction of bacterial resistance and antibiofilm activity, and for the hypothetical low impact on ocular microbiota disturbance. Further in-vitro and in vivo studies on pharmacodynamics properties of ocular formulation of chloramphenicol, as well as its real impact against biofilm and the ocular microbiota, need to be better addressed in the near future.
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Affiliation(s)
- Drago Lorenzo
- Clinical Microbiology, Department of Biomedical Science for Health, University of Milan, 20133 Milan, Italy.
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16
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Reinstein DZ, Stuart AJ, Vida RS, Archer TJ, Carp GI. Incidence and Outcomes of Sterile Multifocal Inflammatory Keratitis and Diffuse Lamellar Keratitis After SMILE. J Refract Surg 2019; 34:751-759. [PMID: 30428095 DOI: 10.3928/1081597x-20181001-02] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/01/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To report the incidence outcomes of sterile multifocal inflammatory keratitis and diffuse lamellar keratitis (DLK) after small incision lenticule extraction (SMILE) in a large population. METHODS This was a retrospective review of a population of 4,000 consecutive eyes treated by SMILE at the London Vision Clinic using the VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany). The inclusion criterion was to have presented with inflammatory keratitis after SMILE. In some cases after SMILE, the inflammatory keratitis presented as sterile multifocal interface keratitis uncharacteristic of classic DLK. The incidence was measured and categorized as primary or secondary by presenting appearance, grade, and time to presentation. Patients were observed for 1 year after surgery and standard outcomes analysis was performed. RESULTS Of the 4,000 eye population, there were 18 cases (0.45%) of DLK grade 1 or 2. All cases were managed and resolved with topical steroid therapy. Of these, 12 cases (67%) were of classic appearance and 6 cases (33%) presented as sterile multifocal inflammatory keratitis. DLK was primary in nature in 11 cases (61%) and secondary in 7 cases (39%). Postoperative uncorrected distance visual acuity was 20/20 or better in 93% of eyes. No patients lost any lines of corrected distance visual acuity and there was no change in contrast sensitivity. CONCLUSIONS DLK occurred after SMILE with an incidence of 0.45% in this population. Topical steroid therapy resolved the DLK in all cases with no sequelae and no adverse effect on refractive or visual outcome at 1 year postoperatively. A unique type of DLK presentation can occur after SMILE, characterized by multiple focal sterile inflammatory spots. Management is the same as for classic DLK, but with a lower threshold for performing an interface washout. [J Refract Surg. 2018;34(11):751-759.].
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Farooqui JH, Gandhi A, Mathur U, Bharti G, Dubey S. Increased postoperative anterior chamber inflammation secondary to heat-resistant endotoxins. J Cataract Refract Surg 2018; 45:188-195. [PMID: 30471849 DOI: 10.1016/j.jcrs.2018.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/24/2018] [Accepted: 09/04/2018] [Indexed: 01/18/2023]
Abstract
PURPOSE To evaluate the cause of clusters of increased postoperative anterior chamber inflammation after uneventful cataract surgery, and to examine its relation to the presence of endotoxins in sterile consumables. SETTING Tertiary eye center in north India. DESIGN Single-center retrospective case series. METHODS All cataract surgeries performed at the tertiary eye center over 12 weeks (October 1, 2017 to December 31, 2017) were noted. Any patient with a "severe reaction" postoperatively was monitored closely and the postoperative drug regimen was altered accordingly. "Severe reaction" was defined as any patient with more than 4+ cells and/or fibrin with or without hypopyon. The Hospital Infection Control committee was informed, and a root cause analysis was performed to determine the cause. All the consumables were recalled and replaced. The samples were sent for microbiological evaluations. RESULTS Of the 781 cataract surgeries performed, 81 patients had a severe reaction. Most patients were men (71%) and the mean age of the patients was 63 years. Twelve patients had fibrin, 3 of whom presented with hypopyon. Because all samples were negative of any growth, endotoxin tests were performed. All the samples were found to be negative, except for the ophthalmic viscosurgical device (OVD), which showed positive endotoxin levels. The OVD was changed and the anterior chamber reactions ceased to occur. CONCLUSION A careful, stepwise approach is necessary when investigating clusters of increased postoperative anterior chamber reactions after uneventful surgery. A high degree of suspicion is important to rule out all possible reasons and in the absence of any identifiable cause, sterile consumables should be checked for endotoxins.
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Affiliation(s)
| | - Arpan Gandhi
- Dr. Shroff's Charity Eye Hospital, Kedarnath Marg, Daryaganj, New Delhi, India
| | - Umang Mathur
- Dr. Shroff's Charity Eye Hospital, Kedarnath Marg, Daryaganj, New Delhi, India
| | - Gaurav Bharti
- Dr. Shroff's Charity Eye Hospital, Kedarnath Marg, Daryaganj, New Delhi, India
| | - Suneeta Dubey
- Dr. Shroff's Charity Eye Hospital, Kedarnath Marg, Daryaganj, New Delhi, India
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Risk Factors for Sporadic Diffuse Lamellar Keratitis After Microkeratome Laser-Assisted In Situ Keratomileusis: A Retrospective Large Database Analysis. Cornea 2018; 37:1124-1129. [PMID: 29923860 DOI: 10.1097/ico.0000000000001674] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the factors associated with sporadic diffuse lamellar keratitis (DLK) after microkeratome laser-assisted in situ keratomileusis (LASIK). METHODS This large database retrospective study included consecutive cases of LASIK performed between 2007 and 2016 at Care-Vision Laser Centers, Tel-Aviv, Israel. Patients were divided into 2 groups according to whether or not they subsequently developed DLK. RESULTS A total of 24,026 eyes of 12,013 patients with a mean age of 32.9 ± 10.3 years were included. Post-LASIK DLK developed in 464 eyes (1.9%), and the annual rate decreased from 7.1% (2007) to 1.7% (2016) (P < 0.001). The DLK group had a higher proportion of males (58.5% vs. 52.1%, P = 0.006), greater preoperative central corneal thickness (549.5 ± 32.6 vs. 545.3 ± 30.5 μm, P = 0.005), and a lower proportion of high astigmatism (>3 D) (0.4% vs. 1.6%, P = 0.05). The DLK group had a higher proportion of previous LASIK treatment (2.8% vs. 1.3%, P = 0.006), Moria M2 (rather than the SBK) microkeratome (71.1% vs. 34.0%, P < 0.001), smaller suction ring number (P < 0.001), greater stop size (P < 0.001), and greater flap thickness (119.2 ± 50.4 vs. 110.8 ± 22.2, P = 0.007). In multivariable analysis, a smaller suction ring number [odds ratio (OR) 0.89, P = 0.04], Moria M2 microkeratome (OR 5.26, P < 0.001), larger optical zone (OR = 2.04, P = 0.01), and higher spherical equivalent (OR = 1.08, P = 0.02) were associated with DLK. CONCLUSIONS In the modern LASIK era, the incidence of DLK continues to decrease. Higher preoperative ametropia, smaller suction ring number, an older type of microkeratome, and larger optical zones are associated with higher DLK rates after LASIK.
