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Liu J, Guo X, Wei Z, Zhang Y, Zhang Z, Xu X, Liang Q. Infectious Keratitis After Keratorefractive Surgery: Update and Review of the Literature. Eye Contact Lens 2023; 49:275-282. [PMID: 37166228 PMCID: PMC10281179 DOI: 10.1097/icl.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To summarize the clinical manifestations, microbiological profile, treatment, and prognosis of corneal infections after different keratorefractive surgery. METHODS To obtain relevant studies, English-language databases, including PubMed, Ovid Embase, Web of Science, and CLNAHL, were searched from January 1979 to March 2022. The fundamentals of the literature, clinical characteristics, pathogens, and treatments were retrieved for each included article. RESULTS Eighty-four studies involving 306 infectious eyes were included in this review. Risk factors of potential infection included a history of blepharitis, contact lens usage, and contaminated surgical instruments. The mean onset time was 22.9±38.7 days (range: 1 day to 3 years). The most common organism isolated from infectious keratitis after keratorefractive surgery were Staphylococcus aureus , followed by Mycobacterium and coagulase-negative Staphylococcus . Most of the infections after refractive procedures were sensitive to medical treatment alone, and the ultimate best-corrected visual acuity after medical treatment was as follows: 20/20 or better in 82 cases (37.0%), 20/40 or better in 170 cases (76.5%), and worse than 20/40 in 52 cases (23.5%). Surgical interventions including flap lift, flap amputation, ring removal, and keratoplasty were performed in 120 eyes (44.5%). CONCLUSIONS Most infections after keratorefractive surgery occur within a week, whereas more than half of the cases after laser-assisted in situ keratomileusis happen after about a month. Gram-positive cocci and mycobacterium are the most common isolates. Infections after LASIK, intracorneal ring (ICR) implantation, and small incision lenticule extraction, which primarily occur between the cornea layers, require irrigation of the tunnels or pocket with antibiotics.
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Affiliation(s)
- Jiamin Liu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Xiaoyan Guo
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Zhenyu Wei
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Yuheng Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Zijun Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Xizhan Xu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Qingfeng Liang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
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Afsharpaiman S, Zare M, Yasemi M, Jamialahmadi T, Sahebkar A. The Prevalence of Infectious Keratitis after Keratorefractive Surgery: A Systematic Review and Meta-Analysis Study. J Ophthalmol 2020; 2020:6329321. [PMID: 32774907 PMCID: PMC7407012 DOI: 10.1155/2020/6329321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/24/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The keratorefractive surgeries (KRS) are one of the most common ocular surgeries. One of the dangerous complications of these surgeries is infectious keratitis (IK), which is the second cause of blindness after cataract surgery. The purpose of this study was to estimate the prevalence of IK after KRS in different parts of the world. METHODS In order to obtain relevant studies, all national and international databases including IranMedex, SID, Magiran, IranDoc, Medlib, ScienceDirect, PubMed, Scopus, Cochrane, Embase, Web of Science, and Google Scholar were searched using standard keywords. RESULTS IK prevalence after KRS was 0.000496% (0.000145% for the left eye and 0.000149% for the right eye). IK prevalence after KRS in the United States, Europe, and Asia was 0.000667%, 0.000473%, and 0.000045%, respectively, in all of which the common microorganisms were Staphylococci. Meta-regression showed no significant association between IK after KRS and either sample size or publication year of the studies. IK prevalence after KRS in the right eye was more than that in the left one. Also, the probability of IK incidence after LASIK surgery was more than PRK and LASEK. In the evaluation of continents, IK after KRS in the United States was more frequent compared with Europe and Asia. CONCLUSIONS This study provided data as to the overall prevalence of IK following KRS and its variations according to the types of eye, surgery, pathogenic microorganism, and geographical location.
