Infectious keratitis after photorefractive keratectomy

doi:10.1016/S0161-6420(02)01936-X

Ophthalmology

Volume 110, Issue 4, April 2003, Pages 743-747

https://doi.org/10.1016/S0161-6420(02)01936-X Get rights and content

Abstract

Purpose

To elucidate risk factors, microbial culture results, and visual outcomes for infectious keratitis after photorefractive keratectomy (PRK).

Design

Multicenter, retrospective chart review, case report, and literature review.

Methods

The records of 12 patients with infectious keratitis after PRK were reviewed.

Main outcome measures

Causative organism, response to medical treatment, and visual outcome.

Results

Infectious keratitis developed in 13 eyes of 12 patients after PRK. Organisms cultured were Staphylococcus aureus (n = 5), including a bilateral case of methicillin-resistant Staphylococcus aureus; Staphylococcus epidermidis (n = 4); Streptococcus pneumoniae (n = 3); and Streptococcus viridans (n = 1). Four patients manipulated their contact lenses, and 2 patients were exposed to nosocomial organisms while working in a hospital environment. Prophylactic antibiotics used were tobramycin (nine cases), polymyxin B-trimethoprim (three cases), and ciprofloxacin (one case). Final best spectacle-corrected visual acuity ranged from 20/20 to 20/100.

Conclusions

Infectious corneal ulceration is a serious potential complication of PRK. Gram-positive organisms are the most common pathogens. Antibiotic prophylaxis should be broad spectrum and should include gram-positive coverage.

Section snippets

Materials and methods

A retrospective chart review took place of 3 referral cornea and refractive disease practices. All charts were reviewed, surgeons were questioned, and patients were interviewed for risk factors related to infectious keratitis. All patients underwent microbial culturing and sensitivity testing, were treated with fluoroquinolones, fortified antibiotics, or both, and were followed up for a minimum of 4 months.

Results

Bacterial keratitis developed in 13 eyes of 12 patients, with a mean age of 28.4 years, after PRK, and these patients were followed up for a minimum of 4 months (Table 1). Eight patients sought treatment on the first postoperative day, 3 patients sought treatment on the second postoperative day, and one patient sought treatment on the third postoperative day. Six ulcers developed in the right eye, 5 ulcers developed in the left eye, and bilateral corneal ulcerations developed in a single

Case report

A 26-year-old female medical resident with a refraction of −7.00 in the right eye and −6.75 in the left eye underwent bilateral PRK. After surgery, the patient received one drop of tobramycin 0.3% solution in both eyes and proparacaine 0.5% topical anesthetic. In both eyes, the PRK was uneventful, and after the PRK, the patient was fit with a bandage soft contact lens and was given tobramycin 0.3%, fluorometholone 0.1%, and diclofenac sodium 0.1% 4 times daily. The patient was sent home with

Discussion

Infectious keratitis is a potentially devastating complication of PRK. The predisposing risk factors for infectious keratitis are breakdown of the barrier function of the corneal epithelium and the use of a bandage contact lens on an extended-wear basis.14 In addition, the use of topical steroids to control wound healing may suppress the ability of the immune system to fight infection.

Although laser in situ keratomileusis (LASIK) has surpassed PRK as the most prevalent form of refractive

