Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis

1. Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis Troeber L, Loew U, Schirra F, Seitz B University of Saarland UKS Department of Ophthalmology Head of department: Prof. Dr. Berthold Seitz, F.E.B.O. The authors have no financial interest in the subject matter of this poster

2. Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis Introduction Today,Laser-in-situ-Keratomileusis (LASIK) is a well-established procedure to treat refractive errors and is usually performed on both eyes at the same day. Infectious diseases that bear the risk of loosing vision or potentially the eye should be avoided.

3. Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis Case-report A 19-year-old male who wanted to become policeman underwent LASIK on both eyes (preoperative refraction OD / OS -2.5 diopters). Three days after the operation he presented with OS > OD massive conjunctival redness and corneal infiltrates in the anterior stroma (interface) (fig.1a-c). Visual acuity was 0.6 on the right eye and 0.3p on the left eye. Topical treatment included Amphotericine B eyedrops (ED), Cefuroxime fortified 5 % ED, Tobramycine fortified 4.2% ED, Polymyxine B- Bacitracine- and Neomycine-ointment (Polyspectran®) at night. Intravenous therapy included Voriconazole (VFEND® ), Ceftriaxone (Rocephin®) and Doxycycline. We lifted the flap sequentially in both eyes and performed an interface-lavage with Vancomycine, Amphotericine B and Iodine 10%. After weeks the infiltrates converted to stable scars. Steroids (Prednisolone-acetate 1% ED) were added after a few days and therapy was tapered very slowly.

4. Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis Visual acuity improved to 1.25 on the right and 0.9 on the left eye despite multifocal paracentral scars persisting in the interface. With PCR (polymerase chain reaction) fusariumoxysporum was found. After the eyes had been treated over more than 2 months with Amphotericine B ED, Cefuroxime fortified 5% ED, Tobramycine fortified 4.2% ED, Polyspectran® ointment at night, Prednisolone-acetate 1% ED and HyloComod® ED, an infectious corneal infiltrate at 10 o`clock on the left eye relapsed after another 3 months (18.12.2008) unexpectedly (fig. 4 a-c). After intense topical and systemic treatment (table 1) it improved again and stayed stable until now (fig. 5a-c). Uncorrected visual acuity was 1.2 on the right eye and 1.0 on the left eye on 21st of september 2009.

5. Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis Conclusion Although LASIK is considered as a safe procedure today, it bears the risk of loosing vision and potentially the eye. However, timely adequate treatment (incl. flap-lifting) may result in good visual prognosis after iatrogenic fungal keratitis.

6. Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis Literature 1. Moshirfar M, Meyer JJ, Espandar L: Fourth-generation fluoroquinolone-resistant mycobacterial keratitis after laser in situ keratomileusis; J Cat Refract Surg 2007; 33(11):1978-81 2. Moshirfar M, Welling JD, Feiz H, Clinch TE: Infectious and noninfectious keratitis after laser in situ keratomileusis: Occurence, management and visual outcome; J Cat Refract Surg 2007; 33:474-483 3. Chen WL, Tsai YY, Lin JM, Chiang CC: Unilateral Candida parapsilosis interface keratitis after laser in situ keratomileusis: case report and review of the literature; Cornea 2009 Jan; 28(1):105-107 4. Chung MS, Goldstein MH, Driebe WT Jr, Schwartz B: Fungal keratitis after laser in situ keratomileusis: a case report; Cornea 2000 Mar; 19(2):236-237 5. Viestenz A, Behrens-Baumann W: Management of Post-refractive Infectious Keratitis; Cornea 2007; Touch Briefings: 73-76

7. Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis fig. 1c fig. 1b fig. 1a: 14.07.2008 OD: beginning paracentral corneal infiltrates 4 days after LASIK fig. 1b+c: 14.07.2008 OS: conjunctival redness, multiple fungal corneal infiltrates 4 days after LASIK in Germany fig. 2c fig. 2a: 17.07.2008 OD: paracentral corneal infiltrates before flap-lifting and interface-lavage, 7 days after LASIK fig. 2b fig. 2b+c: 15.07.2008 OS: distinct fungal corneal infiltrates with hypopyon one day after flap-lifting and interface-lavage

8. Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis fig. 3a: 10.12.2008 OD: paracentral corneal scars after 5 months of treatment of fungal keratitis after LASIK fig. 3b fig. 3c fig. 3b+c: 10.12.2008 OS: paracentral corneal scars after 5 months of treatment of fungal keratitis after LASIK fig. 4b fig. 4c fig. 4a fig. 4a-c: 18.12.2008 OS: relapse of fungal keratitis 3 months after stopping anti-infective treatment; new corneal infiltrate at 10 o`clock

9. Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis fig. 5a: 21.09.2009 OD: paracentral corneal scars 14 months after fungal keratitis after LASIK, uncorrected visual acuity 1.2 fig. 5c: 21.09.2009 OS: paracentral corneal scars 14 months after fungal keratitis after LASIK, (9 months after relapse of fungal keratitis), uncorrected visual acuity 1.0 fig. 5b: 21.09.2009 OD: corneal topographic analysis Pentacam (Oculus)

10. Bilateral iatrogenic fungal keratitis following Laser-in-situ-Keratomileusis table 1: development of visual acuity and therapy

11. leonie.troeber@email.de Thank you for your interest