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Affiliation(s)
- Shahla Afsharpaiman
- Health Research Center, Life Style Institute, Bagiyatallah University of Medical Sciences, Tehran, Iran
| | - Musa Zare
- Department of Ophthalmology, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Masoud Yasemi
- Health Research Center, Life Style Institute, Bagiyatallah University of Medical Sciences, Tehran, Iran
| | - Tannaz Jamialahmadi
- Department of Food Science and Technology, Quchan Branch, Islamic Azad University, Quchan, Iran
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Halal Research Center of IRI, FDA, Tehran, Iran
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Very late-onset flap margin corneal ulcer following laser in situ keratomileusis. Int Ophthalmol 2019; 39:2533-2538. [PMID: 30982142 DOI: 10.1007/s10792-019-01100-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To report and characterize cases of very late onset (5 years or more after surgery) flap margin corneal ulcers after laser in situ keratomileusis (LASIK) procedure. METHODS A retrospective case series of consecutive patients who were diagnosed with very late flap margin corneal ulcers following LASIK, between January 2014 and July 2017. All patients were treated with topical antibiotics and were followed up until complete resolution. RESULTS A total of eight patients, with a mean age of 46.5 ± 11 years, (range 31-64 years), were included in this study. All patients underwent uneventful myopic LASIK 13.3 ± 3 (range 10-20) years before presentation. Patients best corrected visual acuity (BCVA) at presentation was 0.20 ± 0.15 logMAR compared to a final BCVA of 0.10 ± 0.10 logMAR (p = 0.28). The ulcer was located in the bottom two clock hours of the flap margin (5-7 o'clock) in six (75%) patients and superior (11 o'clock) in the remaining two patients (p = 0.048). Seven patients (87.5%) suffered from blepharitis, and only one did not. CONCLUSIONS LASIK may be associated with an increased risk of late-onset corneal ulcer occurring years after the procedure. Instability of the flap margin, blepharitis and dry eye are possible causes of epithelial disturbance and may account for this complication.
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Schicht M, Garreis F, Hartjen N, Beileke S, Jacobi C, Sahin A, Holland D, Schröder H, Hammer CM, Paulsen F, Bräuer L. SFTA3 - a novel surfactant protein of the ocular surface and its role in corneal wound healing and tear film surface tension. Sci Rep 2018; 8:9791. [PMID: 29955092 PMCID: PMC6023927 DOI: 10.1038/s41598-018-28005-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/11/2018] [Indexed: 11/08/2022] Open
Abstract
The study aimed to characterize the expression and function of SFTA3 at the ocular surface and in tears. Ocular tissues, conjunctival (HCjE) and human corneal (HCE) epithelial cell lines as well as tearfilm of patients suffering from different forms of dry eye disease (DED) were analyzed by means of RT-PCR, western blot, immunohistochemistry, and ELISA. A possible role of recombinant SFTA3 in corneal wound healing was investigated performing in vitro scratch assays. Tear film regulatory properties were analyzed with the spinning drop method and the regulation of SFTA3 transcripts was studied in HCE and HCjE after incubation with proinflammatory cytokines as well as typical ocular pathogens by real-time RT-PCR and ELISA. The results reveal that human ocular tissue as well as tears of healthy volunteers express SFTA3 whereas tears from patients with DED showed significantly increased SFTA3 levels. In vitro wounding of HCE cell cultures that had been treated with recombinant SFTA3 demonstrated a significantly increased wound closure rate and rSFTA3 reduced the surface tension of tear fluid. The results indicate that SFTA3 at the ocular surface seemed to be involved in wound healing and the reduction of surface tension.
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Affiliation(s)
- Martin Schicht
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Fabian Garreis
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Nadine Hartjen
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stephanie Beileke
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christina Jacobi
- Department of Ophthalmology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Ophthalmological Practice Tibarg, Hamburg, Germany
| | - Afsun Sahin
- Department of Ophthalmology, Eskisehir Osmangazi University Hospital, Eskisehir, Turkey
| | | | - Henrik Schröder
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christian M Hammer
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Friedrich Paulsen
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Lars Bräuer
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Refractive Errors & Refractive Surgery Preferred Practice Pattern®. Ophthalmology 2018; 125:P1-P104. [DOI: 10.1016/j.ophtha.2017.10.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/02/2017] [Indexed: 11/19/2022] Open
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Ide T, Kurosaka D, Senoo T, Kinoshita S, Ohashi Y, Inoue Y, Tsubota K. First multicenter survey on infectious keratitis following excimer laser surgery in Japan. Taiwan J Ophthalmol 2014. [DOI: 10.1016/j.tjo.2014.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Lyall DA, Srinivasan S, Roberts F. A case of interface keratitis following anterior lamellar keratoplasty. Surv Ophthalmol 2012; 57:551-7. [PMID: 22542911 DOI: 10.1016/j.survophthal.2012.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Revised: 01/26/2012] [Accepted: 01/31/2012] [Indexed: 11/29/2022]
Abstract
Anterior lamellar keratoplasty (ALK) is indicated in patients with anterior corneal opacities. Benefits over penetrating keratoplasty include quicker visual rehabilitation, less postoperative astigmatism, and preservation of the host endothelium, thus minimizing the chances of graft rejection. A rare complication of lamellar corneal surgery is infectious interface keratitis between the donor and host tissue. We report a case of infectious interface keratitis following automated ALK successfully treated medically and by removal of the ALK disk, eventually having a deep anterior lamellar keratoplasty with good visual recovery.
