A rare case of post-laser-assisted in situ keratomileusis Scedosporium prolificans keratitis

Aditi Parab; Josephine S Christy; Shivananda Narayana; Joseph Gubert

doi:10.4103/ijo.IJO_1081_21

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 2 | Page : 359-361

A rare case of post-laser-assisted in situ keratomileusis Scedosporium prolificans keratitis

Aditi Parab¹, Josephine S Christy², Shivananda Narayana², Joseph Gubert³
¹ Resident, Department of General Ophthalmology, Aravind Eye Hospital, Pondicherry, India
² Department of Cornea and Refractive Services, Aravind Eye Hospital, Pondicherry, India
³ Department of Microbiology, Aravind Eye Hospital, Pondicherry, India

Date of Submission	04-May-2021
Date of Acceptance	18-Oct-2021
Date of Web Publication	13-Apr-2022

Correspondence Address:
Josephine S Christy
Aravind Eye Hospital, Cuddalore Main Road, Thavalakuppam, Pondicherry - 605 007
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1081_21

Abstract

A 21-year-old female presented with a stick injury in her right eye 6 months after an uneventful laser in situ keratomileusis (LASIK). Diffuse lamellar keratitis which responded well to the initial treatment with topical steroids, progressed rapidly within the next 3 weeks to develop corneal perforation. A microbiological examination revealed a rare fungus Scedosporium prolificans. The patient was successfully managed with topical voriconazole 1% and cyanoacrylate glue for corneal perforation. At the end of 7 weeks, keratitis healed with a best-corrected visual acuity of hand movements. Hence, a strong suspicion of infectious interface keratitis is warranted while treating post-LASIK keratitis.

Keywords: DLK, post-LASIK infection, Scedosporium prolificans

How to cite this article:
Parab A, Christy JS, Narayana S, Gubert J. A rare case of post-laser-assisted in situ keratomileusis Scedosporium prolificans keratitis. Indian J Ophthalmol Case Rep 2022;2:359-61

How to cite this URL:
Parab A, Christy JS, Narayana S, Gubert J. A rare case of post-laser-assisted in situ keratomileusis Scedosporium prolificans keratitis. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 18];2:359-61. Available from: https://www.ijoreports.in/text.asp?2022/2/2/359/342868

Infectious keratitis following laser-assisted in situ keratomileusis (LASIK) is a rare but serious sight-threatening complication. Since LASIK is the most commonly done refractive surgery, the incidence of post-LASIK infections is also showing an increasing trend.^[1] Varied etiological organisms reported in the literature include bacteria, fungi, Mycobacteria, and Nocardia.^[2] In the present report, we describe the clinical course and outcome of a rare case of post-LASIK Scedosporium prolificans keratitis.

Case Report

A 21-year-old female presented with pain, redness, and blurring of vision following stick injury in the right eye (RE) 1 day back. She had undergone an uneventful simultaneous bilateral myopic LASIK surgery 6 months back. Her visual acuity in RE at the presentation was 20/120. A slit-lamp examination revealed a loose dislodged edematous flap with wavy aggregates of cellular infiltrate in the interface and an overlying epithelial defect of size 2 mm [Figure 1]a. Flap lift with interface wash and irrigation of moxifloxacin 0.5% were done on the same day of the presentation. The corneal bed and flap under the surface were scraped for microbiological analysis that included Grams stain, potassium hydroxide (KOH) stain, and culture in blood and potato dextrose agar. The microbiological reports at this point were negative. On the next day, the visual acuity in RE improved to 20/20 and the cornea was clear except for a faint 1 mm nebular lesion in the interface at the inferior pupillary border. On day 3, the interface showed diffuse refractile deposits typical like 'Sands of Sahara' along with two well-defined 1 mm white lesions at the inferior pupillary border and mild flap edema [Figure 1]b. Traumatic diffuse lamellar keratitis (DLK) was suspected and the patient was started on prednisolone acetate suspension 1% six times a day and topical moxifloxacin 0.5% 2 hourly. Since two suspicious pin-head-sized lesions were present along with cellular grainy infiltrates, hourly 5% natamycin eye drops were also added and monitored under close observation on admission. On the following days, the DLK decreased significantly albeit with persistent stellate infiltrate in the pupillary region. The patient maintained a best corrected visual acuity (BCVA) of 20/20.

