Novel anti-collagenolytic regimen applied for treating stage IV DLK

A new treatment strategy consisting of oral doxycycline and topical sodium citrate 10% may have a positive role in the treatment of post-LASIK inflammatory conditions characterized by increased collagenolytic activities, said Elias F. Jarade, MD.

Dr. Jarade, a corneal surgeon at the International Medical Centre, Dubai, United Arab Emirates, presented a case of a referral patient who underwent this intervention as part of her management for bilateral stage IV diffuse lamellar keratitis (DLK).

When seen at 1 week after her refractive surgery, the patient presented with a dense white corneal infiltrate with a mud crack appearance accompanied by flap melting, deep striae, and fluid accumulation within the interface. The flaps were lifted, thorough irrigation with BSS was performed, the beds and caps were gently cleansed, and the interfaces were washed out with 1 mg/ml dexamethasone.

A 6-week course of treatment was started with topical 10% sodium citrate 6 times a day and oral doxycycline 100 mg twice daily. The patient was also started on topical methylprednisolone 1% with tapering.

Follow-up through 6 months showed fluid accumulation disappeared immediately after the cleansing and the infiltrate began to decrease by postoperative day 3 and continued to approve to the point where it was only barely visible. At 1 week, the patient demonstrated a significant hyperopic shift in both eyes, but serial topographic evaluation showed a progressive decrease of corneal flattening with the development of a more regular surface. The hyperopia and best-corrected visual acuity improved progressively.

"Traditional management for stage IV DLK with lifting of the flap and irrigating is of little benefit and may result in additional stromal volume loss if aggressive tissue mainipulation is performed," Dr. Jarade said. "Our strategy uses two agents that have anti-collagenolytic activity, and we believe it may have played a favorable role in this case by halting autodigestion of the cornea and preventing the further corneal ectasia and progressive hyperopic shift that is the usual scenario in stage IV DLK.

"Considering its potential mechanism, we propose this therapeutic strategy might also be considered in the treatment of other post-LASIK corneal inflammatory conditions characterized by increased collagenolytic activity, including keratectasia," Dr. Jarade said.