PRK, LASIK, and Infectious Keratitis

Infectious keratitis, which occurs in approximately 1 in 500 photorefractive keratectomy (PRK) patients and in 1 in 2,000 LASIK cases, can result in permanent vision loss. At Friday’s Refractive Surgery Day, Deepinder K. Dhaliwal, MD, recommended the following steps for recognition and treatment of the condition.

Preoperative strategies. Begin by treating conditions that affect the ocular surface, such as dry eye syndrome, blepharitis, and rosacea. Dr. Dhaliwal also recommended asking the patient about prior herpes infection. Treatment is naturally driven by diagnosis and may include oral omega-3 supplementation, punctal plugs, topical steroids, oral doxycycline, and even tea tree oil lid scrubs (for Demodex mites, which have been linked to blepharitis and rosacea).

Intraoperative strategies. “I am super compulsive about draping—I even drape myself,” Dr. Dhaliwal said. “You want those lids sequestered.” She also uses 2 separate sets of instruments (1 for each eye) in the operating room. In addition, she said, “There should be no nonsterile fluids” in the OR, as contaminated water exposure has been linked to mycobacterium infection.

Postoperative strategies. The postoperative day 1 exam is critical, Dr. Dhaliwal said. “I never delegate that to anyone else.” She uses a broad-spectrum antibiotic and continues with any treatments needed to optimize the ocular surface.

When trouble occurs. Infections after PRK are typically acute and caused by gram-positive organisms. Early LASIK infections (within 2 weeks) also are usually linked to gram-positive organisms, while late-onset LASIK infections may be fungal or mycobacterial in nature. In any event, it is critical to lift the flap and culture for the infection, Dr. Dhaliwal said. “And if you don’t have a lab that can handle the culture, send it to us in Pittsburgh; we’ll be happy to take a look at it.” The infiltrates should be debulked, and the interface should be irrigated with antibiotics. Further treatment will be driven by the culture results.—Jean Shaw

Financial disclosures: Dr. Dhaliwal: Abbott: S; Avedro: S; Imprimis: S; Novabay: C; Ocular Systems, Inc: L; Ocular Therapeutix: L.

Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.