Infection After LASIK
Infection is a potentially serious complication of LASIK. Patients with post-LASIK infection typically present with vision loss and pain. Infection may progress to flap melt, requiring amputation of the flap. Severe cases of post-LASIK infection may lead to intraocular infection known as endophthalmitis.
Sources of contamination include the ocular flora, any instruments or sponges used during surgery, the surgeon’s hands, blades from the first eye reused on the 2nd eye, or airborne contaminants.
Infection is treated with antibiotics. Dense scarring, as shown above, results in permanent visual impairment or legal blindness. Some cases of post-LASIK infection require a corneal transplant.
OSN SuperSite Top Story 4/5/2008
Latest ASCRS survey finds MRSA has risen to top of list of infection culprits
From the article: "Methicillin-resistant Staphylococcus aureus has emerged as the most common infection occurring after LASIK and surface ablation procedures, according to survey results evaluating trends in infectious keratitis throughout 2007."
Meeting the Challenge of Bacterial Resistance - Review of Ophthalmology 05/2008
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.]
From the full text:
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.
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.
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.
Infections following laser in situ keratomileusis: an integration of the published literature.
Surv Ophthalmol. 2004 May-Jun;49(3):269-80.
Chang MA, Jain S, Azar DT.
Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Infections occurring after laser in situ keratomileusis (LASIK) surgery are uncommon, but the number of reports have steadily increased in recent years. This systematic, comprehensive review and analysis of the published literature has been performed in order to develop an integrative perspective on these infections. We have stratified the data by potential associations, microbiology, treatment, and the degree of visual loss, using Fisher's exact tests and Student's t-tests for analysis. In this review, we found that Gram-positive bacteria and mycobacterium were the most common causative organisms. Type of postoperative antibiotic and steroid use was not associated with particular infecting organisms or severity of visual loss. Gram-positive infections were more likely to present less than 7 days after LASIK, and they were associated with pain, discharge, epithelial defects, and anterior chamber reactions. Fungal infections were associated with redness and tearing on presentation. Mycobacterial infections were more likely to present 10 or more days after LASIK surgery. Moderate or severe visual reductions in visual acuity occurred in 49.4% of eyes. Severe reductions in visual acuity were significantly more associated with fungal infections. Flap lift and repositioning preformed within 3 days of symptom onset may be associated with better visual outcome.
Methicillin-resistant Staphylococcus aureus infectious keratitis following refractive surgery.
Am J Ophthalmol. 2007 Apr;143(4):629-34.
Solomon R, Donnenfeld ED, Perry HD, Rubinfeld RS, Ehrenhaus M, Wittpenn JR Jr, Solomon KD, Manche EE, Moshirfar M, Matzkin DC, Mozayeni RM, Maloney RK.
Ophthalmic Consultants of Long Island, Rockville Centre, New York 11570, USA.
PURPOSE: To elucidate risk factors, clinical course, visual outcomes, and treatment of culture-proven methicillin-resistant Staphylococcus aureus (MRSA) infectious keratitis following refractive surgery.
DESIGN: Interventional case series.
METHODS: Multicenter chart review of 13 cases of MRSA keratitis following refractive surgery and literature review.
RESULTS: Thirteen eyes of 12 patients, nine of whom were either healthcare workers or exposed to a hospital surgical setting, developed MRSA keratitis following refractive surgery. All patients presented with a decrease in visual acuity and complaints of pain or irritation in the affected eye. Common signs on slit-lamp biomicroscopy were corneal epithelial defects, focal infiltrates with surrounding edema, conjunctival injection, purulent discharge, and hypopyon. All patients were diagnosed with infectious keratitis on presentation and treated with two antibiotics. All eyes were culture-positive for MRSA.
