late diffuse lamellar keratitis in post-lasik infective keratitis
DESCRIPTION
Late Diffuse Lamellar Keratitis in Post-LASIK Infective Keratitis. Dr. Umang Mathur Dr. Amit Agrawal Dr. Manisha Acharya The authors have no financial interest in the subject of this poster. History. - PowerPoint PPT PresentationTRANSCRIPT
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
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