A case of keratitis associated with limbal relaxing incision

Abstract

We report a case of keratitis associated with limbal relaxing incision (LRI). The patient presented with progressive loss of vision with best-corrected visual acuity 20/40. Immature cataract with 1.43D against the rule astigmatism was noted. Prophylactic topical antibiotic was administered before surgery. He underwent uneventful phacoemulsification with intraocular lens implantation with LRI. On the 33^rd postoperative day (POD), he presented with infiltrate along LRI site with mild iritis. Corneal scraping was positive for Staphylococcus aureus. After the treatment with topical moxifloxacin and fortified cefazolin, the infiltrate started to resolve. On the 50^th POD, the corneal infection was resolved with marked thinning at LRI site.

Limbal relaxing incision (LRI) is a minimally invasive and reliable method of astigmatism correction during cataract surgery.[1,2] We report a case of bacterial keratitis at the site of LRI, in a patient who underwent phacoemulsification.

Case Report

A 79-year-old gentleman presented with bilateral nuclear sclerosis grade 3. His best-corrected visual acuity (BCVA) in the right eye was 20/40, and phacoemulsification with intraocular lens implantation was planned. Right eye keratometry (K) was 45.12 D × 77° and 46.55 × 167° and axial length 23.96 mm. Topical ofloxacin 3 mg/ml was applied for every 3 h, 1 day before surgery. Povidone-iodine was used to clean the periorbital area, followed by topical povidone-iodine instillation in conjunctival cul-de-sac immediately before surgery. A nasal 6-mm LRI was performed using a 550-micron diamond knife before wound construction. Gills nomogram was used for correction of astigmatism. Phacoemulsification done through temporal corneal 2.2 mm incision was uneventful. On the first postoperative day (POD), his right eye BCVA was 20/20, and anterior segment was normal. Topical prednisolone acetate with ofloxacin combination eye drops was prescribed in tapering doses for 6 weeks postoperative.

On the 33^rd POD, he presented with irritation, redness, and mild pain in his operated eye, his BCVA was 20/240. He also complained of eye rubbing over the last week. There was no history of trauma, lagophthalmos, or chronic dacryocystitis. Slit-lamp examination showed full-thickness corneal infiltrate along inferior aspect of LRI, corneal stromal edema, keratic precipitates, and mild iritis [Fig. 1]. Posterior segment was within normal limits. Corneal scraping was done at the site of infiltrate and culture grew Staphylococcus aureus, sensitive to drugs such as cefazolin, vancomycin, tobramycin, gentamicin, and cefuroxime. The patient was treated with topical 0.5% moxifloxacin, fortified 5% cefazolin, 2% homatropine, and oral doxycycline 100 mg.

Figure 1.

Limbal relaxing incision keratitis showing keratic precipitates, anterior chamber cells, circumciliary congestion, and limbal relaxing incision infiltrate

On the 40^th POD [Fig. 2a], his symptoms improved and corneal infiltrate at LRI started to heal. BCVA improved to 20/40. On the 50^th POD, cornea showed thinning at LRI site [Fig. 2b], totally resolved infiltrate with uncorrected corrected visual acuity (UCVA) and BCVA of 20/20, and residual astigmatism 0.25D cylinder.

Figure 2.

Postoperative resolved limbal relaxing incision keratitis; (a) resolving infiltrate and thinning at limbal relaxing incision site (b) clear cornea with thinning at limbal relaxing incision site and quiet anterior chamber

At 5 months postoperative, keratotopography performed with the Pentacam showed focal steepening with corresponding mild thinning of the cornea at LRI site. K reading was 45.5D × 45° and 45.7D × 135°; UCVA and BCVA were 20/20. Anterior segment optical coherence tomography showed local scarring which matched with the Pentacam image.

Discussion

Carvalho et al. have shown that LRI performed during phacoemulsification surgery is a safe, effective, and stable procedure to reduce preexisting corneal astigmatism.[2] Moon et al. reported neurotrophic corneal ulcer in a patient who had lagophthalmos and ectropion following cataract surgery with a LRI.[3] To the best of our knowledge, ours is the first case report of LRI keratitis in an eye with no ocular comorbidity which underwent phacoemulsification.

In the year 2014, we performed 26,623 phacoemulsification procedures, 745 (2.8%) with a LRI. Although we have previously reported endophthalmitis associated with LRI in an eye which underwent manual small incision cataract surgery,[4] this is the first case of keratitis at LRI site in a phacoemulsification case. The LRI was partial thickness and phacoemulsification uneventful. As the corneal wound was clear, we presume that the organism may have penetrated the cornea at the LRI site through possible microperforations when the patient rubbed his eye almost a month after surgery. This case report reminds us that even 4 weeks after surgery, patients are still at risk for infections. The keratitis caused by S. aureus responded well to treatment and vision was completely restored. The fellow eye underwent phacoemulsification 3 months later, with no evidence of postoperative infection.

In summary, this report stresses the need for a cautious approach to the adoption of this method of astigmatism correction, especially in monocular eyes. Timely management of the condition with appropriate medications can help salvage the eye and vision.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.