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					Post Lasik Fungal
Keratitis
            Dr Foo Fong Yee
              Medical Officer
      Tan Tock Seng Hospital
History
   28/Bangladeshi/F           POD1 UAVA OU 6/6
   CL wearer X 15 years       R stromal opacity
   OD: 4.5/ 2.5  3        L SPK
   OS: 4.5/ 3.0  175      Gutt. tobradex
   BCVA OU 6/6                TCU 1/52
   Uneventful LASIK
    12.06.05
Stromal opacity post LASIK
1.   Non-infective
     •   Diffuse lamellar keratitis (SOS)
     •   MK
     •   Epithelial ingrowth
2.   Infective
     •   Bacterial – G+ve cocci, atypical mycobacteria
     •   Fungal - HSV
     •   Viral, reactivation of post-viral SEIs
     •   Protozoal – microsporidial, rare
History
• ? Defaulted f/u
• P/w RE redness, irritation & BOV on POD 17
   UAVA OD 6/60             UAVA OS 6/12
   Mild conj injection      NAD except for trace
   Tiny areas of ED          SPK
   Conglomerate of SPK
   Flap in position
   Interface healthy
   AC trace cells
History
OD                            OS
 Rx as for early keratitis    Continue gutt.
 Gutt. ofloxacin hourly        tobradex
 Occ. ciloxan ON
 Gutt. homatropine bd
 Review following day
Progression
OD                               OS
 VA 6/45                         ISQ

 Superficial to 1/3 stromal
  feathery, filamentous
  infiltrate
 Flap edema
 Impression: fungal keratitis
 Scraped
 Started on gutt. natamycin
  ½ hourly
    Fungal stains & c/s media
   Gram stain (yeast, wall)       Sabouraud dextrose
   Giemsa (cytoplasm)              agar @ room temp
   Gomori methanamine silver      Blood agar @ room
    (hyphae)                        temp
   Potassium hydroxide (wall)     BHIB
   Periodic acid-Schiff (wall)    No cycloheximide
   Acridine orange
   Calcofluor white
Progression
OD                           OS
 Stain – G+ve cocci,         Conglomerate of ED
  fungal elements             A/w surrounding
 Responded to                 stromal haze
  treatment                   Started on ½ hourly
 Infiltrate  in size and     natamycin as for
  density                      fungal keratitits
      Came to Singapore for 2nd opinion
In Singapore…
OD                              OS
 6/60  6/30                    6/12
 Melted flap w button hole      Intra-lamellar infiltrate
 Infiltrate with surrounding
                                 AC cells +
  scar
 AC cells +


• Bilateral scrapings done
• Started on gutt. moxifloxacin hourly OD, 3hourly OS &
gutt. amphotericin 0.5mg hourly OU
In Singapore…
OD




                OS
Progress
   Bilateral flap lifting, irrigation with moxifloxacin
    & amikacin 06.07.05
   Added gutt. amikacin to moxifloxacin &
    amphotericin
   Bilateral flap amputation, irrigation with
    moxifloxacin & amikacin – OD 09.07.05, OS
    12.07.05
   Gutt. amikacin, moxifloxacin, natamycin
   Responded to treatment
   C/S: OD & OS penicillium
Penicillium sp.
   Septate, filamentous
    fungi except Penicillium
    marneffei (dimophic)
   Widespread in soil,
    decaying vegetation & the
    air
   Corneal infections usually
    post traumatic
   Mycotoxin, ochratoxin A
     nephrotoxic and
    carcinogenic
Progress
OD




     

           
Progress
OS




     

           
Progress
   Moxifloxacin and amikacin tailed off over 1
    month
   Last TCU 05.10.05 (4/12 post LASIK):
   VA OD 6/21 6/12 OS 6/21  6/12
   Bilateral central scar
   Gutt. natamycin qds
   Added gutt. FML qds
     Discussion
       Risk of infectious keratitis post-LASIK 0.1-0.2%1
       Presentation varies considerably
       Multiple foci/ single abscess, central/ peripheral,
        flap/ intralamellar/ flap melt
       Risk factors:
              LASIK  devices e.g. microkeratomes & excimer lasers
               cannot be completely heat sterilized
              Creation of new lamellar plane for organisms to
               invade
              Corneal nerves disrupted
              Use of topical steroids

1Bilateral   infectious keratitis after LASIK: a case report & review of the literature. Ophthalmology 2001;108:121-5
1Fungal   keratitis after LASIK. J Cataract Refract Surg 2000;26:613-15
Discussion
   Staphylococcus (acute) & atypical mycobacteria
    (subacute, infectious crystalline keratopathy) most
    common2
   Fungal not uncommon – candida, aspergillus, nattrassia
    mangiferae, acremonium, curvularia
   Type of post-op Abx & steroid use not associated with
    particular infecting organism or severity of VA loss3
   Gram +ve more likely to present < 7days post LASIK
   Mycobacterial more likely to present > 10 days post
    LASIK


    2Infectious   keratitis after LASIK. Results of an ASCRS survey. J Cataract Refract Surg 2003;29:2001-6
    3infections   following LASIK: an integration of the published literature. Surv Ophthalmol 2004;49:269-80
Management
1.       High index of suspicion
2.       Acute vs sub-acute presentation
3.       Flap lifting, scraping, staining and culture
4.       Irrigation of stromal bed with Abx
     •     G+ve: vancomycin 25mg/ml with moxifloxacin/ gatifloxacin
     •     Atypical mycobacteria: amikacin/ clarithromycin 1% with
           moxifloxacin/ gatifloxacin
5.       Flap amputation/ excision if necrotic/ button-
         hole  facilitaes Abx penetration
6.       Therapeutic keratectomy/ PTK
7.       PK for deep infections/ resistant to therapy
Thank you
A presentation by
The Eye Institute @
Tan Tock Seng Hospital

				
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