1. Late Diffuse Lamellar Keratitis in Post-LASIK Infective Keratitis
Dr. Umang Mathur
Dr. Amit Agrawal
Dr. Manisha Acharya
The authors have no financial interest in the subject of this poster

2. History
23-year-old female underwent uneventful Bilateral Myopic LASIK, elsewhere, on 22nd January 2008
Post-operative # 3
Patient presents to the doctor with Bilateral Infective Keratitis
Pain, Photophobia, Redness, Watering/Discharge
Vision: CF 1/2m, both eyes
Central infiltrates, both eyes
New Delhi, India

3. Management
Flap lifted in both eyes and scraping sent for Bacterial and Fungal smears and culture
No organisms grown
Empirical treatment
Moxifloxacin eye drops q1h
Tobramycin eye drops q1h
Natamycin eye drops q1h
Cyclopentolate eye drops tid
New Delhi, India

4. Impression: Healing Keratitis
Post-operative # 7
Patient responds to treatment
↓ Pain, watering, photophobia
↓ size of infiltration
Improvement in Vision, RE>LE
Impression: Healing Keratitis
New Delhi, India

5. Post-operative # 13 ↑ ↑ Pain, watering, photophobia ↑ Congestion
↑ signs of inflammation
Referred to us for opinion and management
New Delhi, India

6. Post-operative # 13 OS OD
New Delhi, India
BCVA: CF 50cm
BCVA: CF 50cm

7. What are we dealing with?
Unresolved infection?
Why recurrence after good initial response?
Atypical infection
Immunocompromised patient…HIV?
Blood reports WNL
Collagen vascular disease?
RA factor, ANA, CRP, ESR: WNL
Clinically: WNL
Blepharokeratoconjunctivitis?
HSV Keratitis?
No history of recurrence
?Bilateral and simultaneous- very rare
New Delhi, India

8. Review DLK? OS OD Prednisolone acetate eye drops tid, added Stromal
Edema
Prednisolone acetate eye drops tid, added
New Delhi, India

9. Post-operative # 20 Symptomatic relief
↓ Congestion, Infiltrate, Stromal edema
Topical steroids frequency increased
New Delhi, India

10. Post-operative # 30 OD: 20/20p (-1D cyl x 20) OS: 20/100
( 20/20p with RGP Contacts)
New Delhi, India

11. B/L DLK, Post-LASIK Infective KeratitisOD OS
New Delhi, India

12. Discussion
Diffuse lamellar keratitis (DLK) is an inflammatory infiltrate occurring at the keratectomy interface after laser in situ keratomileusis (LASIK)
Endotoxins released from bacteria and inflammatory bi-products may be the causative agents for producing DLK in our case
While the infection was controlled by the Antibiotic treatment, endotoxins released from the bacteria continued to produce an inflammatory reaction
Holland SP, Mathias RG, et.al. Diffuse lamellar keratitis related to endotoxins released from sterlizer reservoir biofilms. Ophthalmology Jul;107(7):
Peters NT, Iskander NG,et.al. Diffuse lamellar keratitis: isolation of endotoxin and demonstartion of the inflammatory potential in a rabbit laser in situ keratomileusis model. J Cataract Refract Surg Jun;27(6):917-23
New Delhi, India