准分子激光原位角膜磨镶术后非结核分枝杆菌性角膜炎一例

随着准分子激光原位角膜磨镶术（laser in situ keratomileusis,LASIK）的普及，术后并发的感染性角膜炎逐渐引起临床医师的关注，现将我院经临床及实验室明确诊断的一例LASIK术后非结核分枝杆菌（non-tubereculous mycobacteria. NTM）性角膜炎报告如下。     

LASIK术后非结核分枝杆菌性角膜炎1例

0引言随着激光原位角膜磨镶术(LASIK)手术的广泛开展,LASIK术后并发症也在增加,术后感染性角膜炎的发病率为0.1%~0.2%,而真实的发病率可能远超过所报道过的病例[1]。我们在LASIK术后3d发现1例非典型性分枝杆菌性角膜炎,现报告如下。1病例报告患者,男,35岁,因双眼视物不清20a+于2008-03-16在外院行LASIK手术,术后常规使用糖皮质激素滴眼。术后第1d复查,裸视力右1.2,左1.0,无不适感,术后检查未发现异常;第3d双眼轻度畏光,流泪,右眼角膜未见异常,左眼视力明显下降,裂隙灯检查显示:角膜水肿,角膜瓣下有散在圆点状上皮下浸润,边界不清(图1);第4d,双眼畏光     

LASIK术中不完全瓣的临床处理

LASIK是目前矫治近视的主要角膜屈光手术,但不完全瓣仍然是LASIK术中最常见的角膜瓣并发症之一,我们用LASEK当场处理不完全瓣,术后效果满意,现报告如下。1资料与方法1.1临床资料对2004年5月～2006年3月行LASIK术中制作角膜瓣时出现的6例(6眼)不完全瓣的患眼和对侧健眼2眼当场施行LASEK。6眼中有3眼为“纽扣”状瓣,中央4～6mm直径大小角膜未切到;1眼为圆环形角膜瓣,即1点～11点宽4mm左右的角膜瓣,余角膜未切到;2眼为半圆环状角膜瓣,即1点～7点宽4mm左右的角膜瓣,余角膜未切到。1.2手术方法将直径8.0mm上皮环钻置于角膜中央,环钻内…     

加替沙星治疗非结核性分枝杆菌性角膜炎的实验研究

目的 探讨加替沙星对兔非结核分枝杆菌（NTM）性角膜炎的治疗效果。方法 利用龟分枝杆菌建立兔NTM角膜炎模型，随机分为6组，分别使用加替沙星、左氧氟沙星、环丙沙星、阿米卡星及加替沙星联合阿米卡星进行治疗，平衡盐溶液（BSS）作为对照；观察治疗前后角膜浸润面积及临床表现的变化，并对治疗1周后的角膜病灶进行细菌定量分析。结果 加替沙星可抑制角膜组织内NTM的生长，使NTM角膜炎角膜浸润面积明显减小，与阿米卡星联合使用可增强其抗菌作用。结论 加替沙星是治疗NTM角膜炎的有效药物之一。     

LASIK术中卡刀患者的再矫正

目的 报告5例准分子激光原位角膜磨镶术(LASIK)术中卡刀后再次行LASIK手术治疗的方法及疗效。方法 5例LASIK术中卡刀，形成不完全角膜瓣。仔细观察角膜瓣终止的位置，位于瞳孔缘3例，瞳孔外缘1mm2例，先放弃激光切削，待角膜愈合后再次行LASIK手术矫正。结果 5例经做第二次角膜瓣及激光切削后，裸眼视力均达到术前最佳矫正视力。结论 LASIK术中如出现卡刀现象，等待角膜瓣愈合后再次手术是安全而有效的。     

LASIK术后感染性角膜炎相关因素分析

准分子激光原位角膜磨镶术（laser situ in keratomileusis,LASIK）安全有效,是目前治疗近视最广泛采用的方法。术后感染是最常见、最棘手的并发症之一,直接关系到患者的满意度和术后效果。我院从2003年行LASIK以来,共行手术4218例,术后仅一例发生感染性角膜炎（通常LASIK术后角膜感染率为1/1000～1/10000）,远低于平均感染率,     

