Anterior uveitis after laser in situ keratomileusis

Interface fluid syndrome after small incision lenticule extraction surgery secondary to posner schlossman syndrome - A case report

Purpose

This report describes a case of interface fluid syndrome (IFS) secondary to Posner Schlossman Syndrome (PSS) following small incision lenticule extraction (SMILE) surgery.

Case presentation

A 19-year-old male was diagnosed with IFS secondary to PSS in his left eye 1 month after undergoing SMILE. Detailed patient history and clinical findings, auxiliary examination results, and short-term follow-up are reported. In this patient, the IFS was caused by elevated intraocular pressure (IOP) due to PSS. Treatment with topical steroids in combination with anti-glaucoma drops led to complete regression of the fluid, and there was no recurrence during a 7-month follow-up period.

Conclusion

IFS is a potential complication of SMILE, and anterior segment ocular coherence tomography (AS-OCT) can definitively diagnose the condition. This case demonstrates that the treatment for IFS should be based on the underlying cause, and requires prompt and vigorous management for resolution.

Activation of Ocular Syphilis After Small-Incision Lenticule Extraction

A 41-year-old female presented to the Willis-Knighton Eye Institute to undergo evaluation for refractive surgery. The patient had a best-corrected visual acuity for a distance of 20/15-1 of the right eye (OD) and 20/15-1 of the left eye (OS) with a manifest refraction of -2.75 OD and -1.75 OS. Near visual acuity was J1+ in both eyes (OU). A trial of a monovision contact lens was successful with the dominant eye selected for distance. The patient was then planned for small-incision lenticule extraction (SMILE) OD only with a plano target. SMILE was performed and was uncomplicated with uncorrected visual acuity of 20/15- on postoperative day one. Two weeks after the initial SMILE procedure, the anterior segment was notable for 1-2+ cells OD. Topical prednisone was changed to difluprednate 0.05% TID OD with improvement in symptoms. However, the anterior chamber cell was never fully resolved by month three. A systemic workup revealed a positive rapid plasma reagin with 1:64 titer and a positive fluorescent treponemal antibody absorption in a patient never treated for syphilis. The patient was diagnosed with ocular syphilis and received a two-week course of intravenous penicillin G. A slow topical prednisone tapper was performed with the resolution of inflammation by one year. Anterior uveitis after refractive surgery is uncommon. The incidence of anterior uveitis after SMILE is even rarer with no previously documented incidence in the literature. As a result, persistent cell seen in refractive procedures, especially SMILE, is a concerning finding, warranting further workup to rule out underlying systemic diseases including syphilis.

Anterior uveitis after transepithelial photorefractive keratectomy: Demographics and clinical characteristics - a one-year analysis

PURPOSE

To report a case series of anterior uveitis after Transepithelial Photorefractive Keratectomy (TransPRK) and determine its incidence, demographics and associated clinical features over a study period of 1 year.

METHODS

This retrospective case series comprised of 200 eyes (100 patients) which underwent elective TransPRK surgery for ametropia correction at a tertiary eye care center by two refractive surgeons over 1 year. TransPRK was performed on Streamlight software (EX500, Alcon Wavelight, Inc.). Postoperatively, all patients received topical antibiotic and steroid eye drops and tapered over 4 weeks.

RESULTS

The mean age of study patients was 25.76 ± 4.29 years with a pre-operative mean refractive spherical equivalent (MRSE) of -3.49 ± 2.12 diopter (D); 11.76% eyes had simple myopia and 88.23% had compound myopic astigmatism, mean ablation depth of 61.99 ± 24.27 um. Four patients (seven eyes) developed anterior uveitis with mean age of 25 ± 3.53 years, mean MRSE -2.91 ± 0.32 D, ablation depth 44.75 ± 5.29 um with a mean onset at 33.28 days postoperatively after surgery and 5.28 days after the routine postoperative topical steroid withdrawal. Laboratory and immunological tests were negative in all four patients. The incidence of TransPRK-related anterior uveitis was 3.5% over 1 year.

CONCLUSION

Anterior uveitis after TransPRK is infrequent. It could be due to intraocular transmittance of high frequency excimer laser beams used for longer durations to provide continuous, single step ablation in this novel type of PRK surgery. Further studies are needed to investigate the mechanisms of this association.

