- Email: [email protected]
Fine lattice lines on the corneal surface after laser in situ keratomileusis (LASIK)
BRIEF REPORTS Fine Lattice Lines on the Corneal Surface After Laser In Situ Keratomileusis (LASIK) Emmett F. Carpel, MD, Keith H. Carlson, MD, and Susan Shannon, COMT PURPOSE: To present an example of a pattern of lines resembling fine lattice on the corneal surface subsequent to laser in situ keratomileusis (LASIK). This subtle phenomenon may be relatively common and may affect visual outcome. METHOD: Case report. RESULTS: A 41-year-old year old man with high myopia and best-corrected visual acuity of 20/20 ⴙ2 in each eye underwent laser in situ keratomileusis (LASIK). No operative or postoperative complications occurred. No striae were evident on slit-lamp examination with direct illumination and retroillumination at the time of surgery or in the postoperative period. Postoperative uncorrected visual acuity was 20/25 with a best-corrected spectacle correction of 20/25 in both eyes. Fine lines in a lattice pattern were seen only with fluorescein dye in the precorneal tear film as areas of “negative stain” within the LASIK flap. With tear film supplementation, the lines were less evident and visual acuity improved. One year postoperatively, his uncorrected visual acuity was 20/25 in both eyes. The best-corrected spectacle visual acuity was RE: 20/20 ⴚ2, LE: 20/25. The fine lines were still present within the flap. A soft contact lens improved visual acuity to 20/20 in both eyes. Although all four puncta were occluded, he had no epiphora. CONCLUSION: Fine lines in a lattice pattern that may represent folds in the epithelium or Bowman layer may be present within the flap after LASIK and may adversely affect visual acuity. They may be visible as areas of negative stain with fluorescein dye in the precorneal tear film in the absence of any striae visible in the flap. These superficial lines have been seen more in patients with high degrees of correction and in patients with dry eye. If Accepted for publication Sept 29, 1999. From the Ophthalmology Department, Hennepin County Medical Center (E.F.C.), the University of Minnesota (E.F.C.), the Phillips Eye Institute (E.F.C., K.H.C., S.S.), and Health Partners, Inc (E.F.C., K.H.C.), Minneapolis, Minnesota. Inquiries to Emmett F. Carpel, MD, Ophthalmology Department, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415; fax: (612) 904-4278. 0002-9394/00/$20.00
©
2000 BY
visual acuity is affected, it may be improved with punctal occlusion, tear supplements, or a contact lens. (Am J Ophthalmol 2000;129:379 –380. © 2000 by Elsevier Science Inc. All rights reserved.)
L
ASER IN SITU KERATOMILEUSIS (LASIK)1 HAS BECOME A
commonly performed procedure. Complications are infrequent, but may include over- and undercorrections, infiltrates, epithelial ingrowth, and striae in the corneal flap2; the latter may degrade the optical image. We report a variation of striae that may not be noticed on usual slit-lamp examination with either direct illumination or retroillumination. Fine reticular lines in a lattice pattern that involve the corneal epithelium and probably the Bowman layer are seen as a negative staining pattern with fluorescein dye in the precorneal tear film within the LASIK flap. They are best demonstrated by holding the eyelids apart just after a blink, as we would do to demonstrate dry spots in the tear film. A 41-year-old man with a preoperative refraction of ⫺8.50 ⫹0.50 axis 95 RE, and ⫺8.00 ⫹0.25 axis 75 LE correctable to 20/20 ⫹2 visual acuity in both eyes underwent bilateral LASIK. No operative or postoperative complications occurred. At 1 month postoperatively, the uncorrected visual acuity was 20/25 in both eyes. The best-corrected spectacle acuity was RE: 20/25 with ⫹0.25 sphere and LE: 20/25 with ⫺0.25 sphere. The images on the eye chart were slightly fuzzy, but improved with a blink or artificial tears. No striae were evident in the visual axis in direct illumination or retroillumination (Figure 1). With fluorescein dye in the precorneal tear film, prominent reticular lines in a
FIGURE 1. In a 41-year-old man 1 month post-LASIK, the cornea of the left eye is clear and without striae.
ELSEVIER SCIENCE INC. ALL
RIGHTS RESERVED.
379
Diffuse Interface Keratitis After Laser In Situ Keratomileusis (LASIK): A Nonspecific Syndrome Roger F. Steinert, MD, Ann Z. McColgin, MD, April White, COT, and Gwynn M. Horsburgh, OD, PhD PURPOSE:
To characterize the presentation of diffuse interface keratitis after laser in-situ keratomileusis (LASIK). METHODS: Case report. RESULTS: Diffuse interface keratitis occurred in the left eye of a postoperative LASIK patient after central epithelial debridement without exposure of the flap margin or elevation of the flap. CONCLUSION: Diffuse interface keratitis is a nonspecific presentation of corneal inflammation after LASIK, with accumulation of inflammatory cells in the potential space of the interface. Diffuse interface keratitis after LASIK may have multiple causes. (Am J Ophthalmol 2000; 129:380 –381. © 2000 by Elsevier Science Inc. All rights reserved.)