LASIK术后感染性角膜炎相关因素分析

目的 减少和杜绝LASIK术后感染性角膜炎的发生。方法 对6例LASIK术后感染性角膜炎患者进行结膜囊细菌培养，并进行术前、术中、术后临床分析。结果 6例送检标本，4例培养阳性，经过全身、局部抗感染治疗，角膜瓣下冲洗，均痊愈，术后裸眼视力均〉4．9。结论 术前、术中的结膜囊无菌化要求在临床上给予充分重视，术后抗菌药物的准确使用及健康宣教要详细告诉病人使之接受。     

15例20眼准分子激光原位角膜磨镶术后感染及处理

目的探讨准分子激光原位角膜磨镶术（LASIK）后感染的诊断与治疗。方法收集非结核分枝杆菌性角膜炎19眼,鲍曼不动杆菌性角膜炎1眼,回顾分析,早期采用局部清创,2.5%碘酊烧灼,联合药物治疗方法。结果18眼临床治愈,1眼板层角膜移植,1眼全层角膜移植。结论对于LASIK术后感染应迅速采取相应措施,清创下碘酊烧灼及抗菌药物的联合应用,可使多数早期感染患者临床治愈。     

LASIK术中不同厚度角膜瓣治疗中高度近视的比较

准分子激光原位角膜磨镶术（LASIK）的关键步骤是制作角膜瓣,瓣过薄可能致术中操作困难和一些并发症的发生,瓣过厚则导致残留基质床厚度减小。随着技术和设备的发展,出现了薄角膜瓣的LASIK技术,将角膜瓣厚度由理想的160μm缩小为110～130μm,扩大了LASIK的手术适应证范围。本研究比较不同厚度角膜瓣的LASIK手术效果,报告如下。     

准分子激光原位角膜磨镶术后角膜细菌性感染的实验研究

目的:建立日本大耳白兔LASIK术后感染模型,了解LASIK术后细菌性角膜炎的病理过程,为LASIK术后细菌性角膜炎诊断、治疗提供依据。方法:选取健康成年日本大耳白兔20只,右眼行LASIK术后接种金黄色葡萄球菌,在术后12h;1,3,5,10d各时期行肉眼、数字化裂隙灯和共焦显微镜观察,10d后处死实验动物取角膜行病理切片。结果:18眼成功建立了LASIK术后细菌性角膜炎模型。其早期表现为角膜瓣浅基质层点状或小斑片状炎性浸润,随着时间的推移慢慢融合,并以层间为起点同时向前（角膜瓣）和向后（深基质层）发展,晚期造成角膜瓣移位、角膜瓣溃疡、穿孔伴前房积脓。结论:建立LASIK术后细菌性角膜炎模型可行。LASIK术后细菌性角膜炎会导致严重的病理损害。     

Bilateral peripheral infiltrative keratitis after LASIK

PURPOSE: To present a case of peripheral infiltrative keratitis mimicking infectious keratitis on the flap margin and limbus, which appeared on the first postoperative day after the laser in situ keratomileusis (LASIK). METHODS: A 36-year-old woman who underwent uneventful bilateral simultaneous LASIK developed multiple round infiltrate along the flap margin reaching to limbus from the 11 o'clock to 6 o'clock area in both eyes. RESULTS: The flap was lifted and irrigation was performed with antibiotics. but infiltration seemed to appear again. The infiltrate was more concentrated at the periphery and was extended to the limbus. Direct smear and culture for bacteria and fungus were negative. Topical prednisolone acetate 1% eye drops was added, infiltrative condition was resolved. CONCLUSIONS: LASIK induced peripheral infiltrative keratitis, in which infectious origin was ruled out, is reported.     

Features of the clinical course and treatment of some types of complications in the early postoperative period after intrastromal laser keratectomy

Some complications observed during the early postoperative period after intrastromal laser keratectomy by LASIK and REIK are described: diffuse interface infiltration, flap "ripples", central dystrophy of the flap, infective keratitis. Differential diagnostic signs of diffuse infiltration in the interface, central dystrophy of the flap, and infective keratitis are described and data on the clinical physiological status of the cornea (fluorescein penetrability, lacrimal production tests) in these conditions are presented. The efficiency of drug therapy is evaluated and protocols for the treatment of these complications are presented.     

