Types of Refractive Surgery. Infection and Inflammation in the Refractive Surgery Patient. Inflammation vs Infection. Types of Infection

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1 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 Incisional Relaxing Incisions Lamellar LASIK PRK Lens Based Lens Exchange Intraocular Contact Lens 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 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 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

2 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

3 Incisional Infection after RK After PK 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 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 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

4 AH Case Study After Removal of Ingrowth 49 y/o w/f with retrolental fibrodysplasia and NLP OD Preop 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 AH Case Study 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 AH DP LASIK after PK DP 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 x 42 20/40 The vision had been excellent prior to surgery but immediately after surgery the vision was uncorrectable and soon thereafter pain developed 4

5 DP LASIK after PK Infection After LASIK 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 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 Common Inflammatory Problems 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 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 Inflammation and scarring after PRK after RK 5

6 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

7 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 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 Abnormal corneal wound healing 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 Rheumatoid cornea 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

8 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 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 Low Dose Pulse Methotrexate 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

9 Moderate Diffuse Interstitial Keratitis Severe Diffuse Interstitial Keratitis SOS syndrome.. JB SOS syndrome..1 day 20\40 This patient had a preop refraction of x \20 One day postop had 20\40 vision and good topography Vision dropped treated with MTX x 3m with return of vision JB 1 week 20\ Diopters month 20\400 MTX Treatment Last 20\ Day 1 Month 3 months 1 year 7 Patients 13 eyes Small Clinical Study SOS Syndrome age avg preop -7.39D 3 One day uncorrected 2 vision is usually pretty good with later rapid 1 deterioration 0 One day Vaoc 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 9

10 more Uncorrected visual acuity in SOS syndrome over time JG SOS study # day 1 month final SOS study #2 SOS study #3 WS MN SOS study #4 SOS study #5 MD 10

11 LS 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 Interface Debris Interface Debris Irrigation Lashes Interface debris comes from one of 2 sources Airborne and from drapes Tearfilm 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 Epithelial Disruption Disruption after PRK 11

12 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 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 Hansatome Critical Corner Rust and Residual Epithelium Inflection Journal Traction Plane 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 Original Critical Corner Mastel Refinished Corner 12

13 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 x 4 20/ x 13 20/ Vaoc OD Vaoc OS VaccOD Vacc OS 3 months 2 months 1 month 1 day preop Case study.. PS Case study.. PS OD 1 month OS Treated with PTK OU Slow improvement over additional 6 weeks Uncorrected 20/30 OU x 32 20/ x /25 13

14 MZ Recurrent Erosion Recurrent Erosion MZ 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 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 JG Recurrent Erosion JG 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 Disruption with SOS No history of trauma and prior recurrent erosions This erosion occurred along the lamellar flap margin Fairly severe SOS accompanied the abrasion Moderate SOS MM MDF and Epithelial Ingrowth Edge Lift from epi ingrowth 9247 Preop plano x 135 Postop Vaoc 20/20 14

15 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

16 The flap is very delicate This patient experienced a flap melt after lifting the flap for epithelial ingrowth Flap Melt 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 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 Summary 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