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Ghanwate NA, Tiwari AA, Thakare PV. Importance of biofilm in medical sciences: With special reference to uropathogens. ACTA ACUST UNITED AC 2016. [DOI: 10.5897/ajmr2016.8178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Jarade E, Slim E, Antoun J, Khzam RA. Treatment of grade IV diffuse lamellar keratitis with oral doxycycline and topical 10% sodium citrate. Can J Ophthalmol 2016; 51:e178-e184. [PMID: 27938979 DOI: 10.1016/j.jcjo.2016.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 07/06/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Elias Jarade
- Beirut Eye Specialist Hospital, Beirut, Lebanon; Mediclinic, Dubai Mall, Dubai, United Arab Emirates.
| | - E Slim
- Beirut Eye Specialist Hospital, Beirut, Lebanon; Saint-Joseph University, Faculty of Medicine, Beirut, Lebanon
| | - J Antoun
- Beirut Eye Specialist Hospital, Beirut, Lebanon; Saint-Joseph University, Faculty of Medicine, Beirut, Lebanon
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Kymionis GD, Tsoulnaras KI, Tsakalis NG, Grentzelos MA. Diffuse lamellar keratitis in the femtosecond-assisted LASIK flap tunnel. Clin Ophthalmol 2014; 8:1065-7. [PMID: 24940043 PMCID: PMC4051804 DOI: 10.2147/opth.s64253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Here we report a case of a 29-year-old myopic female who underwent femtosecond laser-assisted in situ keratomileusis (LASIK) and, on the first postoperative day slit-lamp examination revealed a dense, white, granular reaction with the presence of some blood droplets (stage I diffuse lamellar keratitis [DLK]) in her left eye, specifically localized into the femtosecond LASIK flap tunnel (not extended to the flap interface). The patient received intensive treatment with topical corticosteroids and 5 days later the granular reaction had completely resolved. A new site of DLK, ie, the flap tunnel, in femtosecond-assisted LASIK is presented. DLK into the flap tunnel could be managed with corticosteroids if detected early, without affecting the flap interface.
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Affiliation(s)
- George D Kymionis
- Vardinoyiannion Eye Institute of Crete, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece ; Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Konstantinos I Tsoulnaras
- Vardinoyiannion Eye Institute of Crete, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Nikolaos G Tsakalis
- Vardinoyiannion Eye Institute of Crete, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Michael A Grentzelos
- Vardinoyiannion Eye Institute of Crete, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece
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Mazhar K, Gunawardana M, Webster P, Hochstim C, Koempel J, Kokot N, Sinha U, Rice D, Baum M. Bacterial biofilms and increased bacterial counts are associated with airway stenosis. Otolaryngol Head Neck Surg 2014; 150:834-40. [PMID: 24515969 DOI: 10.1177/0194599814522765] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Most airway stenoses are acquired secondary to the use of prolonged endotracheal intubation. Antibiotics have been shown to decrease local inflammation and granulation tissue formation in the trachea. However, antibiotic therapy is not 100% effective in preventing or treating granulation tissue formation. Development of bacterial biofilms may explain this finding. This study evaluates the difference between tracheal stenotic segments and normal trachea in terms of (1) presence of bacterial biofilms, (2) quantitative bacterial counts, and (3) inflammatory markers. STUDY DESIGN Cross-sectional study. SETTING Tertiary care academic medical center. SUBJECTS A total of 12 patients were included in the study. Tissue from stenotic segments from 6 patients with airway stenosis undergoing open airway procedures were compared with tracheal tissue from 6 patients without airway stenosis undergoing tracheostomy. METHODS Scanning electron microscopy for biofilm detection, quantitative polymerase chain reaction for quantitative analysis of bacterial count, and immunohistochemistry were performed for inflammatory markers transforming growth factor β1 (TGF-β1) and SMAD3. RESULTS Compared with the patients without airway stenosis, patients in the airway stenosis group showed presence of bacterial biofilms, a significantly higher expression of 16S rRNA gene copies per microgram of tissue (187.5 vs 7.33, P = .01), and higher expression of TGF-β1 (91% vs 8%, P < .001) and SMAD3 (83.5% vs 17.8%, P < .001). CONCLUSION Bacterial biofilms, increased bacterial counts, and higher expression of TGF-β1 and SMAD3 are associated with airway stenosis.
