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Medical Treatment of Operative Corneal Perforation Caused By CASE REPORTS AND SMALL CASE SERIES and clinical course of a patient with the stromal bed was thin; in the left Medical Treatment a LASIK-induced corneal perfora- eye, the corneal flap was very edema- of Operative Corneal tion that affected the final visual acu- tous and a space was visible between Perforation Caused ity. We believe that this report on the the corneal flap and the stromal bed treatment and recovery of the cor- (Figure 1, left). The anterior cham- by Laser In Situ neal perforation will be valuable in- ber was very shallow, and aqueous Keratomileusis formation for refractive surgeons. humor was observed to leak onto the ocular surface with blinking (Figure Laser in situ keratomileusis (LASIK) Report of a Case. A 33-year-old man 1, right). A round, 0.25-mm diam- is an effective procedure to treat a was referred to us with a complaint eter perforation site was observed in wide range of myopia.1 The advan- of decreased visual acuity in the left the center of the stromal bed by slit- tages of LASIK over photorefrac- eye after bilateral simultaneous lamp examination. tive keratectomy (PRK) are rapid vi- LASIK performed 3 days previ- We treated the corneal perfo- sual recovery, lower risk of corneal ously at a different facility. A cor- ration by applying a therapeutic soft haze, greater regression of myopia, neal perforation was noticed in the contact lens with topical antibiot- and less postoperative pain.1-3 How- left eye during LASIK laser abla- ics, oral carbonic anhydrase inhibi- ever, LASIK requires more skillful tion in this eye. The surgeon stated tors, and eye patching. After 1 week surgical technique and more instru- that, before surgery, the patient had of treatment (10th day postopera- mentation than PRK. Thus, inaccu- myopia in both eyes (−9.5 diopters tively), the aqueous humor leakage rate and inadequate procedures dur- [D] −5.0 D 3 65° OD and −9.0 D had ceased, the anterior chamber ing LASIK have a higher potential of −5.5 D 3 110° OS) and his best- depth was normal, and the corneal complications. corrected visual acuity was 10/20 flap was closer to the stromal bed. The complications of LASIK OU. The corneal flap was intended However, the flap remained edema- include severing of the corneal flap, to be 160 µm thick, otherwise, pre- tous. Topical medications were dis- epithelial ingrowth, flap wrinkling, cise information on the intended ab- continued but the therapeutic con- corneal astigmatism, and corneal in- lation depth could not be obtained tact lens and eye patching were fection.2-4 To our knowledge, only from the surgeon. However, the sur- continued for 3 more weeks. On the one case report by Pallikaris and geon found that the remaining stro- 32nd postoperative day, the edema Siganos5 has been published of cor- mal bed was thin due to excessive and diffuse opacification of the neal perforation following LASIK; it thickness of the corneal flap. corneal flap suddenly resolved with was a survey of their early 43 pa- Our initial examination showed no space observed between the flap tients. Unfortunately, the treat- best-corrected visual acuity of 20/60 and the stromal bed although one ment and the clinical course of the OD and 20/500 OS. Slitlamp exami- had been present on the previous corneal perforation was not re- nation of the right eye revealed that day. The patient’s best spectacle- ported. We describe the treatment the corneal flap was missing and that corrected visual acuity was still de- Figure 1. Left eye. Three days after bilateral laser in situ keratomileusis. Left, The corneal flap is edematous and a space is evident between the flap and the stromal bed (arrow). The anterior chamber is very shallow. Right, Following a blink, aqueous humor is visible on the ocular surface (arrows). ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1422 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 tic contact lens than to suture the cor- neal flap, because the suturing method has a high possibility of in- ducing new irregular astigmatism. This case suggests that eye surgeons should treat corneal perforations by conservative medical therapy, wait- ing at least 1 month before determin- ing the best course of possible sub- sequent surgical therapy. Yuichi Hori, MD Hitoshi Wantanabe, MD Naoyuki Maeda, MD Yoshitsugu Inoue, MD Yoshikazu Shimomura, MD Yasuo Tano, MD Suita, Japan This investigation was supported in Figure 2. Left eye. Thirty-two days after laser in situ keratomileusis and following treatment as described in the “Report of a Case” section. The cornea is generally clear and anterior chamber depth is normal, part by grant-in-aid 09671800 for Sci- but areas of corneal opacification and irregular corneal astigmatism remained. Neovascularization is entific Research from