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Affiliation(s)
- Douglas A Lyall
- Department of Ophthalmology, Ayr University Hospital, Ayr, Scotland, UK
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8
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Solomon R, Donnenfeld ED, Holland EJ, Yoo SH, Daya S, Güell JL, Mah FS, Scoper SV, Kim T. Microbial keratitis trends following refractive surgery: results of the ASCRS infectious keratitis survey and comparisons with prior ASCRS surveys of infectious keratitis following keratorefractive procedures. J Cataract Refract Surg 2011; 37:1343-50. [PMID: 21700112 DOI: 10.1016/j.jcrs.2011.05.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 03/03/2011] [Accepted: 03/15/2011] [Indexed: 10/18/2022]
Abstract
In 2008, the American Society of Cataract and Refractive Surgery (ASCRS) surveyed its 9121 United States and international members to evaluate the changing trends and incidence, culture results, treatment, and visual outcomes of infectious keratitis following keratorefractive procedures worldwide. This paper presents and analyzes the results with comparisons to the data in surveys conducted in 2001 and 2004. Nineteen infections were reported by 14 surgeons who had performed an estimated 20,941 keratorefractive procedures, an incidence of 1 infection in every 1102 procedures. Sixteen cases presented in the first postoperative week, 1 case during the second week, 1 case between the second and fourth weeks, and 1 case at 1 month or later. The 16 cases that presented in the first week were diagnosed at initial presentation. The most common organism cultured was methicillin-resistant Staphylococcus aureus (MRSA). Microbial keratitis following refractive surgery is an increasingly recognized sight-threatening complication.
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Affiliation(s)
- Renée Solomon
- Department of Ophthalmology, NYU Medical Center, New York, New York, USA.
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Merayo-Lloves J, Blanco-Mezquita T, Ibares-Frías L, Cantalapiedra-Rodríguez R, Alvarez-Barcia A. Efficacy and safety of short-duration topical treatment with azithromycin oil-based eyedrops in an experimental model of corneal refractive surgery. Eur J Ophthalmol 2010; 20:979-88. [PMID: 20544676 DOI: 10.1177/112067211002000612] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2010] [Indexed: 11/15/2022]
Abstract
PURPOSE To assess the tolerance and side effects of azithromycin eyedrops at the ocular surface after corneal refractive surgery in an experimental animal model. METHODS The effect of azithromycin eyedrops was evaluated in hen corneas that underwent laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) surgery in 1 eye, using the fellow eye (not manipulated) as a control. Animals were treated bid 3 days prior to surgery and 3 days after surgery with T1225 1.5% azithromycin eyedrops or saline eyedrops (balanced salt solution), or were left untreated as a control. Clinical course and cell biology (apoptosis, proliferation, and differentiation) measurements were assessed. RESULTS Infections were present in the following proportions of corneas operated on by LASIK: 0% treated with azithromycin, 60% treated with BSS, and 30% untreated. No corneal abscess or keratitis were present in any PRK or unmanipulated corneas. Conjunctival edema and redness were less prevalent in LASIK-operated eyes treated with azithromycin than in BSS-treated or untreated eyes and were not observed in any PRK or unmanipulated corneas. In PRK-operated eyes treated with azithromycin, a decrease was observed in the apoptosis and an increase in the stromal proliferation. There were no differences in these parameters for LASIK and unmanipulated eyes. CONCLUSIONS Topical administration of T1225 oil-based azithromycin eyedrops was well tolerated in both unmanipulated hen corneas and those treated with corneal refractive surgery (PRK and LASIK). T1225 demonstrated a potent antibiotic effect after LASIK treatment.
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Affiliation(s)
- Jesús Merayo-Lloves
- Instituto Universitario de Oftalmobilogía Aplicada (IOBA), Valladolid, Spain.
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Jäger K, Garreis F, Posa A, Dunse M, Paulsen FP. Functional relationship between cationic amino acid transporters and beta-defensins: implications for dry skin diseases and the dry eye. Ann Anat 2010; 192:65-9. [PMID: 20307963 DOI: 10.1016/j.aanat.2010.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 01/23/2010] [Indexed: 12/30/2022]
Abstract
The ocular surface, constantly exposed to environmental pathogens, is particularly vulnerable to infection. Hence an advanced immune defence system is essential to protect the eye from microbial attack. Antimicrobial peptides, such as beta-defensins, are essential components of the innate immune system and are the first line of defence against invaders of the eye. High concentrations of L-arginine and L-lysine are necessary for the expression of beta-defensins. These are supplied by epithelial cells in inflammatory processes. The limiting factor for initiation of beta-defensin production is the transport of L-arginine and L-lysine into the cell. This transport is performed to 80% by only one transporter system in the human, the y(+)-transporter. This group of proteins exclusively transports the cationic amino acids L-arginine, L-lysine and L-ornithine and is also known under the term cationic amino acid transporter proteins (CAT-proteins). Various infections associated with L-arginine deficiency (for example psoriasis, keratoconjuctivitis sicca) are also associated with an increase in beta-defensin production. For the first time, preliminary work has shown the expression of human CATs in ocular surface epithelia and tissues of the lacrimal apparatus indicating their relevance for diseases of the ocular surface. In this review, we summarize current knowledge on the human CATs that appear to be integrated in causal regulation cascades of beta-defensins, thereby offering novel concepts for therapeutic perspectives.