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Affiliation(s)
- Kashif Mazhar
- Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Tomita M, Sotoyama Y, Yukawa S, Nakamura T. Comparison of DLK incidence after laser in situ keratomileusis associated with two femtosecond lasers: Femto LDV and IntraLase FS60. Clin Ophthalmol 2013; 7:1365-71. [PMID: 23874077 PMCID: PMC3711877 DOI: 10.2147/opth.s47341] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Purpose To compare the incidence of diffuse lamellar keratitis (DLK) after laser in situ keratomileusis (LASIK) with flap creation using the Femto LDV and IntraLase™ FS60 femtosecond lasers.0 Methods A total of 818 consecutive myopic eyes had LASIK performed using either Femto LDV or IntraLase FS60 for flap creation. The same excimer laser, the Allegretto Wave® Eye-Q Laser, was used for correcting refractive errors for all patients. In the preoperative examination, uncorrected distance visual acuity, corrected distance visual acuity, and manifest refraction spherical equivalent were measured. At the postop examination, the same examinations were performed along with a slit-lamp biomicroscopic examination, and patients with DLK were classified into stages. For the statistical analysis of the DLK occurrence rate and the visual and refractive outcomes, the Mann-Whitney’s U-test was used. Results In the Femto LDV group with 514 eyes, 42 (8.17%) had DLK. In the IntraLase FS60 group with 304 eyes, 114 (37.5%) had DLK. There was a statistically significant difference in the DLK incidence rate between these groups (P < 0.0001). Both groups had excellent visual and refractive outcomes. Although low levels of DLK were observed for both groups, they did not affect visual acuity. Conclusion While there were significantly fewer incidences of low level DLK when using Femto LDV, neither femtosecond laser induced high levels of DLK, and any postoperative DLK cleared up within 1 week. Therefore, both lasers provide excellent results, with no clinical differences, and both excel at flap creation for LASIK.
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Affiliation(s)
- Minoru Tomita
- Shinagawa LASIK Center, Chiyoda-ku, Tokyo, Japan ; Department of Ophthalmology, Wenzhou Medical College, Wenzhou, People's Republic of China ; Eye Can Cataract Surgery Center, Manila, Philippines
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Reddy JC, Tibbetts MD, Hammersmith KM, Nagra PK, Rapuano CJ. Successful management of Burkholderia cepacia keratitis after LASIK. J Refract Surg 2013; 29:8-9. [PMID: 23311735 DOI: 10.3928/1081597x-20121228-02] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Corneal Inflammation Following Corneal Photoablative Refractive Surgery With Excimer Laser. Surv Ophthalmol 2013; 58:11-25. [DOI: 10.1016/j.survophthal.2012.04.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 04/16/2012] [Accepted: 04/24/2012] [Indexed: 11/24/2022]
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Acute intraocular inflammation caused by endotoxin after intravitreal injection of counterfeit bevacizumab in Shanghai, China. Ophthalmology 2012; 120:355-61. [PMID: 23084126 DOI: 10.1016/j.ophtha.2012.07.083] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 07/11/2012] [Accepted: 07/27/2012] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To describe an outbreak of intraocular inflammation caused by endotoxin-contaminated counterfeit bevacizumab in China. DESIGN Retrospective, observational case series. PARTICIPANTS Patients undergoing intravitreal injection at a public hospital in September 2010. METHODS The medical records and microbiology results of patients who presented with intraocular inflammation after injection with intravitreal counterfeit bevacizumab were reviewed. MAIN OUTCOME MEASURES The incidence of intraocular inflammation, results of pathogen cultures, and clinical features of inflammation. RESULTS A total of 116 patients (70 men and 46 women) were injected from 3 vials of counterfeit bevacizumab. Intraocular inflammation developed in 80 patients. The estimated median incubation period was 12 hours (range, 2-24 hours), and the median duration of symptoms was 6 days (range, 3-22 days). All patients were treated initially with topical corticosteroid and antibiotics. Vitreous tap and intravitreal injection were performed on 43 patients. Twenty-one patients with hypopyon and significant vitreous inflammation underwent vitrectomy. Microscopic evaluations and microbiologic cultures of all ocular specimens were negative for bacterial and fungal contamination. The presence of endotoxin in specimens was confirmed by laboratory testing. We refer to this new clinical syndrome as "endotoxin-induced ocular toxic syndrome" (EOTS). The inflammation regressed rapidly after treatment, and 63 patients (78.8%) recovered their pre-injection vision. CONCLUSIONS This study implicates endotoxin as the cause of intraocular inflammation after the intravitreal injection of counterfeit bevacizumab. The EOTS appeared clinically distinct from typical infectious endophthalmitis.
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Randleman JB, Shah RD. LASIK interface complications: etiology, management, and outcomes. J Refract Surg 2012; 28:575-86. [PMID: 22869235 DOI: 10.3928/1081597x-20120722-01] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 07/16/2012] [Indexed: 01/31/2023]
Abstract
PURPOSE To describe the etiology, diagnosis, clinical course, and management of LASIK interface complications. METHODS Literature review. RESULTS Primary interface complications include infectious keratitis, diffuse lamellar keratitis, central toxic keratopathy, pressure-induced stromal keratopathy (PISK), and epithelial ingrowth. Infectious keratitis is most commonly caused by Methicillin-resistant Staphylococcus aureus (early onset) or atypical Mycobacterium (late onset) postoperatively, and immediate treatment includes flap lift and irrigation, cultures, and initiation of broad-spectrum topical antibiotics, with possible flap amputation for recalcitrant cases. Diffuse lamellar keratitis is a white blood cell infiltrate that appears within the first 5 days postoperatively and is acutely responsive to aggressive topical and oral steroid use in the early stages, but may require flap lift and irrigation to prevent flap necrosis if inflammation worsens. In contrast, PISK is caused by acute steroid response and resolves only with cessation of steroid use and intraocular pressure lowering. Without appropriate therapy PISK can result in severe optic nerve damage. Central toxic keratopathy mimics stage 4 diffuse lamellar keratitis, but occurs early in the postoperative period and is noninflammatory. Observation is the only effective treatment, and flap lift is usually not warranted. Epithelial ingrowth is easily distinguishable from other interface complications and may be self-limited or require flap lift to treat irregular astigmatism and prevent flap melt. CONCLUSIONS Differentiating between interface entities is critical to rapid appropriate diagnosis, treatment, and ultimate visual outcome. Although initial presentations may overlap significantly, the conditions can be readily distinguished with close follow-up, and most complications can resolve without significant visual sequelae when treated appropriately.
