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Endophthalmitis after radial keratotomy enhancement
Endophthalmitis after radial keratotomy enhancement David G. Heidemann, MD, Steven P. Dunn, MD, Mark Haimann, MD
ABSTRACT A 45-year-old man developed endophthalmitis after a radial keratotomy (RK) enhancement. He developed severe intraocular inflammation, hypopyon, and dense vitreous membranes 4 days after the enhancement surgery. Cultures of the corneal wound yielded a heavy growth of Streptococcus viridans. The inflammation subsided after treatment with intraocular, intravenous, and topical antibiotics. The patient subsequently developed a cataract and retinal detachment. This case demonstrates the risk of endophthalmitis after RK enhancement. J Cataract Refract Surg 1997; 23:951-953
A
lthough many cases of infectious keratitis have been reported after incisional refractive procedures, endophthalmitis is rare. 1- 5 We report a case of severe endophthalmitis that developed after a radial keratotomy (RK) enhancement procedure.
Case Report A 45-year-old man had four-incision RK and astigmatic keratotomy in the right eye followed by an enhancement procedure 2 months later. Subsequently, several incisions were sutured because hyperopia developed. Several months later, an additional enhancement was performed in which the nasal incision was deepened. No intraoperative perforation was noted. Three days later, the patient noted ocular redness and irritation. He was treated with hourly ciprofloxacin drops and was referred to us the following day. Examination revealed visual acuity of hand motion, moderate corneal stromal haze, and a mid-stromal infiltrate in the paracentral aspect of the nasal RK incision. No epithelial defect or wound leak was present. The anterior chamber had
From the Department of Ophthalmology, Straith Memorial Hospital, Southfield, Michigan, USA. Reprint requests to David C. Heidemann, MD, Farmbrook Medical Building, Suite 201,29829 Telegraph, Southfield, Michigan 48034, USA.
moderate cell and flare and a 1.0 mm hypopyon. The retina was not well visualized; B-scan ultrasonography revealed no significant vitreous opacification. Scrapings of the nasal incision were taken for cultures on blood, chocolate, Sabouraud's agar, and meat broth. No wound leak or perforation was noted while the scrapings were performed. The patient was treated with hourly vancomycin (33 mg/mL) and tobramycin (14 mg/mL) drops and oral ciprofloxacin (750 mg) two times daily. The next day, a corneal wound leak, markedly increased anterior chamber inflammation, and a 2.5 mm hypopyon were noted; B-scan ultrasonography revealed dense vitreous membranes. The patient was admitted to the hospital, and a vitreous tap and injection of intravitreal vancomycin, amikacin, and dexamethasone were performed on the same day. Postoperatively, he was treated with intravenous vancomycin and ceftazidime and topical vancomycin and tobramycin drops. Cultures of the corneal wound yielded a heavy growth of Streptococcus viridans. The vitreous cultures were negative. Two days after the vitreous tap, examination revealed visual acuity of light perception, a 50% hypopyon, and dense vitreous membranes on B-scan ultrasonography. Two weeks after initial presentation, the corneal infiltrate had resolved and anterior chamber inflammation was decreased (Figure 1); B-scan ultrasonography revealed new posterior vitreous separations. Five weeks later, the anterior segment was quiet, but B-scan ultrasonography revealed an inferior retinal detachment. The patient had cataract extraction followed by vitrectomy and scleral buckle. Six weeks after the vitrectomy, examination revealed visual acuity of hand motion, diffuse corneal edema, and an attached retina.
J CATARACT REFRACT SURG-VO L 23, JULY/AUGUST 1997
951
CASE REPORTS: HEIDEMANN
Figure 1. (Heidemann) Two weeks after initiation of antibiotic treatment, the corneal infiltrate had resolved and the hypopyon was smaller. The arrow indicates the original site of the infiltrate and microperforation, which were no longer present at the time of this photograph.