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This study sought to assess the frequency of refractive surgery complications in HIV+ individuals and related risk factors.
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The U.S. Military HIV Natural History Study is a prospective observational cohort study of HIV+ service members and beneficiaries. Participants were selected who had Current Procedural Terminology codes for laser in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and other refractive surgeries. The frequency of complications was determined using International Classification of Diseases-9 codes. Covariates included age, sex, antiretroviral therapy, time since HIV diagnosis, history of AIDS, and CD4 (T lymphocytes) count and viral load. Statistical analysis was completed using univariate (χ² and Wilcoxon-Mann-Whitney tests) and multivariate analyses.
Seventy-nine of 2073 participants had refractive surgery. Fifty-three patients underwent PRK, 23 LASIK, 2 radial keratotomy (RK), and 1 astigmatic correction. Complications occurred in 6 (7.6%) of 79 participants, including 5 patients who underwent PRK and 1 after RK, occurring between 8 and 217 days after surgery. Five ulcers and 1 unspecified keratitis were noted. In the univariate analysis, type of surgery (P = .02) and history of AIDS (P = .02) were risk factors for complications. In logistic regression analysis, no variables were found to be risk factors for complications.
Complications were infrequent among HIV+ participants after refractive surgery. Point estimates suggest that PRK might have more complications than LASIK and that advanced HIV, reflected by previous AIDS, might be associated with an increased risk for complications. Further study will be required to confirm these findings.
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To describe the incidence and risk factors associated with microbial keratitis in a large population of laser vision correction (LVC) patients.
Optical Express centers, Glasgow, United Kingdom.
Retrospective case series.
Records were searched to identify all cases of presumed microbial keratitis after LVC between January 1, 2008, and April 1, 2015. Consecutive patients having primary or enhancement LVC during that time served as controls. Data on preoperative age, sex, refraction, procedure, and surgery specifics were collected. A multivariate Cox proportional hazards model was used, and hazard ratios were calculated.
Definite or probable microbial keratitis occurred in 26 of 564 165 eyes after laser in situ keratomileusis (LASIK) and in 11 of 81 792 eyes after photorefractive keratectomy (PRK) during the study period, for an overall incidence of 0.0046% (1 case per 21 697 procedures) after LASIK and 0.0013% (1 case per 7434 procedures) after PRK. A multivariate analysis found that those having PRK had a significantly higher incidence of microbial keratitis than those having LASIK (hazard ratio, 2.92; 95% confidence interval, 1.42-6.00; P = .004). No other analyzed factors were significant.
Although the incidence of infectious keratitis was higher after PRK, the overall risk after any LVC procedure was very low.
Incidence of corneal infections after laser in situ keratomileusis and surface ablation when moxifloxacin and tobramycin are used as postoperative treatment
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Citation Excerpt :
As in our previous studies, the present study is limited by the high rate of negative cultures, which could be the result of technical issues, such as the low number of samples, alteration of samples during transport to the reference microbiology laboratory, and previous growth-inhibiting antibiotic therapy. The potential risk factors for keratitis after surface ablation and LASIK reported in the literature include blepharitis, contact lens manipulation, and being in a healthcare environment.6,11,12 We identified blepharitis, dry eye, floppy-eyelid syndrome, and working as a farmer to be possible risk factors after surface ablation.
To assess the incidence, culture results, and visual outcomes of infectious keratitis after laser in situ keratomileusis (LASIK) and surface ablation when topical moxifloxacin was added to postoperative prophylaxis with tobramycin.
Clínica Baviera, Instituto Oftalmológico Europeo, Bilbao, Spain.
Retrospective case series review.
The medical records of 55 255 patients (108 014 eyes) who had LASIK and surface ablation were reviewed to identify cases of infectious keratitis. The incidence, risk factors, clinical course, days to diagnosis, treatment, and final visual outcomes were recorded. These data were compared with previously published data of 221 437 eyes that received postoperative tobramycin alone.
Post-LASIK infectious keratitis was diagnosed in 10 eyes (9 patients) and post-surface ablation infectious keratitis in 11 eyes (10 patients). The onset of infection was early in 40.00% of cases after LASIK and in 36.36% after surface ablation. Cultures were positive in 2 cases after surface ablation. Immediate flap lifting and irrigation with antibiotics were performed in all eyes after LASIK. The final corrected distance visual acuity was 20/20 or better in 7 cases after LASIK (70.00%) and 7 cases after surface ablation (63.64%) and 20/40 or better in all cases after LASIK or surface ablation.
