Infection After LASIK

Mycobacterium chelonae infection after LASIK, now blind

A 37 year old woman had LASIK in July 2017 after being misled into believing that the surgery is safe. She immediately had a problem with one eye. Her surgeon tried various treatments, but her eye continued getting worse. A few months later she sought a second opinion from another eye doctor who diagnosed her with mycobacterium chelonae infection. Because the infection raged for so long her cornea was destroyed. She is now blind in that eye and in constant pain. Her only hope to recover her vision is to find a doctor who can get the infection under control and then to undergo a corneal transplant. The toll that this situation has taken on her life is enormous. She feels she is no longer able to be there fully for her 3 children. The stress and depression has caused other health issues, and she has withdrawn socially. She is sharing her story in the hope that it may save someone else from becoming a victim.

Rabina et al. Very late-onset flap margin corneal ulcer following laser in situ keratomileusis. Int Ophthalmol. 2019 Apr 13. doi: 10.1007/s10792-019-01100-0.

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.

Pseudomonas keratitis 4 years after laser in situ keratomileusis.
Ferrer C, Rodriguez-Prats JL, Abad JL, Claramonte P, Alió JL, Signes-Soler I.
Optom Vis Sci. 2011 Oct;88(10):1252-4.

PURPOSE.: To report a patient who presented an infectious keratitis 4 years after laser in situ keratomileusis (LASIK) without any other predisposing risk factor than the LASIK procedure itself.

CASE REPORT.: We report a 32-year-old man operated by LASIK in January 2006 who presented with infectious keratitis in the OD in April 2010. Clinical examination showed a corneal abscess at 10-o'clock position in the interface and fibrin and Tyndall 4+ in the anterior chamber. Microbiological analysis identified Pseudomonas aeruginosa as the cause of infection. The patient was given ofloxacin, sulfate neomycin, polymyxin B, and prednisolone acetate to be used every 2 h. Treatment led to clinical improvement with resolution of corneal infiltrate. Keratitis with intact epithelium by Pseudomonas can occur up to 4 years after LASIK.

CONCLUSIONS.: LASIK treatment is a predisposing factor for bacterial keratitis even years after surgery. This report demonstrates the importance of continued postoperative vigilance by patient and his/her clinician.

Late-onset Klebsiella oxytoca flap-margin-related corneal ulcer following laser in situ keratomileusis.
J Cataract Refract Surg. 2011 Aug;37(8):1551-4.
Yeung SN, Lichtinger A, Kim P, Amiran MD, Slomovic AR.

A 45-year-old woman developed a spontaneous flap-margin-related corneal ulcer 11 years after the original laser in situ keratomileusis (LASIK) procedure. Two enhancements had been performed; the most recent was 3 years prior to presentation. Cultures were positive for a heavy growth of Klebsiella oxytoca. The ulcer responded clinically to topical treatment with fortified cefazolin. Eighteen days after presentation, the infiltrate had resolved and the cornea had fully epithelialized. To our knowledge, this is the first report of post-LASIK infectious keratitis caused by K oxytoca.

Pseudomonas Keratitis 4 Years After Laser in Situ Keratomileusis.
Optom Vis Sci. 2011 Jun 9. [Epub ahead of print]
Ferrer C, Rodriguez-Prats JL, Abad JL, Claramonte P, Alió JL, Signes-Soler I.

PURPOSE.: To report a patient who presented an infectious keratitis 4 years after laser in situ keratomileusis (LASIK) without any other predisposing risk factor than the LASIK procedure itself.

CASE REPORT.: We report a 32-year-old man operated by LASIK in January 2006 who presented with infectious keratitis in the OD in April 2010. Clinical examination showed a corneal abscess at 10-o'clock position in the interface and fibrin and Tyndall 4+ in the anterior chamber. Microbiological analysis identified Pseudomonas aeruginosa as the cause of infection. The patient was given ofloxacin, sulfate neomycin, polymyxin B, and prednisolone acetate to be used every 2 h. Treatment led to clinical improvement with resolution of corneal infiltrate. Keratitis with intact epithelium by Pseudomonas can occur up to 4 years after LASIK.