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Affiliation(s)
- J Bradley Randleman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA.
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Associated factors and treatment outcome of presumed noninfectious endophthalmitis occurring after intravitreal triamcinolone acetonide injection. Graefes Arch Clin Exp Ophthalmol 2012; 251:715-23. [PMID: 22820815 DOI: 10.1007/s00417-012-2111-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 06/07/2012] [Accepted: 07/01/2012] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND To investigate the associated factors and treatment outcomes in patients with presumed noninfectious endophthalmitis after intravitreal triamcinolone acetonide (IVTA) injection. METHODS Among 219 consecutive cases of 186 patients who had undergone IVTA injection for macular diseases, presumed noninfectious endophthalmitis was diagnosed if the patient showed severe inflammation in the anterior chamber and vitreous cavity within 7 days after injection but no organism was isolated on microbiological examination. Clinical features and previously performed surgical procedures were evaluated to assess their association with presumed noninfectious endophthalmitis using logistic regression. After surgical or medical treatment for endophthalmitis, the visual outcome was evaluated in all patients. RESULTS Noninfectious endophthalmitis developed in six of 219 eyes (2.7 %). Previous vitrectomy, history of IVTA injection, and pseudophakia were significantly associated with the occurrence of presumed noninfectious endophthalmitis after IVTA injection (p = 0.049, 0.034, and 0.009, respectively). Internal limiting membrane (ILM) peeling during vitrectomy also showed statistically significant association (odds ratio = 13.6, p = 0.017). Five of six patients (83.3 %) regained pre-injection vision. CONCLUSION In addition to previous vitrectomy, history of IVTA injection, internal limiting membrane (ILM) peeling, and pseudophakia may render the eye vulnerable to presumed noninfectious endophthalmitis following IVTA injection. Visual outcome shows generally good prognosis after treatment.
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Tu KL, Aslanides IM. Surgical intervention in central toxic keratopathy. Eur J Ophthalmol 2012; 23:0. [PMID: 22562297 DOI: 10.5301/ejo.5000155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2012] [Indexed: 11/20/2022]
Abstract
Purpose. To report management and outcome of 3 cases of bilateral central toxic keratopathy (CTK). Methods. A retrospective chart review on 3 laser-assisted in situ keratomileusis patients who developed CTK within a short time of one another. Results. Patient A had flap lifts and irrigation (FL+I) twice in the right eye (OD) on postoperative day 1 at diffuse lamellar keratitis (DLK) stage 3 and once each on days 1 (at DLK stage 3) and 5 (at CTK) for the left eye (OS). She attained 20/20 unaided visual acuity (UVA) OD at 1 month. Her UVA OS remained at 20/32 but best-corrected visual acuity (BCVA) gradually improved to 20/25 at 8 months. Patient B had right FL+I on day 3 and left FL+I on day 5 (both for CTK). His OS achieved full visual potential (20/25 UVA) by 1 month but UVA OD was reduced to 20/25 (preoperative BCVA 20/20) at 8 months. Patient C had medical management only. Her preoperative BCVA OD of 20/33 fell to 20/50 postoperative UCVA/BCVA; OS regained full visual potential of 20/40 between 2 and 8 months. Patient A's OD did not develop a full-blown CTK; instead an arrested CTK resulted. All except that one eye had initial hyperopic/astigmatic errors that gradually lessened. Artemis II imaging confirmed early stromal loss posterior to the flap with stroma regaining some thickness over the following months. Conclusions. Surgical intervention in cases of CTK may improve clinical outcomes.
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Affiliation(s)
- Kyaw L Tu
- Emmetropia Mediterranean Eye Institute, Heraklion, Crete - Greece; and HM Stanley Hospital, St Asaph - UK
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Diffuse lamellar keratitis after laser in situ keratomileusis with femtosecond laser flap creation. J Cataract Refract Surg 2012; 38:1014-9. [PMID: 22487775 DOI: 10.1016/j.jcrs.2011.12.030] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 12/12/2011] [Accepted: 12/14/2011] [Indexed: 12/30/2022]
Abstract
PURPOSE To identify possible associations with the development of diffuse lamellar keratitis (DLK) after laser in situ keratomileusis (LASIK) with femtosecond laser flap creation. SETTING University-based academic practice, Ann Arbor, Michigan, USA. DESIGN Case-control study. METHODS Myopic LASIK was performed between October 2006 and December 2010 using an Intralase 60 kHz femtosecond laser for flap creation. Preoperative clinical characteristics, treatment parameters, and intraoperative and postoperative complications were recorded. Statistical comparisons were made using t, chi-square, and Fisher exact tests and repeated-measures logistic regression to adjust for inter-eye dependency. RESULTS The study enrolled 801 eyes (419 patients). Ninety-nine eyes (12.4%) of 70 patients developed DLK; most cases comprised mild flap interface inflammation and were treated with a routine postoperative antiinflammatory regimen. Twenty-two eyes (2.7%) required more than 1 week of antiinflammatory treatment. There was a statistically significant increase in the incidence of DLK with larger flap diameter (P=.0171), higher side-cut energy (P=.0037), and higher raster energy (P=.0033). Patients with DLK were less likely to achieve corrected distance visual acuity of 20/20 or better 1 day postoperatively (P=.0453). The difference in acuity was no longer present at 1 week. There were no significant associations between the incidence of DLK and preoperative refractive error, flap thickness, ablation depth, or other treatment parameters. CONCLUSIONS Diffuse lamellar keratitis after LASIK with femtosecond laser flap creation tended to be mild with little effect on visual acuity. Higher energy level for flap creation and larger flap diameter were associated with an increased risk for DLK.