CONCLUSIONS: According to a computerized MEDLINE literature search, this is the first case series of MRSA infectious keratitis following refractive surgery, the first reports of MRSA keratitis after refractive surgery in patients with no known exposure to a healthcare facility, the first report of MRSA keratitis after a laser in situ keratomileusis (LASIK) enhancement, and the first reports of MRSA keratitis after prophylaxis with fourth-generation fluoroquinolones. MRSA keratitis is a serious and increasing complication following refractive surgery. Patients with exposure to a healthcare environment should be considered at additional risk for developing MRSA keratitis. However, in addition, surgeons should now be vigilant for community-acquired MRSA. Prompt identification with culturing and appropriate treatment of MRSA keratitis after refractive surgery is important to improve visual rehabilitation.
Unilateral Fungal and Mycobacterial Keratitis After Simultaneous Laser In Situ Keratomileusis
Cornea 2003; 22(1):72-75
Mona Pache, M.D.; Isac Schipper, M.D.; Josef Flammer, M.D.; Peter Meyer, M.D.
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. (Full cornea transplant.)
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.
Shewanella putrefaciens keratitis in the lamellar bed 6 years after LASIK.
J Refract Surg. 2007 Oct;23(8):830-2.
Park HJ, Tuli SS, Downer DM, Gohari AR, Shah M.
PURPOSE: To present a case of infectious keratitis occurring 6 years after LASIK due to the rare human pathogen Shewanella putrefaciens.
METHODS: A 58-year-old man presented with redness and pain in the right eye 6 years following LASIK retreatment. Examination revealed a corneal infiltrate at the flap interface. Corneal scraping of stroma beneath the flap was submitted for histopathologic and microbiologic evaluation.
RESULTS: An infiltrate located at the LASIK flap interface originated from an epithelial defect at the flap-corneal junction. Corneal stroma cultures demonstrated Shewanella putrefaciens. The infection resolved with antibiotic treatment.
CONCLUSIONS: LASIK-related complications, such as infections, can occur many years following the procedure. The potential space created under the LASIK flap may predispose patients to infection by opportunistic organisms.
Fourth-generation fluoroquinolone-resistant mycobacterial keratitis after laser in situ keratomileusis.
J Cataract Refract Surg. 2007 Nov;33(11):1978-81. Moshirfar M, Meyer JJ, Espandar L.
We report a case of mycobacterial keratitis resistant to fourth-generation fluoroquinolones after laser in situ keratomileusis (LASIK) with fourth-generation fluoroquinolone prophylaxis. While receiving moxifloxacin post LASIK, the patient was diagnosed with moxifloxacin-resistant Mycobacterium chelonae keratitis. Culture susceptibilities revealed isolates resistant to moxifloxacin and gatifloxacin, and treatment with topical amikacin and clarithromycin with oral doxycycline and clarithromycin along with flap amputation was necessary to control the infection. This case demonstrates the potential limitations in the coverage of these antibiotic agents.
Aspergillus fumigatus keratitis following laser in situ keratomileusis.
J Cataract Refract Surg. 2007 Oct;33(10):1806-7. Sun Y, Jain A, Ta CN.
A 31-year-old woman developed pain, decreased vision, and a corneal flap infiltrate 4 days following laser in situ keratomileusis (LASIK). Treatment with topical antibiotic agents did not improve the symptoms. Approximately 2 weeks after surgery, the patient was referred to Stanford University, with 20/400 visual acuity in the left eye and a stromal infiltrate posterior to the flap. Cultures demonstrated Aspergillus fumigatus sensitive to voriconazole. The corneal ulcer progressed despite aggressive antifungal treatment, requiring amputation of the corneal flap and daily debridement. The infiltrate resolved in response to topical voriconazole, natamycin, and oral voriconazole. Aspergillus fumigatus keratitis is a rare but serious complication of LASIK surgery. The infection was successfully treated with flap amputation and daily debridement in addition to antifungal therapy.
Bilateral deep anterior lamellar keratoplasty for the management of bilateral post-LASIK mycobacterial keratitis.
J Cataract Refract Surg. 2007 Sep;33(9):1641-3. Susiyanti M, Mehta JS, Tan DT.
Singapore National Eye Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
A 25-year-old Vietnamese man who had bilateral simultaneous laser in situ keratomileusis (LASIK) for moderate myopia developed bilateral Mycobacterium abscessus keratitis that was treated with intensive medical therapy, flap removal, superficial keratectomy, and, following disease progression, therapeutic deep anterior lamellar keratoplasty (DALK). To our knowledge, this is the first reported case of bilateral post-LASIK mycobacterial keratitis successfully treated with DALK.
