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Dr.Ajay Khanna,Dr.Rohit Om Parkash,Dr. Tushya om parkash,Dr.Shruti Mahajan

31-year-old male came to our hospital on 3rd may 2018 for Lasik

  • Refractive Error:

OD -1.75D Spherical/-0.75D Cylindrical Axis 70o -6/6

OS -1.75D Spherical/-0.75D Cylindrical Axis 65o -6/6

  • Corneal Topography: Normal – OU
  • Thinnest Pachymetry:

OD- 518 Microns

OS- 522 Microns

  • Slit lamp Examination: Normal-OU
  • Fundus Examination: Normal-OU
  • Pre-Operative antibiotics: Gatif loxacin 0.5% eye drops & Tobramycin 0.3% eye drops 4 times a day were started OU two days before Lasik.
  • Lasik was Planned on 21st May 2018.
  • Slit Lamp Examination was done by our surgeon (fellow) before taking the patient to Lasik OT.
  • First Case on list.
  • Lasik surgery performed by same surgeon(fellow) using Moria Microkeratome.
  • Surgery was uneventful.
  • After about one and half hour, the patient was feeling more pain, irritation, and watering in right eye as compared to left eye.
  • On Slit Lamp Examination: many small whitish round unusual spots were seen on front surface of cornea in right eye only. Left eye was normal.
  • Immediately, I examined the video of Lasik surgery and found that there were few white round spots were visible over the front surface of corneal f lap in the right eye. Left eye was normal.
  • May be these spots were missed during Slit Lamp Examination done just before surgery and also during surgery by our surgeon (fellow).

  • Gatifloxacin 0.5% eye drops, Tobramycin 0.3% eye drops & Lubricant eye drops were given to be instilled one hourly on day of surgery till next follow-up after 24
  • Next day, whitish spots were very faint and the patient was feeling much better, almost asymptomatic.
  • We started routine Topical eye Drops:

– Gatiquin –P(gatifloxacin 0.3% + prednisolone 1%)eye drops four hourly – Tobramycin 0.3% eye drops four hourly

– Systane Ultra(lubricant) eye drops four hourlies in both eyes.

Again, we re-examined the patient after 48 hours of starting steroid drops, there was:

  • Pain
  • Redness
  • Watering
  • Blurred Vision
  • Whitish round spots again reappeared on anterior corneal surface in R/E only

Superficial round white spots

Conjunctival congestion

Initial impression was of non-specific viral keratoconjunctivitis but unilateral, very superficial

appearance of keratitis spots involving just superficial aspect of epithelial layer of cornea led to suspicion.

Occupational History: Gym Owner with frequent exposure to steam bath and Sauna in his premises.

We decided to take corneal scrapings for study under microscope by microbiologist.

In Operation Theatre, under microscope:

  • Whitish round superficial spots were gently scraped with hockey stick knife and scrapings were sent to Laboratory for microscopic examination by Microbiologist.
  • Corneal surface was thoroughly cleaned with BSS.
  • Microbiologist found microsporidia with Gram staining.
  • Treatment started:

– Tab. Albendazole 400mg BD orally

Topically: -Voriconazole 1%eye drops two hourlies

-Homatropine 2%eye drops eight hourlies

-Lubricant eye drops two hourlies

MICROSPORIDIA

After that we examined the patient after 3 days

He started improving. Whitish spots became very faint.

  • Homatropine 2% eye drops were discontinued. Rest of the treatment was continued for two weeks on examination after two weeks of treatment:
  • All White spots disappeared.
  • No redness, watering, irritation and pain
  • Visual acuity: 6/9 in R/E and 6/5 in L/E

We started Gatilox-DM(gatif loxacin 0.3%+dexamethasone 0.1%) eye drops and stopped voriconazole 1% eye drops. Gatilox-DM eye drops were continued in R/E three times a day for one week.Visual acuity improved to 6/6 in R/E after one week. After that only lubricant eye drops were continued and we examined the patient every month up to three months. Final visual acuity improved to 6/5 in right eye after 3 months.

Discussion

  • Microsporidia –Intracellular parasites causing human infections. These are usually waterborne pathogens usually affecting immunocompromised individuals.
  • Recently, there is increase in incidence of Microsporidial
  • KeratoConjunctivitis (MKC) affecting normal immunocompetent individuals worldwide.
  • Presentation is usually Unilateral Superficial KeratoConjunctivitis with punctate superficial keratitis in immunocompetent individuals.
  • Usually younger age group with history of exposure to rain water, swimming pool water, mud, sauna, steam bath and hot springs.
  • Usually self-limiting in immunocompetent individuals resolving in 1-2 weeks.
  • May take more time to resolve when steroids are used.
  • Bilateral and deeper involvement usually occurs in immunocompromised individuals.
  • Responds very well to antifungal and antiparasitic agents especially in immunocompetent individuals.
  • Topical steroids and bandage contact lenses should be avoided during active phase as these may cause deeper involvement especially in immunocompromised individuals.

 

 

 

 

 

 

 

 

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