Infection and Inflammation in the Refractive Surgery

Types of Refractive Surgery
Infection and Inflammation in the
Refractive Surgery Patient
Kurt Buzard MD FACS
Assistant Clinical Professor
University of Nevada Medical School
Tulane University Medical School
The Buzard Eye Institute
Las Vegas Nevada
Inflammation vs Infection
• It is often difficult to differentiate between
infection and inflammation
• Stromal infiltrate can occur in either
condition
• Staining can occur after epithelial disruption
and may or may not be a sign of infection
• Peripheral location may differentiate
Central Corneal Ulcer
• Incisional
– Relaxing Incisions
• Lamellar
– LASIK
– PRK
• Lens Based
– Lens Exchange
– Intraocular Contact Lens
Types of Infection
• Central Corneal Ulcers
– Infiltrate/staining/sometimes hypopeon
• Incisional Infiltrates
– Abcess/often without staining/hypopeon
• Herpetic Infections
– Dendritic Pattern/SPK
• Endophthalmitis
– Hypopeon
Central Corneal Ulcer
• This case is typical of central ulcers which
are extremely rare after LASIK
• This is a Pseudomonas ulcer with shiny
surface, conjunctival injection and relatively
fast growing
1
Peripheral Corneal Ulcer
Peripheral Corneal Ulcer
• Again peripheral ulcers are rare but more
likely to be inflammatory rather than a real
infection
• This is a Staph ulcer with raised borders,
sunken center, corneal staining,
conjunctival injection and relatively
indolent and slow growing
Methacillin Resistant Staph
after PTK
Methacillin Resistant Staph
after PTK
• This case is confusing because the
periphery shows a flat paralimbal infiltrate
which appears to be immune and not
infectious
• But the central cornea has a diffuse
gelatinous appearance with staining
• Unusual appearance is the hallmark of
infection in and after refractive surgery
Incisional Infection after RK
Incisional Infection after RK
• This case is typical of infection after
incisional surgery
• Any sudden appearance of staining of
incisions long after surgery should be
considered a possible infection and treated
aggressively
• Failure to treat properly may lead to a rapid
decompensation of the cornea
2
Incisional Infection after RK
Incisional Infection after RK
• This case shows how quickly infection can
progress to corneal decompensation
• Only 3 days between foreign body sensation
and this appearance of imminent corneal
perforation
After PK
Herpetic Infection in RK
Herpetic Infection in RK
• This example of herpes simplex some time
after RK is rare but shows the influence the
incisions can have on the infection process
• Previous herpetic infection is a relative
contraindication for refractive surgery
unless the patient is quiet for a long time or
is willing to be on chronic antiviral meds
Hs
25619
Infection after LASIK
Infection After LASIK
• S/P LASIK OU in
Mexico with epithelial
ingrowth
• S/P removal x 2
• Sudden onset of
redness and pain with
methacillin resistant
staph OD
3
AH
18692
Case Study
• 49 y/o w/f with retrolental fibrodysplasia
and NLP OD
• Preop -10 + 3.25 x 90 20/20 5/1999
• Postop 20/20 oc
• RD after retinal hemmorhage 9/2000
• Corneal scraping during RD surgery and
removal of lens
AH
18692
Case Study
After Removal of Ingrowth
AH
18692
AH
18692
Case Study
• On exam after RD surgery LP OD 1/01
• Removal of ingrowth 1/11/01
• Subsequent flap melt inferotemporally
stabilized with therapeutic contact lens
• Abrasion 4/01 with finger with rapid
development of methacillin resistant staph
• Removal of flap, slight residual scar
DP
27232
LASIK after PK
• 65 y/o w/m s/p PK OU 30 years prior by
Max Fine with cataract formation OU
• 2 months postop LASIK OU elsewhere
• The patient had a high degree of
astigmatism and the “surgeon” performed
relaxing incisions in the bed of the graft
• Results OD CF
OS -3.00 + 7.50 x 42
20/40
DP
27232
LASIK after PK
• The vision had been
excellent prior to
surgery but
immediately after
surgery the vision was
uncorrectable and
soon thereafter pain
developed
4
DP
27232
LASIK after PK
• An infection
developed which was
controlled with
antibiotics and lifting
flap leaving a large
corneal scar
• The patient is
presently on the
cornea transplant list
Common Inflammatory Problems
Infection After LASIK
• Epithelial ingrowth is a risk factor for
infection
• Any abnormality of the flap can be an entry
for bacteria
• Once begun, infection can be difficult to
eradicate without removal or lifting of flap