Discussion Endophthalmitis has been reported after RK, hexagonal keratotomy, and the Ruiz procedure. 1- 5 This is the first documented case of endophthalmitis after an RK enhancement procedure. Patients and physicians must be aware that sight-threatening complications may occur after any incisional refractive procedure, including enhancements such as incision lengthening or deepening procedures. In cases of infectious keratitis after incisional refractive surgery, one must be aware of the risk of endophthalmitis from entry of organisms through a deep corneal incision into the anterior chamber. Most cases of endophthalmitis after RK have been associated with an intraoperative perforation. 1- 3 No intraoperative perforation was noted in our patient but a wound leak occurred 5 days later, when his clinical course had markedly worsened. Cultures from the corneal incision yielded a heavy growth of S. viridans. The vitreous cultures were negative; however, the patient had already received topical antibiotics and oral ciprofloxacin when the vitreous cultures were performed. Clinically, he had severe endophthalmitis as demonstrated by dense vitreous membranes on B-scan ultrasonography and visual acuiry of light perception. For endophthalmitis to occur after incisional refractive surgery, organisms must traverse Descemet's membrane and enter the anterior chamber. However, McLeod et al. 3 point out that endophthalmitis may oc952
cur without a history of recognized perforation. Our patient may have had an unrecognized perforation intraoperatively or could have subsequently developed a microperforation from necrosis at the base of the wound. This microperforation might not have been clinically evident, especially if stromal edema later sealed the site. We are uncertain whether our patient had early endophthalmitis on the day he presented to us or whether he developed endophthalmitis over the next day. With incisional refractive surgery, it is important to be aware that an occult perforation may occur at the time of surgery or may develop at the base of infected incisions subsequent to surgery. This case highlights the importance of close observation and aggressive treatment in cases of infectious keratitis after any type of incisional refractive surgery. Ciproflaxacin penetrates the aqueous and vitreous after oral administration, and McLeod et al. 3 recommend considering oral ciprofloxacin as an adjunct to topical antibiotic treatment in cases of infectious keratitis after incisional refractive surgery. If vitreous inflammation is noted, prompt vitreous cultures and injection of intravitreal antibiotics are indicated. This case should heighten the awareness of potential complications associated with multiple incisional refractive procedures. Because of the progressive hyperopia reported in the 10 year Prospective Evaluation of Radial Keratotomy (PERK) study,6 many refractive surgeons have advocated the use of an intentionally staged, titrated RK technique in which a significant number of patients have one or two additional operations to achieve the desired refractive outcome. Werblin and Stafford7 performed enhancement procedures in 33% of eyes, ranging from one to seven additional operations. They noted an improvement over the PERK technique in that 99% of eyes had uncorrected visual acuiry of 20/40 or better at 1 year. In light of the current trend toward staged RK techniques, this report can serve as a reminder of the potential hazards associated with performing multiple incisional refractive procedures.
References 1. Rashid ER, Waring GO III. Complications of radial and transverse keratotomy. Surv Ophthalmol 1989; 34:73106 2. Jain S, Azar DT. Eye infections after refractive keratotomy. J Refract Surg 1996; 12:148-155
J CATARACT REFRACT SURG-VOL 23. JULY/AUGUST 1997
CASE REPORTS: HEIDEMANN
3. McLeod SO, Flowers CW, Lopez PF, et al. Endophthalmitis and orbital cellulitis after radial keratotomy. Ophthalmology 1995; 102: 1902-1907 4. Manka RL, Gast TJ. Endophthalmitis following Ruiz procedure (letter). Arch Ophthalmol1990; 108:21 5. Basuk WL, Zisman M, Waring GO III, et al. Complications of hexagonal keratotomy. Am J Ophthalmol 1994; 117:37-49
6. Waring GO III, Lynn MJ, McDonnell PJ, and the PERK Study Group. Results of the prospective evaluation of radial keratotomy (PERK) study 10 years after surgery. Arch Ophthalmol 1994; 112: 1298 -1308 7. Werblin TP, Stafford GM. The Casebeer system for predictable keratorefractive surgery; one-year evaluation of 205 consecutive eyes. Ophthalmology 1993; 100:10951102
J CATARACT REFRACT SURG-VOL 23. JULY/AUGUST 1997
953
ABSTRACT A 45-year-old man developed endophthalmitis after a radial keratotomy (RK) enhancement. He developed severe intraocular inflammation, hypopyon, and dense vitreous membranes 4 days after the enhancement surgery. Cultures of the corneal wound yielded a heavy growth of Streptococcus viridans. The inflammation subsided after treatment with intraocular, intravenous, and topical antibiotics. The patient subsequently developed a cataract and retinal detachment. This case demonstrates the risk of endophthalmitis after RK enhancement. J Cataract Refract Surg 1997; 23:951-953
A
lthough many cases of infectious keratitis have been reported after incisional refractive procedures, endophthalmitis is rare. 1- 5 We report a case of severe endophthalmitis that developed after a radial keratotomy (RK) enhancement procedure.
