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Outbreak of Post-LASIK Infectious Keratitis from Single Laser Center

Outbreak of Post-LASIK Infectious Keratitis from Single Laser Center . Takefumi Yamaguchi 1 , Yoshiko Hori-Komai 1 , Hiroko Bissen-Miyajima 2 , Yukihiro Matsumoto 3 , Kazuo Tsubota 3 , Jun Shimazaki 1,3

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Outbreak of Post-LASIK Infectious Keratitis from Single Laser Center

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  1. Outbreak of Post-LASIK Infectious Keratitis from Single Laser Center Takefumi Yamaguchi1, Yoshiko Hori-Komai1, Hiroko Bissen-Miyajima2, Yukihiro Matsumoto3, Kazuo Tsubota3, Jun Shimazaki1,3 1. Department of Ophthalmology, Ichikawa Hospital, Tokyo Dental College, Chiba, Japan 2. Department of Ophthalmology, Suidobashi Hospital, Tokyo Dental College, Tokyo, Japan 3. Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan The authors have no financial interest in any of the materials mentioned in the presentation.

  2. Introduction • Bacterial keratitis following laser-assisted in situ keratomileusis (LASIK) is a rare complication. • Between October 2008 and March 2009, we experienced an outbreak of infectious keratitis after LASIK performed by the same surgeon. • The Japanese health authorities reported an estimated number of infectious cases of 70, which is the largest in reported cases to our knowledge. The authorities reported the cause of this outbreak was nosocomial infection due to the improper sterilization procedures at the clinic in question.

  3. Purpose To elucidate the cause and characteristics of the outbreak of infectious keratitis after LASIK and to report clinical outcomes following the treatment.

  4. Methods • Questionnaire • Surgery and onset • Visual acuities • Characteristics • Microbiological profile • Treatment • Outcome Data collection In March 2009, we requested 12 major hospitals in the Tokyo Metropolitan area to report any recent cases of infectious keratitis originating from this particular LASIK clinic, using a standardized questionnaire. • Patients Thirty-nine eyes in 30 patients were identified as exhibiting post-LASIK infectious keratitis from 12 different hospitals. Mean age: 34 years (range, 18-64) Gender: Female/Male : 32/7 eyes No. of eyes Total 39 eyes A-K : Hospitals near Tokyo Metropolitan area.

  5. Number of patients, dates of surgery and onset The first patient involved in this outbreak underwent bilateral LASIK in September 2008. He then developed mycobacterial keratitis in October 2008. Despite the subsequent increase in the number of such cases in other patients treated at the same clinic, the surgeon continued to perform LASIK until the public health authorities launched an inquiry into the clinic and ordered him to stop in January 2009, resulting in a large-scale outbreak of post-LASIK infectious keratitis.

  6. Slit-lamp manifestation At initial presentation Hyperemia 33 eyes(84.6%) Epithelial defect 12eyes(30.8%) Granular infiltration 28eyes(71.8%) Multiple infiltration 26eyes(66.7%) Corneal edema29eyes(74.4%) Keratic precipitates 11eyes (28.2%) Hypopyon3eyes(7.7%) These manifestations were consistent with those of previous reports on mycobacterialinfection.

  7. Bacterialinvestigation Total 39 eyes Total 29 eyes No. of eyes No. of eyes Culture or stain examinations of corneal scrapings were performed in 29 eyes (76.7%). NP: Not performed The causative organisms were identified as Mycobacterium in 9 eyes (30.3%). No causative organism could be detected in 18 eyes (62.1%).

  8. Treatment Initial treatment at LASIK clinic • Topical (GFLX, TFLX, TOB) 100% • Flap lift and irrigation 56% • Systemic antibiotics (CMX) 28% Initial treatment could not prevent deterioration of the infection Resolution of the infection was obtained within 1 to 6 months of initial presentation. Representative case Treatment after referral • Topical (AMK, AMK, EM/CL etc.) 100% • Flap excision 41% • Systemic antibiotics (CAM etc.) 28% AMK: amikacin, ABK: arbekacin, EM/CL:erythromycin/colistin, GFLX: gatifloxacin, TFLX: tosufloxacin, TOB: tobramycin, CMX: cefmenoxime, CAM: clarithromycin,

  9. Visualoutcome Initial visual acuity after referral Final visual acuity Total 39 eyes Total 39 eyes No. of eyes No. of eyes Residual corneal scar was left in all eyes to varying degrees. Decimal visual acuity

  10. Discussion On antibiotics • The initial treatment by gatifloxaxin and tosufloxacin at the clinic did not prevent the development of keratitis, although topical fourth-generation fluoroquinolones have been reported to be more effective than third-generation for the treatment of mycobacterial keratitis. • Resistant mycobacterial infection wasreported in several cases. Fortified clarithromycin and amikacin might be effective in addition to fourth-generation fluoroquinolones in cases of this study.

  11. Discussion On the social issue of medical administration This study revealed the potential possibility of an epidemic infectious keratitis, which could not be detected until many patients were involved. Patients with severe infection were referred to many different hospitals, making it difficult for this outbreak to be detected. On visual outcome Final visual acuities in the cases in this study were almost the same as, or favorable compared with the previous studies.1,2

  12. Conclusion • Mycobacterium was identified as one of the causative organisms. • This multicenter study showed comparable outcomes to previous infectious reports. REFERENCES Chang MA, Jain S, Azar DT. Infections following laser in situ keratomileusis: an integration of the published literature. SurvOphthalmol 2004;49(3):269-80. John T, Velotta E. Nontuberculous (atypical) mycobacterial keratitis after LASIK: current status and clinical implications. Cornea 2005;24(3):245-55.

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