ABSTRACT

We report two cases of acute haemorrhagic keratoconjunc-tivitis which occurred following laser in situ keratomileusis(LASIK) during an ongoing epidemic. Both cases underwentpreoperative investigation and surgery on the same day.The possible sources of contamination include the para-medical staff, the contact instruments used for performingpreoperative investigation, surgeon, nurse, surgical instru-ments and eye drops. However, the flap was intact with nohaze or regression and at 1 year follow up, the visual acuitywas maintained at 6/6 in both the patients. We recommendgreater caution while performing contact investigations andstrict surgical asepsis during LASIK surgery, routinely as well as during epidemics of conjunctivitis.

Key words: acute conjunctivitis, acute haemorrhagic con-junctivitis, laser in situ keratomileusis.

INTRODUCTION

Bacterial keratitis after excimer laser photorefractive kerat-ectomy1–4 and laser in situ keratomileusis (LASIK)5,6 are wellknown. No case of infective keratoconjunctivitis has beenreported in the immediate postoperative period followingLASIK. An epidemic of acute haemorrhagic keratoconjunc-tivitis caused by Enterovirus 70 occurred in New Delhibetween December 1998 and February 1999. The viralantigen in conjunctival specimens of the patients wasdetected by indirect immunofluorescence assay and isolatedon tissue culture using HEP2 cells.

We herein report two cases of acute haemorrhagic kerato-conjunctivitis which occurred following LASIK during anongoing epidemic. In both the eyes the integrity of thecorneal flap was not disturbed.

CASE REPORT

Case 1

A 39-year-old man underwent bilateral simultaneous LASIKsurgery on 19 December 1998 for hypermetropia. His pre-operative refractive error was +2.50/+1.50 × 15 in his righteye and +2.50/+1.50 × 165 in his left eye.

Strict surgical asepsis was observed during LASIK surgeryas per the protocol followed at our centre. One drop ofciprofloxacin 0.3% was instilled 60 and 30 min beforesurgery. The eyelids and skin were painted with povidone-iodine. The eyes were cleaned and draped in the operationtheatre observing strict surgical asepsis. Postoperative treat-ment included betamethasone sodium phosphate eye drops0.1% and Neosporin eye drops (Glaxowellcome, Mumbai,India) 0.5% four times a day for 1 week.

Slit-lamp examination at 1 h and 24 h postoperativelywas unremarkable. On the second postoperative day thepatient developed pain, watering, photophobia, chemosisand patchy subconjunctival haemorrhages in the right eye,followed by a similar clinical picture in the left eye, on thethird postoperative day. However, the corneal flap wasintact and the cornea was clear with no evidence of punctatekeratitis.

A diagnosis of acute haemorrhagic conjunctivitis wasmade, an epidemic of which had been ongoing in the cityduring that time. The corticosteroid–antibiotic combinationwas withdrawn and the patient was started on framycetineye drops (q.i.d.) in addition to symptomatic treatment inthe form of cold compresses, artificial tears, decongestantdrops and the wearing of dark glasses.

Eight days later, the patient developed superficial punc-tate keratitis involving the entire cornea, more so in theinferior part. The pinpoint opacities involved the epithe-lium, subepithelium and the anterior stroma (Fig. 1). Thekeratoconjunctivitis resolved after 3 weeks and the patient

Clinical and Experimental Ophthalmology (2000) 28, 431–433

Case Report

Acute haemorrhagic keratoconjunctivitis following laser in situ keratomileusisNamrata Sharma MD, Tanuj Dada MD, Vijay K Dada MBBS MS and Rasik B Vajpayee MBBS MSDr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

■ Correspondence: Namrata Sharma, MD, Assistant Professor, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences,

New Delhi 110029, India. Email: namrata103@hotmail.com

had an uncorrected Snellen visual acuity of 6/6 in both eyes.One year later, the visual acuity remained the same and theflap was intact with no haze or regression.