Unilateral fungal and mycobacterial keratitis after simultaneous laser in situ keratomileusis

PURPOSE: To report a case of unilateral fungal and mycobacterial keratitis after simultaneous laser in situ keratomileusis (LASIK). METHODS: Case report of a 37-year-old woman who developed corneal infiltrates located at the flap-stroma interface in her left eye 3 weeks after LASIK for myopia. The infiltration progressed despite topical antibiotic therapy; therefore, the flap was lifted and irrigated with antibiotic solution. Parallel corneal scrapings were taken. The patient's condition deteriorated, prompting a lamellar keratoplasty. RESULTS: Corneal scrapings demonstrated no growth. Microbiologic cultures of the corneal specimen were reported as negative, whereas histopathologic examination disclosed fungal filaments. Two months later, the patient presented corneal infiltrates of the left eye again. Because the situation worsened despite therapy, a penetrating keratoplasty was performed. Histopathologic examination of the host cornea revealed no pathogenic species; microbiologic cultures, however, demonstrated Mycobacterium chelonae. CONCLUSION: Fungi and M. chelonae are rare and insidious causes of infectious keratitis after LASIK. Our case emphasizes the possible difficulties in diagnosing and treating a combined or subsequent infection with both species.     

Pneumococcal keratitis after laser in situ keratomileusis

A 20-year-old man developed keratitis in his right eye 2 days after laser in situ keratomileusis (LASIK). The patient had rubbed the eye with unclean fingers the night before the onset of symptoms. Examination showed an inferior corneal ulcer with dense infiltration at the junction of the lamellar flap and the surrounding cornea associated with a hypopyon. Streptococcus pneumoniae was isolated on culture. The ulcer resolved with combination therapy of cephazolin 5% and tobramycin 1.3% eyedrops. Patients having LASIK should be instructed that inadequate patient hygiene may predispose to bacterial keratitis.     

Bacterial keratitis after [correction of following] laser in situ keratomileusis

PURPOSE: The development of bacterial keratitis after laser in situ keratomileusis (LASIK) has been described in only a few isolated cases. We report the development of bacterial keratitis as a postoperative complication of LASIK in three subjects. DESIGN: A retrospective interventional small case series. PARTICIPANTS: Three patients who underwent LASIK for correction of myopia during July and August 1998 and had bacterial keratitis develop after surgery. METHODS: Bacterial keratitis was encountered in the operated eyes between 1 and 22 days after surgery. Topical antibiotic therapy was administered. In one eye, which had significant opacification and irregularity of the flap was developed, lamellar keratoplasty was performed. MAIN OUTCOME MEASURES: Postoperative inflammation was followed clinically and photographically until it resolved. Visual acuity was measured at intervals throughout the follow-up period. RESULTS: Keratitis resolved within 3 to 16 days of starting antibiotic therapy. The final best-corrected visual acuities were 20/30, 20/15, and 20/25. CONCLUSIONS: Although infectious keratitis after LASIK is an infrequently reported event, it should be discussed preoperatively with patients as a possible complication.     

Idiopathic peripheral necrotizing keratitis after femtosecond laser in situ keratomileusis

We report a case of necrotizing peripheral keratitis after laser in situ keratomileusis (LASIK) using the low-energy Femto LDV femtosecond laser in a 31-year-old helicopter pilot with no history of medical or ocular disease. The severe peripheral flap inflammation resulted in stromal necrosis that was unresponsive to intensive topical steroid but improved rapidly on oral prednisone. The uncorrected distance visual acuity was maintained at 20/15 in both eyes, and the flaps were left undisturbed rather than attempting a more aggressive intervention such as a flap lift with culture and antibiotic irrigation. Identification of sterile corneal infiltration must be distinguished from infectious etiologies as the treatment is distinctly different. Although increased corneal infiltration has been reported with increasing femtosecond laser energy level for flap creation, to our knowledge this is the first report of necrotizing sterile corneal infiltration after LASIK with the low-energy femtosecond laser. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.     