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Affiliation(s)
- Kristin Jäger
- Department of Anatomy and Cell Biology, Martin Luther University of Halle-Wittenberg, Grosse Steinstrasse 52, D-06097 Halle/Saale, Germany.
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Garg P, Chaurasia S, Vaddavalli PK, Muralidhar R, Mittal V, Gopinathan U. Microbial Keratitis After LASIK. J Refract Surg 2010; 26:209-16. [DOI: 10.3928/1081597x-20100224-07] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2008] [Accepted: 04/02/2009] [Indexed: 11/20/2022]
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Abstract
PURPOSE To report 4 cases of flap margin-related corneal ulcer that developed 5 years after laser in situ keratomileusis (LASIK) procedures. METHODS We retrospectively documented the clinical and laboratory characteristics of all patients between 2004 and 2008 who presented with LASIK-related corneal ulcer that appeared >5 years postoperatively. The 4 patients who had this condition were 25-, 33-, 61-, and 62-year-old males. RESULTS Two patients had cultures positive to Staphylococcus aureus and Streptococcus epidermidis. Two ulcers healed after standard fortified topical antibiotic regimen, 1 ulcer healed after treatment with moxifloxacin, and the fourth healed after treatment with lomefloxacin. All cases presented 5 years after the LASIK procedure. CONCLUSIONS LASIK procedures can be associated with the risk of corneal infection even years later. The mechanism may be flap margin instability causing epithelial defense barrier disturbance.
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13
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Minsel I, Mentlein R, Sel S, Diebold Y, Bräuer L, Mühlbauer E, Paulsen FP. Somatostatin actions via somatostatin receptors on the ocular surface are modulated by inflammatory processes. Endocrinology 2009; 150:2254-63. [PMID: 19106227 DOI: 10.1210/en.2008-0577] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Recent investigations support the presence of human somatostatin (SS) in the excretory system of the human lacrimal gland. To get deeper insights into a possible role of SS at the ocular surface and in the lacrimal apparatus, we investigated the distribution pattern of SS and its receptors 1-5 (SSTR1-5) by means of RT-PCR, real-time RT-PCR, Western blot and immunodot blot analysis as well as immunohistochemistry in lacrimal gland, tear fluid, conjunctiva, cornea, nasolacrimal duct epithelium, and conjunctival (HCjE) and corneal (HCE) epithelial cell lines. Cell culture experiments with HCjE and HCE were performed to analyze a possible impact of SS and inflammatory mediators on the regulation of SSTR. The results confirmed the presence of SS in lacrimal gland and tear fluid, whereas it was absent at the protein level in all other tissues and cell lines investigated. Expression of SSTR1, -2, and -5 was detectable in lacrimal gland, conjunctiva, cornea, and nasolacrimal ducts. HCjE expressed only hSSTR1 and -2, and HCE revealed only SSTR2. SSTR3 and -4 were not detected in any of the analyzed samples or cell lines. In vitro on cultured immortalized HCjE cells SS leads to a concentration-dependent down-regulation of SSTR1 mRNA but does not affect SSTR2 mRNA expression. Relative expression of SSTR1 and -2 is differentially modulated by proinflammatory cytokines and bacterial components, suggesting that the expression of both receptors is immunomodulated. Our data support an autocrine and paracrine role of SS in the lacrimal system and at the ocular surface and implicate a role of SS in corneal immunology.
