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Photorefractive Keratectomy with Mitomycin-C for the Combined Treatment of Myopia and Subepithelial Infiltrates After Epidemic Keratoconjunctivitis

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Photorefractive Keratectomy with Mitomycin-C for the Combined Treatment of Myopia and Subepithelial Infiltrates After Epidemic Keratoconjunctivitis ARTICLE Photorefractive keratectomy with mitomycin-C for the combined treatment of myopia and subepithelial infiltrates after epidemic keratoconjunctivitis David Alevi, MD, Allon Barsam, MA, FRCOphth, Jonathan Kruh, MD, Jessica Prince, MD, Henry D. Perry, MD, Eric D. Donnenfeld, MD PURPOSE: To report the use of photorefractive keratectomy (PRK) with mitomycin-C (MMC) to treat concomitant myopia and visually significant infiltrates associated with epidemic keratoconjunctivitis (EKC). SETTING: Ophthalmic Consultants of Long Island, Nassau University, Long Island, New York, USA. DESIGN: Interventional case series. METHODS: Consecutive patients with myopia and recalcitrant subepithelial infiltrates after EKC were treated with custom wavefront PRK (Visx S4 IR) and MMC with a target of emmetropia in all cases. RESULTS: The study evaluated 6 eyes of 3 patients. One year after treatment, all eyes attained an uncorrected distance visual acuity of 20/20 or better. There was no recurrence of infiltrates within the ablation zone in any eye. CONCLUSION: The use of topical MMC in conjunction with PRK to treat subepithelial infiltrates due to EKC provided good visual and refractive results. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2012; 38:1028–1033 Q 2012 ASCRS and ESCRS Excimer laser photoablation in the form of photother- comfort. Using a laser instead of conventional exci- apeutic keratectomy (PTK) has been used since the late sional corneal surgery may allow more controlled re- 1980s to manage and treat anterior corneal pathology.1 moval of pathological tissue by minimizing adjacent The 193 nm argon–fluoride laser photochemically tissue damage. breaks intermolecular bonds, expelling corneal tissue Phototherapeutic keratectomy is effective in superfi- in a controlled manner without thermal damage. cial corneal pathology that is present in Bowman Excimer laser photoablation can remove corneal membrane or in the anterior cornea stroma. Removing pathology, improving visual acuity and patient or reducing this corneal pathology allows a smoother and clearer cornea.2 Ablating and flattening the more central areas of the cornea with use of PTK often re- Submitted: September 13, 2011. sults in a hyperopic change in refractive error that is di- Final revision submitted: December 13, 2011. 3 Accepted: December 16, 2011. rectly related to the depth of the ablation. This hyperopic shift is unpredictable and may diminish From Ophthalmic Consultants of Long Island, Rockville Centre, over time.3 Haze, likely secondary to deposition of New York, USA. new irregular collagen fibers or from light scattering Corresponding author: Allon Barsam, MA, FRCOphth, Consultant by activated keratocytes in the wound, is another com- 4 Ophthalmic Surgeon, Luton and Dunstable University Hospital plication of PTK. Also, variations in the eye’s rate and NHS Foundation Trust, Lewsey Road, Luton LU4 0DZ, United ability to reepithelialize contribute to further compli- Kingdom. E-mail: [email protected]. cations, including irregular astigmatism and scarring. 1028 Q 2012 ASCRS and ESCRS 0886-3350/$ - see front matter Published by Elsevier Inc. doi:10.1016/j.jcrs.2011.12.039 PRK FOR MYOPIA AND RECALCITRANT ADENOVIRAL KERATITIS 1029 Several case reports document elimination of corneal been reports of myopic photorefractive keratectomy opacities followed by a recurrence in the pathology.5 (PRK) without MMC used with partial success to per- Finally, in certain cases in which recurrence does oc- manently remove the infiltrates in patients with sube- cur, multiple treatments of PTK are necessary to re- pithelial infiltrates.18 To our knowledge, the present duce corneal pathology and improve patient series is the first description of the use of PRK with satisfaction. Despite these potential complications, MMC to treat myopia and visually significant infil- PTK has been used with much success to reduce and trates associated with EKC. eliminate corneal pathology, delaying and avoiding more invasive methods including lamellar and pene- PATIENTS AND METHODS 6,7 trating keratoplasty. Patients with myopia and recalcitrant subepithelial infil- Epidemic keratoconjunctivitis (EKC) is caused by trates after EKC were treated with custom wavefront PRK multiple adenovirus strains and is associated with (Visx S4 IR, Abbott Medical Optics); the target was emmetro- infection and inflammation of the cornea and conjunc- pia in all cases. Approximately 10 to 15 subepithelial infil- tiva. Adenovirus is a nonenveloped double-stranded trates were observed in each patient. After informed consent and extensive discussion, each patient elected to DNA virus. The virus is extremely stable, being have PRK to treat the myopia and to remove the corneal resistant to most solvents