Infectious Keratitis after Photorefractive Keratectomy in the United States Army and Navy

doi:10.1016/j.ophtha.2005.09.038

Ophthalmology

Volume 113, Issue 4, April 2006, Pages 520-525

https://doi.org/10.1016/j.ophtha.2005.09.038 Get rights and content

Purpose

To review the incidence, culture results, clinical course, management, and visual outcomes of infectious keratitis after photorefractive keratectomy (PRK) at 6 Army and Navy refractive surgery centers.

Design

Retrospective study.

Participants

Twelve thousand six hundred sixty-eight Navy and Army sailors and service members.

Methods

Army and Navy refractive surgery data banks were searched for cases of infectious keratitis. A retrospective chart review and query of the surgeons involved in the care of those patients thus identified provided data regarding preoperative preparation, perioperative medications, treatment, culture results, clinical course, and final visual acuity.

Results

Between January 1995 and May 2004, we performed a total of 25337 PRK procedures at the 6 institutions. Culture proven or clinically suspected infectious keratitis developed in 5 eyes of 5 patients. All patients received topical antibiotics perioperatively. All cases presented 2 to 7 days postoperatively. Cultures from 4 cases grew Staphylococcus, including 2 methicillin-resistant S. aureus (MRSA). One case of presumed infectious keratitis was culture negative. There were no reported cases of mycobacterial or fungal keratitis. In addition, we identified 26 eyes with corneal infiltrates in the first postoperative week that were felt to be sterile, and which resolved upon removal of the bandage contact lens and increasing antibiotic coverage.

Conclusions

Infectious keratitis is a rare but potentially vision-threatening complication after PRK. It is often caused by gram-positive organisms, including MRSA. Early diagnosis, appropriate laboratory testing, and aggressive antimicrobial therapy can result in good outcomes.

Section snippets

Materials and Methods

We searched the Army and Navy data banks containing preoperative and postoperative patient information for cases of infectious keratitis, corneal ulcer, or corneal infiltrate. We conducted a retrospective chart review and queried all the surgeons involved in the care of those patients identified. Where possible, we obtained culture results and clinical photographs. We obtained the following information for review and analysis: preoperative preparation (povidone–iodine preparation, lid drapes),

Results

From January 1995 until May 2004, the United States Army and Navy completed 25337 PRK procedures at the 6 different institutions. All patients had a preoperative best-corrected visual acuity (BCVA) of 20/20 bilaterally. All patients were given a therapeutic bandage contact lens (BCL) and prophylactic antibiotics during surgery. All patients were discharged on topical antibiotics 4 times daily. Infectious keratitis developed in 5 eyes of 5 patients. These patients’ cases are summarized in Table 1

Discussion

Our review of 25337 PRK procedures at 6 institutions is the largest retrospective review of infectious keratitis after PRK. All of our patients except one received topical fluoroquinolones until the corneal epithelium healed. The other patient received trimethoprim–polymyxin B. Our cases presented within the first week after surgery, and despite the use of prophylactic fluoroquinolones and trimethoprim–polymyxin B in 1 patient, we had 4 culture-proven cases of gram-positive infectious

Acknowledgments

The authors acknowledge the assistance of COL (retired) Thomas Mader, MD, for review of the manuscript.

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Fungal keratitis is an uncommon condition that can occur after ocular surgery or trauma to the eye. Some cases have been reported after corneal refractive surgery. Most cases of keratitis following refractive surgery are due to gram-positive bacteria. However, there are a few reports in the literature of fungal and protozoal infections.
A 29-year-old healthy male developed fungal keratitis Five days following photorefractive keratectomy.
The patient was admitted to the hospital, corneal scraping was performed and sent for staining and routine cultures. A corneal swab was also performed and sent for polymerase chain reaction (PCR). On day 10 post-admission, the fungal culture was positive for Bipolaris.
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Refractive surgery in the HIV-positive U.S. Military Natural History Study Cohort: complications and risk factors
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Citation Excerpt :
Demographic and clinical data were extracted from the study database for analysis including age, sex, race, time since HIV diagnosis, history of AIDS (Centers for Disease Control and Prevention 1993 revised classification system7), ART by medication class, CD4 count and HIV viral load at time of ophthalmic diagnosis, total number of ophthalmic diagnoses, diabetes mellitus type 2, hypertension, hyperlipidemia, and smoking. Baseline was defined as earliest documented HIV+ test date; ART was defined as in previous NHS studies (Supplemental Table 1, available at http://jcrsjournal.org).8 Most patients were taking two or more nucleoside reverse transcriptase inhibitors and either a nonnucleoside reverse transcriptase inhibitor, unboosted versus boosted protease inhibitor, or an integrase inhibitor.
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Multiple centers in the United States.
Prospective observational cohort study.
The U.S. Military HIV Natural History Study is a prospective observational cohort study of HIV+ service members and beneficiaries. Participants were selected who had Current Procedural Terminology codes for laser in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and other refractive surgeries. The frequency of complications was determined using International Classification of Diseases-9 codes. Covariates included age, sex, antiretroviral therapy, time since HIV diagnosis, history of AIDS, and CD4 (T lymphocytes) count and viral load. Statistical analysis was completed using univariate (χ² and Wilcoxon-Mann-Whitney tests) and multivariate analyses.
Seventy-nine of 2073 participants had refractive surgery. Fifty-three patients underwent PRK, 23 LASIK, 2 radial keratotomy (RK), and 1 astigmatic correction. Complications occurred in 6 (7.6%) of 79 participants, including 5 patients who underwent PRK and 1 after RK, occurring between 8 and 217 days after surgery. Five ulcers and 1 unspecified keratitis were noted. In the univariate analysis, type of surgery (P = .02) and history of AIDS (P = .02) were risk factors for complications. In logistic regression analysis, no variables were found to be risk factors for complications.
Complications were infrequent among HIV+ participants after refractive surgery. Point estimates suggest that PRK might have more complications than LASIK and that advanced HIV, reflected by previous AIDS, might be associated with an increased risk for complications. Further study will be required to confirm these findings.
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: Manuscript no. 2004-448

: There was no financial support, public or private, used to fund the study. The authors have no financial interest in any product, drug, instrument, or equipment discussed in the article

: The opinions expressed in the article are those solely of the authors and do not represent the views or official policies of the United States Army or Department of Defense

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Original ArticleInfectious Keratitis after Photorefractive Keratectomy in the United States Army and Navy

Purpose

Design

Participants

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Ophthalmology

Ophthalmology

Ophthalmology

J Cataract Refract Surg

J Cataract Refract Surg

Ophthalmology

J Cataract Refract Surg

J Cataract Refract Surg

Ophthalmology

Original Article
Infectious Keratitis after Photorefractive Keratectomy in the United States Army and Navy