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Affiliation(s)
- Ivonne Minsel
- Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Grosse Steinstrasse 52, D-06097 Halle (Saale), Germany
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Paulsen F, Jäger K, Worlitzsch D, Bräuer L, Schulze U, Schäfer G, Sel S. Regulation of MUC16 by inflammatory mediators in ocular surface epithelial cell lines. Ann Anat 2008; 190:59-70. [DOI: 10.1016/j.aanat.2007.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Revised: 05/23/2007] [Accepted: 05/26/2007] [Indexed: 10/22/2022]
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Solomon R, Donnenfeld ED, Perry HD, Rubinfeld RS, Ehrenhaus M, Wittpenn JR, Solomon KD, Manche EE, Moshirfar M, Matzkin DC, Mozayeni RM, Maloney RK. Methicillin-resistant Staphylococcus aureus infectious keratitis following refractive surgery. Am J Ophthalmol 2007; 143:629-34. [PMID: 17320811 DOI: 10.1016/j.ajo.2006.12.029] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2005] [Revised: 12/13/2006] [Accepted: 12/17/2006] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Renée Solomon
- Ophthalmic Consultants of Long Island, Rockville Centre, New York 11570, USA
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16
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de Oliveira GC, Solari HP, Ciola FB, Lima ALH, Campos MS. Corneal Infiltrates After Excimer Laser Photorefractive Keratectomy and LASIK. J Refract Surg 2006; 22:159-65. [PMID: 16523835 DOI: 10.3928/1081-597x-20060201-14] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine the frequency and clinical characteristics of corneal infiltrates after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) and to evaluate the efficacy of treatment. METHODS We retrospectively reviewed the records of 8508 eyes treated with PRK or LASIK in a university-based clinic for the correction of refractive errors for 60 days postoperatively. RESULTS Corneal infiltrates were observed in 35 (0.8%) of 4492 PRK-operated eyes and in 4 (0.1%) of 4016 LASIK-operated eyes. The mean time of diagnosis was 5.46 days. Among the 39 eyes with infiltrates, 10 (9 PRK, 1 LASIK) had culture-verified infectious keratitis. Coagulase-negative Staphylococcus was the most frequently isolated bacterium (50%), followed by S aureus (20%), Corynebacterium xerosis (10%), Streptococcus viridans (10%), and an unidentified gram-positive coccus (10%). Final visual acuity of > or = 20/30, without correction, was achieved in 79.5% of the 39 eyes. CONCLUSIONS Corneal infiltrates occurred in 0.8% of PRK eyes and 0.1% of LASIK eyes. Bacterial smears were positive for several eyes. In all cases, prompt treatment was responsible for good visual outcome.
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Affiliation(s)
- Giselle C de Oliveira
- Sector of Refractive Surgery, Department of Ophthalmology, Federal University of São Paulo, Paulista School of Medicine, São Paulo, Brazil
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Chang MA, Jain S, Azar DT. Infections following laser in situ keratomileusis: an integration of the published literature. Surv Ophthalmol 2004; 49:269-80. [PMID: 15110665 DOI: 10.1016/j.survophthal.2004.02.007] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Margaret A Chang
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Albietz JM, Lenton LM. Management of the Ocular Surface and Tear Film Before, During, and After Laser in situ Keratomileusis. J Refract Surg 2004; 20:62-71. [PMID: 14763473 DOI: 10.3928/1081-597x-20040101-11] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To identify evidence-based, best practice strategies for managing the ocular surface and tear film before, during, and after laser in situ keratomileusis (LASIK). METHODS After a comprehensive review of relevant published literature, evidence-based recommendations for best practice management strategies are presented. RESULTS Symptoms of ocular irritation and signs of dysfunction of the integrated lacrimal gland/ocular surface functional gland unit are common before and after LASIK. The status of the ocular surface and tear film before LASIK can impact surgical outcomes in terms of potential complications during and after surgery, refractive outcome, optical quality, patient satisfaction, and the severity and duration of dry eye after LASIK. Before LASIK, the health of the ocular surface should be optimized and patients selected appropriately. Dry eye before surgery and female gender are risk factors for developing chronic dry eye after LASIK. Management of the ocular surface during LASIK can minimize ocular surface damage and the risk of adverse outcomes. Long-term management of the tear film and ocular surface after LASIK can reduce the severity and duration of dry eye symptoms and signs. CONCLUSIONS Strategies to manage the integrated ocular surface/lacrimal gland functional unit before, during, and after LASIK can optimize outcomes. As problems with the ocular surface and tear film are relatively common, attention should focus on the use and improvement of evidence-based management strategies.
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Affiliation(s)
- Julie M Albietz
- Centre for Eye Research, Queensland University of Technology, Brisbane, Australia.