Keratitis following laser refractive surgery: Clinical spectrum,prevention and management

Laser refractive surgery (LRS) is one of the most demanding areas of ophthalmic surgery and high level of precision is required to meet outcome expectations of patients. Post-operative recovery is of vital importance. Keratitis occurring after LRS can delay visual recovery. Both surface ablations [Photorefractive keratectomy (PRK)] as well as flap procedures [Laser in-situ keratomileusis (LASIK)/Small incision lenticule extraction] are prone to this complication. Reported incidence of post-LRS infectious keratitis is between 0% and 1.5%. The rate of infections after PRK seems to be higher than that after LASIK. Staphylococci, streptococci, and mycobacteria are the common etiological organisms. About 50–60% of patients present within the first week of surgery. Of the non-infectious keratitis, diffuse lamellar keratitis (DLK) is the most common with reported rates between 0.4% and 4.38%. The incidence of DLK seems to be higher with femtosecond LASIK than with microkeratome LASIK. A lot of stress is laid on prevention of this complication through proper case selection, asepsis, and use of improved protocols. Once keratitis develops, the right approach can help resolve this condition quickly. In cases of suspected microbial keratitis, laboratory identification of the organism is important. Most lesions resolve with medical management alone. Interface irrigation, flap amputation, collagen cross-linking and therapeutic penetrating keratoplasty (TPK) are reserved for severe/non-resolving cases. About 50–75% of all infectious keratitis cases post LRS resolve with a final vision of 20/40 or greater. Improved awareness, early diagnosis, and appropriate intervention can help limit the damage to cornea and preserve vision.     

Delayed keratitis after laser in situ keratomileusis

We report 2 cases of delayed keratitis that occurred after uneventful laser in situ keratomileusis (LASIK). The first patient presented with a peripheral corneal infiltrate 3 months after a LASIK enhancement procedure. The infiltrate progressed despite treatment with topical combination tobramycin-dexamethasone. The flap was then lifted and the interface was irrigated with fortified antibiotics. The keratitis promptly resolved, and the patient recovered a best corrected visual acuity (BCVA) of 20/20. The second patient presented with decreased vision, inflammation, and a sublamellar infiltrate 1 month after primary LASIK. The flap was promptly lifted and irrigated with antibiotics. Cultures were positive for Staphylococcus epidermidis. One week later, the infiltrate had resolved and BCVA had returned to 20/20. Delayed bacterial keratitis has been described as a rare occurrence after incisional refractive surgery. To the best of our knowledge, it has not yet been reported after LASIK. It is important to consider infectious keratitis in the differential diagnosis of a patient who presents with corneal inflammation, even months after having LASIK.     

Microbial keratitis after laser in situ keratomileusis

PURPOSE AND METHOD: To review the literature on microbial keratitis reported after laser in situ keratomileusis (LASIK). RESULTS: Forty-one eyes have been reported to have microbial keratitis after LASIK. The causative organisms vary from gram positive bacteria to atypical mycobacteria, fungal, and viral pathogens. The infection is usually acquired intraoperatively, but may also be caused by postoperative contamination. A majority of the patients present within 72 hours of the surgery with an acute onset of symptoms. Management of microbial keratitis after LASIK includes aggressive topical fortified antibiotic therapy, irrigation of stromal bed with antibiotic solution after lifting the flap, and sending the scraping of the infiltrate for microbiological evaluation. The keratitis heals with scarring and a best spectacle-corrected visual acuity of 20/40 or better can be obtained in the majority of the patients. CONCLUSION: Microbial keratitis is a sight-threatening complication of LASIK.     

Complications of laser-in-situ-keratomileusis

Laser-in-situ-keratomileusis (LASIK) has become a popular technique of refractive surgery because of lower postoperative discomfort, early visual rehabilitation and decreased postoperative haze. Compared to photorefractive keratectomy (PRK), LASIK involves an additional procedure of creating a corneal flap. This may result in complications related to the flap, interface and underlying stromal bed. The common flap-related complications include thin flap, button holing, free caps, flap dislocation and flap striae. The interface complications of diffuse lamellar keratitis, epithelial ingrowth and microbial keratitis are potentially sight threatening. Compared to PRK, there is less inflammation and faster healing after LASIK, but there is a longer period of sensory denervation leading to the complication of dry eyes. The refractive complications include undercorrection, regression, irregular astigmatism, decentration and visual aberrations. Honest and unbiased reporting is important to understand the aetiology and redefine the management.