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Javaloy J, Alió JL, Rodríguez A, González A, Pérez-Santonja JJ. Epidemiological Analysis of an Outbreak of Diffuse Lamellar Keratitis. J Refract Surg 2011; 27:796-803. [DOI: 10.3928/1081597x-20110411-01] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Accepted: 03/25/2011] [Indexed: 11/20/2022]
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Choe CH, Guss C, Musch DC, Niziol LM, Shtein RM. Incidence of diffuse lamellar keratitis after LASIK with 15 KHz, 30 KHz, and 60 KHz femtosecond laser flap creation. J Cataract Refract Surg 2010; 36:1912-8. [PMID: 21029900 DOI: 10.1016/j.jcrs.2010.09.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 06/01/2010] [Accepted: 06/15/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE To compare the incidence of diffuse lamellar keratitis (DLK) after laser in situ keratomileusis (LASIK) with flap creation using the 15 kHz (FS15), 30 kHz (FS30), or 60 kHz (FS60) femtosecond laser. SETTING University-based academic practice, Ann Arbor, Michigan, USA. DESIGN Retrospective comparative case series. METHODS Consecutive myopic LASIK cases performed between January 1, 2005, and June 1, 2007, using the IntraLase FS15, FS30, or FS60 femtosecond laser for flap creation were reviewed. Preoperative clinical characteristics, treatment parameters, and intraoperative and postoperative complications were recorded. Statistical comparisons were made using repeated measures analysis, analysis of variance, chi-square, and Fisher exact tests. RESULTS Five hundred twenty eyes of 274 patients were included in the study. One hundred seventy-six eyes (93 patients) were treated with the FS15 laser, 180 eyes (93 patients) with the FS30 laser, and 164 eyes (89 patients) with the FS60 laser. Seventeen eyes (10%) in the FS15 laser group, 24 eyes (13%) in the FS30 laser group, and 23 eyes (14%) in the FS60 laser group developed DLK. There was no statistically significant difference in the incidence of DLK between the 3 groups (P = .68). CONCLUSION There was no significant difference in the incidence of DLK between the FS15, FS30, and FS60 groups.
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Affiliation(s)
- Christina H Choe
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, USA
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Spontaneous Bilateral, Recurrent, Late-onset Diffuse Lamellar Keratitis After LASIK in a Patient With Cogan’s Syndrome. J Refract Surg 2008; 24:548-50. [DOI: 10.3928/1081597x-20080501-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sanders DR. Matched Population Comparison of the Visian Implantable Collamer Lens and Standard LASIK for Myopia of -3.00 to -7.88 Diopters. J Refract Surg 2007; 23:537-53. [PMID: 17598571 DOI: 10.3928/1081-597x-20070601-02] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare matched populations of LASIK and Visian Implantable Collamer Lens (ICL) cases in the correction of myopia between -3.00 and -7.88 diopters (D). METHODS One hundred sixty-four LASIK eyes with prospective data collected from a single center and 164 ICL eyes from the multicenter US ICL Clinical Trial were compared in this observational non-randomized study. The LASIK and ICL groups were well matched for age, gender, and mean level of preoperative spherical equivalent refraction. RESULTS At 6 months, best spectacle-corrected visual acuity (BSCVA) > or = 20/20 was 85% with LASIK and 95% with ICL (P = .003) compared to preoperative values of 93% and 88%, respectively (P = .292). Loss of > or = 2 lines of BSCVA was significantly lower with the ICL at 1 week (0.6% vs 10%, P < .001) and 1 month (7% vs 0%, P = .001) with comparable outcomes at 6 months (0% vs 1%). At 6 months postoperatively, uncorrected visual acuity (UCVA) > or = 20/15 (11% vs 25%, P = .001) and > or = 20/20 (49% vs 63%, P = .001) was better in the ICL cases. Predictability within 0.50 D at 6 months for ICL cases was 85% (67% LASIK, P < .001); 97% of ICL cases were within 1.00 D (88% LASIK, P = .002). Refractive stability (+/- 0.50 D) between 1 and 6 months was 93% with ICL compared to only 82% with LASIK (P = .006). CONCLUSIONS The ICL performed better than LASIK in almost all measures of safety, efficacy, predictability, and stability in this matched population comparison, supporting the ICL as an effective alternative to existing refractive laser surgical treatments for the range of myopia studied.
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Affiliation(s)
- Donald R Sanders
- Center For Clinical Research, 242 N York Rd, Ste 102, Elmhurst, IL 60126, USA.
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Javaloy J, Artola A, Vidal MT, Muñoz G, de Rojas V, Alió JL. Severe diffuse lamellar keratitis after femtosecond lamellar keratectomy. Br J Ophthalmol 2007; 91:699. [PMID: 17446518 PMCID: PMC1954784 DOI: 10.1136/bjo.2006.104075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Villarrubia A, Palacín E, Gómez del Río M, Martínez P. Description, Etiology, and Prevention of an Outbreak of Diffuse Lamellar Keratitis After LASIK. J Refract Surg 2007; 23:482-6. [PMID: 17523510 DOI: 10.3928/1081-597x-20070501-11] [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: 11/20/2022]
Abstract
PURPOSE To describe an outbreak of diffuse lamellar keratitis (DLK) and provide a hypothesis about the etiology. METHODS A retrospective analysis was carried out on 328 eyes of 220 patients who underwent LASIK over 9 months. The occurrence of DLK using two different methods of cleaning and sterilizing surgical instruments and an autoclave reservoir were analyzed. Microbial analyses were carried out by two laboratories on samples obtained from the original autoclave reservoir and tubing. A chi-square test was used to compare qualitative values. The Student t test was used to compare numerical values. RESULTS Forty-six (24.5%) of 188 cases of DLK were diagnosed. Sphingomona paucimobilis and Burkholderia pickettii were isolated in the reservoir of the steam sterilizer. Electron microscopy revealed gram-negative microbes on the tubing walls. After changing the reservoir of the steam sterilizer and implementing a new cleaning and sterilization protocol based on air-drying the instruments and draining and drying the reservoir of the sterilizer, the occurrence of DLK stopped. No statistically significant correlation was noted between the occurrence of DLK and gender, age, or volume of tissue removed. CONCLUSIONS Data obtained during this DLK outbreak support the theory that a bacterial endotoxin, which can survive short-cycle steam sterilization, could be responsible for an outbreak of DLK. We recommend cleaning and sterilization protocols based on air-drying surgical instruments and leaving the reservoirs completely dry at the end of each surgical day.