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Donnenfeld ED, O'Brien TP, Solomon R, Perry HD, Speaker MG, Wittpenn J. Infectious keratitis after photorefractive keratectomy. Ophthalmology 2003; 110:743-7. [PMID: 12689896 DOI: 10.1016/s0161-6420(02)01936-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To elucidate risk factors, microbial culture results, and visual outcomes for infectious keratitis after photorefractive keratectomy (PRK). DESIGN Multicenter, retrospective chart review, case report, and literature review. METHODS The records of 12 patients with infectious keratitis after PRK were reviewed. MAIN OUTCOME MEASURES Causative organism, response to medical treatment, and visual outcome. RESULTS Infectious keratitis developed in 13 eyes of 12 patients after PRK. Organisms cultured were Staphylococcus aureus (n = 5), including a bilateral case of methicillin-resistant Staphylococcus aureus; Staphylococcus epidermidis (n = 4); Streptococcus pneumoniae (n = 3); and Streptococcus viridans (n = 1). Four patients manipulated their contact lenses, and 2 patients were exposed to nosocomial organisms while working in a hospital environment. Prophylactic antibiotics used were tobramycin (nine cases), polymyxin B-trimethoprim (three cases), and ciprofloxacin (one case). Final best spectacle-corrected visual acuity ranged from 20/20 to 20/100. CONCLUSIONS Infectious corneal ulceration is a serious potential complication of PRK. Gram-positive organisms are the most common pathogens. Antibiotic prophylaxis should be broad spectrum and should include gram-positive coverage.
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Affiliation(s)
- Eric D Donnenfeld
- Department of Ophthalmology, Nassau University Medical Center, East Meadow, New York, USA
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Karp CL, Tuli SS, Yoo SH, Vroman DT, Alfonso EC, Huang AH, Pflugfelder SC, Culbertson WW. Infectious keratitis after LASIK. Ophthalmology 2003; 110:503-10. [PMID: 12623812 DOI: 10.1016/s0161-6420(02)01760-8] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To report the clinical course, management, and outcomes of culture-proven infectious keratitis in 15 eyes of 13 subjects after LASIK. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Fifteen eyes of 13 subjects who underwent LASIK and developed culture-positive keratitis. INTERVENTION Infectious keratitis was encountered in the operative eyes between 1 day and 450 days. Cultures were obtained, and topical antibiotic therapy was administered in all cases. Some cases required flap lifting, irrigation, and soaking of the bed with antibiotics, flap amputation, or further surgical intervention. MAIN OUTCOME MEASURES Time periods from onset to diagnosis, from clinical diagnosis to clinical resolution, final acuities, microbiologic profiles, and medical and surgical interventions were reviewed. RESULTS Onset of symptoms of infection varied, depending on the infectious organism. Bacterial organisms tended to present earlier, whereas mycobacterial and fungal organisms had a later mean onset of presentation. Furthermore, the atypical organisms such as mycobacteria, fungus, and acanthamoeba also had a more delayed diagnosis, resulting in a prolonged disease course. CONCLUSIONS Infectious keratitis after LASIK is a potentially vision-threatening complication. Onset of symptoms varies depending on causative agents. Furthermore, atypical organisms in the interface or beneath the flap can pose both diagnostic and therapeutic dilemmas. Location in the interface can make it more difficult to culture the organisms and prevent adequate penetration of topical antibiotics.
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Affiliation(s)
- Carol L Karp
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida
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21
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Freitas D, Alvarenga L, Sampaio J, Mannis M, Sato E, Sousa L, Vieira L, Yu MC, Martins MC, Hoffling-Lima A, Belfort R. An outbreak of Mycobacterium chelonae infection after LASIK. Ophthalmology 2003; 110:276-85. [PMID: 12578767 DOI: 10.1016/s0161-6420(02)01643-3] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe an outbreak of mycobacterial keratitis after laser in situ keratomileusis (LASIK), including the microbiologic investigation, clinical findings, treatment response, and outcome. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Patients (n = 10) who underwent LASIK surgery between August 22 and September 4, 2000, and developed mycobacterial infection. METHODS Patients were prospectively followed in relation to microbiologic investigation, clinical findings, treatment response, and outcome. MAIN OUTCOME MEASURES Most patients underwent bilateral simultaneous LASIK. Postoperative infection was signaled by the appearance of corneal infiltrates in the third postoperative week. The microbiologic workup was performed on cultures obtained either by direct scraping of the cornea or by lifting the flap. Medical therapy was instituted based on drug susceptibility testing. Surgical interventions such as corneal debridement and flap removal were performed during recurrences or when there was no satisfactory clinical response. RESULTS Cultures revealed Mycobacterium subspecies chelonae. Patients were treated with topical clarithromycin (1%), tobramycin (1.4%), and ofloxacin (0.3%). Oral clarithromycin (500 mg twice a day) was prescribed for those patients who did not respond clinically to topical treatment. Four eyes healed on this regimen. Flap removal was necessary in seven eyes. CONCLUSIONS This report highlights mycobacteria as an etiologic infectious agent after LASIK. Diagnosis can be difficult and is often delayed. The treatment mainstay is prolonged antibiotic therapy. Surgical debridement and flap removal may shorten the disease course.
