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Figure 1. Examination after treatment with topical amikacin, clarithromycin, vancomycin hydrochloride, and moxifloxacin revealed large confluent infiltrates in both eyes with satellite lesions.

Figure 1. Examination after treatment with topical amikacin, clarithromycin, vancomycin hydrochloride, and moxifloxacin revealed large confluent infiltrates in both eyes with satellite lesions.

Figure 2. After treatment with topical linezolid, complete control of infection was accomplished. The final examination showed a subtle leukoma, larger in the left eye.

Figure 2. After treatment with topical linezolid, complete control of infection was accomplished. The final examination showed a subtle leukoma, larger in the left eye.

1.
Giaconi J, Pham R, Ta CN. Bilateral Mycobacterium abscessus keratitis after laser in situ keratomileusis.  J Cataract Refract Surg. 2002;28(5):887-890PubMedArticle
2.
Moshirfar M, Meyer JJ, Espandar L. Fourth-generation fluoroquinolone-resistant mycobacterial keratitis after laser in situ keratomileusis.  J Cataract Refract Surg. 2007;33(11):1978-1981PubMedArticle
3.
Villar M, Sotgiu G, D’Ambrosio L,  et al.  Linezolid safety, tolerability and efficacy to treat multidrug- and extensively drug-resistant tuberculosis.  Eur Respir J. 2011;38(3):730-733PubMedArticle
4.
Verma S, Watson SL, Dart JK, Eykyn SJ. Bilateral Mycobacterium chelonae keratitis following LASIK.  J Refract Surg. 2003;19(3):379-380PubMed
Research Letters
Nov 2012

Topical Linezolid for Refractory Bilateral Mycobacterium chelonae Post–Laser-Assisted In Situ Keratomileusis Keratitis

Author Affiliations

Author Affiliations: Departments of Ophthalmology (Drs Dolz-Marco, Udaondo, Gallego-Pinazo, and Díaz-Llopis)and Genetics (Dr Millán), University and Polytechnic Hospital La Fe, Centro de Investigación en Red de Enfermedades Raras (Dr Millán), and Faculty of Medicine, University of Valencia (Dr Díaz-Llopis), Valencia, Spain.

Arch Ophthalmol. 2012;130(11):1475-1476. doi:10.1001/archophthalmol.2012.1495

Keratitis after laser-assisted in situ keratomileusis (LASIK) caused by Mycobacterium has been widely reported.1 Different regimens of antibiotic treatments have been published, but fourth-generation fluoroquinolones are the most effective drugs. However, management may be difficult owing to the delay in diagnosis, the long-term antibiotic treatment required in most cases, and the presence of multidrug-resistant pathogens.2 Systemic infection by multidrug-resistant Mycobacterium has been successfully treated with linezolid (Zyvoxid), an oxazolidinone antibiotic.3

We report a case of bilateral post-LASIK keratitis due to Mycobacterium chelonae resistant to fourth-generation fluoroquinolones that was successfully treated with topical linezolid. After an automated search in PubMed, this appears to be the first case of Mycobacterium keratitis treated with topical linezolid.

Report of a Case

A 33-year-old man had mild photophobia and redness in his right eye with blurred vision 1 month after an uneventful bilateral LASIK procedure using the same blade for both eyes. Slitlamp examination revealed mild ciliary injection and a white corneal infiltrate in the interface 1.5 mm from the flap edge, with no overlying epithelial defect. With suspicion of bacterial keratitis, topical treatment with ciprofloxacin hydrochloride (Oftacilox) and tobramycin (Tobrex) was initiated. After the first week, the inflammation was reduced but the infiltrate increased in size; thus, lifting and scrapping were performed and samples were obtained from the stromal bed of the ulcer. The microbiological study revealed multiple acid-fast bacilli; therefore, treatment was initiated with amikacin, 0.1%, clarithromycin, 1%, vancomycin hydrochloride, 1%, moxifloxacin, 0.3% (Vigamox), and oral clarithromycin. The intensive treatment failed to control the infection and the infiltrate coalesced, with new satellite lesions appearing (Figure 1). The final result of the culture showed M chelonae resistant to amikacin and clarithromycin; thus, topical linezolid (2 mg/mL) was initiated (6 times daily). Both the infiltrate and the inflammation improved dramatically after the first week of treatment. Control of the infection was achieved after 2 months (Figure 2). Although the final examination revealed a subtle leukoma, the final visual acuity was 20/30 OD and 20/40 OS.

Comment

Infection following LASIK procedures is uncommon, with a reported incidence of 1 in 5000 to 10 000 surgical procedures. It usually appears as a prominent conjunctival inflammation and a dominant corneal lesion involving the flap limits. In contrast, infection with atypical Mycobacterium species may be indolent with mild inflammation, therefore delaying the diagnosis. Several cases of mycobacterial keratitis following LASIK have been reported in the literature. The most frequently involved pathogen is M chelonae (66%). To our knowledge, only 3 cases of bilateral keratitis due to M chelonae have been published, and all cases responded to classic treatment with fourth-generation fluoroquinolones amikacin and vancomycin.4

To our knowledge, this is the first case of multidrug-resistant bilateral M chelonae keratitis after LASIK that was successfully treated with topical linezolid. This drug may be an effective alternative in treating post-LASIK keratitis, which is a dreaded complication with difficult diagnosis and management.

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Article Information

Correspondence: Dr Dolz-Marco, Department of Ophthalmology, University and Polytechnic Hospital La Fe, Bulevar Sur s/n, Valencia 46026, Spain (rosadolzmarco@gmail.com).

Conflict of Interest Disclosures: None reported.

References
1.
Giaconi J, Pham R, Ta CN. Bilateral Mycobacterium abscessus keratitis after laser in situ keratomileusis.  J Cataract Refract Surg. 2002;28(5):887-890PubMedArticle
2.
Moshirfar M, Meyer JJ, Espandar L. Fourth-generation fluoroquinolone-resistant mycobacterial keratitis after laser in situ keratomileusis.  J Cataract Refract Surg. 2007;33(11):1978-1981PubMedArticle
3.
Villar M, Sotgiu G, D’Ambrosio L,  et al.  Linezolid safety, tolerability and efficacy to treat multidrug- and extensively drug-resistant tuberculosis.  Eur Respir J. 2011;38(3):730-733PubMedArticle
4.
Verma S, Watson SL, Dart JK, Eykyn SJ. Bilateral Mycobacterium chelonae keratitis following LASIK.  J Refract Surg. 2003;19(3):379-380PubMed
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