Pressure-Induced Stromal Keratopathy After Smile: A Diagnostic Challenge Mimicking Diffuse Lamellar Keratitis
Published 2026 - 44th Congress of the ESCRS
Reference: POREF005 | Type: Case Report | DOI: 10.82333/s3t2-bm61
Authors: Mrs Maria Fernanda Castillo De La Rosa* 1 , Dr Arturo Ramirez Miranda 2 , Dr Nicolas Kahuam Lopez 1 , Dr Enrique Graue Hernandez 2
1Cornea,Instituto Conde de Valenciana,Mexico,Mexico, 2Cornea and refractive surgery,Instituto Conde de Valenciana,Mexico,Mexico
Purpose
Pressure-induced stromal keratopathy (PISK), also known as interface fluid syndrome, is a rare but potentially vision-threatening complication after corneal refractive surgery. Only a few cases have been reported after small-incision lenticule extraction (SMILE). Because PISK can mimic diffuse lamellar keratitis (DLK), misdiagnosis may lead to inappropriate steroid escalation and rapid intraocular pressure (IOP) elevation. This
Setting
Case report evaluated at a tertiary referral ophthalmology center. Diagnostic assessment included slit-lamp examination, intraocular pressure measurement, and anterior segment optical coherence tomography (AS-OCT).
Report of case
A 31-year-old woman underwent uneventful bilateral SMILE for myopic astigmatism (−3.75 −2.75 ×0 OD; −4.00 −2.75 ×180 OS). One month postoperatively she presented with central corneal haze and blurred vision. Diffuse lamellar keratitis was suspected and topical dexamethasone initiated. Five weeks after surgery she returned with severe ocular pain, headache, and decreased vision (20/200 OD, 20/400 OS). Intraocular pressure measured 60 mmHg OD and 56 mmHg OS. Anterior segment OCT (MS-39) demonstrated a well-defined fluid pocket within the cap–bed interface in both eyes, confirming pressure-induced stromal keratopathy. Topical corticosteroids were immediately discontinued and combination ocular hypotensive therapy (dorzolamide, brimonidine, and timolol) was started. Within three days symptoms resolved, intraocular pressure normalized (12 mmHg OD, 10 mmHg OS), and OCT confirmed disappearance of interface fluid. At two months, uncorrected visual acuity returned to 20/20 in both eyes with complete resolution of corneal haze.
Conclusion/Take home message
Pressure-induced stromal keratopathy should be considered when interface haze occurs after SMILE, particularly in patients receiving topical steroids. Early recognition is essential to avoid unnecessary steroid escalation and prevent glaucomatous damage. Anterior segment OCT is a key diagnostic tool because it clearly identifies interface fluid that may be missed on slit-lamp