First Author: M.Latasiewicz SPAIN
Co Author(s): M. Figueras Roca P. D J. Torras
Purpose:
To describe a case of presumed infectious keratitis after ICRS implantation in a patient with keratoconus.
Setting:
Hospital Clķnic of Barcelona, Department of Ophthalmology
Methods:
A 48-year-old man presenting bilateral keratoconus and a pronounced against the rule astigmatism was selected for ICRS implantation in his right eye. He achieved a best corrected visual acuity (BCVA) with rigid gas-permeable contact lenses of 20/60 in his right eye and 20/25 in his left eye. Manual and automated refraction were 95ŗ -22.00 +5.50 in his right eye (achieving BCVA of 20/50) and 95ŗ -12.00 +5.50 in his left eye (achieving BCVA of 20/20). Corneal Orbscan topography of both eyes showed a pellucid marginal degeneration-like pattern featuring in his right eye a K1 of 47.2 (2ŗ), a K2 of 39.2 (92ŗ) and a thinnest point of 492mc. Two ICRS (Corneal-Ring®) of 155ŗ and 0.2mm (inferior) and 0.15mm (superior) were surgically implanted through a temporal (180ŗ) corneal incision with no complications. The incision site was closed with a single 10-0 Nylon suture, which was removed after 2 weeks. Postoperative follow-up with tobramycin and dexamethasone drops was carried out with no complications.
Results:
Postoperative refraction changed to 90ŗ -9.00 -4.50 (BCVA of 20/25). After 3.5 months of follow-up with no complications the patient consulted for right red eye, pain and blurred vision (BCVA of 20/25) during the last two weeks. Biomicroscopy of the anterior segment showed conjunctival hyperaemia, oedema and infiltration of corneal stroma in the surroundings of the superior ICRS incision point, associated with anterior chamber inflammation. Topical treatment was initiated with fortified ceftazidime (50mg/ml) and vancomycin (25mg/ml) hourly, fluorometholone BID and cyclopentolate TID. Two days after no improvement was found and the patient was selected for surgical explantation of the superior ICRS and irrigation of the corneal tunnel with vancomycin, ceftazidime and voriconazole (2%). Microbiology exams of corneal surface frotis and cultivation of ICRS were reported negative. Treatment with topical fortified ceftazidime, vancomycin and voriconazole was progressively decreased during his postoperative follow-up of 2 months with neither recurrence of corneal infiltration nor corneal ulceration. He conserved a BCVA of 20/25 with a refraction of 90ŗ -11.00 +3.50.
Conclusions:
Microbial keratitis is a rare but serious complication of intracorneal ring segments which can develop even several months after implantation. In literature the most common microorganisms involved are Gram-positive bacteria: Staphylococcus aureus and Staphylococcus epidermidis. Fungal and Acanthamoeba infections are rare. The keratitis requires intensive antimicrobial topical treatment and in most cases explantation of the ICRS to ensure resolution of the infection. Therefore long postoperative follow-up, patient education on possible symptoms, early recognition, and finally, immediate installation of appropriate treatment is crucial for the patient's visual outcome. FINANCIAL DISCLOSURE?: No
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