CONCLUSIONS.: LASIK treatment is a predisposing factor for bacterial keratitis even years after surgery. This report demonstrates the importance of continued postoperative vigilance by patient and his/her clinician.

A rare devastating complication of LASIK: bilateral fungal keratitis.
J Ophthalmol. 2010;2010:450230. Epub 2010 Nov 11.
Taylan Sekeroglu H, Erdem E, Yar K, Yağmur M, Ersoz TR, Uguz A.

Department of Ophthalmology, Cukurova University, Yuregir, 01330 Adana, Turkey.

Abstract

Purpose. To report an unusual case of severe bilateral fungal keratitis following laser in situ keratomileusis (LASIK).

Method. A 48-year-old man developed bilateral diffuse corneal infiltration two weeks after LASIK. The corneal scrapings revealed fungal filaments but cultures were negative.

Results. The corneal ulceration was improved on the left eye whereas spontaneous perforation occurred and finally evisceration was needed on the right eye despite topical and systemic antifungal treatment.

Conclusions. Fungal keratitis, especially with bilateral involvement, is a very rare and serious complication of LASIK surgery. Clinical suspicion is crucial because most of fungal keratitis are misdiagnosed as bacterial keratitis and can lead serious visual results, even eye loss.

Infectious Keratitis after LASIK - Update and Survey of the Literature.
Klin Monbl Augenheilkd. 2010 Nov 24. [Epub ahead of print]
Linke SJ, Richard G, Katz T.

Universitätsklinikum Eppendorf (UKE), Klinik und Poliklinik für Augenheilkunde.
Abstract

LASIK has become the preferred surgical procedure for the correction of refractive errors. Microbial keratitis is a rare but severe complication. The incidence of post-LASIK keratitis, (uni- and bilateral) is difficult to estimate. The risk of bilateral infection could until now only be approximated by calculating it from the risk of unilateral infection. Due to the fortunately low incidence of post-LASIK keratitis, large-scale studies are necessary to obtain valid statistical data. The American Society of Cataract and Refractive surgery (ASCRS) developed a post-LASIK infectious keratitis survey in 2001. 116 post-LASIK infections were reported by the members of the society. The calculated incidence was 0.035 % or 1 infection in every 2919 procedures. Llovet et al. found 9 patients (18 eyes) with bilateral post-LASIK keratitis out of 204 586 procedures (incidence 0.0084 %). Gram-positive bacteria and atypical mycobacteria are the most common causes for microbial post-LASIK keratitis. There is an increasing literature of post-LASIK case reports caused by rare or atypical species. Severe cases of keratitis are more often correlated with a prolonged onset of infection and caused by atypical species. An overview of the current literature and our own data regarding post-LASIK keratitis (uni-, and bilateral) are presented.

Microbial Keratitis After LASIK
Journal of Refractive Surgery Vol. 26 No. 3 March 2010
Prashant Garg, MD; Sunita Chaurasia, MS; Pravin K. Vaddavalli, MS; Muralidhar R, MS; Vikas Mittal, MD, DNB and Usha Gopinathan, PhD

Excerpts:

Infectious keratitis after LASIK is a devastating, vision threatening complication. It is not uncommon to see reports of keratitis after LASIK in the ophthalmic literature.

The incidence of this complication is estimated to be between 1 in 1000 and 1 in 5000 procedures. However, the true incidence of postoperative LASIK infection is not available from most parts of the world. Therefore, these estimates may represent an underestimation of the true incidence, as many cases of infection are often not reported.

Although LASIK is a surgical procedure involving an incision performed through the corneal stroma, it is associated with various standards of surgical asepsis and postoperative care. Suboptimal sterile precautions, multiple uses of microkeratome blades, minimal postoperative follow-up, inclusion of high-risk patients, and bilateral simultaneous procedures may potentially expose patients to an increased risk of infection and other postoperative inflammatory complications.