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Affiliation(s)
- Denise Freitas
- Ophthalmology Department, Federal University of São Paulo, Paulista School of Medicine, São Paulo Hospital, Rua Botucatu 822, 04023-062 São Paulo, Brazil.
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22
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Pache M, Schipper I, Flammer J, Meyer P. Unilateral fungal and mycobacterial keratitis after simultaneous laser in situ keratomileusis. Cornea 2003; 22:72-5. [PMID: 12502955 DOI: 10.1097/00003226-200301000-00018] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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. 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.
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MESH Headings
- Antifungal Agents/therapeutic use
- Corneal Stroma/microbiology
- Eye Infections, Bacterial/diagnosis
- Eye Infections, Bacterial/etiology
- Eye Infections, Bacterial/surgery
- Eye Infections, Fungal/diagnosis
- Eye Infections, Fungal/etiology
- Eye Infections, Fungal/surgery
- Female
- Humans
- Keratitis/diagnosis
- Keratitis/microbiology
- Keratitis/surgery
- Keratomileusis, Laser In Situ/adverse effects
- Keratoplasty, Penetrating
- Middle Aged
- Mycobacterium Infections, Nontuberculous/diagnosis
- Mycobacterium Infections, Nontuberculous/etiology
- Mycobacterium Infections, Nontuberculous/surgery
- Mycobacterium chelonae/isolation & purification
- Postoperative Complications
- Surgical Flaps/microbiology
- Treatment Outcome
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Affiliation(s)
- Mona Pache
- University Eye Clinic, P.O. Box, CH-4012 Basel, Switzerland
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Fleiszig SMJ, Evans DJ. The pathogenesis of bacterial keratitis: studies with Pseudomonas aeruginosa. Clin Exp Optom 2002; 85:271-8. [PMID: 12366347 DOI: 10.1111/j.1444-0938.2002.tb03082.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2002] [Accepted: 03/21/2002] [Indexed: 10/20/2022] Open
Abstract
Bacterial keratitis is a sight-threatening corneal disease that is most commonly associated with the extended wear of soft contact lenses. Over the past decade, we have investigated the pathogenesis of infectious keratitis involving the opportunistic pathogen Pseudomonas aeruginosa. Our research has focused on understanding the respective roles of bacteria and host in the establishment of this infection. Here, we provide a current perspective on P. aeruginosa keratitis, reviewing some of the research developments that have helped shape our views on the mechanisms by which pathogen and host response cause corneal disease. P. aeruginosa may provide a model for the pathogenesis of bacterial keratitis and help further elucidate the complex array of host factors that normally protect the cornea from infectious agents.
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Affiliation(s)
- Suzanne M J Fleiszig
- School of Optometry, 688 Minor Hall, University of California at Berkeley, Berkeley, CA, 94720-2020, USA
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Abstract
PURPOSE To describe the time course, diagnosis, clinical features, and treatment of seven patients with Mycobacterium szulgai keratitis that developed from 7 to 24 weeks after laser in situ keratomileusis (LASIK). METHODS Seven of 30 eyes of 18 patients were identified with keratitis after LASIK. The first two patients presented 12 to 14 weeks after LASIK; nontuberculous mycobacteria were identified 1 month after the flaps were cultured. Patient recall identified three additional cases by culture and two cases by clinical features alone. Pulsed-field gel electrophoresis (PFGE) was used to type the isolates, and treatment was modified based on susceptibilities. RESULTS M. szulgai was identified in five patients for whom cultures were performed, but response to empiric therapy based on cultures proved unsatisfactory. The keratitis resolved in all patients with treatment including clarithromycin based on susceptibilities. Medical therapy was sufficient, although one patient required flap amputation. Six of seven patients recovered best-corrected visual acuity (BCVA), while one patient lost one line of BCVA. Two patients lost one line of postoperative uncorrected visual acuity (UCVA), two patients gained one line of UCVA, and three patients recovered postoperative UCVA. PFGE analysis revealed that the M. szulgai strains were identical, and the infection source was contaminated ice used to chill syringes for saline lavage. CONCLUSIONS Nontuberculous mycobacterial keratitis after LASIK is a diagnostic and management challenge, but outcomes can be preserved with treatment based on susceptibilities. This cluster underscores the importance of adherence to sterile protocol during LASIK.
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Affiliation(s)
- Samuel F A Fulcher
- Division of Ophthalmology, Scott & White Memorial Hospital and Clinic, 2401 South 31st Street, Temple, TX 76508, USA.