FIGURE 2. Same patient as in Figure 1 immediately after administration of topical fluorescein dye. Lines resembling lattice appear centrally within the LASIK flap (arrow). They are superficial and do not stain.
lattice pattern were seen as areas of negative stain (Figure 2). Artificial tears and punctal occlusion helped improve vision subjectively, although the best-corrected spectacle visual acuity remained 20/25 in both eyes. A soft contact lens improved visual acuity to a “crisp” 20/20 in both eyes. One year postoperatively, uncorrected visual acuity was 20/25 in both eyes. Best-corrected spectacle visual acuity was RE: 20/20 –2 with ⫹0.50 sphere and LE: 20/25 plano. The vision was slightly fuzzy. The fine lattice lines were still present. A soft contact lens brought visual acuity to a “crisp” 20/20. The authors have seen this phenomenon relatively often, and their clinical impression is that it occurs more often with higher degrees of correction (⬎⫺6.00 diopters) and in dry eye patients. We have been unable to predict in whom this may occur and have seen it unilaterally in some patients with simultaneous, bilateral LASIK, although it frequently occurs bilaterally. The lines probably represent folds in epithelium and Bowman layer. They degrade the optical image slightly, but vision may be improved by enhancing the tear film. Spectacles do not seem to improve vision, but contact lenses provide excellent vision, which affirms that this is a surface phenomenon. With time, epithelial hyperplasia may remodel and smooth the surface and lead to some improvement in vision. The visual outcome is generally good.
T
REFERENCES
Accepted for publication Sept 29, 1999. From the Department of Ophthalmology, Harvard Medical School (R.F.S.), and the Ophthalmic Consultants of Boston and the Center for Eye Research and Education (R.F.S., A.Z.M., A.W., G.M.H.), Boston, Massachusetts. Inquiries to Roger F. Steinert, MD, Ophthalmic Consultants of Boston, 50 Staniford St, Suite 600, Boston, MA 02114; fax: (617) 573-4912; e-mail: [email protected]
1. Pallikaris IG, Papatzanaki ME, Stathi EZ, Frenschock O, Georgiadis A. Laser in situ keratomileusis. Lasers Surg Med 1990;10:463– 468. 2. Filatov V, Vidaurri-Leal JS, Talamo JH. Selected complications of radial keratotomy, photorefractive keratectomy, and laser in situ keratomileusis. Int Ophthalmol Clin 1997;37: 123–148.
380
AMERICAN JOURNAL
HE APPEARANCE OF DIFFUSE INFLAMMATORY CELLS IN
the interface of corneas 1 to 5 days after having been treated with laser in situ keratomileusis (LASIK) is a recently described syndrome.1,2 The syndrome has been termed diffuse lamellar keratitis, “sands of the Sahara” because of the characteristic appearance of waves of inflammatory cells, or, most precisely, diffuse interface keratitis. The origin of this syndrome is unknown, except that it is not infectious.1 An allergic or toxic reaction has been the most commonly invoked hypothesis. The inflammation typically responds rapidly to topical corticosteroid therapy. The search for the inciting agent has been elusive, however. Possible interface contaminants, including meibomian gland secretions, topical antibiotics and antiseptics, bacterial toxins present in autoclave water reservoirs, chemical and foreign body contaminants on the microkeratome blades, and contaminants from the microkeratome motor have all been suspected, but none of these elements is common to all cases1,2 (Roundtable on Sands of the Sahara Syndrome, unpublished data, Eye World News, May 15, 1999). Indeed, diffuse interface keratitis has occurred in cases of lifted flaps in retreatments where no microkeratome was employed.1
OF
OPHTHALMOLOGY
MARCH 2000
©
2000 BY
visual acuity is affected, it may be improved with punctal occlusion, tear supplements, or a contact lens. (Am J Ophthalmol 2000;129:379 –380. © 2000 by Elsevier Science Inc. All rights reserved.)
L
ASER IN SITU KERATOMILEUSIS (LASIK)1 HAS BECOME A
commonly performed procedure. Complications are infrequent, but may include over- and undercorrections, infiltrates, epithelial ingrowth, and striae in the corneal flap2; the latter may degrade the optical image. We report a variation of striae that may not be noticed on usual slit-lamp examination with either direct illumination or retroillumination. Fine reticular lines in a lattice pattern that involve the corneal epithelium and probably the Bowman layer are seen as a negative staining pattern with fluorescein dye in the precorneal tear film within the LASIK flap. They are best demonstrated by holding the eyelids apart just after a blink, as we would do to demonstrate dry spots in the tear film. A 41-year-old man with a preoperative refraction of ⫺8.50 ⫹0.50 axis 95 RE, and ⫺8.00 ⫹0.25 axis 75 LE correctable to 20/20 ⫹2 visual acuity in both eyes underwent bilateral LASIK. No operative or postoperative complications occurred. At 1 month postoperatively, the uncorrected visual acuity was 20/25 in both eyes. The best-corrected spectacle acuity was RE: 20/25 with ⫹0.25 sphere and LE: 20/25 with ⫺0.25 sphere. The images on the eye chart were slightly fuzzy, but improved with a blink or artificial tears. No striae were evident in the visual axis in direct illumination or retroillumination (Figure 1). With fluorescein dye in the precorneal tear film, prominent reticular lines in a
FIGURE 1. In a 41-year-old man 1 month post-LASIK, the cornea of the left eye is clear and without striae.
