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Experts retrospectively review case complicated by infection

Issue: December 25, 2017

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In this issue of Ocular Surgery News,Eric D. Donnenfeld, MD, presents a case of corneal inferior steepening refractively managed with PRK and complicated postoperatively by methicillin-resistant gram-positive Staphylococcus infection. A panel of experts convened for the annual Cornea Health Round Table at OSN New York 2017 considers management options for this case in retrospect.

The case

A 39-year-old man who wants to become a bus driver wants refractive surgery for occupational reasons. His topography is unusual, showing inferiorly displaced posterior float and minimal corneal thickening inferiorly. Dry eye and epithelial basement membrane dystrophy are ruled out.

Source: Eric D. Donnenfeld, MD

Donnenfeld: Many people would do PRK in this case, and that is what I told the patient: “Let’s do PRK because PRK is much safer than LASIK, with a smaller risk of ectasia.” So, I did PRK on this patient bilaterally, applied a bandage contact lens, and prescribed prednisolone acetate 1%, a fourth-generation fluoroquinolone and an NSAID four times daily. Surgery was uneventful.

On postoperative day 2, the patient returned. He had stopped taking the antibiotic but had continued taking the NSAID. His vision was down: 20/100 in the right eye and 20/70 in the left eye. He had some lid edema but no significant pain. He had a subepithelial infiltrate in the right eye. He had no hypopyon or ulceration. We cultured the cornea and increased the drops.

So, if a patient comes in with an infection, is increasing the same antibiotic a good strategy?

Penny A. Asbell, MD, FACS, MBA: One of the issues in this case is that the patient was not compliant. So, the question is, whether you switch or not, is this going to be effective? Is he not compliant because he did not understand the directions, or will he just not follow them? One of the key things to do is to figure out why.

Richard L. Lindstrom, MD: Did you stop the NSAID?

Donnenfeld: Yes.

Lindstrom: And continued the steroid?

Donnenfeld: Continued the steroid and increased the fluoroquinolone.

Lindstrom: I think it is reasonable to restart the fluoroquinolone, but I might have chosen to add an additional antibiotic to cover the most expected pathogens.

John P. Berdahl, MD: And you think he took the antibiotic?

Donnenfeld: He probably stopped after the first day.

Berdahl: Then within 24 hours, he has this big bad something coming. I do think that having an additional antibiotic on board would have been prudent.

Donnenfeld: I agree. The lesson I learned here is that when you have a patient who has any type of infection, increasing the same antibiotics is not the right thing to do.

For the guy in the trenches who wants to use an antibiotic that gives great gram-positive coverage to fill the holes that the fluoroquinolones miss, what medications can you buy in a drugstore without compounding?

Asbell: I wish it were that simple. The drug that continues to be effective in every study over and over is vancomycin, which still is not commercially available. Polytrim (polymyxin B and trimethoprim, Allergan), which is available and cheap, is quite good for methicillin-resistant S. aureus, but it is not 100% effective. I do exactly what you are thinking of, which is a fluoroquinolone and the Polytrim. I use both, alternating the two. You can start them immediately, they are readily available, and they are inexpensive.

Source: Eric D. Donnenfeld, MD

Donnenfeld: So readily available antibiotics that patients can buy are Polytrim, bacitracin and Neosporin ophthalmic solution (neomycin and polymyxin B sulfates and gramicidin ophthalmic solution, Pfizer). All three of those would have been good choices to add here, and I did not. I did take the contact lens out.

Now on day 3, the patient returned with a rip-roaring infection with a 4 mm by 4 mm inferior paracentral infiltrate and finger counting vision in the right eye. We put him on fortified antibiotics, started him on vancomycin, continued the fluoroquinolones and stopped the prednisolone. Cornea and lid culture revealed methicillin-resistant gram-positive staph as the pathogen.

On postop day 7, I looked at him and said, “This eye could not possibly look worse.” I mean, this is day 7 after an uneventful PRK in a very nice gentleman who wants to be a bus driver. Now is it possible that this eye could be worse (Figure 1)?

Lindstrom: Yes, it could perforate.

Donnenfeld: Next day he came back, and it was perforated (Figure 2). And now he actually looked worse. At this point I was applying cyanoacrylate glue and continuing the medications. Would you do a PK or observe? How would you manage a case like this with an obviously significant infection?

William B. Trattler, MD: Over time the cornea will heal and the patient will be left with a scar in the visual axis, but hopefully the scar will not be very dense. Many of these patients with corneal scars in the visual axis can achieve significantly improved vision with a scleral contact lens in the future and get to 20/25 or so level of vision with a scleral lens, so I would not be jumping right to a transplant at this point. I like to manage the patient and determine how well their vision can be improved.

Donnenfeld: You never want to do a transplant unless you have to.

Trattler: Right.

Donnenfeld: The only time you do it is if the perforation is so large you cannot fill it with glue. There have been some reports of gram-negative organisms growing underneath the glue, but gram-positives generally do pretty well.

