Diffuse lamellar keratitis associated with gonococcal keratoconjunctivitis 3 years after laser in situ keratomileusis

Diffuse lamellar keratitis after LASIK with low-energy femtosecond laser

PURPOSE

To evaluate the incidence, evolution, and prognosis of diffuse lamellar keratitis (DLK) in a large series of laser in situ keratomileusis (LASIK) with low-energy femtosecond laser.

SETTING

Private practice, Siena, Italy.

DESIGN

Retrospective, consecutive, noncomparative case series study.

METHODS

Single-use instruments, powder-free gloves, and no corneal marking were used. Flap was created by a low-energy femtosecond laser (Ziemer Z2 and Z4).

RESULTS

A total of 37 315 eyes of 19 602 patients were reviewed. DLK was observed in 236 eyes (0.63%) of 149 patients (0.76%). Grade 1 DLK was observed in 231 eyes of 142 patients, grade 2 in 1 eye: when treated with topical steroids, they had no visual consequences. Three patients had bilateral grade 3 to 4 DLK: one of them, with bilateral grade 3, despite flap lifting and irrigation worsened to stage 4 (central stroma thinning and flattening), partially recovered in 2 years, and underwent repeat femtosecond laser-assisted LASIK for hyperopic shift in 1 eye. In all the 5 eyes that developed grade 4 DLK, corneal thickness decreased until the first month and then partially recovered; mean final tissue loss at 1 to 2 years was 35 µm. Compensatory epithelial thickening was observed.

CONCLUSIONS

DLK after low-energy femtosecond laser-assisted LASIK is rare; severe DLK (stages 3 and 4) was found in only 6 eyes (0.016%). Flap lifting and irrigation might not prevent progression. Spontaneous reformation of stromal tissue and epithelial thickening improve visual acuity in the long term; residual hyperopic shift can be corrected by repeat femtosecond laser-assisted LASIK.

Late-onset diffuse lamellar keratitis following laser in situ keratomileusis

OBJECTIVE

To analyze 12 cases of late-onset diffuse lamellar keratitis (DLK) following uncomplicated LASIK and propose a method of management.

DESIGN

Retrospective observational case series, literature review.

PARTICIPANTS

Patients who developed late-onset DLK following LASIK.

METHODS

Retrospective chart review of all patients with late-onset DLK from January 2014 to August 2015. Data collected included demographic information, probable cause of DLK, stage of DLK, baseline examination, treatment, clinical course, outcomes, complications, and last follow-up examination. Review of relevant literature included searching for all prior cases and case series relating to "diffuse lamellar keratitis," "late-onset DLK," "Secondary Sands," and "delayed-onset DLK" by searching PubMed with these search terms.

RESULTS

Twelve eyes of 11 patients presented with late-onset DLK following LASIK. Onset ranged from 8 months to 17 years following LASIK. Stage of DLK ranged from stage I to III, and all patients responded well to aggressive corticosteroids without lifting of the LASIK flap. Final visual acuity for stage I/II and III eyes did not demonstrate a significant difference (p = 0.218). DLK resolved by a mean of 4.86 weeks for all eyes.

CONCLUSION

Late-onset DLK can present at any time following LASIK with a wide range of inciting factors causing a nonspecific (and likely immune-related) inflammatory reaction. Based on our findings, aggressive oral and topical corticosteroids should be tried before lifting the LASIK flap as long as infection is not suspected or inciting debris is not seen in the flap because the vast majority resolve with such therapy.

LASIK interface keratitis: epidemiology, diagnosis and care

PURPOSE OF REVIEW

Diffuse lamellar keratitis (DLK) is one of the more common interface complications occurs after laser in-situ keratomileusis (LASIK). The diagnosis can sometimes be challenging, as the differential diagnosis includes infectious keratitis, which requires a completely different treatment compared to DLK. This review assesses our current knowledge of the epidemiology, diagnosis and treatment of DLK.

RECENT FINDINGS

DLK occurs during the immediate postoperative period, but there are also late-onset cases. Early cases can occur in outbreaks, related to exogenous factors. Late-onset cases are most often related to inciting factors. Over time, case reports and series have reported DLK onset occurring further after surgery. It is probable that additional inciting factors will also be reported over time. Visual outcomes following DLK tend to be good when the condition is diagnosed properly and treated with intensive topical or systemic steroids, possibly combined with interface irrigation.

SUMMARY

DLK is a well recognized and well described complication occurring after LASIK. Associated inciting and risk factors and treatment algorithms have been described, but additional questions remain. Our knowledge and our patients will benefit from further research and development of evidence-based treatments.