1. Andrea N. Lora M.D., Sonia H. Yoo MD.,William Culbertson MD., Carol L. Karp MD., Richard M. Awdeh MD. Bascom Palmer Eye Institute University of Miami Miller School of Medicine ASCRS Conference April 2010 Andrea Lora, MD- No Financial Disclosures Sonia Yoo, MD- Alcon Labs (S), AMO (S), Allergan (G), Ista (C), Inspire (C), Carl Zeiss Meditec (S), (G), Haag Streit (C) William Culbertson, MD- AMO, Zeiss, Alcon, Optimedica Carol Karp, MD- No Financial Disclosures Richard Awdeh, MD- Alcon (G), Allergan (S), Inspire Pharmaceuticals (C), (S), ISTA Pharmaceuticals (S)

2. Introduction Laser in situ keratomileusis (LASIK) has been shown to be an effective treatment for myopia, hyperopia, and astigmatism. Peripheral inflammatory keratitis is typically a sterile inflammatory response at or near the limbus that is usually mediated by an immune response. We report an unusual case series of peripheral inflammatory keratitis (PIK) in the early postoperative period following laser in situ keratomileusis (LASIK) with flap creation using the IntraLase femtosecond laser.

3. Case 1 49 year old male POD # 7 s/p monovision LASIK OU, with the IntraLase femtosecond laser, was referred for evaluation of a possible corneal infection in the left eye. Complains of photophobia, foreign body sensation, pain 8/10, and blurry vision left eye. Past Medical History- Acne rosacea and DMII Medications- Artificial tears PRN Doxycycline and facial steroid cream BCVA OD 20/20, OS 20/30 Left eye- Stromal haze involving the interface & non- ablated peripheral anterior stroma

4. Case 1- Clinical Photographs POD # 7- Cultures sent Fortified Vancomycin q2 hrs OS Pred Forte q 2 hrs OS Doxycycline 100 mg PO BID POD # 8- Cultures negative  Vancomycin q 6 hrs Pred Forte q 2 hrs & Doxy BID BCVA OS 20/25 POD # 15- Pain & VA improved Area of infiltrate improved D/C Vancomycin;  Pred Forte Continue Doxycycline OS

5. Case 2 33 year old female POD # 3 s/p LASIK OU, with the IntraLase femtosecond laser, complains of pain 8/10, blurry vision, and foreign body sensation right eye. Past Medical History- HSV I & II with no ocular involvement and ocular rosacea Medications- Vigamox & Pred Forte q 4 hours Doxycycline 100 mg PO BID BCVA OU 20/20 Right eye- Peripheral stromal infiltrate, mostly involving the peripheral, non-ablated anterior stroma, + faint fluorescein staining.

6. Case 2- Clinical Photographs POD # 5- Cultures sent Fortified Vanc & Zymar q1hr OD Pred Forte q 1 hr OD Doxycycline 100 mg PO BID POD # 7- Cultures negative  Vancomycin & Zymar q 8 hrs Pred Forte q 1 hr Pain improving POM # 3- BCVA OU 20/20 Mild persistent stromal haze Off all medications Asymptomatic OD

7. Case 3 A 39-year-old male POD # 2 s/p LASIK OU, with the IntraLase femtosecond laser, complains of photophobia, redness, and irritation of the left eye. Past Medical History- Controlled diabetes mellitus and acne rosacea. Medications- Pred Forte and Zymar QID OU BCVA OU 20/20 Right eye had a peripheral stromal infiltrate along the flap margin, trace staining with fluorescein Left eye had a stromal infiltrate of both the ablated corneal stroma and the adjacent peripheral, non-ablated anterior stroma

8. Case 3- Clinical Photographs POD # 2- Cultures sent Fortified Vancomycin q 2 hrs OU Zymar QID OU Pred Forte QID OU POD # 3- Cultures negative  Vancomycin QID  Pred Forte q 2 hrs Zymar QID POM # 4- BCVA OD 20/70 OS 20/25 Stromal haze improved Underwent uneventful retreatment right eye, final BCVA OD 20/20 OD OS After treatment

9. Discussion Peripheral inflammatory keratitis (PIK) is often associated with chronic blepharitis & MGD Limbal vessels allow rapid recruitment of inflammatory cells from the vasculature Epithelial injury with LASIK flap formation triggers cytokine release (IL-1  and TNF-  ) 1-4 Triggers release of chemokines (monocyte chemotactic and activating factor (MCAF), granulocyte colony- stimulating factor(G-CSF), IL-4, etc) Chemokines attract inflammatory cells into the cornea from the limbal blood vessels and the tear film.

10. Discussion Blepharitis predisposes patients to increased cellular migration to the peripheral cornea by chemokines triggered by LASIK trauma. Inflammatory debris accumulates at the incision site Important to differentiate from infectious keratitis Treatment includes Steroids Lid hygiene Doxycycline

11. Conclusion PIK after LASIK is uncommon and can be associated with favorable outcomes with aggressive management and careful vigilance for infectious causes. Rosacea, chronic blepheritis, and meibomian gland dysfunction may be markers of patients who are at a greater risk for PIK. Additionally, the use of a femtosecond laser for flap creation may predispose these patients to PIK. Preoperative screening for these risk factors with preoperative prophylactic treatment may decrease the incidence of PIK.

12. References 1. Ambrósio, Renato Jr, MD; Periman, Laura M. MD; Netto, Marcelo V. MD; Wilson, Steven E. MD. Bilateral Marginal Sterile Infiltrates and Diffuse Lamellar Keratitis After Laser in situ Keratomileusis. Journal of Refr Surgery.Volume 19(2), March/April 2003, p 154–158 2. Netto MV. Mohan RR. Medeiros FW. Dupps WJ Jr. Sinha S. Krueger RR. Stapleton WM. Rayborn M. Suto C. Wilson SE. Femtosecond laser and microkeratome corneal flaps: comparison of stromal wound healing and inflammation. Journal of Refractive Surgery. 23(7):667-76, 2007 Sep. 3. Lahners WJ. Hardten DR. Lindstrom RL. Peripheral keratitis following laser in situ keratomileusis. Journal of Refractive Surgery. 19(6):671-5, 2003 Nov-Dec. 4. Kaufman SC. Maitchouk DY. Chiou AG. Beuerman RW. Interface inflammation after laser in situ keratomileusis. Sands of the Sahara syndrome. Journal of Cataract & Refractive Surgery. 24(12):1589-93, 1998 Dec.