Combined treatment with flap amputation, phototherapeutic keratectomy, and collagen crosslinking in severe intractable post-LASIK atypical mycobacterial infection with corneal melt

Abstract

A 23-year-old woman was referred for management of intractable post-laser in situ keratomileusis (LASIK) keratitis due to atypical mycobacteria in the left eye. Corrected distance visual acuity was 20/20 in the right eye and counting fingers at 3 meters in the left eye. Slitlamp examination revealed multiple infiltrates in the flap interface and severe corneal stromal melting with thinning. Despite maximum antibiotic therapy for 7 days, the keratitis continued to worsen. A penetrating keratoplasty (PKP) was scheduled. While waiting for a corneal graft, corneal collagen crosslinking (CXL) with riboflavin and ultraviolet-A was proposed as an alternative treatment. Flap amputation and limited phototherapeutic keratotomy (PTK) (10 μm) were also performed. One week postoperatively, all infiltrates and stromal edema had resolved. At 3 months, the uncorrected distance visual acuity improved to 20/35. Corneal crosslinking after flap amputation and limited PTK was an effective treatment for severe intractable post-LASIK keratitis with corneal melting and obviated PKP.

Efeito terapêutico do crosslinking corneal na ceratite infecciosa

“…Thus, it increases resistance against microbial degradation and corneal melting (26,(35)(36) . Even though some clinical trials and experimental studies have shown improvement of fungal ulcers with CXL (21,23) , this was not observed in our study. All of our patients with fungal ulcers underwent adjuvant surgical treatment aimed at curing the infectious process.…”

“…Studies show that therapeutic transplants represent 2.6% to 17.9% of total penetrating transplants (17) . There are reports of corneal ulcers treated successfully with corneal collagen crosslinking (CXL) (18)(19)(20)(21)(22)(23)(24)(25) . An experimental study found increased resistance to enzymatic digestion by collagenase, pepsin, and trypsin in corneas subjected to CXL (26) .…”

“…Currently, CXL is usually indicated for cases of keratoconus (30) , pellucid marginal degeneration (31) , painful bullous keratopathy (32) , and iatrogenic ectasia after refractive surgery with laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) (30) . The therapeutic effects of CXL in infectious keratitis are still unclear (18)(19)(20)(21)(22)(23)(24)(25)(26) . This study aimed to evaluate the effect of CXL on infectious keratitis resistant to medical treatment.…”

Therapeutic Flap Amputation for Atypical LASIK Flap and Interface Abnormalities

“…5,6 Planned therapeutic flap amputation has been reported in cases of recalcitrant epithelial ingrowth or infectious keratitis not responding to conservative therapy. [7][8][9] In most cases with flap or interface complications, concerted attempts are made to preserve the flap, even in cases of late dislocation. We are not aware of any reports of planned flap amputation for irregular astigmatism or flap-specific opacity.…”

“…16 Corneal remodeling occurs for several months after the procedure 4 ; therefore, an additional laser procedure, such as PRK, should not immediately follow the flap amputation. 9 Phototherapeutic keratectomy may be performed to smooth corneal irregularities caused by variations in corneal thickness, which can improve refractive outcomes. The epithelium has a tremendous capacity to compensate for irregular curvature [17][18][19] ; thus, direct epithelial measurements will benefit direct determination of stromal surface topography to guide optimal therapeutic ablations and may improve outcomes.…”