Case Report A 45-year-old man had four-incision RK and astigmatic keratotomy in the right eye followed by an enhancement procedure 2 months later. Subsequently, several incisions were sutured because hyperopia developed. Several months later, an additional enhancement was performed in which the nasal incision was deepened. No intraoperative perforation was noted. Three days later, the patient noted ocular redness and irritation. He was treated with hourly ciprofloxacin drops and was referred to us the following day. Examination revealed visual acuity of hand motion, moderate corneal stromal haze, and a mid-stromal infiltrate in the paracentral aspect of the nasal RK incision. No epithelial defect or wound leak was present. The anterior chamber had
From the Department of Ophthalmology, Straith Memorial Hospital, Southfield, Michigan, USA. Reprint requests to David C. Heidemann, MD, Farmbrook Medical Building, Suite 201,29829 Telegraph, Southfield, Michigan 48034, USA.
moderate cell and flare and a 1.0 mm hypopyon. The retina was not well visualized; B-scan ultrasonography revealed no significant vitreous opacification. Scrapings of the nasal incision were taken for cultures on blood, chocolate, Sabouraud's agar, and meat broth. No wound leak or perforation was noted while the scrapings were performed. The patient was treated with hourly vancomycin (33 mg/mL) and tobramycin (14 mg/mL) drops and oral ciprofloxacin (750 mg) two times daily. The next day, a corneal wound leak, markedly increased anterior chamber inflammation, and a 2.5 mm hypopyon were noted; B-scan ultrasonography revealed dense vitreous membranes. The patient was admitted to the hospital, and a vitreous tap and injection of intravitreal vancomycin, amikacin, and dexamethasone were performed on the same day. Postoperatively, he was treated with intravenous vancomycin and ceftazidime and topical vancomycin and tobramycin drops. Cultures of the corneal wound yielded a heavy growth of Streptococcus viridans. The vitreous cultures were negative. Two days after the vitreous tap, examination revealed visual acuity of light perception, a 50% hypopyon, and dense vitreous membranes on B-scan ultrasonography. Two weeks after initial presentation, the corneal infiltrate had resolved and anterior chamber inflammation was decreased (Figure 1); B-scan ultrasonography revealed new posterior vitreous separations. Five weeks later, the anterior segment was quiet, but B-scan ultrasonography revealed an inferior retinal detachment. The patient had cataract extraction followed by vitrectomy and scleral buckle. Six weeks after the vitrectomy, examination revealed visual acuity of hand motion, diffuse corneal edema, and an attached retina.
J CATARACT REFRACT SURG-VO L 23, JULY/AUGUST 1997
951
CASE REPORTS: HEIDEMANN
Figure 1. (Heidemann) Two weeks after initiation of antibiotic treatment, the corneal infiltrate had resolved and the hypopyon was smaller. The arrow indicates the original site of the infiltrate and microperforation, which were no longer present at the time of this photograph.
