Delayed onset Mycobacterium intracellulare keratitis after laser in situ keratomileusis: A case report and literature review

Abstract

Rationale: Infectious keratitis is a relatively uncommon but potentially sight-threatening complication of laser in situ keratomileusis (LASIK). Mycobacterial keratitis is usually regarded as late onset keratitis among post-LASIK keratitis. There has been no documented case of Mycobacterium intracellulare post-LASIK keratitis of a long-latent period.

Patient concerns: A 36-year-old man was referred to our out-patient clinic, for persistent corneal epithelial defect with intrastromal infiltration. He had undergone uneventful bilateral LASIK procedure 4 years before. He complained decreased vision, accompanied by ocular pain, photophobia, and redness in his left eye for 7 months.

Diagnosis: Lamellar keratectomy was taken using femtosecond laser. Bacterial culture with sequenced bacterial 16s ribosomal DNA confirmed the organism to be M intracellulare.

Interventions: After 3 months of administration of topical clarithromycin, amikacin, and moxifloxacin, the corneal epithelial defect was resolved and the infiltration was much improved. However, newly developed diffuse haziness with surrounding granular infiltration in the central cornea was noted. Drug toxicity was suspected and topical moxifloxacin was discontinued, resulting in resolution of the diffuse haze with infiltration.

Outcome: The patient was followed up regularly without medication thereafter and recurrence was not found for 7 years.

Lessons: This case presents the first case of M intracellulare keratitis after LASIK. LASIK surgeons should aware that post-LASIK keratitis can develop long after the operation and careful suspicion of infectious disease with meticulous diagnostic test is needed.

Figure 1

(A) Slit-lamp examination at presentation shows 2 round corneal infiltrates with surrounding edema at 3 O’clock position at initial presentation. (B) Corneal optical coherence tomography shows the LASIK flap was perforated (marked as white arrow) and the infiltration (marked as arrow head) originated from LASIK flap interface. (C) Newly developed LASIK flap perforation on the previously increased corneal infiltrate was noted in slit lamp examination after use of topical moxifloxacin for 1 month (marked as arrow heads). (D) Corneal optical coherence tomography shows perforated flap where the infiltration increased previously. (E) Six months of topical clarithromycin, amikacin, and moxifloxacin to post-LASIK Mycobacterium intracellulare infection produced diffuse epithelial haziness with surrounding small dot-shaped infiltration (marked as arrow heads). (F) Corneal optical coherence tomography confirms this opacity is confined to epithelial layer (marked as white arrow). The infiltration was resolved soon after discontinuation of moxifloxacin.

Figure 2

(A) Slit lamp finding 1 day after lamellar keratectomy with femtosecond laser. Newly developed epithelial defect and infiltrative lesion was thought to be the site of active infection, so it was removed completely. (B) After administrating topical clarithromycin, amikacin, and moxifloxacin for 3 months to post-LASIK Mycobacterium intracellulare infection, slit lamp examination showed completely resolved epithelial defect and infiltrative lesion. (C) Stabilized lesion with stromal opacity was noted 7 years after initial presentation.