ELSEVIER SCIENCE INC. ALL
RIGHTS RESERVED.
379
Diffuse Interface Keratitis After Laser In Situ Keratomileusis (LASIK): A Nonspecific Syndrome Roger F. Steinert, MD, Ann Z. McColgin, MD, April White, COT, and Gwynn M. Horsburgh, OD, PhD PURPOSE:
To characterize the presentation of diffuse interface keratitis after laser in-situ keratomileusis (LASIK). METHODS: Case report. RESULTS: Diffuse interface keratitis occurred in the left eye of a postoperative LASIK patient after central epithelial debridement without exposure of the flap margin or elevation of the flap. CONCLUSION: Diffuse interface keratitis is a nonspecific presentation of corneal inflammation after LASIK, with accumulation of inflammatory cells in the potential space of the interface. Diffuse interface keratitis after LASIK may have multiple causes. (Am J Ophthalmol 2000; 129:380 –381. © 2000 by Elsevier Science Inc. All rights reserved.)
FIGURE 2. Same patient as in Figure 1 immediately after administration of topical fluorescein dye. Lines resembling lattice appear centrally within the LASIK flap (arrow). They are superficial and do not stain.
lattice pattern were seen as areas of negative stain (Figure 2). Artificial tears and punctal occlusion helped improve vision subjectively, although the best-corrected spectacle visual acuity remained 20/25 in both eyes. A soft contact lens improved visual acuity to a “crisp” 20/20 in both eyes. One year postoperatively, uncorrected visual acuity was 20/25 in both eyes. Best-corrected spectacle visual acuity was RE: 20/20 –2 with ⫹0.50 sphere and LE: 20/25 plano. The vision was slightly fuzzy. The fine lattice lines were still present. A soft contact lens brought visual acuity to a “crisp” 20/20. The authors have seen this phenomenon relatively often, and their clinical impression is that it occurs more often with higher degrees of correction (⬎⫺6.00 diopters) and in dry eye patients. We have been unable to predict in whom this may occur and have seen it unilaterally in some patients with simultaneous, bilateral LASIK, although it frequently occurs bilaterally. The lines probably represent folds in epithelium and Bowman layer. They degrade the optical image slightly, but vision may be improved by enhancing the tear film. Spectacles do not seem to improve vision, but contact lenses provide excellent vision, which affirms that this is a surface phenomenon. With time, epithelial hyperplasia may remodel and smooth the surface and lead to some improvement in vision. The visual outcome is generally good.
T
REFERENCES
Accepted for publication Sept 29, 1999. From the Department of Ophthalmology, Harvard Medical School (R.F.S.), and the Ophthalmic Consultants of Boston and the Center for Eye Research and Education (R.F.S., A.Z.M., A.W., G.M.H.), Boston, Massachusetts. Inquiries to Roger F. Steinert, MD, Ophthalmic Consultants of Boston, 50 Staniford St, Suite 600, Boston, MA 02114; fax: (617) 573-4912; e-mail: [email protected]
1. Pallikaris IG, Papatzanaki ME, Stathi EZ, Frenschock O, Georgiadis A. Laser in situ keratomileusis. Lasers Surg Med 1990;10:463– 468. 2. Filatov V, Vidaurri-Leal JS, Talamo JH. Selected complications of radial keratotomy, photorefractive keratectomy, and laser in situ keratomileusis. Int Ophthalmol Clin 1997;37: 123–148.
380
AMERICAN JOURNAL
HE APPEARANCE OF DIFFUSE INFLAMMATORY CELLS IN
the interface of corneas 1 to 5 days after having been treated with laser in situ keratomileusis (LASIK) is a recently described syndrome.1,2 The syndrome has been termed diffuse lamellar keratitis, “sands of the Sahara” because of the characteristic appearance of waves of inflammatory cells, or, most precisely, diffuse interface keratitis. The origin of this syndrome is unknown, except that it is not infectious.1 An allergic or toxic reaction has been the most commonly invoked hypothesis. The inflammation typically responds rapidly to topical corticosteroid therapy. The search for the inciting agent has been elusive, however. Possible interface contaminants, including meibomian gland secretions, topical antibiotics and antiseptics, bacterial toxins present in autoclave water reservoirs, chemical and foreign body contaminants on the microkeratome blades, and contaminants from the microkeratome motor have all been suspected, but none of these elements is common to all cases1,2 (Roundtable on Sands of the Sahara Syndrome, unpublished data, Eye World News, May 15, 1999). Indeed, diffuse interface keratitis has occurred in cases of lifted flaps in retreatments where no microkeratome was employed.1
OF
OPHTHALMOLOGY
MARCH 2000