• LASIK surgery is real corneal surgery
particularly after PK
Inflammation After PRK
•
•
•
•
•
Central sterile infiltrates
Marginal infiltrates
Sub-epithelial infiltrates
Superficial Punctate Keratopathy (SPK)
Diffuse Interstitial Lamellar Keratitis
(DILK)
• Recurrent erosion syndrome
Inflammation After PRK
Inflammation and scarring after
PRK after RK
• Inflammatory infiltrates after PRK can
resemble infection
• They are multifocal, appear suddenly and
must be treated with heavy steroids to avoid
scarring
• They may be induced by reactions to meds
particularly nonsteroidal anti-inflamatories
5
Scarring After PRK
Scarring After PRK
• After inflammation, scarring occurs in most cases
resulting in diminished vision and myopic
regression
• Treatment involves non-touch transconjunctival
ablation and careful removal of the scar
• I usually utilize low dose pulse methotrexate
before and after the treatment to prevent
reoccurance of the scar and Mitomycin 0.1%
during and after surgery
Post-EKC after LASIK
Post-EKC after LASIK
• Post-EKC syndrome is an inflammatory
response to the dead viral particles left from
a previous viral infection, usually about 2
weeks previous
• Treatment is topical steroids with a slow
taper, and prevention of the syndrome is
steroids during the active phase of the EKC
SPK and Filaments
Superficial Punctate Keratopathy
• SPK is the endpoint of many allergic and
inflammatory conditions of the cornea
• The most common cause is medicamentosa
to topical medications
• Don’t forget Acanthomoeba as a possibility
• Oral Evoxac 30 mg QD to TID
• 0.1% pilocarpine QID
6
Dry Eyes
• Preservative free tears
• The “vegas” syndrome
– Dry eyes
– Blepharitis
– Allergies
• Increase estrogen
• Oral Evoxac 30 mg QD to TID
• 0.1% pilocarpine QID
Abnormal corneal wound
healing
Sands of Sahara Syndrome
• First described by Dr Maddox
• First attempts at treatment include
increasing steroids, lifting flap and
irrigating bed
• Equivocal results..in fact softening of bed
caused worsening of condition in several
patients
Rheumatoid cornea
• A variety of factors can affect corneal
wound healing in general and healing in
LASIK in particular
• Reactions to topical medications and/or
autoimmune diseases are common
etiologies of abnormal corneal wound
healing
Scleromalcia Perforans
• Autoimmune disease
resulting in melting of
cornea and sclera
• Steroids can worsen
condition
• Well treated with low
dose methotrexate
Wound healing in PK with
Rheumatoid arthritis
After treatment with MTX
7
Methotrexate and SOS
• There are many clinical similarities between
scleritis and SOS syndrome
• Softening of sclera and cornea
• Relationship between autoimmune and
toxic etiologies
• Good response to MTX in both
Low Dose Pulse Methotrexate
Low Dose Pulse Methotrexate
• Comes in 2.5 mg pill
• Usual dose 7.5 to 12.5
mg a week
• Monitor CBC, BUN,
Cr, Liver
• Give with internist or
rheumatologist
Mild Diffuse Interstitial Keratitis
• Very common and effective treatment for a
wide range of autoimmune disease,
particularly scleritis
• Once begun, treatment takes about 1 month
to begin experiencing effects and is usually
continued for 3 -6 months
Moderate Diffuse Interstitial
Keratitis
Diffuse Interstitial Keratitis
8
Moderate Diffuse Interstitial
Keratitis
Severe Diffuse Interstitial
Keratitis
SOS syndrome .. JB
SOS syndrome ..1 day 20\40
• This patient had a preop
refraction of
JB
– 9.50 + 0.75 x 145 20\20
• One day postop had 20\40
vision and good
topography
• Vision dropped … treated
with MTX x 3m with
return of vision
1 month 20\400
1 week 20\100
Last 20\25
0.5
0
MTX
Treatment
-0.5
-1
Diopters
-1.5
-2
-2.5
-3
1 Day
Small Clinical Study SOS
Syndrome
• 7 Patients
• 13 eyes
– age 28-52
– avg preop -7.39D
• One day uncorrected
vision is usually pretty
good with later rapid
deterioration
One day Vaoc
4
3
2
1
0
1 Month
3 months
1 year
Small Clinical Study SOS
Syndrome
• At 2-4 weeks, both uncorrected and best
corrected vision drops with variable
refraction and irregular corneal astigmatism
• All patients here treated with MTX pulse at
10mg/week for 2 -6 months
• 7 of 13 eyes were retreated without
recurrence of SOS syndrome
20 25 30 40 50 60 70
9
7
6
5
4
3
2
1
0
Uncorrected visual acuity
in SOS syndrome over
time
JG
e
or
m
80
70
1 month
60
50
40
30
25
20
1 day
SOS study #1
final
SOS study #2
SOS study #3
WS
MN
SOS study #4
SOS study #5
MD
10
SOS study #6
Causes of toxic keratopathy ..
