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Corneal Inlay Implantation Complicated by Infectious Keratitis

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Corneal Inlay Implantation Complicated by Infectious Keratitis Downloaded from http://bjo.bmj.com/ on February 18, 2016 - Published by group.bmj.com Clinical science Corneal inlay implantation complicated by infectious keratitis Emma S Duignan,1 Stephen Farrell,1 Maxwell P Treacy,2 Tim Fulcher,2 Paul O’Brien,1 William Power,1 Conor C Murphy1,3 1Royal Victoria Eye and Ear ABSTRACT type of modern inlay, which was not encountered Hospital, Dublin, Ireland Background/aims To report five cases of infectious in this series, has a similar refractive index to the 2Mater Misericordiae University keratitis following corneal inlay implantation for the cornea and alters its refraction by changing the Hospital, Dublin, Ireland 2 3Department of surgical correction of presbyopia. anterior corneal curvature. The KAMRA inlay is Ophthalmology, Royal College Methods This was a retrospective, observational case an opaque, ring-shaped structure, 3.8 mm in diam- of Surgeons in Ireland, Dublin, series. Five eyes of five patients were identified eter, with a 1.6 mm central aperture that increases Ireland consecutively in two emergency departments during a the depth of focus by pinhole optics. It is com- fl 3 Correspondence to 1-year period, from November 2013 to November 2014. posed of polyvinylidene uoride and carbon. The Dr Emma S Duignan, Royal Patients’ demographics, clinical features, treatment and Flexivue Microlens inlay is a transparent circular Victoria Eye and Ear Hospital, outcomes are described. inlay, 3 mm in diameter, with a peripheral annular Adelaide Road, Dublin 2, Results There were four female patients and one male, refractive element and a central plano surface; it Ireland; [email protected] aged 52–64 years. Three patients had the KAMRA inlay acts as a bifocal optical inlay. It is made from a bio- 4 Received 10 February 2015 (AcuFocus) and two had the Flexivue Microlens inlay compatible, hydrophilic acrylic material. Revised 10 May 2015 (Presbia Coöperatief U.A.) inserted for the treatment of The efficacy of the KAMRA and Flexivue Accepted 6 June 2015 presbyopia and they presented from 6 days to 4 months Microlens inlays has been demonstrated in several Published Online First postoperatively. Presenting uncorrected vision ranged studies and they have both obtained the mark of 29 June 2015 from 6/38 to counting fingers. One patient’s corneal Conformité Européenne, allowing them to be used – scrapings were positive for a putatively causative commercially in Europe.3 19 The market for these organism, Corynebacterium pseudodiphtheriticum, and inlays is significant; to date there have been more all patients responded to broad-spectrum fortified topical than 20 000 KAMRA and 500 Flexivue Microlens antibiotics. All patients lost vision with final uncorrected inlays implanted worldwide.220They are currently visual acuity ranging from 6/12 to 6/60 and best- undergoing review for the US Food and Drug corrected vision ranging from 6/7.5 to 6/12. Two Administration (FDA) approval. patients’ corneal inlays were explanted and three A small number of KAMRA and Flexivue remained in situ at last follow-up. Microlens inlay complications including glare, Conclusions Infectious keratitis can occur at an early haloes, compromised distance and night-vision, epi- or late stage following corneal inlay implantation. Final thelial ingrowth and decentration of the inlay have visual acuity can be limited by stromal scarring; in the been reported.21314However, no case of infec- cases where the infiltrate was small and off the visual tious keratitis has been described in any type of axis at the time of presentation, the final visual acuity corneal inlay for presbyopia. The aim of this report was better than those patients who presented with is to present a case series of the first five patients larger lesions affecting the visual axis. Though infection with infectious keratitis secondary to corneal inlay may necessitate removal of the inlay, early positive implantation. They were referred as emergencies to response to treatment may enable the inlay to be two university teaching hospitals in Dublin, left in situ. Ireland, over a 1-year period. CASE 1 INTRODUCTION A 64-year-old woman was referred to the emer- Many advances in the surgical correction of presby- gency department 6 days following left Flexivue opia have been made in recent years, including the Microlens corneal inlay implantation. The inlay refinement of corneal inlays. These are monocular was placed through an intrastromal tunnel created devices placed in the corneal stroma that improve using a femtosecond laser. The patient gave a 3-day near visual acuity by a variety of methods, while history of left eye pain and photophobia and had maintaining distance vision. The insertion of been prescribed topical ofloxacin (0.3%) and chlor- corneal inlays to alter ocular optics was first amphenicol (0.5%) hourly 3 days previously. described by Barraquer in 