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Flapless sands of the Sahara is unlikely, but possible
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BOSTON — A clinical syndrome with symptoms similar to that of the so-called sands of the Sahara may occur in association with epithelial defects, as well as in cases where topical fluoroquinolones are used. Kathryn Colby, MD, presented a series of cases of diffuse lamellar keratitis (DLK)-like findings in patients with no laser in situ keratomileusis (LASIK) flaps, here at the annual meeting of the American Society of Cataract and Refractive Surgery. “DLK, the so-called sands of the Sahara syndrome, manifests as a diffuse, sterile infiltration of leukocytes within the flap interface,” Dr. Colby said. “DLK is a well-established, but thankfully infrequent, complication of LASIK. Our series indicates that a DLK-like picture can be seen in the absence of a LASIK flap.”
Potential causes of DLK-like findings include bacterial endotoxins, microkeratome oil, thermal damage, meibomian secretions and topical medications. “Data from the Refractive Surgery Service at the Massachusetts Eye and Ear Infirmary suggest that DLK occurs in approximately 1% of LASIK cases,” Dr. Colby said. “DLK has the potential to cause flap melts with associated irregular astigmatism, induced hyperopia and loss of best corrected visual acuity.”
Dr. Colby reported on four patient groups with DLK-like findings, not associated with LASIK primary surgery or re-operation. “Common features among our cases include the presence of an epithelial defect and treatment with topical Ocuflox [ofloxacin; Allergan],” Dr. Colby said. “Topical steroids were effective for management of this condition and no long-term loss of vision was noted,” she said.
Case studies
The first patient Dr. Colby reported on was a 36-year-old man with a history of pigment dispersion syndrome who underwent uneventful photorefractive astigmatic keratectomy using a Visx (Santa Clara, Calif.) S2 laser following epithelial removal with 18% ethanol. He was treated with Dr. Colby’s standard postoperative photorefractive keratectomy (PRK) regimen, which included topical Ocuflox, FML (fluorometholone; Allergan) and a bandage contact lens.
On the day after surgery, the patient presented with a diffuse inflammatory reaction within the anterior stroma, as well as the post-PRK epithelial defect, which was expected. “Interestingly, there was one other case of LASIK-associated DLK that occurred among the 15 patients who underwent PRK in our laser center that day,” Dr. Colby said.
The patient was treated with hourly Pred Forte (prednisolone acetate; Allergan), which resulted in a “dramatic improvement” in his clinical appearance within 72 hours, according to Dr. Colby. The steroids were tapered, and he attained 20/20 uncorrected acuity with no visible cornea sequelae.
The second patient on whom Dr. Colby reported was a 32-year-old woman who had undergone an eight-cut radial keratotomy (RK) 5 years prior to presentation. The patient was treated with topical Ocuflox during an acute episode of recurrent erosion, and subsequently developed DLK-like symptoms, including scattered cells in the anterior stroma, as well as some swelling in the central cornea. She was treated with Pred Forte four times daily. Following resolution of the lamellar inflammation, she was left with some visible anterior stromal haze but retained 20/20 uncorrected visual acuity. This patient had, coincidentally, developed recurrent erosion syndrome in one of her eyes following a traumatic corneal abrasion, Dr. Colby said.
The remaining two cases occurred in the setting of contact lens related corneal ulcers. The third patient on whom Dr. Colby reported was a 42-year-old woman who had a history of extended wear use of contact lenses. She presented to the Massachusetts Eye and Ear emergency room with a focal corneal ulcer of her left eye, and was treated with Ocuflox drops and Polysporin ointment (polymyxin B-bacitracin; Glaxo Wellcome) empirically.
The focal ulcer resolved within 3 days, Dr. Colby said, but the patient developed DLK-like symptoms of diffuse lamellar inflammation and corneal edema. Steroids were added and the lamellar keratitis gradually resolved over a 3-week period without sequelae.
The final patient in Dr. Colby’s series was a 47-year-old monocular man who also presented with a focal corneal ulcer that also was treated with Ocuflox. He also developed diffuse lamellar inflammation and corneal edema 2 days later. “His ulcer was small, focal and off-axis, but he developed a diffuse corneal involvement,” Dr. Colby said. “Pred Forte was given three times per day with dramatic improvement within 3 days, and eventually complete resolution to 20/20 acuity,” she said.
In addition to the cases described, Dr. Colby and her colleagues have seen two other cases with a similar appearance, she said. One case involved a patient with herpes simplex keratitis and the other was in the setting of recurrent erosion syndrome from granular dystrophy.
For Your Information:
- Kathryn Colby, MD, can be reached at Massachusetts Eye & Ear Infirmary Department of Ophthalmology, 243 Charles St., Room 808, Boston, MA 02114; (617) 573-5537; fax: (617) 573-3364. Dr. Colby has no direct financial interest in any of the products mentioned in this article, nor is she a paid consultant for any companies mentioned.