Journal of Refractive Surgery

Brief Reports 

Pneumococcal Infection After Temporary Tarsorrhaphy for Epikeratophakia

Massimo Busin, MD; Andrea Cusumano, MD; Manfred Spitznas, MD

Abstract

CASE REPORT

To prevent inadvertent manipulation of the operated eye, an 11-year-old handicapped aphakic patient received a temporary tarsorrhaphy immediately after aphakic epikeratophakia surgery. Despite prophylactic administration of systemic cephalosporin, periocular inflammation developed. When the tarsorrhaphy was opened on the 7th postoperative day, a central epithelial defect with infiltration of both the lenticule and the subjacent recipient cornea was present (Fig 1A). Smears and cultures were performed before initiating hourly topical treatment with fortified gentamicin and cephazolin. Because of the extension and the central location of the infiltrate, the epikeratophakia-lens was removed. It was submitted for both light and electi'on microscopic examination. Both cultures and microscopic examination demonstrated a pneumococcal infection of the lenticule with abundant granulocytic infiltration. The bacterial growth was mainly present in the external layers of the lenticule (Fig 2), causing extensive lysis of the stromal collagen lamellae (Fig 3). Under continued topical antibiotic treatment, reepithelization of the recipient cornea was completed within 6 days. A faint, paracentral stromal haze persisted for several weeks, despite topical application of steroids (Fig 1B). Two months after removal of the lenticule, best spectacle corrected visual acuity had returned to the initial preoperative value of 20/30.

DISCUSSION

Temporary tarsorrhaphy has been used with success for the treatment of persistent epithelial defects after corneal surgery.1 It was performed originally in conjunction with epikeratophakia when bandage contact lenses had failed to achieve complete reepithelialization of the lenticule within 2 weeks after surgery.2 More recently, Wagoner and Steinert have advocated temporary tarsorrhaphy as a routine procedure at the end of surgery, with the claim that this would shorten the time necessary for reepithelialization.3 However, in our experience, a partial tarsorrhaphy (central tarsorrhaphy) while making postoperative observation of the eye difficult does not greatly reduce the time necessary for reepithelialization. On the other hand, a total temporary tarsorrhaphy is much more effective in speeding up reepithelialization of epikeratophakia lenticules but precludes direct examination.

Even though use of prophylactic systemic antibiotics has greatly reduced the incidence of bacterial infections after epikeratophakia in pediatric patients,4 it was ineffective in the case reported above.

Thus, the benefits of performing a temporary tarsorrhaphy routinely after epikeratophakia surgery remain questionable, as this procedure precludes the view of the operated eye during a critical postoperative phase.

1. Wolfley DE. Surgical management of eyelid abnormalities. In: Kaufman HE. Barron BA, McDonald MB, Waltman SR eds. The Cornea. New York, NY: Churchill Livingstone lnc; 1988:161-188.

2. Arffa RC, Busin M, Barron BA, McDonald MB. Kaufman HE. Epikeratophakia with commercially prepared tissue for the correction of aphakia in adults. Arch Ophthalmol. 1986;104:1467-1472.

3. Wagoner MD, Steinert RF. Temporary tarsorrhaphy enhances reepithelialization after epikeratoplasty. Arch Ophthalmol. 1988; 106: 13.

4. Morgan KS, McDonald MB, Hiles DA, et al. The nationwide study of epikeratophakia for aphakia in children. Am J Ophthalmol. 1987;103:366-376.…