Figure 1: (a): Day 1 presentation showing nasal flap edema. Inset image showing the fluorescein-stained epithelial defect. (b): Day 3 picture showing fine granular sand-like interface infiltrate resembling 'Sands of Sahara' along with central two discrete white infiltrates at the inferior pupillary border

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On day 8, the patient presented again with severe pain in the RE along with a significant drop in the vision to hand movements (HM). The examination revealed a 5 mm × 6 mm interface infiltrate with feathery margins, flap edema, and 360° cellular infiltrate along the flap edge [Figure 2]. Topical voriconazole 1% eye drops were initiated hourly along with hourly natamycin 5% and moxifloxacin 0.5% eye drops. Systemic fluconazole 150 mg twice daily was started and topical prednisolone eye drops were stopped. Interface flap wash with flap suturing was done and repeat interface corneal scraping was sent for smear examination and culture. The smear showed yeast fungus on examination, and hence, the patient was initiated on hourly topical amphotericin B 0.15% along with voriconazole 1% eye drops. The culture on potato dextrose and blood agar grew gray to blackish colored colonies of expanding, flat, moist, depressed cobweb-like aerial mycelium [Figure 3]a. The examination on lactophenol cotton blue mount showed smooth-walled conidia aggregating in dense slimy heads and characteristic flask-shaped conidigenous cells suggestive of Scedosporium prolificans [Figure 3]b.

Figure 2: Day 8 picture showing central 5 mm × 6 mm interface infiltrate with feathery margin and 360° cellular infiltrate along the flap edge

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Figure 3: (a) Culture on blood agar showing growth of grayish-black colonies of flat, moist, depressed cobweb-like aerial mycelium. (b): Lactophenol cotton blue mount showing smooth-walled conidia of Scedosporium prolificans aggregating in dense slimy heads

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Though the ulcer responded well to topical treatment with healing margins [Figure 4]a, the central active area perforated on day 20. The perforation was managed with cyanoacrylate glue application with bandage contact lens (BCL) and anterior chamber reformation [Figure 4]b. At the end of 7 weeks, the glue remnants and BCL were removed. The infiltrate had healed completely with a 360° corneal vascularization and a visual acuity of hand movements.

Figure 4: (a): Day 15 picture showing well-healing ulcer with supero-temporal active margins. (b): Day 35 picture showing cyanoacrylate glue precipitates over healed infiltrate with peripheral corneal vascularization

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Discussion

Infections are not uncommon after LASIK and the literature reports an overall incidence of 0.0046%.^[3] Oftentimes, post-LASIK fungal keratitis is easily missed and confused with DLK as in our case due to the clinical similarities.^[2] The largest case series of post-LASIK microbial keratitis by Garg et al.^[4] stated that infection was not suspected in 46.6% of cases and all of them were receiving corticosteroids at the time of presentation. Topical steroids are the mainstay of treatment for DLK, whereas the addition of steroids can aggravate an underlying fungal infection. They can be detrimental in fungal keratitis in many ways such as enhancing fungal replication, expansion of infection to deeper layers due to immune suppression and delayed diagnosis due to a false picture of symptomatic and clinical improvement.^[5] Hence, it is very crucial to differentiate infectious interface keratitis from a non-infectious DLK. Interface infectious keratitis is ideally identified by their distinct corneal lesions, intense conjunctival injection, and hypopyon. Also, it is important to remember that an early interface fungal keratitis might not have the classical clinical features of fungal keratitis unlike in a virgin cornea.^[4]

Scedosporium prolificans is a dematiaceous fungus found in the soils of ornamental and greenhouse plants.^[6] Documented ocular infections include traumatic and endogenous endophthalmitis and sclerokeratitis following the use of beta irradiation in pterygium surgery.^[7] They exhibit notorious resistance to the commonly used antifungal including newer systemic triazoles and echinocandins. All patients in the previous case reports had required surgical debridement or excision of the infected organ/area with or without antifungal treatment. Sridhar et al.^[8] reported a single case of immediate post-LASIK infection by Scedosporium apiospermum which also required therapeutic keratoplasty. In our patient, the response to topical voriconazole and amphotericin B was promising although eventually cyanoacrylate glue was required for corneal perforation.

In general, interface fungal keratitis is postulated to have a worse prognosis because of a poor bioavailability of drug and sequestrated organisms in the interface.^[9] However, the analysis of various case reports (total = 30 cases) of post-LASIK fungal keratitis in the existing literature revealed that 56.6% had resolved with medical treatment, and the remaining required keratoplasty.^[2] A prompt diagnosis and early intervention like flap amputation/repeated interface voriconazole wash can provide successful visual outcomes even in interface fungal keratitis.^[2]

Conclusion

A high index of suspicion is necessary while treating any post-LASIK keratitis and cautious use of topical steroids is of utmost importance. Early diagnosis with compulsory interface scraping and prompt initiation of appropriate medications can offer a good visual outcome.

Financial support and sponsorship

Aravind Eye Hospital, Pondicherry.

Conflicts of interest

There are no conflicts of interest.

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