and detergents. The more opacities. virulent serotypes, such as serotypes 8 or 19, were Manual epithelial debridement was performed followed found to be viable for up to 4 to 5 weeks on inert ma- by excimer ablation. After PRK with the laser, MMC 0.02% terial.8,9 Ophthalmology offices are prone to epidemics was applied for 30 seconds before the cornea was fully irri- – gated with a cooled balanced salt solution. Each patient due to contamination of instruments or hand eye had a bandage contact lens placed and was treated with ga- contact by ocular secretions from the infected pa- tifloxacin 0.3% 4 times a day for 6 days; ketorolac 0.5% 4 tient.10 In addition, EKC has been found in hospital times a day for 2 days; and prednisolone acetate 1.0% 4 times outbreaks, public swimming pools, and upper respira- a day for 1 week, 3 times a day for 1 week, 2 times a day for 1 tory tract infections.11 week, and every day for 1 week. The bandage contact lens was removed 3 to 5 days after surgery. Patients were then ex- Epidemic keratoconjunctivitis is characterized amined 1 week and 1, 3, 6, and 12 months after treatment. by follicular conjunctivitis, papillary hypertrophy, conjunctival hemorrhage, lid edema, and chemosis. RESULTS Preauricular and submandibular adenopathy may assist in the diagnosis. In severe cases, membranes or Six eyes of 3 patients were treated. pseudomembranes may develop on the tarsal conjunc- Case 1 tiva, which may lead to conjunctival fibrosis and symblepharon formation.12 A 27-year-old myopic male ophthalmology resident The corneal findings of EKC begin with a diffuse with a refraction of À2.50 À0.50 Â 110 in the right eye epithelial keratitis that stains with fluorescein and and À2.75 in the left eye developed EKC in both eyes may coalesce into focal epithelial lesions approxi- with visually significant subepithelial infiltrates. He mately 1 week after infection. Subepithelial corneal had worn a soft contact lens for 7 years and was devel- infiltrates of 1.0 to 2.0 mm in diameter develop within oping increased contact lens wear intolerance. Seven the second or third week after conjunctival symptoms months before evaluation, the patient had a severe begin and diffuse epithelial keratitis is seen.13 These case of EKC that left him with multiple central bilateral infiltrates generally develop in the center of the cornea; subepithelial infiltrates. The patient was treated with however, they may cover the entire corneal surface. a tapering dose of prednisolone acetate 1% starting Due to the corneal infiltrates, permanent glare or at 4 times a day for 3 months without resolution of photophobia may develop; decreased visual acuity is the infiltrates. After an additional 4 months without also likely to occur as a result of irregular astigmatism corticosteroids, the patient presented for evaluation and corneal opacities occluding the visual axis.14 Some with continued central subepithelial infiltrates and of these visual effects may (in part) resolve spontane- a corrected distance visual acuity (CDVA) of 20/20 ously over several years and can be treated with in both eyes; however, he reported glare and halo low-dose topical corticosteroid agents.15 Corticoste- that had not been present before the development of roid therapy may require months of treatment and the infiltrates 40 mm beneath the epithelium. The pa- once discontinued, the infiltrates often reoccur. In tient had 8 to 10 infiltrates, mostly clustered around addition, long-term corticosteroid use is associated the central 6.0 mm of each cornea, with a few extend- with cataract formation and glaucoma. ing to the peripheral 9.0 mm point. Successful removal of adenoviral EKC corneal Wavefront analysis was obtainable in both eyes and opacities using PTK and mitomycin-C (MMC)14 or matched the patient’s refraction. The decision was PTK alone16,17 has been reported. There have also made to enlarge the custom wavefront ablation zone J CATARACT REFRACT SURG - VOL 38, JUNE 2012 1030 PRK FOR MYOPIA AND RECALCITRANT ADENOVIRAL KERATITIS to 8.8 mm, which increased the depth of the ablation to 68 mm in the right eye and 77 mm in the left eye. By en- larging the ablation zone and depth of ablation, the in- filtrates in the midperiphery of the cornea would also be treated. This decision was made to prevent peripheral infiltrates from causing symptoms under mesopic conditions, in which the pupil may become larger. One year after PRK, the patient had 20/15 uncor- rected distance visual acuity (UDVA) in both eyes, a refraction of plano in both eyes, no glare or halo, and clear corneas with complete resolution of all infiltrates. Case 2 Figure 1. Case 3. Subepithelial infiltrate after EKC in the visual axis A 24-year-old myopic woman with a refraction before PRK. of À4.50 À0.25 Â 90 in the right eye and À4.75 À0.50 Â 95 in the left eye developed EKC with visually signif- Photorefreative keratectomy was performed with icant infiltrates 40 mm beneath the epithelium. The a central ablation depth of 109 mm in both eyes; the ab- infiltrates developed 2 weeks after the acute infection lation zone was 8.0 mm.
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