EyeWorld Asia-Pacific December 2016 Issue

December 2016 EWAP refractive 43 how newer medications with an advanced vehicle designed to decrease toxicity and improve lubrication and comfort might inhibit wound healing. “She was taking besifloxacin, nepafenac, and difluprednate,” he said, adding that ASCRS found that all three of these could inhibit wound healing in laser refractive patients. Intrigued by the fact that she was on such medications, investigators considered whether this could have been a contributory factor, where her AK incisions may not have healed as readily as in someone who was on different medications. Clinical message From a clinical perspective, the case drives home a couple of points, Dr. Chou said. For one, it clarifies the importance of blepharitis awareness. “In this patient’s case, she had advanced blepharitis that was not well-controlled at the time she presented to us,” he said. “The referring surgeons had not identified that or put her on any blepharitis treatment beforehand.” Dr. Chou thinks it is important for surgeons to carefully identify patients who may be at higher risk of not only MRSA but also common bacteria that could be on the ocular surface due to blepharitis and to treat them prior to surgery. Secondly, the case reveals the importance of proper patient preparation from the start. “In this center, they did not prep the patient during the laser-assisted portion of the cataract surgery,” Dr. Chou said. “Once they did the laser cuts, they moved the patient over to the operating area and at that point prepped the patient.” Investigators here don’t think this is sufficient. “We have suggested that since these laser cuts go right through the epithelium, the patient should be prepped prior to the laser portion of the laser- assisted cataract surgery,” Dr. Chou said. While this is just one case, another possibility for avoiding infection may be to use intrastromal keratotomies instead since the relaxing incisions can be made with the cornea stroma itself without breaking through the epithelium, he pointed out. Dr. Chou stressed that while these infections are uncommon, they should remain on the radar. “I think that laser-assisted keratotomies and laser-assisted cataract surgery has been shown to be generally safe, but MRSA and other resistant infections are a growing problem that has been recognized and identified,” he said. “Surgeons should be careful to identify patients at risk and treat accordingly prior to cataract surgery.” EWAP Reference 1. Chou TY, et al. Early-onset methicillin- resistant Staphylococcus aureus keratitis and late-onset infectious keratitis in astig- matic keratotomy incision following fem- tosecond laser-assisted cataract surgery. J Cataract Refract Surg . 2015;41:1772–7. Editors’ note: Dr. Chou has no financial interests related to his comments. Contact information Chou : Timothy.Chou@stonybrookmedicine.edu Views from Asia-Pacific CHAN Wing Kwong, MD Eye & Retina Surgeons #13-03 Camden Medical Centre 1 Orchard Boulevard Singapore 248649 Tel. no. +65 6738-2000 Fax no. +65 6738-2111 www.ers.clinic I completely agree with Dr. Chou’s comments on the reasons that this patient suffered two episodes of infectious keratitis after femtosecond laser-assisted cataract surgery and astigmatic keratotomy. This patient had risk factors of advanced age and untreated blepharitis. Several learning points can be summarised from this case: 1. Preexisting blepharitis should be recognized and appropriately managed before cataract surgery. The fact that MRSA was cultured from the infective keratitis site suggests that the MRSA was a commensal organism already present in the patient’s eye lids. The outcome for this patient could have been better and different if the patient had had appropriate preoperative treatment of the blepharitis in the form of lid scrubs, topical antibiotic ointments and perhaps a course of oral doxycycline. 2. Eye preparation should be done before the femtosecond laser portion of the surgery. This should apply to all patients and not just those with blepharitis. There is considerable manipulation of the eye for the femtosecond laser part of cataract surgery. Lid and conjunctival microorganisms could be innoculated into the corneal incisions resulting in keratitis and endophthalmitis. A lid scrub and conjunctival irrigation with povidone iodine is the most effective method to reduce conjunctival and lid flora prior to surgery. 3. Do not stop topical antibiotics too early postoperatively. This patient had her topical antibiotics discontinued 1 week after cataract surgery, with continuation of topical steroids. This probably set the patient up for the infectious keratitis with a fresh astigmatic keratotomy wound, no antibiotic cover, blepharitis, and local immune suppression with topical steroids. Even in routine and uneventful cases of cataract surgery, one should continue topical antibiotics for at least 2-3 weeks postoperatively, and in this particular case, I would not stop antibiotic coverage until I was certain that the epithelium had completely healed over the astigmatic keratotomy and corneal incisions. This can be verified by staining the cornea with fluorescein. Astigmatic keratotomy, be it performed with a femtosecond laser or a diamond knife, is not the procedure of choice to correct corneal astigmatism during cataract surgery in the Asia-Pacific region. This is because toric intraocular lenses are now widely available and are proven to be more effective and predictable compared to astigmatic keratotomy. Editors’ note: Dr. Chan declared no relevant financial interests.