The incidence of infectious keratitis decreased from 0.025% to 0.011% (P < .001) per procedure after LASIK and from 0.200% to 0.066% (P < .001) after surface ablation. Infectious keratitis was less frequent after LASIK than after surface ablation. The frequency of infection, mainly early-onset infection, was lower when the postoperative treatment was tobramycin and moxifloxacin rather than tobramycin alone.
No author has a financial or proprietary interest in any material or method mentioned.
Current knowledge about and recommendations for ocular methicillin-resistant Staphylococcus aureus
2014, Journal of Cataract and Refractive Surgery
Staphylococcus aureus is the most important and common pathogen that infects patients following cataract surgery, laser in situ keratomileusis, and photorefractive keratectomy. It is reported to be the second most common pathogen causing bacterial keratitis around the world. Of special concern are increasing reports of postoperative methicillin-resistant S aureus (MRSA) infection. For example, MRSA wound infections have been reported with clear corneal phacoemulsification wounds, penetrating keratoplasty, lamellar keratoplasty, and following ex vivo epithelial transplantation associated with amniotic membrane grafts. These and other data suggest that MRSA has become increasingly prevalent worldwide. In this article, we review the current medical literature and describe the current challenge of ocular MRSA infections. Recommendations are made based on an evidence-based review to identify, treat, and possibly reduce the overall problem of this organism.
No author has a financial or proprietary interest in any material or method mentioned.
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Methicillin-resistant Staphylococcus aureus (MRSA) has been recognized as an increasingly common cause of nosocomial infections since the 1980s.¹ Reports of ocular infections due to MRSA are composed primarily of case reports. But a recent report from the United States suggests that ocular infections due to MRSA are about to become more common than methicillin-sensitive S. aureus (MSSA).² However, this observation is not consistent with anecdotal experience at the University of Alberta. The purpose of this study is to evaluate the ocular microbiology trends in a tertiary care eye center in Canada.
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Over a 10-year period, between 2000 and 2010, 6.4% of S. aureus isolates were MRSA; there were 2030 MSSA and 129 MRSA isolates, including 46 MSSA and 4 MRSA isolates from deep eye cultures. The prevalence of MRSA over the total number of S. aureus isolates, regardless of specimen source, steadily increased in the 10-year period, from 0.5% in 2002 to 12.6% in 2010. Gram-positive cocci were the most common organisms to cause ocular infections (82.6%). In vitro susceptibility of ocular MSSA and MRSA samples demonstrated 100% sensitivity to vancomycin.
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Le Staphylococcus aureus résistant à la méticiline (SARM) est reconnu comme étant une cause croissante d'infections nosocomiales depuis les années 1980.¹ On trouve généralement les infections oculaires dues au SARM dans les rapports de cas. Et pourtant, un rapport récent des États-Unis suggère que les infections oculaires dues au SARM sont en voie de devenir plus communes que le Staphylococcus aureus sensible à la méticiline (SASM).² Néanmoins, cette observation ne concordait pas avec l'expérience anecdotique de l'Université de l'Alberta. La présente étude a donc pour objet d'évaluer les tendances microbiologiques oculaires dans un centre de soins oculaires tertiaires du Canada.
Étude transversale, utilisant une recherche informatique dans la base de données des Services de laboratoire de diagnostic DynaLIFE_DX pour toutes les cultures oculaires positives et sensibilités aux antibiotiques in vitro, effectuée dans la zone d'Edmonton.
Sur une période 10 ans, 6,4 % des isolats du Staphylococcus aureus étaient résistants à la méticiline (MRSA); entre 2000 et 2010, il y eut 2030 isolats SASM et 129 isolats SARM, y compris 46 isolats SASM et 4 isolats SARM venant des cultures oculaires profondes. La prévalence du SARM sur la totalité des isolats du Staphylococcus aureus, indépendamment des sources de spécimens, a augmenté régulièrement dans la période de 10 ans, allant de 0,5 % en 2002 à 12,6 % en 2010. Les cocci Gram positifs étaient les organismes les plus répandus causant des infections oculaires (82,6 %). La susceptibilité in vitro des échantillons oculaires DASM et SARM ont démontré une sensibilité de 100 % à la vancomycine.
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Manuscript no. 220109

Supported in part by the Lions Eye Bank of Long Island, New York.

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Infectious keratitis after photorefractive keratectomy☆

Abstract

Purpose

Design

Methods

Main outcome measures

Results

Conclusions

Section snippets

Materials and methods

Results

Case report

Discussion

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