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Affiliation(s)
- Alberto Villarrubia
- Instituto de Oftalmología La Arruzafa, Avenida de la Arruzafa 9, 14012, Córdoba, Spain.
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Abstract
PURPOSE OF REVIEW To review, summarize and update our present understanding of toxic anterior segment syndrome. RECENT FINDINGS Toxic anterior segment syndrome has emerged within the last 2 years as a complication of increasing frequency following uneventful cataract surgery. Over 100 North American clinics reported toxic anterior segment syndrome cases to a specially constituted task force over a 4-month period in 2006. Toxic anterior segment syndrome is now recognized as a specific, noninfectious condition presenting as anterior segment inflammation that occurs within days of surgery and is responsive to topical steroids. Specific causes have been identified such as endotoxin contamination of balanced salt solutions and antibiotic ointment accessing the anterior chamber, although most cases appear to result from inadequate instrument sterilization and preparation. Outcomes are usually excellent, but delayed treatment and severe cases may result in glaucoma and persisting corneal edema requiring penetrating keratoplasty. SUMMARY Toxic anterior segment syndrome has become a significant complication of cataract surgery. Rapidly increasing knowledge made possible by ophthalmic organizations and the prompt dissemination of research findings, however, appear to have provided the information necessary to help prevent and resolve this condition.
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Affiliation(s)
- Simon P Holland
- Department of Ophthalmology, University of British Columbia, Vancouver, British Columbia, Canada.
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Hainline BC, Price MO, Choi DM, Price FW. Central Flap Necrosis After LASIK With Microkeratome and Femtosecond Laser Created Flaps. J Refract Surg 2007; 23:233-42. [PMID: 17385288 DOI: 10.3928/1081-597x-20070301-05] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To report nine cases of severe central flap inflammation and necrosis after LASIK. METHODS A retrospective chart review was conducted on 17,100 LASIK cases performed at two laser centers in Indiana from January 1995 through May 2005. All patients with central lamellar flap necrosis were identified. RESULTS Severe central flap inflammation and necrosis occurred in nine eyes of eight patients. Six patients underwent flap creation with a mechanical microkeratome and two with a femtosecond laser. Of eight eyes with > 2-month follow-up, one lost at least two lines of best spectacle-corrected visual acuity and two experienced a hyperopic shift in spherical equivalent refraction. Typically, inflammation was minimal the day after surgery, peaked 5 to 10 days later, and subsided by 60 days. Six of nine cases were treated by lifting the flap and irrigating the stromal bed. In each of these cases, few or no inflammatory cells were observed in the stromal bed, the posterior flap surface was intact, and the central portion of the anterior flap had a jelly-like consistency. CONCLUSIONS Central lamellar flap necrosis appears to differ from diffuse lamellar keratitis because the location of stromal inflammation is not in the flap interface but rather in the flap anterior stroma. Treatment with corticosteroids seemed to have little effect on outcomes. This is thought to be the first documentation of central lamellar flap necrosis following the use of a femtosecond laser.
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Affiliation(s)
- Bryan C Hainline
- Indiana University, Department of Ophthalmology, Indianapolis, Ind, USA
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de Rojas Silva MV, Abraldes MJ, Díez-Feijóo E, Yáñez PM, Javaloy J, Sánchez-Salorio M. Confocal Microscopy and Histopathological Examination of Diffuse Lamellar Keratitis in an Experimental Animal Model. J Refract Surg 2007; 23:299-304. [PMID: 17385297 DOI: 10.3928/1081-597x-20070301-14] [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 investigate the cell populations and structural alterations of the cornea in an experimental model of diffuse lamellar keratitis (DLK) using confocal microscopy and histopathology. METHODS A corneal flap was cut in 22 eyes of 11 New Zealand rabbits and the stromal interface was exposed to balanced salt solution (BSS, BSS group) and Pseudomonas aeruginosa lipopolysaccharide (LPS) endotoxin (5 mg/mL) (LPS 5 mg/mL group) and (3.5 mg/mL) (LPS 3.5 mg/mL group). Postoperatively, eyes were examined with a slit-lamp microscope (DLK grading) and confocal microscopy. Animals were sacrificed on day 3 (BSS group and LPS 5 mg/mL group) and day 4 (LPS 3.5 mg/mL group). Corneoscleral buttons were excised and processed for histopathologic examination. RESULTS Seven eyes were excluded. Slit-lamp microscopy revealed no cellular infiltration in the BSS group (five eyes). In the LPS groups, all eyes developed DLK, with iritis only observed in grade III eyes. In the LPS 5 mg/mL group, four eyes had DLK grade III, with iritis in three eyes. In the LPS 3.5 mg/mL group, three eyes had grade II and three eyes had grade III with iritis. On confocal microscopy, the BSS group had no cellular infiltration. Dense accumulation of inflammatory cells at the interface was noted in both LPS groups. Histopathology in the BSS group had a normal appearance. In the LPS groups, an inflammatory infiltrate was present at the interface that consisted of three cell populations--eosinophils, neutrophils, and lymphocytes. CONCLUSIONS Lipopolysaccharide endotoxin induced DLK in all exposed eyes, with iritis in a considerable proportion of eyes. The infiltrate consisted of three cell populations. Confocal microscopy showed the infiltrate in all affected eyes. Histopathological and confocal microscopic findings correlated well with the clinical appearance.