A cluster of Nocardia keratitis after LASIK.
J Refract Surg. 2007 Mar;23(3):309-12.
Garg P, Sharma S, Vemuganti GK, Ramamurthy B. Cornea and Anterior Segment Service, L V Prasad Eye Institute, Hyderabad, India. prashant@lvpei.org
PURPOSE: To report a cluster of Nocardia asteroides keratitis cases after LASIK.
METHODS: Retrospective review of the history and examination of three patients (four eyes) operated on the same day at a single center who developed postoperative keratitis. All patients underwent lifting of the superficial flap for microbiologic evaluation of the corneal scrapings. The operating surgeon was contacted to identify the possible source of contamination.
RESULTS: Two patients underwent simultaneous bilateral LASIK; however, only one developed postoperative keratitis in both eyes. One patient had unilateral surgery and developed keratitis in the operated eye. Microscopic examination of smears from all eyes revealed thin, branching, acid-fast, filamentous bacteria that were identified as Nocardia asteroides after culture. The infiltrates resolved with topical administration of amikacin sulphate (2.5%) and topical and oral trimethoprim-sulfamethoxazole. Final visual acuity ranged between 20/25 and 20/80. The operating surgeon had used the same blade and microkeratome in all patients.
CONCLUSIONS: Nocardia, a relatively unusual organism, can cause an epidemic of infection after LASIK.
Acanthamoeba keratitis after LASIK.
J Refract Surg. 2006 Jun;22(6):616-7.
Balasubramanya R, Garg P, Sharma S, Vemuganti GK.
Cornea & Anterior Segment Service, L. V. Prasad Eye Institute, Hyderabad, India.
PURPOSE: To report a case of Acanthamoeba infection following LASIK.
METHODS: A 20-year-old woman developed pain, redness, decreased vision, and corneal infiltrate in the right eye 15 days after bilateral LASIK. She did not use contact lenses postoperatively. Patient examination 3 months after surgery revealed a large, central, full-thickness corneal infiltrate with multiple satellite lesions in the right eye. Corneal scrapings were taken and the flap excised, and submitted for histopathologic examination.
RESULTS: Microscopic examination of smears revealed Acanthamoeba cysts and non-nutrient agar showed a significant growth of Acanthamoeba. Histopathology examination of the excised flap demonstrated numerous Acanthamoeba cysts in tissue sections. The infiltrate was treated with a combination of topical polyhexamethylene biguanide, chlorhexidine, atropine sulfate, and oral itraconazole and resolved within 2 months.
CONCLUSIONS: Laser in situ keratomileusis can be complicated by Acanthamoeba infection. Microbiologic evaluation is essential for accurate early diagnosis and treatment.
Endophthalmitis after astigmatic myopic laser in situ keratomileusis.
J Cataract Refract Surg. 1997 Jul-Aug;23(6):948-50. Mulhern MG, Condon PI, O'Keefe M. Department of Ophthalmology, Mater Private Hospital, Dublin, Ireland.
A 36-year-old woman had uneventful astigmatic myopic laser in situ keratomileusis (LASIK) to correct -12.00 -1.50 x 70. Three days later, she developed a corneal abscess, hypopyon, and an intense vitreous cellular reaction-endophthalmitis. The patient was immediately given intravenous ciprofloxacin and topical vancomycin and ceftazidime. The infecting organism was Streptococcus pneumoniae. One day after therapy was instituted, the hypopyon resolved. Seven months later, best corrected visual acuity was 20/25 and refractive error, -4.00 diopters. A stromal scar (grade 2 haze) was causing a slight reduction in acuity. Endophthalmitis after LASIK, if treated promptly, need not lead to a permanent reduction in visual acuity.
Disclaimer: The information contained on this web site is presented for the purpose of warning people about LASIK complications prior to surgery. LASIK patients experiencing problems should seek the advice of a physician.