Dr. Umang MathurDr. Umang Mathur

Dr. Amit AgrawalDr. Amit Agrawal

Dr. Manisha AcharyaDr. Manisha AcharyaThe authors have no financial The authors have no financial

interest in the subject of this posterinterest in the subject of this poster

Late Diffuse Lamellar Late Diffuse Lamellar Keratitis in Post-Keratitis in Post-LASIK Infective LASIK Infective

KeratitisKeratitis

New Delhi, India

HistoryHistory 23-year-old female underwent uneventful 23-year-old female underwent uneventful

Bilateral Myopic LASIK, elsewhere, on 22Bilateral Myopic LASIK, elsewhere, on 22ndnd January 2008January 2008

Post-operative # 3Post-operative # 3Patient presents to the doctor with Bilateral Patient presents to the doctor with Bilateral Infective KeratitisInfective Keratitis

Pain, Photophobia, Redness, Watering/DischargePain, Photophobia, Redness, Watering/Discharge Vision: CF 1/2m, both eyesVision: CF 1/2m, both eyes Central infiltrates, both eyes Central infiltrates, both eyes

New Delhi, India

ManagementManagement

Flap lifted in both eyes and scraping sent Flap lifted in both eyes and scraping sent for Bacterial and Fungal smears and for Bacterial and Fungal smears and cultureculture

No organisms grownNo organisms grown

Empirical treatmentEmpirical treatment Moxifloxacin eye drops q1hMoxifloxacin eye drops q1h Tobramycin eye drops q1hTobramycin eye drops q1h Natamycin eye drops q1hNatamycin eye drops q1h Cyclopentolate eye drops tidCyclopentolate eye drops tid

New Delhi, India

Post-operative # 7Post-operative # 7

Patient responds to treatmentPatient responds to treatment

↓ ↓ Pain, watering, photophobiaPain, watering, photophobia ↓ ↓ size of infiltrationsize of infiltration Improvement in Vision, RE>LEImprovement in Vision, RE>LE

Impression: Healing KeratitisImpression: Healing Keratitis

New Delhi, India

Post-operative # 13Post-operative # 13

↑ ↑ ↑ ↑ Pain, watering, photophobiaPain, watering, photophobia ↑ ↑ CongestionCongestion ↑ ↑ signs of inflammationsigns of inflammation

Referred to us for opinion and Referred to us for opinion and managementmanagement

New Delhi, India

OD OS

BCVA: CF 50cm BCVA: CF 50cm

Post-operative # 13Post-operative # 13

New Delhi, India

What are we dealing What are we dealing with?with? Unresolved infection?Unresolved infection?

Why recurrence after good initial response?Why recurrence after good initial response? Atypical infectionAtypical infection

Immunocompromised patient…HIV?Immunocompromised patient…HIV? Blood reports WNLBlood reports WNL

Collagen vascular disease?Collagen vascular disease? RA factor, ANA, CRP, ESR: WNLRA factor, ANA, CRP, ESR: WNL Clinically: WNLClinically: WNL

Blepharokeratoconjunctivitis?Blepharokeratoconjunctivitis? Clinically: WNLClinically: WNL

HSV Keratitis?HSV Keratitis? No history of recurrenceNo history of recurrence ?Bilateral and simultaneous- very rare?Bilateral and simultaneous- very rare

New Delhi, India

ReviewReview

OD OS

StromalEdema

DLKDLK??

Prednisolone acetate eye drops tid, addedPrednisolone acetate eye drops tid, added

New Delhi, India

Post-operative # 20Post-operative # 20

Symptomatic reliefSymptomatic relief ↓ ↓ Congestion, Infiltrate, Stromal edemaCongestion, Infiltrate, Stromal edema Topical steroids frequency increasedTopical steroids frequency increased

New Delhi, India

Post-operative # 30Post-operative # 30

OD: 20/20p (-1D cyl OD: 20/20p (-1D cyl x 20)x 20)

OS: 20/100OS: 20/100

( 20/20p with RGP ( 20/20p with RGP Contacts)Contacts)

New Delhi, India

B/L DLK, Post-LASIK Infective B/L DLK, Post-LASIK Infective KeratitisKeratitis

OD OS

New Delhi, India

DiscussionDiscussion Diffuse lamellar keratitis (DLK) is an Diffuse lamellar keratitis (DLK) is an

inflammatory infiltrate occurring at the inflammatory infiltrate occurring at the keratectomy interface after laser in situ keratectomy interface after laser in situ keratomileusis (LASIK) keratomileusis (LASIK)

Endotoxins released from bacteria and Endotoxins released from bacteria and inflammatory bi-products may be the causative inflammatory bi-products may be the causative agents for producing DLK in our caseagents for producing DLK in our case

While the infection was controlled by the While the infection was controlled by the Antibiotic treatment, endotoxins released from Antibiotic treatment, endotoxins released from the bacteria continued to produce an the bacteria continued to produce an inflammatory reactioninflammatory reactionHolland SP, Mathias RG, et.al. Diffuse lamellar keratitis related to endotoxins released from sterlizer

reservoir biofilms. Ophthalmology. 2000 Jul;107(7):1227-33Peters NT, Iskander NG,et.al. Diffuse lamellar keratitis: isolation of endotoxin and demonstartion of the inflammatory potential in a rabbit laser in situ keratomileusis model. J Cataract Refract Surg. 2001 Jun;27(6):917-23