the Japanese evident between the corneal flap and the stromal bed (arrows) and epithelial ingrowth was localized Ministry of Education, Science, and at the temporal edge of the flap (arrowheads). Culture, Tokyo (Dr Watanabe) and by the Osaka Eye Bank Association Fund, Osaka, Japan (Drs Watanabe, creased at 30/50 OS due to residual perforation with photoablation in Maeda, Inoue, and Shimomura). areas of corneal opacification and ir- this case. Corresponding author: Hitoshi regular astigmatism. In addition, The most interesting observa- Watanabe, MD, Department of Oph- neovascularization was noted be- tion was that abrupt clearing of the thalmology, Osaka University Medi- tween the corneal flap and the stro- corneal edema and the recovery of cal School, Room E7, 2-2 Yamad- mal bed and epithelial ingrowth was transparency occurred approxi- aoka, 565-0871 Suita, Japan. present focally at the temporal edge mately 1 month after the injury by of the flap (Figure 2). LASIK. This phenomenon suggests 1. Pallikaris IG, Papatzanaki ME, Siganos DS, Tsi- that wound closure and functional limbaris MK. A corneal flap technique for laser in situ keratomileusis: human studies. Arch Oph- Comment. No standard treatment recovery of the endothelium leads thalmol. 1991;109:1699-1702. has been established for corneal per- to a prompt normalization of the 2. Marinho A, Pinto MC, Pinto R, Vaz F, Neves MC. foration with leakage of aqueous hu- corneal thickness. The site of per- LASIK for high myopia: one year experience. Ophthalmic Surg Lasers. 1996;27(suppl 5):S517- mor onto the ocular surface after foration in the LASIK surgery was S520. LASIK. Because this is the first case 0.25 mm in diameter and, there- 3. Fiander DC, Tayfour F. Excimer laser in situ ker- of corneal perforation due to LASIK fore, may require approximately 1 atomileusis in 124 myopic eyes. J Refract Surg. 1995;11(suppl 3):S234-S238. presenting to our institution, medi- month for recovery of the endothe- 4. Watanabe H, Sato S, Maeda N, Inoue Y, Shimo- cal treatment was intuitive. Never- lial function. mura Y, Tano Y. Bilateral corneal infection as a complication of laser in situ keratomileusis. Arch theless, it was effective; the perfo- Despite recovery of the cornea, Ophthalmol. 1997;115:1593-1594. ration closed, the edema cleared, and high corneal irregular astigmatism 5. Pallikaris IG, Siganos DS. Laser in situ keratomi- visual acuity improved to 30/50 OS. and residual opacification re- leusis to treat myopia: early experience. J Cata- The surgeon did not mention mained, and this patient will even- ract Refract Surg. 1997;23:39-49. whether the patient had keratoco- tually require lamellar or penetrat- nus; however, preoperatively the pa- ing keratoplasty for better vision. One tient had high myopia and astigma- may question whether surgery should tism, with a best-corrected visual have been immediately performed. Infectious Ulcerative acuity of 10/20 OS. In addition, the However, suturing of the flap to pro- Keratitis After Laser stromal bed in the unperforated right mote wound closure carries a high In Situ Keratomileusis eye appeared very thin. These data risk of inducing additional high suggest that the patient may have irregular astigmatism. In our pa- With any laser refractive surgical had keratoconus. In cases of kera- tient who had no suturing, the cor- procedure in which the epithelial toconus, the cornea is thin and ex- neal edema disappeared completely barrier is broken, there is an inher- cessive thickness of the flap may be in 1 month. We can then choose the ent risk of infectious complication. created by the microkeratome be- most appropriate treatment after re- As laser in situ keratomileusis cause of distortion of the cornea, sidual astigmatism and opacifica- (LASIK) becomes more widely avail- resulting in a thin stromal bed. We tion have resolved. In our patient, it able, cases of LASIK-associated in- presume that this may have led to was more effective to use a therapeu- fectious keratitis have begun to be ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1423 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 reported.1-6 We report 6 eyes of 5 pa- tients that developed ulcerative kera- titis after LASIK. Report of Cases. Case 1. A 33-year- old woman noted a foreign body sen- sation in the right eye 4 days after bilateral LASIK. She was found to have a corneal infiltrate. She was given subconjunctival injections of vancomycin hydrochloride, cefazo- Figure 1. Slitlamp photograph showing Figure 2. Slitlamp photograph showing lin sodium, and betamethasone a paraxial 2-mm-round, anterior stromal scar an epithelial defect at the flap margin sodium phosphate and started on within the flap edge, with striae extending with organizing stromal infiltrate. Visual therapy with ciprofloxacin hydro- radially.
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