Corneal Interface Haze To Clear Vision: A Case Report On The Effective Management Of Diffuse Lamellar Keratitis And Epithelial Ingrowth Following Clear Surgery

To describe the timely identification and effective management of diffuse lamellar keratitis (DLK) and rare epithelial ingrowth in the left eye following Corneal Lenticular Extraction for Advanced Refractive Correction (CLEAR). Thus, underscores the importance of thorough clinical evaluation, advanced imaging techniques, and targeted interventions—including lenticule interface washout and manual debridement—in optimizing corneal clarity and preserving visual acuity postoperatively.

This study was conducted at a specialized refractive surgical center equipped with advanced diagnostic tools, including anterior segment optical coherence tomography (AS-OCT). A single, experienced surgeon performed the CLEAR procedure, and rigorous follow-up protocols ensured early recognition and resolution of an uncommon postoperative Keratorefractive Lenticular(KLEx) complication.

A 31-year-old moderate myopic patient underwent bilateral femtosecond CLEAR in 2024 for myopia correction. On postoperative Day 1, examination revealed only mild sectoral stromal opacities in the left eye’s paracentral region, with no evidence of diffuse lamellar keratitis (DLK). The patient was prescribed Gt. Prednisolone Acetate 1% (q2h), Gt. Gatifloxacin 0.5% (q4h), and topical lubricants (q4h). On postoperative Day 7, DLK was diagnosed in the left eye when AS-OCT confirmed a thickened lenticular stromal layer. Treatment was intensified to include Gt. Prednisolone Acetate 1% (q1h) and oral Prednisolone 20mg daily for three days, with follow-up scheduled to assess the need for a stromal interface washout. On postoperative Day 15, a new floral-patterned anterior stromal interface opacity suggested epithelial nest ingrowth; AS-OCT demonstrated increased hyperreflectivity of the stromal interface, prompting immediate lenticule interface debridement and washout. At the next-day review, the cornea was mostly clear with mild oedema. By Day 14 post-debridement, the corneal stroma was clear and the left eye’s unaided visual acuity improved from 6/12 to 6/7.5. The topical steroid was tapered (administered bd for 1 week) and then discontinued. On postoperative Day 23 following the secondary procedure, complete healing was observed with no further evidence of epithelial ingrowth or DLK. The patient was satisfied with the outcome, and a six-month follow-up was scheduled.

Effective postoperative surveillance and prompt intervention were pivotal in resolving DLK and suspected epithelial ingrowth. AS-OCT imaging facilitated early diagnosis, while secondary surgical intervention and tailored pharmacotherapy restored corneal clarity. This case underscores the importance of timely detection and appropriate treatment in maintaining optimal outcomes following CLEAR surgery. The favorable outcome and high patient satisfaction confirm the efficacy of this management strategy, supporting its application in similar cases.