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Post Lasik Fungal Keratitis

Post Lasik Fungal Keratitis. Dr Foo Fong Yee Medical Officer Tan Tock Seng Hospital. 28/Bangladeshi/F CL wearer X 15 years OD:  4.5/ 2.5  3 OS:  4.5/ 3.0  175 BCVA OU 6/6 Uneventful LASIK 12.06.05. POD1 UAVA OU 6/6 R stromal opacity L SPK Gutt. tobradex TCU 1/52. History.

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Post Lasik Fungal Keratitis

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  1. Post Lasik Fungal Keratitis Dr Foo Fong Yee Medical Officer Tan Tock Seng Hospital

  2. 28/Bangladeshi/F CL wearer X 15 years OD: 4.5/ 2.5  3 OS: 4.5/ 3.0  175 BCVA OU 6/6 Uneventful LASIK 12.06.05 POD1 UAVA OU 6/6 R stromal opacity L SPK Gutt. tobradex TCU 1/52 History

  3. Stromal opacity post LASIK • Non-infective • Diffuse lamellar keratitis (SOS) • MK • Epithelial ingrowth • Infective • Bacterial – G+ve cocci, atypical mycobacteria • Fungal - HSV • Viral, reactivation of post-viral SEIs • Protozoal – microsporidial, rare

  4. UAVA OD 6/60 Mild conj injection Tiny areas of ED Conglomerate of SPK Flap in position Interface healthy AC trace cells UAVA OS 6/12 NAD except for trace SPK History • ? Defaulted f/u • P/w RE redness, irritation & BOV on POD 17

  5. OD Rx as for early keratitis Gutt. ofloxacin hourly Occ. ciloxan ON Gutt. homatropine bd Review following day OS Continue gutt. tobradex History

  6. OD VA 6/45 Superficial to 1/3 stromal feathery, filamentous infiltrate Flap edema Impression: fungal keratitis Scraped Started on gutt. natamycin ½ hourly OS ISQ Progression

  7. Gram stain (yeast, wall) Giemsa (cytoplasm) Gomori methanamine silver (hyphae) Potassium hydroxide (wall) Periodic acid-Schiff (wall) Acridine orange Calcofluor white Sabouraud dextrose agar @ room temp Blood agar @ room temp BHIB No cycloheximide Fungal stains & c/s media

  8. OD Stain – G+ve cocci, fungal elements Responded to treatment Infiltrate  in size and density OS Conglomerate of ED A/w surrounding stromal haze Started on ½ hourly natamycin as for fungal keratitits Progression Came to Singapore for 2nd opinion

  9. OD 6/60  6/30 Melted flap w button hole Infiltrate with surrounding scar AC cells + OS 6/12 Intra-lamellar infiltrate AC cells + In Singapore… • Bilateral scrapings done • Started on gutt. moxifloxacin hourly OD, 3hourly OS & gutt. amphotericin 0.5mg hourly OU

  10. OD OS In Singapore…

  11. Bilateral flap lifting, irrigation with moxifloxacin & amikacin 06.07.05 Added gutt. amikacin to moxifloxacin & amphotericin Bilateral flap amputation, irrigation with moxifloxacin & amikacin – OD 09.07.05, OS 12.07.05 Gutt. amikacin, moxifloxacin, natamycin Responded to treatment C/S: OD & OS penicillium Progress

  12. Penicillium sp. • Septate, filamentous fungi except Penicillium marneffei (dimophic) • Widespread in soil, decaying vegetation & the air • Corneal infections usually post traumatic • Mycotoxin, ochratoxin A  nephrotoxic and carcinogenic

  13. Progress OD  

  14. Progress OS  

  15. Progress • Moxifloxacin and amikacin tailed off over 1 month • Last TCU 05.10.05 (4/12 post LASIK): • VA OD 6/21 6/12 OS 6/21  6/12 • Bilateral central scar • Gutt. natamycin qds • Added gutt. FML qds

  16. Discussion • Risk of infectious keratitis post-LASIK 0.1-0.2%1 • Presentation varies considerably • Multiple foci/ single abscess, central/ peripheral, flap/ intralamellar/ flap melt • Risk factors: • LASIK devices e.g. microkeratomes & excimer lasers cannot be completely heat sterilized • Creation of new lamellar plane for organisms to invade • Corneal nerves disrupted • Use of topical steroids 1Bilateral infectious keratitis after LASIK: a case report & review of the literature. Ophthalmology 2001;108:121-5 1Fungal keratitis after LASIK. J Cataract Refract Surg 2000;26:613-15

  17. Discussion • Staphylococcus (acute) & atypical mycobacteria (subacute, infectious crystalline keratopathy) most common2 • Fungal not uncommon – candida, aspergillus, nattrassia mangiferae, acremonium, curvularia • Type of post-op Abx & steroid use not associated with particular infecting organism or severity of VA loss3 • Gram +ve more likely to present < 7days post LASIK • Mycobacterial more likely to present > 10 days post LASIK 2Infectious keratitis after LASIK. Results of an ASCRS survey. J Cataract Refract Surg 2003;29:2001-6 3infections following LASIK: an integration of the published literature. Surv Ophthalmol 2004;49:269-80

  18. Management • High index of suspicion • Acute vs sub-acute presentation • Flap lifting, scraping, staining and culture • Irrigation of stromal bed with Abx • G+ve: vancomycin 25mg/ml with moxifloxacin/ gatifloxacin • Atypical mycobacteria: amikacin/ clarithromycin 1% with moxifloxacin/ gatifloxacin • Flap amputation/ excision if necrotic/ button-hole  facilitaes Abx penetration • Therapeutic keratectomy/ PTK • PK for deep infections/ resistant to therapy

  19. Thank you A presentation by The Eye Institute @ Tan Tock Seng Hospital

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