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Bacterial keratitis following laser in situ keratomileusis is an uncommon complication. Previous reports1-3 have described unilateral bacterial keratitis after various refractive procedures, and Watanabe et al4 reported a case of bilateral staphylococcal bacterial keratitis after laser in situ keratomileusis. To our knowledge, this is the first report of a bilateral infection after refractive surgery in an immunocompromised patient.
Report of a Case
A 55-year-old white man underwent bilateral simultaneous laser in situ keratomileusis by his referring physician for myopia of −5 diopters (D) OD and −3 D OS. His left eye had undergone radial keratotomy 10 years previously. He had a history of human immunodeficiency virus with no opportunistic infections, no acquired immunodeficiency syndrome–defining conditions, and a T-helper lymphocyte count of 0.30×109/L (300 cells/mm3); the patient was on a regimen of protease inhibitors. The referring physician neither used a povidone-iodine (Betadine) preparation nor draped the eyelids. The laser hand controls were not sterile and were handled by the gloved surgeon during the procedure. The same set of instruments and surgical gloves was used for both eyes. After surgery the patient was started on a regimen of 0.3% ciprofloxacin hydrochloride, the combination drug trimethoprim sulfate and polymyxin B sulfate, and prednisolone acetate eyedrops, all to be taken 4 times daily.
One day after surgery, redness and irritation developed in both eyes. The next day, diffuse, fluffy white infiltrates were noted in both flap interfaces. Both flaps were lifted, irrigated with 0.3% ofloxacin eyedrops, and replaced by the referring physician. The left eye was scraped for bacterial culture using a transport medium.
Despite hourly treatment with 0.3% ciprofloxacin eyedrops, the infiltrates worsened. Three days postoperatively the patient was referred to our clinic. Visual acuity was counting fingers OU. Moderate blepharitis was noted, and the conjunctivae were diffusely vasodilated and chemotic. Each flap was displaced from the stromal bed and hanging freely by its hinge. Diffuse corneal infiltrates obscured details of the iris and lens in both eyes. A 5-mm epithelial defect was noted on the right flap. A superior wedge of flap tissue between 2 radial keratotomy incisions in the left eye was absent. The anterior chambers had a grade 2 to 3 cellular reaction without hypopyon.
The corneal flaps and stromal beds in both eyes were scraped for culturing with a stainless steel spatula and the scrapings were transferred directly to blood, chocolate, and Sabouraud agars, and to thioglycolate. The stromal beds were irrigated with 0.3% ofloxacin eyedrops before replacing each flap and allowing the flaps to settle for 10 minutes. Bandage contact lenses were placed on the eyes, and the patient was admitted to the hospital to receive hourly treatments with cefazolin sodium, 50 mg/mL, and tobramycin sulfate, 15 mg/mL, eyedrops. A few colonies of Staphylococcus aureus sensitive to cefazolin grew from the original cultures of scrapings from the left eye. Tobramycin treatment was discontinued after 3 days but was restarted 3 days later when worsening of the infiltrates occurred. During the following weeks, the infiltrates and epithelial defects slowly resolved (Figure 1 and Figure 2). At 4 weeks and 8 weeks after surgery, epithelial ingrowth was removed from beneath the flap in the right eye. Penetrating keratoplasty was performed in the left eye 4 months after surgery because corneal scarring and irregular astigmatism limited his best-corrected visual acuity to 20/200 OS. Nine months after the original surgery, the patient's best-corrected visual acuity with a refraction of –5.50+5.25 × 120 was 20/25 OD. The visual acuity with a refraction of –5.50 + 2.75 × 025 was 20/25 OS (Figure 3 and Figure 4). His general health and T-helper lymphocyte counts have remained stable.
Right eye, 2 weeks postoperatively.
Left eye, 2 weeks postoperatively.
Right eye, 9 months postoperatively.
Left eye, 9 months postoperatively.
This patient suffered a rare complication of refractive surgery. His immune deficiency most likely contributed to his risk of acquiring an infection and probably slowed his recovery, despite prompt recognition of the infection and aggressive use of appropriate antibiotics. This complication occurred despite the surgeon's adherence to standard practices for laser in situ keratomileusis surgery. These standard practices observed by the surgeon include the use of sterilized instruments and gloves and the administration of postoperative antibiotics. To further lessen the risk of bilateral infections, surgeons may want to consider additional precautions. First, bilateral surgery performed on patients with a known history of impaired immunity should be avoided. Second, when unilateral surgery is performed on such patients, strict sterile technique should be used. Finally, preparing and draping the eyelids and the laser hand controls will lessen exposure to ubiquitous bacterial pathogens for all patients.
Reprints: Robert K. Maloney, MD, 10921 Wilshire Blvd, Suite 900, Los Angeles, CA 90024.
Hovanesian JA, Faktorovich EG, Hoffbauer JD, Shah SS, Maloney RK. Bilateral Bacterial Keratitis After Laser In Situ Keratomileusis in a Patient With Human Immunodeficiency Virus Infection. Arch Ophthalmol. 1999;117(7):978–979. doi:
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