A case of intractable infectious keratitis and subsequent flap necrosis after laser in situ keratomileusis.
Kamiya K, Kasahara M, Shimizu K.
Clin Ophthalmol. 2009;3:523-5. Epub 2009 Sep 24.

We report on a patient in whom intractable infectious keratitis and subsequent lamellar flap necrosis necessitating flap amputation after laser in situ keratomileusis (LASIK). A 34-year-old woman undergoing LASIK complained of blurred vision and pain in the left eye. The best spectacle-corrected visual acuity was 0.01, and slit-lamp examination showed a marked presence of stromal infiltrates involving the flap and the underlying stroma in that eye. The patient was treated topically with hourly instillation of micronomicin, levofloxacin, and cefmenoxime, together with systemic administration of imipenem, but the left eye developed corneal flap necrosis. We performed surgical debridement of the diseased stroma and excised the lamellar flap. Since nontuberculous mycobacterium was detected on the surgical instruments, we then added oral clarithromycin, and substituted systemic administration of amikacin with that of imipenem. At one month after the flap removal, the visual acuity gradually improved to 0.7, but the stromal opacity of the central cornea and hyperopic shift of +3.0 diopters remained. LASIK can cause intractable keratitis, resulting in significant visual disturbance that presumably results from insufficient antisepsis of the medical instruments used for this surgery, supporting the importance of strict sterilization of these instruments.

Late-onset laser in situ keratomileusis-related corneal ulcer--a case series.
Varssano D, Waisbourd M, Berkner L, Regenbogen M, Hazarbassanov R, Michaeli A.
Cornea. 2009 Jun;28(5):586-8.

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.

From the full text:

Creating the lamellar flap may introduce organisms into the stromal interface that cause infection after the corneal epithelium regains its continuity. We reason that perioperative inoculation is the probable etiology for infections in the early and intermediate postoperative period, but it cannot explain the pathogenesis in our patients in whom the infection occurred years later. The corneal epithelium is almost always intact by 1 day after a LASIK procedure. The stroma, however, never regains its former structure. We speculate that micro movements at the wound margin may have caused repeated infrequent epithelial damage, thus making the flap margin an entry point for microorganisms.We base our hypothesis on the location of the ulcer at the wound edge in all of our 4 reported cases, the lack of other predisposing factors for corneal ulcer in 2 of the patients, and the long interval since surgery...

To prevent late-onset LASIK-related corneal ulcers, we suggest avoiding eye rubbing, avoiding use of contact lenses, and controlling blepharitis.

To conclude, LASIK might have long-term effects on the cornea, making it vulnerable to flap margin-related corneal ulcers, probably through a mechanism of flap margin instability. It may be prudent to maintain long-term follow-up in patients undergoing the procedure and underline the desired preventive measures.

Late-onset Infections After LASIK
Journal of Refractive Surgery Vol. 24 No. 4 April 2008
Ana Carolina Vieira, MD; Telma Pereira, MD; Denise de Freitas, MD

From the full text:

A possible explanation for the presentation of delayed keratitis after LASIK is that creating the lamellar flap may induce a permanent portal in the corneal periphery for microorganisms to penetrate.

A small epithelial break occurring any time after LASIK allows superficial microbials to penetrate the flap and reach the interface.4 The patient in case 1 had been wearing contact lenses for correction of ametropia. It has been reported that long-term contact lens wear may alter the epithelium barrier,9 facilitating the entrance of microorganisms. In case 2, the patient suffered trauma with a t-shirt, which may have played a role in the fungal inoculation.

The lamellar interface may function as a virtual space in which sequestered infections have the facility to develop.

This report demonstrates the risk of microbial keratitis development years after LASIK and emphasizes the importance of lifelong postoperative vigilance by patient and physician.

OSN SuperSite Top Story 4/5/2008
Latest ASCRS survey finds MRSA has risen to top of list of infection culprits

From the article: "Methicillin-resistant Staphylococcus aureus has emerged as the most common infection occurring after LASIK and surface ablation procedures, according to survey results evaluating trends in infectious keratitis throughout 2007."

