Andrea N. Lora M.D., Sonia H. Yoo MD.,William Culbertson MD.,

Carol L. Karp MD., Richard M. Awdeh MD.

Bascom Palmer Eye InstituteUniversity of Miami Miller School of Medicine

ASCRS ConferenceApril 2010Andrea Lora, MD- No Financial Disclosures

Sonia Yoo, MD- Alcon Labs (S), AMO (S), Allergan (G), Ista (C), Inspire (C), Carl Zeiss Meditec (S), (G), Haag Streit (C)

William Culbertson, MD- AMO, Zeiss, Alcon, OptimedicaCarol Karp, MD- No Financial Disclosures

Richard Awdeh, MD- Alcon (G), Allergan (S), Inspire Pharmaceuticals (C), (S), ISTA Pharmaceuticals (S)

IntroductionLaser in situ keratomileusis (LASIK) has been

shown to be an effective treatment for myopia, hyperopia, and astigmatism.

Peripheral inflammatory keratitis is typically a sterile inflammatory response at or near the limbus that is usually mediated by an immune response.

We report an unusual case series of peripheral inflammatory keratitis (PIK) in the early postoperative period following laser in situ keratomileusis (LASIK) with flap creation using the IntraLase femtosecond laser.

Case 149 year old male POD # 7 s/p monovision LASIK

OU, with the IntraLase femtosecond laser, was referred for evaluation of a possible corneal infection in the left eye.

Complains of photophobia, foreign body sensation, pain 8/10, and blurry vision left eye.

Past Medical History- Acne rosacea and DMIIMedications- Artificial tears PRN

Doxycycline and facial steroid creamBCVA OD 20/20, OS 20/30Left eye- Stromal haze involving the interface &

non-ablated peripheral anterior stroma

Case 1- Clinical Photographs POD # 7- Cultures sent

Fortified Vancomycin q2 hrs OSPred Forte q 2 hrs OSDoxycycline 100 mg PO BID

POD # 8- Cultures negative Vancomycin q 6 hrsPred Forte q 2 hrs & Doxy BIDBCVA OS 20/25

POD # 15- Pain & VA improvedArea of infiltrate improvedD/C Vancomycin; Pred ForteContinue Doxycycline

OS

OS

OS

OS

OSOS

Case 233 year old female POD # 3 s/p LASIK OU, with

the IntraLase femtosecond laser, complains of pain 8/10, blurry vision, and foreign body sensation right eye.

Past Medical History- HSV I & II with no ocular involvement and ocular rosacea

Medications- Vigamox & Pred Forte q 4 hoursDoxycycline 100 mg PO BID

BCVA OU 20/20 Right eye- Peripheral stromal infiltrate, mostly

involving the peripheral, non-ablated anterior stroma, + faint fluorescein staining.

Case 2- Clinical PhotographsPOD # 5- Cultures sentFortified Vanc & Zymar q1hr

ODPred Forte q 1 hr ODDoxycycline 100 mg PO BID

POD # 7- Cultures negative Vancomycin & Zymar q 8 hrsPred Forte q 1 hr Pain improving

POM # 3- BCVA OU 20/20 Mild persistent stromal hazeOff all medicationsAsymptomatic

OD

OD

OD

OD

OD OD

Case 3A 39-year-old male POD # 2 s/p LASIK OU, with

the IntraLase femtosecond laser, complains of photophobia, redness, and irritation of the left eye.

Past Medical History- Controlled diabetes mellitus and acne rosacea.

Medications- Pred Forte and Zymar QID OUBCVA OU 20/20

Right eye had a peripheral stromal infiltrate along the flap margin, trace staining with fluorescein

Left eye had a stromal infiltrate of both the ablated corneal stroma and the adjacent peripheral, non-ablated anterior stroma

Case 3- Clinical PhotographsPOD # 2- Cultures sentFortified Vancomycin q 2 hrs OUZymar QID OUPred Forte QID OUPOD # 3- Cultures negative Vancomycin QID Pred Forte q 2 hrs Zymar QID

POM # 4- BCVA OD 20/70 OS 20/25Stromal haze improvedUnderwent uneventful

retreatment right eye, final BCVA OD 20/20

OD

OS

After treatment

DiscussionPeripheral inflammatory keratitis (PIK) is often

associated with chronic blepharitis & MGDLimbal vessels allow rapid recruitment of

inflammatory cells from the vasculature

Epithelial injury with LASIK flap formation triggers cytokine release (IL-1 and TNF-)1-4 Triggers release of chemokines (monocyte

chemotactic and activating factor (MCAF), granulocyte colony-stimulating factor(G-CSF), IL-4, etc)

Chemokines attract inflammatory cells into the cornea from the limbal blood vessels and the tear film.

DiscussionBlepharitis predisposes patients to increased

cellular migration to the peripheral cornea by chemokines triggered by LASIK trauma.

Inflammatory debris accumulates at the incision site

Important to differentiate from infectious keratitis

Treatment includesSteroidsLid hygieneDoxycycline

ConclusionPIK after LASIK is uncommon and can be

associated with favorable outcomes with aggressive management and careful vigilance for infectious causes.

Rosacea, chronic blepheritis, and meibomian gland dysfunction may be markers of patients who are at a greater risk for PIK.

Additionally, the use of a femtosecond laser for flap creation may predispose these patients to PIK.

Preoperative screening for these risk factors with preoperative prophylactic treatment may decrease the incidence of PIK. 

References1. Ambrósio, Renato Jr, MD; Periman, Laura M. MD; Netto, Marcelo

V. MD; Wilson, Steven E. MD. Bilateral Marginal Sterile Infiltrates and Diffuse Lamellar Keratitis After Laser in situ Keratomileusis. Journal of Refr Surgery.Volume 19(2), March/April 2003, p 154–158

2. Netto MV. Mohan RR. Medeiros FW. Dupps WJ Jr. Sinha S. Krueger RR. Stapleton WM. Rayborn M. Suto C. Wilson SE. Femtosecond laser and microkeratome corneal flaps: comparison of stromal wound healing and inflammation. Journal of Refractive Surgery. 23(7):667-76, 2007 Sep.

3. Lahners WJ. Hardten DR. Lindstrom RL. Peripheral keratitis following laser in situ keratomileusis. Journal of Refractive Surgery. 19(6):671-5, 2003 Nov-Dec.

4. Kaufman SC. Maitchouk DY. Chiou AG. Beuerman RW. Interface inflammation after laser in situ keratomileusis. Sands of the Sahara syndrome. Journal of Cataract & Refractive Surgery. 24(12):1589-93, 1998 Dec.