Case 2

A 29-year-old man underwent bilateral LASIK surgery on 19 December 1998 for high myopia. His preoperativerefractive error was –16.00/–3.00 × 10 in his right eye and–15.00/–3.50 × 160 in his left eye.

Slit-lamp examination at 1 h post-surgery was unremark-able. On the second postoperative day, the patient devel-oped pain, watering, photophobia and had lid oedema withsubconjunctival haemorrhages in both eyes (Fig. 2). Therewas no corneal involvement and the corneal flap was intact.A diagnosis of acute haemorrhagic conjunctivitis was madeand the patient was treated in a manner similar to the pre-vious case.

Six days later, the patient developed diffuse keratitis withinfiltrates involving the entire cornea up to the anteriorcorneal stroma. Fifteen days later the keratoconjunctivitishad resolved and the patient had a Snellen visual acuity of6/6 with a refractive error of –1.00 Dsph in his right eye and–0.75 Dsph in his left eye. One year later, the flap was intactwith no haze or regression and visual acuity was maintained.

DISCUSSION

Acute haemorrhagic keratoconjunctivitis is a sudden onset,bilateral keratoconjunctivitis associated with pain, tearing,photophobia, lid oedema and characterized by the presenceof subconjunctival haemorrhages. In both our patients theclinical features were typical. Although no viral cultureswere obtained from either patient, the clinical features ofacute haemorrhagic keratoconjunctivitis and positive viralcultures during the outbreak of the epidemic led us tobelieve that these were cases of acute haemorrhagic kerato-conjunctivitis.

We treated our patients symptomatically as has beenadvocated. Corticosteroids were withdrawn as they areknown to impair ocular defence mechanisms, alter microbial

flora and facilitate infection.7 Acute haemorrhagic kerato-conjunctivitis occurs due to person to person contamination,although the role of droplet transmission is not known. Theincubation period of Enterovirus 70 is 48 h. It is possible thatthese patients’ surgery had been undertaken on apparentlynormal eyes, during the incubation period. Nevertheless,the possibility of occurrence of infection postoperatively inthese eyes cannot be ruled out. This can be attributed to thepossible ocular surface abnormality following LASIK treat-ment and steroid instillation.

Corneal involvement occurred in both our patients. Inacute haemorrhagic keratoconjunctivitis, superficial keratitishas been reported in 10–90% of the cases in various studies.7Corneal involvement deeper than anticipated occurred inour patients possibly due to the surgical trauma of LASIK,which leads to broken epithelial barriers thereby compro-mising the ocular surface and exposing the stromal bed tothe presence of infectious organisms in the conjunctiva.Fortunately, all corneal flaps survived the viral infection, sothe integrity of the corneal flaps was not jeopardized fol-lowing fulminant keratoconjunctivitis. Yang et al. havedemonstrated that allergic keratoconjunctivitis is a possiblerisk factor for regression and haze after photorefractive keratectomy.8 However, no haze or regression was seen ineither case at 1 year follow up.

The probes for performing contact investigations shouldbe sterilized with extra care during epidemics of conjunc-tivitis. Coincidentally, both the patients underwent contactinvestigations and LASIK surgery on the same day andinstrument-borne infection and cross-contamination cannotbe ruled out. Possible sources of contamination include thehands of the personnel (i.e. of the surgeon, nurse and para-medical staff); the surgical instruments; the contact instru-ments used for investigations; and the eye drops.

Our cases demonstrate a need for greater caution whileperforming preoperative contact investigations like specularmicroscopy, ultrasonic pachymetry and biometry, and alsosuggest that strict asepsis should be maintained while

432 Sharma et al.

Figure 1. Superficial punctate keratitis following laser in situkeratomileusis. Case 1.

Figure 2. Acute haemorrhagic conjunctivitis following laser in situkeratomileusis. Case 2.

performing LASIK both by the surgeon and the assistingparamedical staff. Furthermore, during epidemics of acutekeratoconjunctivitis, a close follow up of the patients under-going any surgery is mandatory.

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