EyeWorld India March 2013 Issue

33 EWAP REFRACTIVE March 2013 Mysterious infection after LASIK has lessons for all by Matt Young EyeWorld Contributing Writerr Refer patients early on when an infection is identi- fied and is non-responsive to antibiotics N ot all refractive surgeons would consider themselves to be corneal specialists. Yet a recent case in the Middle East should give more reasons for refractive surgeons worldwide to be aware of serious corneal problems that can arise from minimally invasive surgery and to be prepared for them at any time. Infection gone awry Nada S. Jabbur, MD , Clemenceau Medical Center, Beirut, Lebanon, and clinical adjunct associate professor, American University of Beirut, was recently referred a case of a young female myope who underwent LASIK bilaterally about a month earlier. The patient was told everything was fine shortly after her procedure. On post-op day 1, she began experiencing irritation and blurriness in her right eye. The left eye was doing well at 20/20. The right eye appeared to have a corneal infection in the LASIK flap, which was not improving. She was treated with a broad spectrum of antibiotics while cultures were taken and sent to the lab to investigate for bacteria and fungi. “Cultures done initially did not reveal any fungi,” Dr. Jabbur said. A week later, the flap was amputated because of the infection progressing and melting the flap. The patient was also treated for possible Acanthamoeba due to her severe pain and poor response to antibacterials. Four weeks after the LASIK surgery, the patient was referred to Dr. Jabbur. “From limbus to limbus, the cornea was an abscess,” Dr. Jabbur said. “It was a mix of pus and necrotic tissue with a central descemetocele. Clinically, we could not be sure if the infection had spread beyond the anterior segment, but ultrasonography showed that the posterior globe was probably intact. “We took the patient to the operating theater and dissected away what was left of the cornea together with a rim of clean sclera where we could suture the donor cornea with its trimmed scleral rim,” Dr. Jabbur continued. The cornea was stuck to the anterior lens capsule; the latter was removed, and the lens material was aspirated. No intraocular lens was placed at this time due to the infection. A donor cornea with a scleral rim was sutured in place. Post-op, the patient slowly improved. She required a second surgery to clean residual cortical material. “She remains aphakic and has been able to see 20/30 with correction,” Dr. Jabbur said. “Her retina was unaffected. She will need further surgery to clean an opacified posterior capsule as well as a secondary IOL.” After sending the patient’s cornea for culture and pathology, the cultures yielded a species of Fusarium found deep in the tissue. Missed red flags Dr. Jabbur said there were important warning signs that were missed in this case. “When an infection is not responsive to antibacterials, one needs to suspect fungal infection. When physicians take cultures they need to take them properly, including normal and abnormal tissue, not just necrotic tissue,” Dr. Jabbur said. Also “inform the lab to keep the plates for a longer period of time if you are suspecting fungal infection. Universities are used to that more than settings where culture plates are sent to an outside facility.” In this case, the fungal infection was not diagnosed early on, and it became difficult to save the cornea. “Initially, removing the flap was essential but not enough. Ideally, the cornea should have been operated on before the infection reached the limbus,” Dr. Jabbur said. “The chance of a graft rejection is more likely when there is a scleral rim that is transplanted and when the graft is larger in size.” Dr. Jabbur said that if the patient’s problem is beyond the capacity of a general ophthalmologist, it should be referred as soon as possible to a cornea specialist. “This case could have happened anywhere in the world, and prompt management is key and alters the prognosis dramatically.” EWAP Editors’ note: Dr. Jabbur has no financial interests related to this article. Contact information Jabbur: +961 1 372888 ext. 1133, nsjabbur@yahoo.com Limbus-to-limbus corneal abscess with central descemetocele Appearance of globe 2 weeks after corneoscleral graft Cultures of the cornea grew Fusarium species Source (all): Nada S. Jabbur, MD