SOS syndrome
• Oil or material from
microkeratome
• Oil or material from
sebaceous glands
• “Plume” debris
• Medicamentosa??
• Epithelial disruption
LS
Interface Debris
Interface Debris
• Interface debris comes from one of 2 sources
– Airborne and from drapes
– Tearfilm
Irrigation
Lashes
Epithelial Disruption
• To avoid this problem, leave flap exposed to air
for as little time as possible
• Irrigate between flap and bed forcefully to remove
debris
• Keep tearfilm clean with irrigation
Epithelial Disruption
Disruption after PRK
11
Epithelial Disruption
•
•
•
•
•
Dry whole cornea…no fluid
Increased risk of flap lift/epithelial ingrowth
Use CTL after surgery
Extra steroid treatment
Muro 128 drops and ointment in the
postoperative period
• Consider immediate PTK
Hansatome
• The tolerances for the
microkeratome are
remarkably restrictive
• Microkeratomes vary
widely from unit to
unit in terms of these
tolerances and finish
• The “critical corner” is
most important in
terms of finish
Critical Corner
Rust and Residual Epithelium
Inflection Journal Traction Plane
Original Critical Corner
• Improper maintenance
and/or cleaning can
result in buildup in
critical areas of the
microkeratome with
increased epithelial
disruption rates
• Rust is a very effective
epithelial stripper
Mastel Refinished Corner
12
Original Traction Plane 100 X
Mastel Polished Traction Plane
Case Study PS
Case study .. PS
• 34 y\o w\f (doctor’s wife) with LASIK OU
for myopia & astigmatism
• Manifest : Vaoc 20/100 OD 20/150 OS
– -3.75 + 3.50 x 4 20/20
– -4.00 + 3.75 x 13 20/20
Case study .. PS
OD
1 month
160
140
120
100
80
60
40
20
0
Vaoc OD
Vaoc OS
VaccOD
Vacc OS
1
pr
da 1 m 2 m 3 m
eo
o
on
on
y
p
th
th nth
s
s
Case study .. PS
OS
• Treated with PTK OU
• Slow improvement over additional 6 weeks
• Uncorrected 20/30 OU
– -0.25 + 0.75 x 32 20/25
– -0.50 + 0.75 x 178 20/25
13
MZ
30045
Recurrent Erosion
Recurrent Erosion
• 42 y/o w/f s/p LASIK
OD for near in
Colorado
• Lift the flap 3 months
prior to presentation
• Epithelial disruption at
time of LTF
• Pain, redness and
photophobia one day
prior
MM
9247
Recurrent Erosion
• On last visit, patient presented from ER
with 24 hour history of photophobia, pain
and redness
• Uncorrected vision 20/100
• Oral and topical steroids with therapeutic
CTL and topical antibiotics
• 37 y/o w/m s/p LASIK
OU x 9 months
elsewhere
• Epithelial disruption at
time of surgery OD
• Since surgery 3
episodes of recurrent
erosion with severe
SOS and mild iritis
JG
30142
MZ
30045
Disruption with SOS
MDF and Epithelial Ingrowth
JG
30142
Recurrent Erosion
• No history of trauma
and prior recurrent
erosions
• This erosion occurred
along the lamellar flap
margin
• Fairly severe SOS
accompanied the
abrasion
Moderate SOS
“Edge Lift” from epi ingrowth
Preop plano + 1.25 x 135
Postop Vaoc 20/20
14
Epithelial Nest
RK and Epithelial Ingrowth
• Previous RK can be a
source of epithelial
ingrowth
• LASIK in patients
with previous RK and
wide scars should be
considered carefully
RK and Epithelial Ingrowth
Epithelial Nest….Treatment
Epithelial Ingrowth with MDF
Epithelial Ingrowth with MDF
Antitorque Closure
Antitorque Closure
15
Flap Melt
• The flap is very
delicate
• This patient
experienced a flap
melt after lifting the
flap for epithelial
ingrowth
Summary
• Preventing infection in refractive surgery
patients is the same as any surgical situation
– Make sure eyelids are clean and wrap them to
keep secretions away at surgery
– Sterile technique in surgery
– Preop muro and antibiotic drops
– Avoid herpes patients
– Fortunately infections are rare but be suspicious
Summary
Summary
• Inflammatory problems can masquerade as
infections and are more common and can cause
serious visual disability
• Epithelial disruption is a serious complication and
can lead to inflammation/infection, prevention is
important
• Low dose pulse methotrexate is an effective
treatment for SOS but must be started early
• The cornea with a lamellar flap is different
than a normal cornea
• Do lamellar flaps ever really heal?
• With a simple corneal erosion years later,
the possiblity of SOS/infection/epithelial
ingrowth is real
• Retinal cases after LASIK should be
considered carefully
16