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Suspect infectious keratitis in cases of late-onset inflammation
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SAN FRANCISCO — Infectious keratitis appearing in the postoperative period following LASIK can be misdiagnosed as diffuse lamellar keratitis, surgeons said here at a panel discussion.
“If you see late-onset DLK, you should be very skeptical of it. Always keep considering it an infection until proven otherwise,” said Stephen Slade, MD, speaking here at VisionQuest 2002.
Dr. Slade said during the panel discussion that most cases of DLK begin to appear within the first 2 days postop. “Infectious keratitis generally begins within the second and third days and manifests up to 4 to 6 weeks later, particularly Mycobacteria, which has a typical onset of 2 weeks to 4 weeks postoperatively,” he said.
Dr. Slade said he has seen several cases initially diagnosed as DLK that were really infectious keratitis. DLK is mainly confined to the flap-stroma interface and does not extend into the stroma. This distinction may help surgeons determine what complication is being faced, he added.
“(DLK) is also less likely to be a focally oriented situation. In infection, you have a focus. The inflammation in the interface extends peripherally and out into the recipient bed, outside the flap, into the stroma and has an anterior chamber reaction,” Dr. Slade said.
The panel noted that postop follow-up of the patient can be crucial in DLK management. All members of the panel agreed the patient should be checked at 1 day postop.
Manus Kraff, MD, said he performs follow-up on the first day postop and at 1 week.
“If I see it, I see it on the first day. If you look very carefully, you are going to see DLK after the procedure very finely, and those [patients] you want to bring back sooner,” he said.
The panel generally agreed that for routine, uncomplicated cases, follow-up at 1 day, 1 week and 1 month is sufficient. The panel also said routine postop use of steroids such as prednisolone acetate can be helpful in preventing DLK. Dr. Kraff noted he routinely prescribes antibiotics and steroids for several weeks postop to prevent DLK.