Infectious keratitis after transepithelial photorefractive k
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Transepithelial photorefractive keratectomy uses a Smart Pulse Technology to ameliorate corneal stromal irregularities following ablation. A smooth stromal bed facilitates re-epithelialization which contributes to a reduction in postoperative inflammation. In addition, it can also accelerate visual rehabilitation and reduce postoperative pain. As compared to alcohol-assisted PRK, tPRK reduces the total operative time by 35% with increased comfort for patient. Infectious keratitis after refractive surgery is a rare but serious complication. The reported risk of keratitis is between 0.01 and 0.1% after LASIK and, between 0.01 and 0.8% after photorefraction keratectomy (PRK). The overall incidence of microbial keratitis after PRK (0.0013%) is less as compared to LASIK (0.0046%). Transepithelial photorefractive keratectomy (tPRK) is a technique that can possibly reduce the risk of infectious keratitis by promoting faster re-epithelialization. We present a case of infectious keratitis after uneventful tPRK.

A 22-year-old man without any past ocular or systemic history was evaluated for laser refractive surgery. The preoperative refraction was –4.0/–1.75 × 180 in the right eye and –3.25/–2.75 × 180 in the left eye with corrected distance visual acuity (CDVA) of 20/20 in both eyes. There were no anterior or posterior segment abnormalities in either eye. In October 2019, the patient underwent an uneventful bilateral tPRK procedure using the Schwind Amaris 750S Excimer laser. Postoperatively, the patient was prescribed 0.5% levofloxacin eye drops four times per day, and 0.1% fluorometholone eye drops four times per day.

On day 5 postoperatively, complete epithelial healing was noted in both eyes after removing the bandage contact lens. At one week postoperatively, the patient experienced mild pain in his left eye. The pain worsened in 24 hours and the patient sought medical advice on day 8 after surgery. His uncorrected visual acuity was 20/25 in the right eye and 20/63 in the left eye. Slit-lamp examination revealed conjunctival hyperemia and a 2 mm × 5 mm area of corneal infiltration with an overlying epithelial defect. AS-OCT showed a linear zone of hyperreflectivity in the corneal stroma. In vivo confocal microscopy revealed a large number of Langerhans cells in the Bowman layer. Subsequently, corneal scrapings were obtained from the left eye. Hourly levofloxacin 0.5% eye drops and once-daily gatifloxacin 0.3% eye gel was prescribed. Microbiological culture and sensitivity reports were available 5 days later (13 days postoperatively) showing Bordetella bronchiseptica. The organism was sensitive to levofloxacin and tobramycin and lactam antibiotics except for ceftriaxone and aztreonam.

At the end of the first week, the UDVA improved to 20/25. Slit-lamp examination showed mild corneal edema over the area of corneal infiltrate. In addition, conjunctival hyperemia had reduced. Levofloxacin eye drops were reduced to four times a day. The corneal infiltrates resolved completely over the next 5 weeks leaving a residual anterior corneal stromal scar. The UDVA was 20/20 with an auto-refraction of -0.75 × 155 in the left eye.