Link to article

Late-onset Infections After LASIK
Journal of Refractive Surgery Vol. 24 No. 4 April 2008
Ana Carolina Vieira, MD; Telma Pereira, MD; Denise de Freitas, MD

PURPOSE
To report two cases of infectious keratitis that developed 2 and 6 years after LASIK.

METHODS
Case 1 was a 56-year-old woman who presented with redness and decreased vision in the right eye 6 years after LASIK. Slit-lamp examination revealed inflammation of the flap interface, a partially detached flap, anterior chamber reaction, and hypopyon. Corneal scrapings were taken. Case 2 was a 23-year-old woman who presented with pain and a corneal infiltrate in the left eye 36 hours after eye trauma. She had undergone bilateral LASIK 2 years prior. The condition worsened despite treatment, and a flap amputation was performed.

RESULTS
Cultures revealed Pseudomonas mesophilic and Fusarium solani, respectively. Keratitis in case 1 resolved after 21 days of fortified antibiotic therapy. Visual acuity of 20/40 was achieved after antibiotic treatment in case 2.

CONCLUSIONS
These case reports demonstrate the risk of microbial keratitis occurring years after LASIK and emphasize the need for lifelong postoperative vigilance by patient and physician. [J Refract Surg. 2008;24:411-413.]

From the full text:

Eyes that have undergone LASIK may be more pre-disposed to infections than unoperated eyes, and the infection may progress more rapidly when it occurs. A possible explanation for the presentation of delayed keratitis after LASIK is that creating the lamellar flap may induce a permanent portal in the corneal periphery for microorganisms to penetrate. In this event, the infiltrate would likely be localized near the flap edge and gradually work its way to the center.

A small epithelial break occurring any time after LASIK allows superficial microbials to penetrate the flap and reach the interface.4 The patient in case 1 had been wearing contact lenses for correction of ametropia. It has been reported that long-term contact lens wear may alter the epithelium barrier,9 facilitating the entrance of microorganisms. In case 2, the patient suffered trauma with a t-shirt, which may have played a role in the fungal inoculation.

The lamellar interface may function as a virtual space in which sequestered infections have the facility to develop. These interface infections are more difficult to treat as the microorganisms are protected from the natural ocular surface defenses and the antimicrobials do not penetrate well.8 Flap amputation may be necessary for a better therapeutic outcome in cases where there is no clinical improvement or when corneal melting has occurred. Patients may develop irregular astigmatism and anterior stromal haze after flap amputation8; however, flap removal benefits outweigh the possible scarring of the cornea. Infections after LASIK may be highly predisposed to perforation due to the cornea’s reduction in thickness during the surgical procedure. This report demonstrates the risk of microbial keratitis development years after LASIK and emphasizes the importance of lifelong postoperative vigilance by patient and physician.

Shewanella putrefaciens keratitis in the lamellar bed 6 years after LASIK.
Park HJ, Tuli SS, Downer DM, Gohari AR, Shah M.
J Refract Surg. 2007 Oct;23(8):830-2.

Excerpt:

After LASIK, stromal remodeling takes place at the flap margin with proliferation of myofibroblasts. However, the tensile strength of this scar is unknown and no fibroblastic scar formation was present in the flap interface. Ease of lifting the corneal flap 6 years after LASIK suggests that the interface remains a potential space, providing an easy conduit to the environment. Although our patient did not report ocular injury, minor unrecognized trauma could have caused an epithelial defect and introduced an organism into this potential space. Pathogens can multiply freely under the flap and they are protected from host defense mechanisms. This may explain why a preponderance exists of unusual and opportunistic infection-causing organisms after LASIK, such as non-tuberculous Mycobacteria and fungal organisms. We present the first reported case of Shewanella putrefaciens keratitis after LASIK and emphasize that flap-related complications can occur many years after the procedure. Infections originating from the flap edge may explain why infiltrates are first seen confined to the lamellar bed.

Infections following laser in situ keratomileusis: an integration of the published literature.
Surv Ophthalmol. 2004 May-Jun;49(3):269-80.
Chang MA, Jain S, Azar DT.
Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

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.