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Affiliation(s)
- Ma Victoria de Rojas Silva
- Fundación Instituto Galego de Oftalmología, Rúa Ramón Baltar, s/n (Hospital Provincial de Conxo), 15706 Santiago de Compostela, Spain.
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Chaieb K, Mahdouani K, Bakhrouf A. Detection of icaA and icaD loci by polymerase chain reaction and biofilm formation by Staphylococcus epidermidis isolated from dialysate and needles in a dialysis unit. J Hosp Infect 2005; 61:225-30. [PMID: 16165246 DOI: 10.1016/j.jhin.2005.05.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Accepted: 05/11/2005] [Indexed: 11/29/2022]
Abstract
Staphylococcus epidermidis, a coagulase-negative staphylococcus, is a major cause of infections associated with indwelling medical devices. Certain strains produce slime and form biofilm on polymer surfaces, where their pathogenicity is associated with biofilm formation. In this report, we investigated the presence or absence of the intercellular adhesion icaA and icaD genes by polymerase chain reaction, and phenotypic biofilm production was examined by qualitative Congo red agar (CRA) assay. A total of 32 strains of S. epidermidis were identified from dialysates and needles 4h after the initiation of dialysis. Qualitative biofilm production revealed that 16 (50%) strains produced slime on CRA plates. Among the 23 strains positive for the ica operon, 15 were biofilm positive on CRA, eight were biofilm negative, and one was icaA and icaD negative but produced slime. These results show that the ability of S. epidermidis to produce slime is not associated with the presence of icaA and icaD genes.
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Affiliation(s)
- K Chaieb
- Laboratoire de Bactériologie de l'Hôpital Ibn El Jazzar, rue Ibn Eljazzr, Kairouan 3140, Tunisia.
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Abstract
PURPOSE To report our experience with late vitritis associated with keratoprosthesis (KPro). METHODS Between 1990 and 2003, 218 patients underwent an all-polymethylmethacrylate, collar button-shaped KPro surgery. Eight patients developed a total of 12 episodes of sudden, massive vitritis. Five of these patients had an Ahmed shunt implant, 3 had anterior vitrectomy during surgery, and 4 had a soft contact lens in place. Preoperative diagnoses were multiple graft failures, chemical burn, Stevens-Johnson syndrome, or ocular cicatricial pemphigoid. All patients were maintained on prophylactic topical ofloxacin 0.3% or polymyxin-B/trimethoprim, as well as prednisolone acetate 1% (in 2 cases, medroxyprogesterone 1%), at least twice daily. Vancomycin (14 mg/mL) was also given twice daily in 2 patients. RESULTS Vitritis occurred in 8 patients (12 episodes), 2 to 23 months postoperatively. All patients presented with sudden, very marked decrease in vision, with little or no pain, tenderness, conjunctival redness, or discharge. Eight of the 12 events were subjected to vitreous tap and injection of antibiotics and steroids on the day of presentation. Cultures grew Staphylococcus epidermidis, only in liquid (broth) media, in 3 cases; the other 5 showed no growth. The vitritis episodes resolved after 2 to 9 weeks. Full recovery to pre-episode status of a quiet eye with clear vitreous was seen in all patients. Visual acuity recovered almost completely or completely (mental debilitation in one patient made accurate assessment uncertain). CONCLUSIONS This phenomenon of sudden vitritis after KPro, with few other symptoms and with complete recovery, would be uncharacteristic of a bacterial endophthalmitis. It may represent a uveitic immune phenomenon.
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Affiliation(s)
- Mahnaz Nouri
- Massachusetts Eye and Ear Infirmary, Harvard Medical School Boston, 02114, USA
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Abstract
PURPOSE To demonstrate a potential cause of a prolonged epidemic of diffuse lamellar keratitis (DLK). METHOD This retrospective review analyzed an epidemic of diffuse lamellar keratitis over a 3-year period in a single surgery center. Altering the brand of surgical gloves used during surgery was associated with an elimination of the DLK epidemic. Optical microscopy, scanning electron microscopy-energy dispersive spectroscopy (SEM-EDS), and Fourier transform infrared (FTIR) spectroscopy were performed on both brands of surgical gloves to allow for comparisons and determine possible surface contaminants responsible for the DLK outbreaks. RESULTS The incidence of DLK during the epidemic ranged from 2% to 38% on a quarterly basis for the 3-year period. A change in the brand of surgical gloves resulted in a cessation of DLK. Surface analysis of both brands of gloves revealed extensive silicone oil contamination on the internal and external surfaces of the DLK-associated gloves and insignificant amounts of silicone oil on the external surface of the DLK-free gloves. CONCLUSION Silicone oil contamination of surgical gloves appears to be associated with epidemic DLK.
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Affiliation(s)
- Richard S Hoffman
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, USA.
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Bashford KP, Shafranov G, Tauber S, Shields MB. Considerations of Glaucoma in Patients Undergoing Corneal Refractive Surgery. Surv Ophthalmol 2005; 50:245-51. [PMID: 15850813 DOI: 10.1016/j.survophthal.2005.02.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Glaucoma patients present a unique set of challenges to physicians performing corneal refractive surgery. Corneal thickness, which is modified during corneal refractive surgery, plays an important role in monitoring glaucoma patients because of its effect on the measured intraocular pressure. Patients undergo a transient but significant rise in intraocular pressure during the laser-assisted in situ keratomileusis (LASIK) procedure with risk of further optic nerve damage or retinal vein occlusion. Glaucoma patients with filtering blebs are also at risk of damage to the bleb by the suction ring. Steroids, typically used after refractive surgery, can increase intraocular pressure in steroid responders, which is more prevalent among glaucoma patients. Flap interface fluid after LASIK, causing an artificially low pressure reading and masking an elevated pressure has been reported. The refractive surgeon's awareness of these potential complications and challenges will better prepare them for proper management of glaucoma patients who request corneal refractive surgery.
