Complications can result after uneventful PRK

Surgeons discuss the case of a patient who accidentally stopped taking antibiotic 1 day postop.

Eric D. Donnenfeld

Eric D. Donnenfeld, MD, FACS: A patient came to me for refractive consultation with myopia, a little cylinder and 20/20- best corrected vision. The corneas were on the thin side, but 500 µm does not perturb me, with flattish keratometry readings. The patient was 46 years old. He wanted to be a bus driver, and he needed to have 20/40 or better uncorrected visual acuity to get there.

I did an Orbscan (Bausch & Lomb) on him (Figure 1). On the upper right-hand corner there was an inferiorly displaced posterior float. We like it right in the middle. The corneal thickening was inferiorly displaced so that it was a little thin area off of the apex, and it did not thicken from the center to the periphery as much as I would like it to. The inferior had corneal steeping inferiorly on topography, and the 3-mm and 5-mm zones were irregularly elevated. These findings were suggestive of forme fruste keratoconus, a very mild case in an older patient. I decided that it was reasonable to do refractive surgery on this patient, but I did not think LASIK was indicated. Would anyone do LASIK, even thin-flap LASIK, on this patient?

Richard L. Lindstrom, MD: No.

Dr. Donnenfeld: Would you do PRK in this patient?

Dr. Lindstrom: I think for an occupational demand with good informed consent that I would consider it.

Dr. Donnenfeld: If this patient were 21 years old, I would have some strong concerns, but on a 46-year-old, it is certainly a reasonable thing.

I said to the patient, “I’m going to offer you PRK because it’s safer than LASIK with a smaller chance of ectasia.” I talked to him about the risks and benefits. He signed the special ectasia consent form that we have, and we did our PRK.

Postop, he had a bandage contact lens, steroid, fourth-generation fluoroquinolone and NSAID, the normal treatment regimen that we use on all of our patients who have PRK. He came back the next day feeling good with 20/40 vision in both eyes. He had a 3-mm epithelium. The epithelium was closing nicely with minimal discomfort. I told him to stop the NSAID at the point. I could have continued it, but I stopped the NSAID. He was comfortable after 1 day, and the epithelial defects were small. And this is an issue of patient compliance, but the patient stopped the antibiotic by accident instead of stopping the nonsteroidal.

So the patient came back on day 2 and had vision of 20/100 and 20/70, but I attributed that to the epithelium, which had grown into the visual axis and was irregular. This is common from day 1 to days 2 and 3 for the vision to actually decrease on PRK patients. He had a little edema in both eyes, no pain, and he had a small group of subepithelial infiltrates in the right eye with no hypopyon, no ulceration and no significant pain.

At this point, how would you manage this patient who had been off of antibiotic and had a little subepithelial infiltrate. Would you just restart the same antibiotic with the same frequency? Would you increase the frequency of the same antibiotics? Would you increase the antibiotics and culture this little infiltrate?

Dr. Mah, what would you do at the Campbell Ophthalmic Microbiology Laboratory?

Francis S. Mah, MD: We would probably culture and increase the antibiotic. It sounds as though you do not have any strong concerns of an infection, and there does not seem to be any ulceration. Subepithelial infiltrates have been described in the literature, and usually they will resolve without significant morbidity. I think increasing the frequency of the antibiotic would be legitimate as well as long as you follow the patient closely.

Dr. Lindstrom: If the patient is on steroids and NSAIDs and develops an infiltrate when stopping antibiotics, my index of suspicion for infection is going to be very high.

Dr. Donnenfeld: I did exactly what Dr. Mah said. I cultured the cornea. I increased the fluoroquinolone to every 2 hours and followed up with the patient the next morning, which was 16 hours later.

The patient had finger counting vision and a 4 mm by 4 mm inferior paracentral infiltrate that was clearly infectious. What would you do at this point in the management?