Refractive surgery for the patient with autoimmune diseases

PURPOSE OF REVIEW

Autoimmune and immune-mediated diseases are considered contraindications for laser refractive surgeries according to the US Food and Drug Administration's guideline. This guideline, however, is based on limited case reports or complications reported during other intraocular procedures. There have been only a handful of new clinical studies that evaluate the efficacy and safety of refractive surgery in this specific patient population. The aim of this article is to review currently available research and offer updated recommendations for the evaluation and management of laser refractive surgery (LRS) in patients with autoimmune diseases.

RECENT FINDINGS

More recent retrospective studies have reported good refractive outcomes in patients with well controlled autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, seronegative spondyloarthropathy, among others. No severe sight-threatening complications have been reported in these reports. Although postoperative complications occur, the risk of refractive surgery is comparable with those without autoimmune diseases.

SUMMARY

With the exception of primary Sjogren's syndrome, patients with autoimmune diseases may be good candidates for LRS if diseases are well controlled and have minimal ophthalmic manifestation. Patients should be made aware of the potential surgical complications and be informed of the currently available data. More multicenter and larger prospective studies are needed to compare the refractive outcomes and surgical complications in patients with and without autoimmune diseases. This will help patients make better informed medical decisions.

Urrets-Zavalia syndrome with interface fluid syndrome following laser in situ keratomileusis

Purpose

We describe the case of a 41-year-old male that underwent laser in situ keratomileusis (LASIK) complicated by Urrets-Zavalia syndrome with interface fluid syndrome and epithelial ingrowth.

Observation

The patient presented at our institution with headache and blurred vision three weeks after a right microkeratome-assisted LASIK procedure. On examination, the visual acuity was hand movements and the intraocular pressure (IOP) was 45 mmHg with fluid in the flap interface, a fixed pupil in moderate mydriasis, iris transillumination and cells in the anterior chamber. A Baerveldt tube implant was necessary to control the IOP. After three months, the corrected visual acuity was 20/40 with normal IOP and an early cataract.

Conclusion and importance

To our knowledge this is the first report of a case of combined Urrets-Zavalia syndrome and interface fluid syndrome after LASIK. We speculate that steroid induced ocular hypertension was the primary cause.

Activation of Cytomegalovirus corneal endotheliitis following laser in situ keratomileusis

A case of Cytomegalovirus (CMV) corneal endotheliitis following laser in-situ keratomileusis (LASIK) is presented. A 32-year-old man presented 3 weeks after uncomplicated myopic LASIK with unilateral LASIK flap oedema, interface fluid accumulation, keratic precipitates, anterior uveitis and raised intraocular pressure. Despite treatment with topical corticosteroids, he had 3 further recurrent episodes. Specular microscopy showed decreased endothelial cell density and aqueous humour. Polymerase chain reaction (PCR) testing was positive for CMV DNA. He was treated with topical ganciclovir and ketorolac, and the inflammation and oedema resolved. Repeat aqueous humour PCR testing was negative for CMV DNA, and he remained well at last follow-up (3 months after stopping all medications). CMV corneal endotheliitis can be reactivated after LASIK, and CMV DNA PCR of aqueous humour samples can help in definitive diagnosis. Early recognition and treatment of this condition is important to prevent permanent endothelial cell loss and corneal decompensation.

Effects of benzalkonium chloride on the blood-aqueous and blood-retinal barriers of pseudophakic eyes

PURPOSE

To evaluate the effects of benzalkonium chloride (BAK) on the blood-aqueous (BAB) and blood-retinal barriers (BRB) of pseudophakic eyes.

METHODS

Prospective, randomized, investigator-masked, comparative study. Patients were randomly assigned to preservative-free artificial tears or BAK-preserved artificial tears. One drop of artificial tears was instilled 4 times a day in the study eye, starting the day after randomization for 30 days. Anterior chamber flare was assessed by a laser flare meter (LFM) and macular thickness measurements were obtained with optical coherence tomography, before, 15, and 30 days after randomization.