Methicillin-resistant Staphylococcus aureus infectious keratitis following refractive surgery.
Am J Ophthalmol. 2007 Apr;143(4):629-34. Solomon R, Donnenfeld ED, Perry HD, Rubinfeld RS, Ehrenhaus M, Wittpenn JR Jr, Solomon KD, Manche EE, Moshirfar M, Matzkin DC, Mozayeni RM, Maloney RK.
Ophthalmic Consultants of Long Island, Rockville Centre, New York 11570, USA.

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.

Unilateral Fungal and Mycobacterial Keratitis After Simultaneous Laser In Situ Keratomileusis
Cornea 2003; 22(1):72-75 Mona Pache, M.D.; Isac Schipper, M.D.; Josef Flammer, M.D.; Peter Meyer, M.D.

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. (Full cornea transplant.)

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.

Shewanella putrefaciens keratitis in the lamellar bed 6 years after LASIK.
J Refract Surg. 2007 Oct;23(8):830-2. Park HJ, Tuli SS, Downer DM, Gohari AR, Shah M.

PURPOSE: To present a case of infectious keratitis occurring 6 years after LASIK due to the rare human pathogen Shewanella putrefaciens.

METHODS: A 58-year-old man presented with redness and pain in the right eye 6 years following LASIK retreatment. Examination revealed a corneal infiltrate at the flap interface. Corneal scraping of stroma beneath the flap was submitted for histopathologic and microbiologic evaluation.

RESULTS: An infiltrate located at the LASIK flap interface originated from an epithelial defect at the flap-corneal junction. Corneal stroma cultures demonstrated Shewanella putrefaciens. The infection resolved with antibiotic treatment.

CONCLUSIONS: LASIK-related complications, such as infections, can occur many years following the procedure. The potential space created under the LASIK flap may predispose patients to infection by opportunistic organisms.

Fourth-generation fluoroquinolone-resistant mycobacterial keratitis after laser in situ keratomileusis.
J Cataract Refract Surg. 2007 Nov;33(11):1978-81. Moshirfar M, Meyer JJ, Espandar L.

We report a case of mycobacterial keratitis resistant to fourth-generation fluoroquinolones after laser in situ keratomileusis (LASIK) with fourth-generation fluoroquinolone prophylaxis. While receiving moxifloxacin post LASIK, the patient was diagnosed with moxifloxacin-resistant Mycobacterium chelonae keratitis. Culture susceptibilities revealed isolates resistant to moxifloxacin and gatifloxacin, and treatment with topical amikacin and clarithromycin with oral doxycycline and clarithromycin along with flap amputation was necessary to control the infection. This case demonstrates the potential limitations in the coverage of these antibiotic agents.

Aspergillus fumigatus keratitis following laser in situ keratomileusis.
J Cataract Refract Surg. 2007 Oct;33(10):1806-7. Sun Y, Jain A, Ta CN.

A 31-year-old woman developed pain, decreased vision, and a corneal flap infiltrate 4 days following laser in situ keratomileusis (LASIK). Treatment with topical antibiotic agents did not improve the symptoms. Approximately 2 weeks after surgery, the patient was referred to Stanford University, with 20/400 visual acuity in the left eye and a stromal infiltrate posterior to the flap. Cultures demonstrated Aspergillus fumigatus sensitive to voriconazole. The corneal ulcer progressed despite aggressive antifungal treatment, requiring amputation of the corneal flap and daily debridement. The infiltrate resolved in response to topical voriconazole, natamycin, and oral voriconazole. Aspergillus fumigatus keratitis is a rare but serious complication of LASIK surgery. The infection was successfully treated with flap amputation and daily debridement in addition to antifungal therapy.