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Affiliation(s)
- Kent P Bashford
- Department of Ophthalmology and Visual Sciences, Yale University School of Medicine, New Haven, Connecticut; and Glaucoma Consultants of Colorado, P.C., Littleton, Colorado, USA
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Abstract
Serious bacterial infections of the eye are often associated with abiotic prosthetic materials, such as contact lenses, intraocular lenses, and scleral buckles. In recent years, microbiologists have recognized substantial differences between bacteria growing in a sessile community attached to a surface and free-living or planktonic bacteria. These sessile surface-attached communities are known as biofilms, whose properties have important consequences for clinical medicine. As a population, bacteria in biofilms are more resistant to antimicrobial agents and the immune system, and they are more persistent than planktonic bacteria in hostile environments. These characteristics are likely the result of both biofilm-specific phenotypes and increased phenotypic diversity within biofilms as compared with planktonic communities of bacteria. Bacterial biofilm formation has been observed on human tissues, as well as on abiotic prosthetic devices. A better understanding of biofilm formation may lead to the development of novel antimicrobial agents as well as prosthetic devices that are resistant to bacterial colonization.
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Affiliation(s)
- Michael E Zegans
- Department of Microbiology and Immunology and Department of Surgery, Dartmouth Medical School, Hanover, NH 03756, USA.
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Morck DW, Holland SP, Ceri H, Hancock R, Scott-Gough M, Nugyen V, Keith EJ, Lee TL. Use of Polymyxin as an Endotoxin Blocker in the Prevention of Diffuse Lamellar Keratitis in an Animal Model. J Refract Surg 2005; 21:152-7. [PMID: 15796220 DOI: 10.3928/1081-597x-20050301-10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine whether bacterial endotoxin, lipopolysaccharide (LPS), could induce diffuse lamellar keratitis (DLK) in an animal model and whether DLK could be prevented by endotoxin blockers such as polymyxin. METHODS Laser in situ keratomileusis (LASIK) flaps were created in rabbit eyes. The stromal bed was treated with 20 microg of Burkholderia cepacia LPS or balanced salt solution (BSS). Development of DLK, histological degree of inflammation, and presence of LPS detected by anti-LPS antibody were evaluated after 48 hours. In a second experiment, all eyes received LPS and were randomly assigned to receive either polymyxin in the form of two drops of Polytrim (Allergan, Irvine, Calif) on the stromal bed or two drops of BSS. RESULTS In the animal model study, LPS was significantly associated with the development of DLK (P<.05, n=30). Infiltration with polymorphonuclear cells and presence of DLK were found in LPS treated eyes but not in controls. In the second experiment, 4 (27%) of 15 eyes that received polymyxin in addition to LPS developed DLK compared to 18 (95%) of 19 eyes that received only LPS (P<.05, n=34). There was a trend towards higher flap displacement in polymyxin treated eyes but this was not significant (P=.07). CONCLUSIONS Diffuse lamellar keratitis in a rabbit model can be caused by bacterial endotoxin (LPS). Endotoxin blockers, such as polymyxin, are effective in decreasing the incidence of endotoxin-induced DLK in a rabbit model.
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Affiliation(s)
- Douglas W Morck
- Life and Environmental Sciences, Animal Resource Centre, University of Calgary, Calgary, Alberta, Canada
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Abstract
PURPOSE To report the incidence and outcomes of diffuse lamellar keratitis (DLK) after LASIK and to analyze potential causative factors. METHODS Retrospective review of 15,119 cases (11,232 primary procedures and 3887 enhancements) from 7168 patients undergoing LASIK from May 1995 through October 2002, comparing preoperative data and postoperative outcomes for each case developing DLK to patients in the study population and a control series of eyes that did not develop DLK. RESULTS We identified 61 eyes (0.40%) that developed DLK after LASIK. Three study groups were identified based on sterilization protocols used: (1) steam autoclave without reservoir (8348 cases), (2) cassette autoclave with reservoir (6771 cases), (3) steam autoclave without reservoir and new instrument cleaner (1758 cases). Significantly more eyes developed DLK with Protocol 2 (47 cases, 0.94%) than with Protocol 1 (11 cases; 0.1%; P < 0.0001) or Protocol 3 (3 cases, 0.2%; P < 0.0005). There was no significant difference in the incidence of DLK in Protocol 1 versus Protocol 3. DLK was significantly more common after primary procedures than with enhancement procedures only under Protocol 2. No individual developed DLK after more than 1 procedure. Treatment protocols included frequent topical steroids only (24 cases, 39.3%), frequent topical steroids and oral steroids (19 cases, 31.2%), or topical and oral steroids combined with lifting and irrigating beneath the flap (18 cases, 29.5%). Final refractions and visual acuities were not significantly different in eyes that developed DLK and those that did not. CONCLUSIONS DLK is a nonspecific inflammatory response to multiple stimuli that cannot be attributed solely to individual variation in the inflammatory response, the microkeratome, or material deposited by the microkeratome. Sterilizers with reservoirs may cause some cases of DLK. With appropriate diagnosis and treatment, DLK should resolve without sequelae, yielding visual outcomes comparable to cases with uneventful postoperative courses.
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Affiliation(s)
- R Doyle Stulting
- Emory University Department of Ophthalmology, Atlanta, Georgia, USA
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