RESULTS

A total of 44 healthy eyes of 44 pseudophakic volunteers were recruited. There were no significant differences regarding demographics (age, gender, and race distributions) and clinical characteristics (eye, mean intraocular pressure, and mean best-corrected visual acuity) between the 2 groups (P>0.05). No significant differences in baseline mean LFM values were observed (P=0.262). However, we detected a statistically significant increase in mean LFM measurements in the BAK-preserved group (11.4 ± 5.1 ph/ms) (P=0.017) after 15 days. After 30 days, the BAK-preserved group maintained significantly higher flare values (11.9 ± 5.9 ph/ms) compared with baseline (P=0.043). On the other hand, the preservative-free group showed mean flare values of 8.4 ± 2.5 ph/ms, not significantly different from those obtained at baseline (P=1.00). We observed no statistically significant change in macular thickness measurements at days 15 and 30 in either group (P>0.05). Cystoid macular edema was not detected in this series.

CONCLUSIONS

Our results suggest that a short-term exposure to BAK can cause disruption of the BAB, without altering the BRB in pseudophakic eyes.

Glaukos® Trabecular Stent used to Treat Steroid-Induced Glaucoma

Purpose

This case report illustrates the efficacy of the Glaukos trabecular bypass (Glaukos i-stent, Glaukos Corporation, Laguna Hills, California, USA) used for intraocular pressure (IOP) control in a patient with glaucoma induced by the steroid treatment of post–laser-assisted in situ keratomileusis (LASIK) bilateral anterior uveitis.

Methods

A 35-year-old woman who had undergone LASIK 5 months previously presented with blurred vision in both eyes. Examination revealed bilateral anterior uveitis and diffuse lamellar keratitis (DLK) requiring steroid treatment. In response to treatment, inflammation improved but the patient had increased IOP that was difficult to control. The course of pressure elevation was more aggressive in the left eye despite the gradual discontinuation of steroids. We therefore decided to place 2 trabecular i-stents in the left eye.

Results

This solution achieved good pressure control with no associated complications after 1 year follow-up.

Conclusions

This trabecular bypass seems a safe and effective therapeutic option for IOP control when there is a poor response to conventional treatment in this type of secondary glaucoma.

Fibrinous anterior uveitis following laser in situ keratomileusis

A 29-year-old woman who underwent laser in situ keratomileusis (LASIK) for myopic astigmatism in both eyes presented with severe pain, photophobia and decreased visual acuity in the left eye eight days after surgery. Examination revealed severe anterior uveitis with fibrinous exudates in the anterior chamber, flap edema and epithelial bullae. Laboratory investigations for uveitis were negative and the patient required systemic and intensive topical steroids with cycloplegics to control the inflammation. This case demonstrates that severe anterior uveitis may develop after LASIK and needs prompt and vigorous management for resolution.

[Reactivation of ocular toxoplasmosis after laser in situ keratomileusis]

Laser in situ keratomileusis (LASIK) is a safe and efficient refractive surgical procedure that provides excellent results in most cases. Several complications have been reported, most of them related to the posterior segment of the eye. Although they are quite rare, a growing number of vitreoretinal pathologic conditions after LASIK have been reported. To date no article has reported an inflammatory or infectious disease of the posterior segment after a LASIK procedure. We report a case of reactivation of toxoplasmic chorioretinitis that occurred 5 days after a LASIK procedure. Clinical outcome was spontaneously favorable after 1 month, with no loss of vision. Although a causal effect between LASIK and toxoplasmic chorioretinitis reactivation cannot be proven with a single case report, we stress the importance of dilated fundus examination in LASIK preoperative assessment: our case suggests that in the presence of preoperative toxoplasmic chorioretinitis scars, increased retinal monitoring is required.

Optic Disc and Retinal Nerve Fiber Layer Analysis With Scanning Laser Tomography After LASIK

PURPOSE

To examine whether LASIK induces changes in the optic disc and retinal nerve fiber layer using scanning laser tomography.

METHODS

Prospective, consecutive study of 53 myopic eyes in 38 patients (mean age: 35.7 +/- 10.4 years; range: 22 to 58 years). Preoperative average refractive error was -6.0 +/- 2.4 diopters (D) (spherical equivalent) (range: -2.0 to -10.0 D). Optic disc morphology and retinal nerve fiber layer thickness were evaluated with scanning laser tomography preoperatively and at 7 and 13 months postoperatively.

RESULTS

No statistically significant differences were noted between the pre- and postoperative optic disc and retinal nerve fiber layer measurements.

CONCLUSIONS

Our results suggest that transient extreme elevation of intraocular pressure during LASIK does not affect the optic disc morphology or retinal nerve fiber layer thickness in normal myopic eyes for at least 1 year after surgery.