Avoiding vision loss from infectious keratitis after LVC

Infectious keratitis is not a common complication after laser vision correction (LVC), but it is important because it can be devastating, said Deepinder K. Dhaliwal, MD.

“Half of patients who develop infectious keratitis after LVC will have moderate-to-severe reduction in visual acuity,” said Dr. Dhaliwal, professor of ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh.

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“Therefore, it is better to prevent infectious keratitis than to have to treat it,” Dr. Dhaliwal said. “If it occurs, prompt recognition and aggressive treatment are critical, and then patients may have a good result.”

Infectious keratitis after LVC can occur early or late after the primary surgery, a flap lift, an enhancement, or even following late trauma, as illustrated by a case Dr. Dhaliwal described involving a patient who was hit in the eye with a banana 10 years postLASIK.

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The pathogen may come from the patient, residing on the conjunctiva, lid margins/lashes, or transferred from the fingers. Alternatively, a host of operative factors can be the source, including surgical instruments, microkeratomes, sponges, or nonsterile water.

Optimization of the ocular surface with treatment of existing conditions, e.g., dry eye, blepharitis, rosacea, is a critical prevention strategy. The agents used depend on the patient’s diagnosis and may include hypochlorous acid 0.01%, oral nutraceuticals, topical anti-inflammatory medications, lid hygiene, and tea tree oil lid scrubs.

Placement of punctal plugs is reserved until after inflammation is controlled, and Dr. Dhaliwal reminded surgeons to ask patients about a history of herpes simplex virus infection, recognizing the risk for reactivation.

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Perioperatively, her infection prophylaxis regimen incorporates treatment with a fourth generation fluoroquinolone, antisepsis with 10% povidone-iodine applied to the lids and lashes, and draping to isolate the lid margin.

“I am super compulsive about draping, and I do it myself, trying to be certain that the meibomian glands are all covered,” Dr. Dhaliwal said.

Two separate sets of instruments are used, one for each eye to avoid cross contamination, and all fluids used are sterile.

“Never use nonsterile water in the surgical environment,” she cautioned, citing an article in Morbidity and Mortality Weekly Report describing a cluster of postLASIK mycobacterial infections occurring in 2015 that were traced to a humidifier used in the LASIK clinic.

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