CORNEAL TRAUMA 7 YEARS AFTER LASIK: DEEP LAMELLAR KERATITIS WITH SUBSEQUENT MICOTIC KERATITIS

We present a case of a delayed deep lamellar keratitis (DLK), following micro stab wound to the cornea with a wooden stick, 7 years after LASIK. The case was further complicated by a fungal keratitis. Through conservative therapeutic approaches, the inflammation was handled and visual acuity (VA) restored to a satisfactorily extent.

A 40-year-old female suffered a blow to the left eye with a wooden stick. At the emergency room visit wooden foreign bodies from the anterior stroma were removed. At 3 days after the injury, she had signs of DLK at the LASIK interface, VA was decreased from initial 0,8 to 0,63.

A two-tier course of antibiotics (moxifloxacine, tobramycine) was continued as initiated at first day. Additionally topical 0,1% dexamethasone was administered to address DLK. The patient regained a best corrected VA of 1,0 in a matter of 10 days. The dexamethasone was continued as DLK was receding. At day 18 a deep white corneal infiltrate was formed with characteristically mycotic appearance and hyphae radiating from the endothelium into the anterior chamber in a “tentacle-like” fashion. Using in vivo confocal microscopy (HRT3) intrastromal double-walled hyphae were observed. With a corneal scarificate Fusarium presence was confirmed. The treatment continued with topical antibiotic regiment, systemic and intensive topical 2% voriconazole, dexamethasone treatment was stopped. The anterior chamber was not rinsed or tapped to avoid dissemination. During the first week of apparent mycotic infection intrastromal inflammation worsened somewhat which caused ulceration, stromal thinning and additional DLK, the anterior chamber cleared however. Due to increased scarring and heightened inflammatory response, topical 0,1% dexamethasone twice daily and systemic doxycycline 100mg were added at day 7 after mycotic keratitis appeared. After epithelial closure, treatment continued with 2% voriconazole 4-times daily, 0.1% dexamethasone once daily continued for 6 months. After 18 months follow up the cornea remained stable with no recurrences. The central stromal deformity and scar has caused a significant irregular astigmatism; however, she managed to reach an uncorrected VA of 0,63, with no subjective need for a keratoplasty.

It is known that DLK can form years after LASIK especial following trauma to cornea. One needs to be especially careful when organic corneal foreign bodies are part of the clinical setting, where anaerobic bacteria and fungi can cause further inflammation. As DLK was reacting well to our treatment and the bacterial microbiota was countered with antibiotics, the fungi caused a delayed keratitis, prolonging visual rehabilitation significantly. We believe that dexamethasone worsened the outbreak of fungal keratitis, however it should rather be tapered down to a minimum to avoid excessive inflammation rather than stopped.