Terry Kim, MD: One of the things we learned from the ASCRS Cornea Clinical Committee is that if you have a suspicious infiltrate after refractive surgery, your tolerance should be low for lifting that flap, or in this case, going ahead and taking that culture. Starting or increasing your antibiotics on an empirical basis without taking a culture, I think, is risky because some unusual organisms can cause these infections as well. So I am in agreement with what you did, starting frequent use of vancomycin and oral doxycycline for this case of methicillin-resistant Staphylococcus aureus following PRK.

Dr. Donnenfeld: Would you keep this patient on steroids on that first day?

Frank A. Bucci Jr., MD: I almost routinely do what you said. I stop it for a day or two and then restart it.

Calvin W. Roberts, MD: I would stop the steroids, and my criteria for restarting them is looking at the edge of the epithelial defect. As soon as that epithelial defect starts to constrict and we start to get migrations centrally, that is when I restart my steroids.

Dr. Mah: I would wait about one day or two until you have made sure it is a bacteria.

Dr. Donnenfeld: I think we all agree that you do not have to wait for the epithelium to close. Many times the epithelial defect will not close until you use steroids, so either you can keep it going that same day or you can stop it for a day or two, but certainly steroids are important in the management of this case.

This is the patient on day 7 after his uneventful PRK (Figure 2). He was handling this pretty well, but I told him that his eye could not possibly look worse. And then he came back the next day and the cornea perforated, so it actually did get worse. I put glue on his eye and managed him (Figure 3). The infection was under control at this point, and we eventually did a corneal transplant on this patient and he did very well. We removed the sutures and he came back, and I did arguably the greatest transplant I have ever done. He had 0.25 D of cylinder on his corneal transplant, verified on wavefront as 0.1 D of cylinder. So I was extraordinarily proud of that transplant.

But he was miserable because he was -5 D. He complained of some anisometropia, and he was contact lens intolerant. How would you manage this patient now, and specifically, how would you prophylax this patient for infection knowing what you know?

Dr. Bucci: Could you ever get him to sign a consent for PRK again, if that is what you want to do? That is what a lot of us do after transplants and have gone to PRK. I know Dr. Lindstrom’s group has gone to PRK instead of LASIK, but you would have to do some aggressive preoperative management.

Dr. Lindstrom: With that good a graft I would be OK doing a LASIK. But I think it would make sense to use a prophylactic antibiotic that could be effective against MRSA.

Dr. Donnenfeld: I did a femtosecond IntraLase (Advanced Medical Optics) laser flap. I made sure that the flap was entirely within the graft-host interface. You cannot pass a graft-host interface with the IntraLase. And the patient did well.

The day we decided to do LASIK, I said to the patient, “We’re going to do a femtosecond laser on you because it’s a lot safer than PRK.” And he looked at me and said, “Doc, didn’t you tell me that PRK was safer the first time around?”

He did great with his LASIK. He ended up 20/20.

For more information:

• Frank A. Bucci Jr., MD, can be reached at Bucci Laser Vision Institute, 158 Wilkes-Barre Township Blvd., Wilkes-Barre, PA 18702; 570-825-5949; fax: 570-825-2645; e-mail: buccivision@aol.com.
• Eric D. Donnenfeld, MD, can be reached at OCLI, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com.
• Terry Kim, MD, can be reached at Duke University Eye Center, Erwin Road, P.O. Box 3802, Durham, NC 27710-3802; 919-681-3568; fax: 919-681-7661; e-mail: terry.kim@duke.edu.
• Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 9801 DuPont Ave. S, Suite 200, Bloomington, MN 55431; 952-888-5800; fax: 952-567-6182; e-mail: rllindstrom@mneye.com.
• Francis S. Mah, MD, can be reached at University of Pittsburgh Medical Center, Eye and Ear Institute, 203 Lothrop St., 8th Floor, Pittsburgh, PA 15213; 412-647-2200; fax: 412-647-5119; e-mail: mahfs@upmc.edu.
• Calvin W. Roberts, MD, can be reached at 876 Park Ave., New York, NY 10021; 212-734-7788; fax: 212-734-4476; e-mail: robertsmd1@aol.com.