Discussion Endophthalmitis has been reported after RK, hexagonal keratotomy, and the Ruiz procedure. 1- 5 This is the first documented case of endophthalmitis after an RK enhancement procedure. Patients and physicians must be aware that sight-threatening complications may occur after any incisional refractive procedure, including enhancements such as incision lengthening or deepening procedures. In cases of infectious keratitis after incisional refractive surgery, one must be aware of the risk of endophthalmitis from entry of organisms through a deep corneal incision into the anterior chamber. Most cases of endophthalmitis after RK have been associated with an intraoperative perforation. 1- 3 No intraoperative perforation was noted in our patient but a wound leak occurred 5 days later, when his clinical course had markedly worsened. Cultures from the corneal incision yielded a heavy growth of S. viridans. The vitreous cultures were negative; however, the patient had already received topical antibiotics and oral ciprofloxacin when the vitreous cultures were performed. Clinically, he had severe endophthalmitis as demonstrated by dense vitreous membranes on B-scan ultrasonography and visual acuiry of light perception. For endophthalmitis to occur after incisional refractive surgery, organisms must traverse Descemet's membrane and enter the anterior chamber. However, McLeod et al. 3 point out that endophthalmitis may oc952
cur without a history of recognized perforation. Our patient may have had an unrecognized perforation intraoperatively or could have subsequently developed a microperforation from necrosis at the base of the wound. This microperforation might not have been clinically evident, especially if stromal edema later sealed the site. We are uncertain whether our patient had early endophthalmitis on the day he presented to us or whether he developed endophthalmitis over the next day. With incisional refractive surgery, it is important to be aware that an occult perforation may occur at the time of surgery or may develop at the base of infected incisions subsequent to surgery. This case highlights the importance of close observation and aggressive treatment in cases of infectious keratitis after any type of incisional refractive surgery. Ciproflaxacin penetrates the aqueous and vitreous after oral administration, and McLeod et al. 3 recommend considering oral ciprofloxacin as an adjunct to topical antibiotic treatment in cases of infectious keratitis after incisional refractive surgery. If vitreous inflammation is noted, prompt vitreous cultures and injection of intravitreal antibiotics are indicated. This case should heighten the awareness of potential complications associated with multiple incisional refractive procedures. Because of the progressive hyperopia reported in the 10 year Prospective Evaluation of Radial Keratotomy (PERK) study,6 many refractive surgeons have advocated the use of an intentionally staged, titrated RK technique in which a significant number of patients have one or two additional operations to achieve the desired refractive outcome. Werblin and Stafford7 performed enhancement procedures in 33% of eyes, ranging from one to seven additional operations. They noted an improvement over the PERK technique in that 99% of eyes had uncorrected visual acuiry of 20/40 or better at 1 year. In light of the current trend toward staged RK techniques, this report can serve as a reminder of the potential hazards associated with performing multiple incisional refractive procedures.
References 1. Rashid ER, Waring GO III. Complications of radial and transverse keratotomy. Surv Ophthalmol 1989; 34:73106 2. Jain S, Azar DT. Eye infections after refractive keratotomy. J Refract Surg 1996; 12:148-155
J CATARACT REFRACT SURG-VOL 23. JULY/AUGUST 1997
CASE REPORTS: HEIDEMANN
3. McLeod SO, Flowers CW, Lopez PF, et al. Endophthalmitis and orbital cellulitis after radial keratotomy. Ophthalmology 1995; 102: 1902-1907 4. Manka RL, Gast TJ. Endophthalmitis following Ruiz procedure (letter). Arch Ophthalmol1990; 108:21 5. Basuk WL, Zisman M, Waring GO III, et al. Complications of hexagonal keratotomy. Am J Ophthalmol 1994; 117:37-49
6. Waring GO III, Lynn MJ, McDonnell PJ, and the PERK Study Group. Results of the prospective evaluation of radial keratotomy (PERK) study 10 years after surgery. Arch Ophthalmol 1994; 112: 1298 -1308 7. Werblin TP, Stafford GM. The Casebeer system for predictable keratorefractive surgery; one-year evaluation of 205 consecutive eyes. Ophthalmology 1993; 100:10951102
J CATARACT REFRACT SURG-VOL 23. JULY/AUGUST 1997
953