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 Post subject: Late-onset Infections After LASIK
PostPosted: Fri Apr 11, 2008 2:32 pm 
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Late-onset Infections After LASIK

Journal of Refractive Surgery Vol. 24 No. 4 April 2008
Ana Carolina Vieira, MD; Telma Pereira, MD; Denise de Freitas, MD

PURPOSE
To report two cases of infectious keratitis that developed 2 and 6 years after LASIK.

METHODS
Case 1 was a 56-year-old woman who presented with redness and decreased vision in the right eye 6 years after LASIK. Slit-lamp examination revealed inflammation of the flap interface, a partially detached flap, anterior chamber reaction, and hypopyon. Corneal scrapings were taken. Case 2 was a 23-year-old woman who presented with pain and a corneal infiltrate in the left eye 36 hours after eye trauma. She had undergone bilateral LASIK 2 years prior. The condition worsened despite treatment, and a flap amputation was performed.

RESULTS
Cultures revealed Pseudomonas mesophilic and Fusarium solani, respectively. Keratitis in case 1 resolved after 21 days of fortified antibiotic therapy. Visual acuity of 20/40 was achieved after antibiotic treatment in case 2.

CONCLUSIONS
These case reports demonstrate the risk of microbial keratitis occurring years after LASIK and emphasize the need for lifelong postoperative vigilance by patient and physician. [J Refract Surg. 2008;24:411-413.]

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PostPosted: Wed May 28, 2008 11:31 am 
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From the full text:

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Eyes that have undergone LASIK may be more pre-disposed to infections than unoperated eyes, and the infection may progress more rapidly when it occurs. A possible explanation for the presentation of delayed keratitis after LASIK is that creating the lamellar flap may induce a permanent portal in the corneal periphery for microorganisms to penetrate. In this event, the infiltrate would likely be localized near the flap edge and gradually work its way to the center. Although PRK patients are more likely to develop corneal infections in the early postoperative period due to large epithelium disruption, it is no longer expected in the late postoperative period after the epithelium has completely healed. A small epithelial break occurring any time after LASIK allows superficial microbials to penetrate the flap and reach the interface.4 The patient in case 1 had been wearing contact lenses for correction of ametropia. It has been reported that long-term contact lens wear may alter the epithelium barrier,9 facilitating the entrance of microorganisms. In case 2, the patient suffered trauma with a t-shirt, which may have played a role in the fungal inoculation. Although the literature is not clear whether an association exists between late-onset keratitis and the presence of risk factors such as contact lens use and eye trauma, Levy et al10 demonstrated that late-onset bacterial keratitis can occur in eyes without history of trauma and contact lens wear. The lamellar interface may function as a virtual space in which sequestered infections have the facility to develop. These interface infections are more difficult to treat as the microorganisms are protected from the natural ocular surface defenses and the antimicrobials do not penetrate well.8 Flap amputation may be necessary for a better therapeutic outcome in cases where there is no clinical improvement or when corneal melting has occurred. Patients may develop irregular astigmatism and anterior stromal haze after flap amputation8; however, flap removal benefits outweigh the possible scarring of the cornea. Infections after LASIK may be highly predisposed to perforation due to the cornea?s reduction in thickness during the surgical procedure. This report demonstrates the risk of microbial keratitis development years after LASIK and emphasizes the importance of lifelong postoperative vigilance by patient and physician.


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