Pressure-induced interface keratitis: a late complication following LASIK

PURPOSE: Interface inflammation is a common complication of laser in situ keratomileusis (LASIK). The most well-described presentation is diffuse lamellar keratitis (DLK), which typically develops early after LASIK and responds quickly to topical steroids. In this report, we describe a novel presentation of interface inflammation that resembles DLK in appearance but presents late in the postoperative period, is associated with increased intraocular pressure, and is exacerbated by steroid treatment. METHODS: A retrospective case series and chart review of all patients treated in our tertiary care private practice for late-onset interface inflammation associated with elevated intraocular pressure. RESULTS: Ten eyes in 6 patients with late-onset interface inflammation and increased intraocular pressure were identified. At presentation, all patients were presumed to have classic DLK and were treated initially with aggressive topical steroids. Eight of the 10 eyes were receiving topical steroids at the time of presentation. The average time of presentation was 17 days after LASIK (range, 7-34). Elevated intraocular pressure was noted on average 28 days after presentation (range, 8-69). Lamellar inflammation was exacerbated by topical steroids. Resolution of the interface inflammation did not occur until intraocular pressure was controlled. CONCLUSIONS: This case series describes a clinically distinct form of interface inflammation that presents late and is associated with elevated intraocular pressure. The lamellar inflammation was refractory to topical steroids and only resolved when pressure was controlled. These findings suggest that elevated intraocular pressure can contribute to interface inflammation. Postoperative assessment of intraocular pressure is essential in patients presenting with flap inflammation.     

Traumatic flap displacement after LASIK

CASE REPORT: We present a case of traumatic displacement of corneal flap in the superior temporal quadrant 13 days after LASIK. The flap was repositioned after gentle irrigation of BSS, cleaned the interface and then drying the flap to verify its stability. In the next day the flap was adhered, clear cornea,smooth and visual acuity without correction was 1.00. DISCUSSION: We should try immediately to reposition the flap after traumatic displacement, as in this case.     

Traumatic wound dehiscence following penetrating keratoplasty

BACKGROUND AND PURPOSE: Blunt ocular trauma to a corneal transplanted eye represents a higher risk for wound rupture at the donor-recipient interface. We have evaluated the causes, clinical characteristics, treatment and outcome, particularly the graft's clarity, in patients with traumatic wound dehiscence after penetrating keratoplasty. METHODS: Between March 1996 and April 2006, over a period of 10 years, 4 patients who had previously undergone successful penetrating keratoplasty and subsequently sustained traumatic wound dehiscence were treated at our department. All eyes underwent primary wound closure with interrupted 10-0 nylon sutures. RESULTS: Over the 10-year period, the incidence of traumatic wound dehiscence in which penetrating keratoplasty was performed was 2.35 % (4 of 170 patients). The ages of our patients at the time of injury were 6, 76, 78 and 39 years. The interval between penetrating keratoplasty and trauma varied from 12 through 16 and 17 to 30 months. All corneal dehiscences occurred at the graft-host junction. All dehiscences were at the temporal-superior quadrant (4 of 4 eyes) and at superior-nasal and temporal quadrants in 3 of 4 eyes. Two eyes that were pseudophakic had lost their implants and required anterior vitrectomy. In one of these patients (a 76-year-old women) delayed-onset expulsive choroidal haemorrhage occurred at the end of surgical repair. Visual outcome was correlated with the force of trauma, previous eye conditions and complications during surgery. All of the resutured grafts retained clarity. CONCLUSION: Traumatic wound dehiscence is a serious and not uncommon complication following penetrating keratoplasty. Despite severe trauma, graft transparency was achieved in all cases and there was no need for regrafting.     

Traumatic wound dehiscence following penetrating keratoplasty.

Four young male patients with keratoconus had traumatic dehiscence of the surgical wound after penetrating keratoplasty. Two were rendered aphakic by the trauma, and in one patient the lens was dislocated posteriorly. In each case the dehiscence was repaired by resuturing the original corneal graft. Despite marked corneal oedema in the immediate postoperative period all four grafts deturgesced and subsequently cleared. The follow-up has been a minimum of 23 months. We recommend therefore primary resuturing of traumatic wound dehiscence after keratoplasty, anterior vitrectomy if the lens dislodged, and prophylactic antibiotics postoperatively. The clearing of the initially oedematous grafts in each case illustrates the resilience of the corneal endothelium.     

Late-onset traumatic laser in situ keratomileusis (LASIK) flap dehiscence

PURPOSE: To report a case of laser in situ keratomileusis (LASIK) flap dehiscence following focal trauma six months after uneventful refractive surgery. METHODS: Case report. A 37 year old man was seen one day after a tree branch snapped tangentially against his left cornea causing a dehiscence of his LASIK flap. RESULTS: The flap was repositioned after treating the exposed flap stroma with a 50:50 mixture of distilled water and balanced salt solution. The patient regained 20/20 uncorrected visual acuity. CONCLUSIONS: Patients should be informed about the potential for traumatic flap dehiscence following LASIK surgery and advised to wear eye protection when appropriate. Due to minimal wound healing except at the edges of the flap, corneal flap dehiscence may occur months or years after uneventful LASIK.     

Two cases of pneumococcal keratitis following myopic LASIK

PURPOSE: To report two cases of pneumococcal keratitis after LASIK. METHODS: Retrospective interventional small case series of two patients who underwent bilateral LASIK for myopia and developed pneumococcal keratitis after surgery. This complication was encountered 2 days after surgery in one eye in both cases. The corneal flap was lifted, and irrigation and cultures from the stromal bed performed. Topical and subconjunctival antibiotics were started. RESULTS: Culture revealed Streptococcus pneumoniae in both cases. The infiltrates responded well to treatment. One year after the procedure, uncorrected visual acuity is > 20/40 in both cases. CONCLUSIONS: Pneumococcal keratitis can complicate LASIK. Patients should be informed of this potential complication, as prompt treatment is crucial.     

Traumatic wound dehiscence 14 years following penetrating keratoplasty

Penetrating keratoplasty eyes are at greater risk of laceration than intact corneas due to persistent wound weakness, even years after surgery. We report a case of traumatic wound dehiscence by fingertip injury 14 years following penetrating keratoplasty.     

Epithelial folds following slippage of LASIK flap

We present a case of a slipped corneal flap after laser-assisted in-situ keratomileusis, LASIK. A 22-year-old, female with myopia and a refractive error of -5.50 D sph OU had an uneventful LASIK performed on her left eye with a Chiron Automated Corneal Shaper (ACS) and a VISX-Star Excimer laser using a nasal hinged flap. On the first postoperative day, slit lamp examination revealed 4.0 mm slippage of the corneal flap. The flap was rolled and folded on itself within the inferior cul-de-sac. With the aid of the operating microscope, the flap was repositioned on the stromal bed. Immediately following the repositioning, many folds were still visible despite centering the flap on the stromal bed and performing stretching maneuvers. Detailed examination showed the folds to be of edematous epithelial origin. The underlying stromal bed was flat. Within days following repositioning, the folds had disappeared and the flap assumed the typical postoperative LASIK appearance. The final uncorrected visual acuity returned to 20/20.     

Delayed onset diffuse lamellar keratitis following enhancement LASIK surgery

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.     

Late dislocation of LASIK flap following fingernail injury

A case of traumatic flap displacement with a fingernail injury four years after LASIK is reported.