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   Table of Contents      
BRIEF REPORT
Year : 2003  |  Volume : 51  |  Issue : 3  |  Page : 263-265

Interface Keratitis due to Mycobacterium fortuitum following Laser In Situ Keratomileusis.


Sankara Nethralaya, Medical Research Foundation, Chennai, India

Correspondence Address:
R Fogla
Sankara Nethralaya, Medical Research Foundation, Chennai
India
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Source of Support: None, Conflict of Interest: None


PMID: 14601856

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  Abstract 

A case of unilateral interface keratitis due to Mycobacterium fortuitum following simultaneous bilateral LASIK procedure for low myopia is reported. Excimer phototherapeutic keratectomy was performed to the stromal bed to reduce the infective load. Intensive topical therapy with topical amikacin and ciprofloxacin resulted in resolution of the keratitis.

Keywords: Interface keratitis, LASIK, Mycobacterium fortuitum , management


How to cite this article:
Fogla R, Rao SK, Padmanabhan P. Interface Keratitis due to Mycobacterium fortuitum following Laser In Situ Keratomileusis. Indian J Ophthalmol 2003;51:263-5

How to cite this URL:
Fogla R, Rao SK, Padmanabhan P. Interface Keratitis due to Mycobacterium fortuitum following Laser In Situ Keratomileusis. Indian J Ophthalmol [serial online] 2003 [cited 2019 Nov 18];51:263-5. Available from: http://www.ijo.in/text.asp?2003/51/3/263/14669

Laser in situ keratomileusis (LASIK) is used worldwide for the correction of myopia, astigmatism and hyperopia. Although there seems to be a lower risk of infection following LASIK due to rapid epithelial healing, several authors have reported infectious keratits following LASIK.[1],[2],[3],[4],[5] Mycobacterial infections following LASIK have been reported infrequently,[2],[3],[4],[5] and successful management requires early detection and surgical intervention in these cases.

We report a case of infective keratitis caused by Mycobacterium fortuitum following simultaneous bilateral LASIK for low myopia.


  Case report Top


A 24-year-old male underwent simultaneous bilateral LASIK for correction of myopia. The patient's preoperative refraction was -3.00 DSph in the right eye and -3.50 DSph in the left eye. Six weeks later the left eye developed pain, redness, watering and photophobia associated with decreased vision. Interface keratitis was noted. The treating ophthalmologist performed a corneal scraping after lifting the corneal flap, which demonstrated acid-fast bacilli (Ziehl-Neelsen technique). He was treated with topical amikacin (25mg/ml), natamycin 5%, and vancomycin (50mg/ml) eye drops. The patient was referred to us two weeks later.

At the time of presentation the uncorrected visual acuity was 6/6 in the right eye and 6/24 in the left eye. Slitlamp examination of the right eye showed a healed LASIK flap with clear interface. The left eye showed lid oedema and diffuse conjunctival congestion. The cornea had a infiltrate at the interface, with hyphate edges bordering the scotopic pupil at 10 o' clock position [Figure1]. Fluorescein staining revealed an intact epithelium. The stroma surrounding the infiltrate appeared hazy. The anterior chamber was of normal depth with 1+ cells. The intraocular pressure was normal digitally. Fundus was normal. As the patient was unwilling to go through a repeat corneal scraping, he was started on topical fortified cefazoline (50mg/ml), amikacin (25mg/ml), ciprofloxacin 0.3%, and amphotericin B 0.15% administered every one hour, and atropine sulphate 1% twice daily. Significant improvement was not seen after one week's therapy. The patient was now willing to undergo the corneal scarring procedure. The corneal flap edge was identified under the microscope. The epithelium was then breached using the sinskey hook to gain access to the interface of the LASIK flap. The flap was raised without much difficulty and corneal scraping was performed both from the stromal bed and the undersurface of the corneal flap. Excimer laser phototherapeutic keratectomy (PTK) (Summit Apex Plus, Waltham, MA) of a spot size of 2.5 mm (200 pulses) was performed using a polish technique to the involved cornea on the undersurface of the corneal flap and the stromal bed. A bandage soft contact lens was applied after repositioning the flap.

Direct smear revealed acid-fast bacilli, which were later identified as Mycobacterium fortuitum . It was sensitive to amikacin, azithromycin, ciprofloxacin and norfloxacin. The patient was continued on the earlier medications, but amphotericin B 0.15% and cefazoline were discontinued. A week later the infiltrates decreased and the patient became asymptomatic. His unaided visual acuity was 6/18 in the left eye. Two weeks later he returned to his local ophthalmologist, who added topical fluorometholone 0.1% four times daily to the regimen. Topical amikacin (25mg/ml) was reduced to six times daily and ciprofloxacin 0.3% to three times daily.

A month later, he returned with exacerbation of symptoms in the left eye. On examination his visual acuity had decreased to 6/60. Slitlamp examination revealed a recurrence of the corneal infiltrate adjacent to the previous scar. It measured 2.5mm in diameter with hyphate edges along with a diffuse haze in the corneal interface. Anterior chamber showed a 1+ cellular reaction. Topical fluorome-tholone 0.1% was discontinued. Amikacin (25mg/ml) and ciprofloxacin 0.3% were administered topically at half-hourly intervals. After 10 days of treatment there was a favourable response with diminution of symptoms and regression of the corneal infiltrate. Topical antibiotics were slowly reduced to four times daily over the next two months. When reviewed three months later, the patient was asymptomatic. The cornea showed a healed scar in the area of infiltrate [Figure - 2]. Topical amikacin (25mg/ml) and ciprofloxacin 0.3% were continued twice daily for another month. At last follow-up six months later, the infection did not recur even after discontinuation of all medications. The patient's unaided visual acuity in the left eye was 6/9, improving to 6/6 with a correction of +0.50 / - 0.75 x 160.