Bilateral deep anterior lamellar keratoplasty for the management of bilateral post-LASIK mycobacterial keratitis.
J Cataract Refract Surg. 2007 Sep;33(9):1641-3. Susiyanti M, Mehta JS, Tan DT.
Singapore National Eye Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

A 25-year-old Vietnamese man who had bilateral simultaneous laser in situ keratomileusis (LASIK) for moderate myopia developed bilateral Mycobacterium abscessus keratitis that was treated with intensive medical therapy, flap removal, superficial keratectomy, and, following disease progression, therapeutic deep anterior lamellar keratoplasty (DALK). To our knowledge, this is the first reported case of bilateral post-LASIK mycobacterial keratitis successfully treated with DALK.

A cluster of Nocardia keratitis after LASIK.
J Refract Surg. 2007 Mar;23(3):309-12.
Garg P, Sharma S, Vemuganti GK, Ramamurthy B. Cornea and Anterior Segment Service, L V Prasad Eye Institute, Hyderabad, India. prashant@lvpei.org

PURPOSE: To report a cluster of Nocardia asteroides keratitis cases after LASIK.

METHODS: Retrospective review of the history and examination of three patients (four eyes) operated on the same day at a single center who developed postoperative keratitis. All patients underwent lifting of the superficial flap for microbiologic evaluation of the corneal scrapings. The operating surgeon was contacted to identify the possible source of contamination.

RESULTS: Two patients underwent simultaneous bilateral LASIK; however, only one developed postoperative keratitis in both eyes. One patient had unilateral surgery and developed keratitis in the operated eye. Microscopic examination of smears from all eyes revealed thin, branching, acid-fast, filamentous bacteria that were identified as Nocardia asteroides after culture. The infiltrates resolved with topical administration of amikacin sulphate (2.5%) and topical and oral trimethoprim-sulfamethoxazole. Final visual acuity ranged between 20/25 and 20/80. The operating surgeon had used the same blade and microkeratome in all patients.

CONCLUSIONS: Nocardia, a relatively unusual organism, can cause an epidemic of infection after LASIK.

Acanthamoeba keratitis after LASIK.
J Refract Surg. 2006 Jun;22(6):616-7. Balasubramanya R, Garg P, Sharma S, Vemuganti GK.
Cornea & Anterior Segment Service, L. V. Prasad Eye Institute, Hyderabad, India.

PURPOSE: To report a case of Acanthamoeba infection following LASIK.

METHODS: A 20-year-old woman developed pain, redness, decreased vision, and corneal infiltrate in the right eye 15 days after bilateral LASIK. She did not use contact lenses postoperatively. Patient examination 3 months after surgery revealed a large, central, full-thickness corneal infiltrate with multiple satellite lesions in the right eye. Corneal scrapings were taken and the flap excised, and submitted for histopathologic examination.

RESULTS: Microscopic examination of smears revealed Acanthamoeba cysts and non-nutrient agar showed a significant growth of Acanthamoeba. Histopathology examination of the excised flap demonstrated numerous Acanthamoeba cysts in tissue sections. The infiltrate was treated with a combination of topical polyhexamethylene biguanide, chlorhexidine, atropine sulfate, and oral itraconazole and resolved within 2 months.

CONCLUSIONS: Laser in situ keratomileusis can be complicated by Acanthamoeba infection. Microbiologic evaluation is essential for accurate early diagnosis and treatment.

Endophthalmitis after astigmatic myopic laser in situ keratomileusis.
J Cataract Refract Surg. 1997 Jul-Aug;23(6):948-50. Mulhern MG, Condon PI, O'Keefe M. Department of Ophthalmology, Mater Private Hospital, Dublin, Ireland.

A 36-year-old woman had uneventful astigmatic myopic laser in situ keratomileusis (LASIK) to correct -12.00 -1.50 x 70. Three days later, she developed a corneal abscess, hypopyon, and an intense vitreous cellular reaction-endophthalmitis. The patient was immediately given intravenous ciprofloxacin and topical vancomycin and ceftazidime. The infecting organism was Streptococcus pneumoniae. One day after therapy was instituted, the hypopyon resolved. Seven months later, best corrected visual acuity was 20/25 and refractive error, -4.00 diopters. A stromal scar (grade 2 haze) was causing a slight reduction in acuity. Endophthalmitis after LASIK, if treated promptly, need not lead to a permanent reduction in visual acuity.