Lindstrom: What do you put these people on, typically vancomycin 50 mg/mL?

Francis S. Mah, MD: Usually 50 mg/mL, or 25 mg/mL if you are worried about toxicity. In that eye, I would use 50 mg/mL. You could continue to use Polytrim; you could also use gentamicin, which is kind of in that neomycin category, or bacitracin. There are some off-label medications such as Cubicin (daptomycin, Merck) and Zyvox (linezolid, Pfizer) that can be compounded and that are very good at killing MRSA specifically.

Donnenfeld: Penny, as an investigator for the ARMOR study, which of the fluoroquinolones would you say has the best activity against staphylococci?

Asbell: The minimum inhibitory concentration is definitely lowest for besifloxacin, which is pretty impressive, almost the same as vancomycin.

Donnenfeld: That was a great study, Penny. I want to compliment you on really important work.

Trattler: The ARMOR study has changed how I use prophylaxis in my PRK patients. I am using two antibiotics in all of my PRK cases. I use Polytrim and a fluoroquinolone combined. Staph is a tough bacteria to knock out, and sometimes the fluoroquinolones cannot do it alone.

Donnenfeld: The Trattler belt and suspenders method.

So the patient ended up having a scar and was not amenable to a contact lens. We needed to do a corneal transplant. When we took out the sutures and he came back for follow-up, he was now –5 D in one eye and –0.25 D in the other — actually 0.12 D cylinder. Incredibly great. Is this a home run? No. You know why? He was miserable. He was plano in one eye and –5 D in the other eye, he could not wear a contact lens, and he still wanted to be a bus driver. So he came to me and said, “You have to do something about it.”

What would you do with this patient now? Are you going to do PRK again? Are you going to do LASIK? Are you going to do a phakic IOL? Are you going to do a clear lens extraction? Or are you going to say, “Suck it up and live with it the way it is right now?” How are you going to manage it?

Asbell: You may want to do a culture before the next procedure just to see what the baseline looks like.

Donnenfeld: That was done. So what I said to him was, “I’m going to do LASIK on you because LASIK is safer than PRK.” And he kind of looked at me and said, “Didn’t you say the opposite about 2 years ago?”

I performed a femtosecond laser and made a small flap inside the corneal transplant, not extending past it, and did LASIK, and he did extraordinarily well with that. That brings up an issue: There is a misconception that PRK is safer than LASIK, and I am going to put it out there that, in my opinion, LASIK is safer than PRK. There is a 2.5 times less risk of infection based on the literature. The worst complications I see now from refractive surgery are scarring associated with PRK, certainly in higher myopia. With femtosecond lasers, I think that LASIK is probably the same or maybe a little safer than PRK. And if I had to tell my patients what I thought was in their best interest, it is probably going to be LASIK for most of my patients.

Lindstrom: Less infection, less haze. For most patients, we abandoned LASIK in our keratoplasties, but we did do a lot of them and they did reasonably well. It is a reasonable option, but I think knowing what you are dealing with, the chance of getting an infection again is one in 1,000 or less.

• Reference:
• Asbell PA, et al. J Cataract Refract Surg. 2016;doi.org/10.1016/j.jcrs.2016.11.008.

• For more information:
• Penny A. Asbell, MD, FACS, MBA, can be reached at Mount Sinai Medical Center, Box 1183, New York, NY 10029; email: penny.asbell@mssm.edu.
• John P. Berdahl, MD, can be reached at Vance Thompson Vision, 3101 W. 57th St., Sioux Falls, SD 57108; email: john.berdahl@vancethompsonvision.com.
• Eric D. Donnenfeld, MD, can be reached at Ophthalmic Consultants of Long Island, 711 Stewart Ave., Suite 160, Garden City, NY 11530; email: ericdonnenfeld@gmail.com.
• Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 9801 Dupont Ave. S., Suite 200, Bloomington, MN 55431-3200; email: rllindstrom@mneye.com.
• Francis S. Mah, MD, can be reached at Scripps Clinic, 10666 N. Torrey Pines Road, MS 214, La Jolla, CA 92037; email: mah.francis@scrippshealth.org.
• William B. Trattler, MD, can be reached at Baptist Medical Arts Building, 8940 N. Kendall Drive, Suite 400-E, Miami, FL 33176; email: wtrattler@gmail.com.

Disclosures: Asbell and Berdahl report no relevant financial disclosures. Donnenfeld reports financial disclosures for Allergan, Alcon, Bausch + Lomb and Johnson & Johnson. Lindstrom reports relevant financial disclosures for Bausch + Lomb, Alcon, Novartis, Allergan and Imprimis. Mah reports conflicts of interest with Alcon, Allergan, Bausch + Lomb and Sun. Trattler reports he is a consultant and speaker for Allergan and Bausch + Lomb and a consultant to Alcon.