CASE REPORT

To prevent inadvertent manipulation of the operated eye, an 11-year-old handicapped aphakic patient received a temporary tarsorrhaphy immediately after aphakic epikeratophakia surgery. Despite prophylactic administration of systemic cephalosporin, periocular inflammation developed. When the tarsorrhaphy was opened on the 7th postoperative day, a central epithelial defect with infiltration of both the lenticule and the subjacent recipient cornea was present (Fig 1A). Smears and cultures were performed before initiating hourly topical treatment with fortified gentamicin and cephazolin. Because of the extension and the central location of the infiltrate, the epikeratophakia-lens was removed. It was submitted for both light and electi'on microscopic examination. Both cultures and microscopic examination demonstrated a pneumococcal infection of the lenticule with abundant granulocytic infiltration. The bacterial growth was mainly present in the external layers of the lenticule (Fig 2), causing extensive lysis of the stromal collagen lamellae (Fig 3). Under continued topical antibiotic treatment, reepithelization of the recipient cornea was completed within 6 days. A faint, paracentral stromal haze persisted for several weeks, despite topical application of steroids (Fig 1B). Two months after removal of the lenticule, best spectacle corrected visual acuity had returned to the initial preoperative value of 20/30.

FIGURE 1: (A) Eleven-year-old patient 7 days after aphakic epikeratophakia showing a corneal ulcer. (B) The same patient 8 weeks after lenticule removal with residual faint stromal haze in the recipient cornea.

FIGURE 1: (A) Eleven-year-old patient 7 days after aphakic epikeratophakia showing a corneal ulcer. (B) The same patient 8 weeks after lenticule removal with residual faint stromal haze in the recipient cornea.

FIGURE 2: Light microscopy ( x 250) of the removed epikeratophakia-lens showing absence of epithelium on Bowman's layer (B) and disruption of the lamellar stromal structure (S) with pneumococcal infiltration.FIGURE 3: Transmission electron microscopy (x 30 000) of the removed epikeratophakia-lens evidencing a pneumococcal body with hair-like fimbriae in an area of collagen lysis.

FIGURE 2: Light microscopy ( x 250) of the removed epikeratophakia-lens showing absence of epithelium on Bowman's layer (B) and disruption of the lamellar stromal structure (S) with pneumococcal infiltration.

FIGURE 3: Transmission electron microscopy (x 30 000) of the removed epikeratophakia-lens evidencing a pneumococcal body with hair-like fimbriae in an area of collagen lysis.

DISCUSSION

Temporary tarsorrhaphy has been used with success for the treatment of persistent epithelial defects after corneal surgery.1 It was performed originally in conjunction with epikeratophakia when bandage contact lenses had failed to achieve complete reepithelialization of the lenticule within 2 weeks after surgery.2 More recently, Wagoner and Steinert have advocated temporary tarsorrhaphy as a routine procedure at the end of surgery, with the claim that this would shorten the time necessary for reepithelialization.3 However, in our experience, a partial tarsorrhaphy (central tarsorrhaphy) while making postoperative observation of the eye difficult does not greatly reduce the time necessary for reepithelialization. On the other hand, a total temporary tarsorrhaphy is much more effective in speeding up reepithelialization of epikeratophakia lenticules but precludes direct examination.

Even though use of prophylactic systemic antibiotics has greatly reduced the incidence of bacterial infections after epikeratophakia in pediatric patients,4 it was ineffective in the case reported above.

Thus, the benefits of performing a temporary tarsorrhaphy routinely after epikeratophakia surgery remain questionable, as this procedure precludes the view of the operated eye during a critical postoperative phase.

REFERENCES

1. Wolfley DE. Surgical management of eyelid abnormalities. In: Kaufman HE. Barron BA, McDonald MB, Waltman SR eds. The Cornea. New York, NY: Churchill Livingstone lnc; 1988:161-188.

2. Arffa RC, Busin M, Barron BA, McDonald MB. Kaufman HE. Epikeratophakia with commercially prepared tissue for the correction of aphakia in adults. Arch Ophthalmol. 1986;104:1467-1472.

3. Wagoner MD, Steinert RF. Temporary tarsorrhaphy enhances reepithelialization after epikeratoplasty. Arch Ophthalmol. 1988; 106: 13.

4. Morgan KS, McDonald MB, Hiles DA, et al. The nationwide study of epikeratophakia for aphakia in children. Am J Ophthalmol. 1987;103:366-376.

10.3928/1081-597X-19920901-08

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