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25
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Pushker N, Dada T, Sony P, Ray M, Agarwal T, Vajpayee RB. Microbial Keratitis After Laser in situ Keratomileusis. J Refract Surg 2002; 18:280-6. [PMID: 12051385 DOI: 10.3928/1081-597x-20020501-12] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE AND METHOD To review the literature on microbial keratitis reported after laser in situ keratomileusis (LASIK). RESULTS Forty-one eyes have been reported to have microbial keratitis after LASIK. The causative organisms vary from gram positive bacteria to atypical mycobacteria, fungal, and viral pathogens. The infection is usually acquired intraoperatively, but may also be caused by postoperative contamination. A majority of the patients present within 72 hours of the surgery with an acute onset of symptoms. Management of microbial keratitis after LASIK includes aggressive topical fortified antibiotic therapy, irrigation of stromal bed with antibiotic solution after lifting the flap, and sending the scraping of the infiltrate for microbiological evaluation. The keratitis heals with scarring and a best spectacle-corrected visual acuity of 20/40 or better can be obtained in the majority of the patients. CONCLUSION Microbial keratitis is a sight-threatening complication of LASIK.
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Affiliation(s)
- Neelam Pushker
- R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Chandra NS, Torres MF, Winthrop KL, Bruckner DA, Heidemann DG, Calvet HM, Yakrus M, Mondino BJ, Holland GN. Cluster of Mycobacterium chelonae keratitis cases following laser in-situ keratomileusis. Am J Ophthalmol 2001; 132:819-30. [PMID: 11730644 DOI: 10.1016/s0002-9394(01)01267-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To describe a cluster of Mycobacterium chelonae keratitis cases involving patients who underwent laser in-situ keratomileusis (LASIK) at a single refractive surgery center. DESIGN Descriptive case series of four patients and cohort study to identify disease associations. METHODS Examination schedules, diagnostic tests, and therapy were based on best medical judgment. Isolates from three patients were compared by pulsed-field gel electrophoresis. Epidemiologic studies were performed to identify the source of infection. RESULTS Seven of eight eyes developed M. chelonae keratitis following bilateral simultaneous LASIK. Each patient was thought to have diffuse lamellar keratitis initially, but all seven eyes were noted to have opacities suggestive of infectious keratitis by 13 to 21 days after surgery. All eyes had undergone hyperopic LASIK over four days in April 2001 by one surgeon in a community-based refractive surgery center. A cohort study of all patients undergoing LASIK at the same center in April 2001 revealed that M. chelonae keratitis occurred only in persons undergoing correction of hyperopia (seven of 14 eyes vs. none of 217 eyes undergoing myopic LASIK, P <.001). The only difference identified between procedures was use of masks created from a soft contact lens in hyperopic LASIK. Three isolates (three patients) were indistinguishable by pulsed-field gel electrophoresis. Eyes were treated with a combination of antimicrobial agents, including topical azithromycin in three patients, with resolution of infection in all eyes over 6 to 14 weeks. The source of infection was not identified on environmental cultures. CONCLUSION Postoperative nontuberculous mycobacterial keratitis can occur in an epidemic fashion following LASIK. Topical amikacin, azithromycin, clarithromycin, ciprofloxacin, or a combination of these agents, appears to be effective treatment for these infections.
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MESH Headings
- Anti-Bacterial Agents
- Bacterial Proteins/analysis
- California
- Cluster Analysis
- Cohort Studies
- Cornea/microbiology
- Cornea/surgery
- Drug Therapy, Combination/therapeutic use
- Electrophoresis, Gel, Pulsed-Field
- Eye Infections, Bacterial/drug therapy
- Eye Infections, Bacterial/epidemiology
- Eye Infections, Bacterial/etiology
- Eye Infections, Bacterial/microbiology
- Female
- Humans
- Hyperopia/surgery
- Keratitis/drug therapy
- Keratitis/epidemiology
- Keratitis/etiology
- Keratitis/microbiology
- Keratomileusis, Laser In Situ/adverse effects
- Middle Aged
- Mycobacterium Infections, Nontuberculous/drug therapy
- Mycobacterium Infections, Nontuberculous/epidemiology
- Mycobacterium Infections, Nontuberculous/etiology
- Mycobacterium Infections, Nontuberculous/microbiology
- Mycobacterium chelonae/isolation & purification
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Affiliation(s)
- N S Chandra
- Ocular Inflammatory Disease Center, Jules Stein Eye Institute, Department of Ophthalmology, UCLA School of Medicine, Los Angeles, CA, USA
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