  Discussion Top


Infectious keratitis is a rare but potentially vision-threatening complication after LASIK. A review of literature suggests that post-LASIK keratitis can be produced by a variety of organisms including bacteria, fungi and atypical mycobacteria. [1],[2],[3],[4] Postulated causes for keratitis include contamination of the stromal bed by microorganisms from eyelids, eyelashes, conjunctiva and microsurgical instruments including the microkera-tome. Reduced corneal sensitivity and use of topical corticosteroids post-LASIK, further weakens the defense mechanism of the ocular surface.

These infections especially of bacterial aetiology become clinically apparent within days after the procedure. Fungal and atypical Mycobacteria usually have an insidious onset and present weeks to months after LASIK.[2],[3],[4],[5] Mycobacterium species are an unusual group of organisms, which rarely infect the cornea. Runyon has classified them into various groups, and group IV includes M. Chelonae and M. fortuitum . Mycobacterium keratitis has been reported following corneal trauma, corneal surgery including corneal trans-plantation and refractive surgery.[2],[3],[4],[5],[6] A Medline search for mycobacterial keratitis after LASIK listed four reports of M. chelonae keratitis and only one report of M. fortuitum keratitis[2],[3],[4],[5]. Five of these six patients (including ours) had simultaneous bilateral LASIK and bilateral infection occurred in one patient.

The clinical picture resembles fungal keratitis and hence diagnosis is often delayed in these cases. Initial corneal scraping after lifting the flap is essential for obtaining material for microbiological diagnosis in these cases. In our patient, this was performed by the treating ophthalmologist. Although the report read acid-fast bacilli, the patient was treated with topical amikacin, vancomycin, and natamycin. In the absence of a repeat scraping at presentation, we also preferred to continue treatment with both antibiotics and antifungal agents. Amikacin is the recommended initial drug of choice for atypical mycobacterial keratitis. Topical clarithromycin 1% has also been used successfully.[3],[4] Topical ciprofloxacin 0.3% has been reported to be more effective against M fortuitum .[7] However, medical therapy is often ineffective because of slow response to therapy, inadequate drug penetration and resistant strains. Therefore these cases often require additional procedures like removal of the LASIK flap to facilitate better antibiotic penetration and even a therapeutic penetrating keratoplasty.[2],[4]

Excimer laser has been used successfully to ablate experimental septate fungal ( Fusarium ) and an atypical mycobacterial ( Mycobacterium fortuitum ) keratitis in an animal model.[8] Due to the superficial location of the corneal infiltrate in the stromal bed, in our case, excimer PTK was performed to debulk the load of infective organism. Although the patient showed a favourable response initially, recurrence of the infective keratitis was noted after four weeks, possibly due to addition of topical corticosteroids. Although topical corticosteroid therapy may result in transient improvement of the inflammatory process and patient symptoms, it has been reported to result in chronicity of the disease and worsening of clinical outcome. Hence it is better to withhold corticosteroids until complete resolution of the infection. Medical treatment needs to be continued for several months to achieve a complete recovery.

 
  References Top

1.
Sridhar MS, Garg P, Bansal AK, Sharma S. Fungal keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2000;26:613-15.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.
Revigilo V, Rodriguez ML, Paradello M, Luna JD, Juarez CP. Mycobacterium chelonae keratitis following laser in situ keratomileusis. J Cataract Refract Surg 1998;14:357-60.  Back to cited text no. 2
    
3.
Gelender H, Carter HL, Bowman B, Beebe WE, Walters GR. Mycobacterium keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2000;16:191-95.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.
Chung MS, Goldstein MH, Driebe WT Jr, Schwartz B. Mycobacterium chelonae keratitis after laser in situ keratomileusis successfully treated with medical therapy and flap removal. Am J Ophthalmol 2000;129:382-84.  Back to cited text no. 4
    
5.
Garg P, Bansal AK, Sharma S, Vemuganti GK. Bilateral infectious keratitis after laser in situ keratomileusis. Ophthalmology 2001;108:121-25.   Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.
Matoba A. Mycobacterium chelonae keratitis. Am J Ophthalmol 1987;103:595-96.   Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.
Hu FR, Luh KT. Topical ciprofloxacin for treating non-tuberculous mycobacterial keratitis. Ophthalmology 1998 ;105:269-72.   Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.
Gottsch JD, Gilbert ML, Goodman DF, Sulewski ME, Dick JD; Stark WJ. Excimer laser ablative treatment of microbial keratitis. Ophthalmology 1991;98:146-49.  Back to cited text no. 8
    


    Figures

  [Figure - 1], [Figure - 2]


This article has been cited by
1 Nontuberculous (atypical) mycobacterial keratitis following refractive surgery with laser in situ keratosmileusis (LASIK)
Chatziralli, I., Vrioni, G.
Acta Microbiologica Hellenica. 2010; 55(6): 461-468
[Pubmed]
2 Recalcitrant Post-LASIK Mycobacterium chelonae Keratitis Eradicated after the Use of Fourth-Generation Fluoroquinolone
Hamam, R.N., Noureddin, B., Salti, H.I., Haddad, R., Khoury, J.M.
Ophthalmology. 2006; 113(6): 950-954
[Pubmed]



 

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