1949.1 More recently, Uncorrected distance visual acuity (UCDVA) in the advancements in biocompatible materials have left eye was 6/38. There was a small, dense corneal helped improve corneal inlays and popularise their infiltrate measuring 0.2 mm at the temporal edge of use. There are three types of modern corneal inlay; the corneal inlay, within the tunnel, with surround- first, there is the small-aperture inlay, an example ing corneal oedema. Due to its depth and lack of of which is the KAMRA corneal inlay (AcuFocus, overlying epithelial defect, the infiltrate was not To cite: Duignan ES, Irvine, California, USA). Second, there is the amenable to corneal scraping and it was decided to Farrell S, Treacy MP, et al. refractive optic inlay, an example of which is the initially observe the patient and continue with Br J Ophthalmol Flexivue Microlens inlay (Presbia Coöperatief U.A., hourly topical ofloxacin (0.3%). However, 24 h – 2016;100:269 273. Amsterdam, the Netherlands) and finally, the third later, the infiltrate had increased in size to 1.5 mm Duignan ES, et al. Br J Ophthalmol 2016;100:269–273. doi:10.1136/bjophthalmol-2015-306641 269 Downloaded from http://bjo.bmj.com/ on February 18, 2016 - Published by group.bmj.com Clinical science and the patient was admitted and treated with hourly topical CASE 3 vancomycin (0.5%) and ceftazidime (1%) (figure 1). The infil- A 52-year-old woman attended the emergency department three trate reduced in size and density over the following week and and a half weeks following left Flexivue Microlens corneal inlay the implant was not removed. Antibiotics were slowly tapered implantation and LASIK. The inlay was placed in a over 3 weeks and then changed to topical chloramphenicol femtosecond-created pocket with LASIK surgery undertaken (0.5%) four times a day for a further 2 weeks. At 3-month superficial to this. Her operating surgeon had routinely pre- follow-up, the inlay remained in situ and there was mild residual scribed prednisolone acetate (1%) and ofloxacin (0.3%), both scarring in the temporal corneal stroma. Notably, no topical four times daily, following surgery. The patient presented dir- steroids were used in the treatment of this patient after her ectly to the emergency department, with a 2-day history of a routine postoperative topical steroid, prednisolone sodium phos- red, painful left eye, and her BCVA was counting fingers. There phate (1%), was stopped on the third day after surgery when was a temporal corneal infiltrate with a large overlying epithelial the keratitis became evident. Her UCDVA in the left eye defect, encompassing the infero-temporal quarter of the flap. improved to 6/12, with a best-corrected visual acuity (BCVA) of She was treated with topical vancomycin (0.5%) and ceftazidime 6/9, and uncorrected vision in the contralateral eye was 6/6. (1%) hourly for 4 days and then changed to moxifloxacin (0.5%) four times a day. Corynebacterium pseudodiphtheriti- cum, sensitive to moxifloxacin and chloramphenicol, was cul- tured from scrapings taken at the time of presentation. The CASE 2 infiltrate resolved over the next 2 weeks but inferior corneal flap A 63-year-old man was referred to the emergency department necrosis and auto-amputation occurred inferiorly. The inlay 7 days after KAMRA corneal inlay implantation through a remained in situ. Seventeen days after presentation, prednisolone femtosecond-created stromal tunnel, with simultaneous photore- sodium phosphate (0.5%) was introduced four times a day. At fractive keratectomy. Eleven months previously, he underwent 3-month follow-up, the corneal epithelium had healed and the bilateral laser-assisted in situ keratomileusis (LASIK) and left inflammation had resolved with residual stromal scarring. At that KAMRA corneal inlay implantation. The patient was dissatisfied visit, UCDVA in the affected eye was 6/60, with BCVA of 6/12, with his reading vision, and the KAMRA was removed 6 months and the contralateral uncorrected visual acuity remained 6/6. following the original procedure. He then opted to have the inlay re-implanted 5 months later. Five days after this procedure, he attended the operating surgeon’s practice for removal of a CASE 4 bandage contact lens and was asymptomatic at that time. The A 54-year-old woman was referred to the emergency depart- following day, he presented with decreased visual acuity and ment 3 months following bilateral LASIK combined with left photosensitivity and re-presented to the operating surgeon who KAMRA corneal inlay insertion. She gave a 1-week history of a removed the implant, started two-hourly ofloxacin (0.3%) and red, photophobic eye on a background of dry eye since the referred the patient to our emergency department. The referral surgery and she had been treated by the operating surgeon with letter described a small, deep infiltrate overlying the inlay prior topical ofloxacin (0.3%) and chloramphenicol (0.5%) every 2 h to explantation. When he attended the emergency department, for 48 h preceding referral with no improvement in symptoms.
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