Early Post-LASIK Flap Amputation in the Treatment of Aggressive Fungal Keratitis in Association With Construction of the Refractive Suite John Au MD - no financial disclosures William Dupps Jr MD, PhD – Avedro Consultant Karolinne Rocha MD, PhD - No financial disclosures Ronald Krueger MD, MSE - Alcon, Clarity Medical Systems and LensAR Consultant

Post Laser Vision Correction Infectious Keratitis Infectious keratitis following laser vision correction as reported by the 2008 American Society of Cataract and Refractive Surgery (ASCRS) survey was 19 of 20,941 eyes or 0.09%. The most commonly cultured organism in this series was methicillin-resistant Staphylococcus aureus (MRSA). One case definitively resulted from a fungal infection Solomon R, Donnenfeld E, Holland E, Yoo S, Daya S, Guel J, Mah F, Scoper S, Kim T. Microbial keratitis trends following refractive surgery: Results of the ASCRS Infectious keratitis survey and comparisons with prior ASCRS surveys of infectious keratitis following keratorefractive procedures. J Cataract Refract Surg 2011;37:1343-1350

Case Presentation 24-year old female -1.25D sphere in both eyes Her exam, pachymetry and corneal tomography were normal Her history included prior right V1 dermatome herpes zoster without ophthalmic involvement Treated with wavefront-optimized femtosecond-LASIK on the WaveLight FS-200 and Allegretto Eye-Q laser platform (Alcon, Fort Worth, TX, USA) She had an uneventful procedure and was started on ciprofloxacin 0.3% (Ciloxan®) and dexamethasone 0.1% drops four times daily each. On post-op day one, UDVA was 20/15 in each eye. Her exam was unremarkable

Case Presentation During the week prior to this case, a new wall was built within the refractive suite waiting area, which was not directly continuous with the laser suite However, the day prior to the case, construction workers had removed some ceiling tiles in the laser suite in preparation for the upcoming construction and removal of an internal wall

Postoperative Day 2 Patient presents with pain and decreased vision UDVA OD 20/50

Clinical Plan Clinical suspicion for fungal keratitis was high The flap was lifted and a gelatinous branching infiltrate was seen, extending superficially into the flap and posteriorly into the stromal bed Cultures were obtained and the interface was irrigated extensively Because the infiltrate penetrated into the flap stroma, and due to the rapid progression (< 24 hours) of a presumed of fungal keratitis, a decision was made to amputate the flap Hourly topical fortified tobramycin (13.5mg/ml), vancomycin (25mg/ml) and voriconazole 1% were begun immediately Although the infiltrate was clearly in the flap interface and not involving the overlying epithelium, a 10 day course of of oral valacyclovir 1 gram TID was given due to the patient’s history of right V1 herpes zoster Prednisolone was discontinued

Postoperative Course Post-flap amputation Day 4 UDVA 20/100- Infiltrate was improving and the epithelium was approximately 85% healed over the stromal bed

Postoperative Course Fungal cultures grew Aspergillus flavus, all other cultures were negative Pathology of the flap showed fungal elements (black arrows) PAS stain

Postoperative Course Post-flap amputation day 11 UDVA 20/40; MRx -0.50 SPH with BCVA 20/20- Post-flap amputation month 5 UDVA 20/15, but having double image Epithelial thickness is variable (40-59 um) due to irregular stromal surface Post-flap amputation day 11

Post-flap amputation month 8 VisX S4 PTK OD 6.5 mm OZ, 0.2 TZ 71 um depth H-PRK OD, +1.0 D Post-flap amputation month 8 planned PTK/PRK ENH 1 Month Post PTK UCVA 20/40 MR -1.00 (20/25+) …still healing! Pre PTK This information is confidential to Reichert, Inc.

Factors That Allowed For Good Visual Outcome Post Flap Amputation Penetration of the antibiotics and antifungal medication to the infiltrate were optimized The patient had a low myopic correction with robust residual stromal bed thickness for possible future refractive treatment The flap was created with a femtosecond laser, and, therefore, had a uniform planar shape, allowing for minimal refractive change when compared to a meniscus shaped microkeratome flap, when amputated

Conclusion Although we cannot not definitively link this infection to the preceding construction work, it is reasonable to conclude one should avoid performing Laser Vision Correction following recent construction work in the refractive suite