Eyeworld

APRIL 2019 | EYEWORLD | 83 R by Maxine Lipner EyeWorld Senior Contributing Writer with antibiotics," he said. Each subsequent case with a similar appearance was treated using the same protocol. The team, while analyzing data for their recently published SMILE textbook, 1 which in- cludes a retrospective review of all of their DLK cases after SMILE, put together a case series. 3 The investigators found that DLK occurred in 18 out of 4,000 eyes. Of these 18 cases, six were described as sterile multifocal inflammatory ker- atitis. All six of the eyes were treated with topical steroids and ultimately resolved. Comparison to DLK In such SMILE cases, the major difference is in the appearance, as the name suggests, Dr. Rein- stein explained. "Classic DLK in both LASIK and SMILE usually appears as a very fine, localized, or diffuse scattering of inflammatory cells," he said. "In sterile multifocal inflammatory keratitis there are a number of isolated focal infiltrates that are not typical of interface inflammation seen after LASIK." The small focal infiltrates may or may not be in conjunction with a background classic DLK. Treatment protocol revolved primarily around quelling the inflammation with steroids. "The protocol, after learning from our first case, was to treat with aggressive topical steroids while cover- ing with a broad-spectrum antibiotic," Dr. Rein- stein said, adding that this is similar to the stan- dard treatment protocol for DLK after LASIK. Investigators determined that at the 1-year mark all of the eyes had responded well, with no eyes losing any lines of corrected distance visual C oncern over diffuse lamellar keratitis (DLK) isn't limited to LASIK. Patients who have undergone SMILE may be vulnerable to a similar condition, according Dan Reinstein, MD. Investi- gators led by Dr. Reinstein conducted a retrospective review of 4,000 SMILE patients. 1 They found that 0.45% of cases had DLK, with one-third of those presenting as a unique sterile multifocal inflammatory keratitis. New syndrome emerges Interest in this SMILE-related presentation was spurred by a case of a patient who presented with a few small focal infiltrates 1 day after uncompli- cated SMILE surgery. 2 "Before this case, we had seen a few cases of classic DLK after SMILE," Dr. Reinstein said. "Because of the unique appearance in this particular case, infection was our leading differential diagnosis." Frustratingly, every culture, scrape, and test came back negative for any infectious component. "It was a scary case, but fortunately everything resolved and the patient ended up seeing very well," Dr. Reinstein said. Since all pathology came back clear, inves- tigators were fairly confident that the multifocal infiltrate appearance was a sterile inflammatory reaction that was unique to SMILE. One year later, investigators encountered a similar case. Again, this occurred on day 1 follow- ing SMILE surgery and involved the presentation of a few small focal infiltrates, which differed from the diffuse "sands of Sahara" appearance linked to cases of DLK after LASIK, Dr. Rein- stein noted. "With the knowledge of how the first case went, we were more comfortable treating it as a sterile inflammatory response and covering RESEARCH HIGHLIGHT Unique SMILE complication Sterile multifocal inflammatory keratitis Slit lamp photos of sterile multifocal inflammatory keratitis, grades 1 to 4 (left to right) Source: Dan Reinstein, MD Contact information Reinstein: dzr@londonvisionclinic.com continued on page 85 About the doctor Dan Reinstein, MD London Vision Clinic London, U.K. References 1. Reinstein DZ, et al. The Surgeon's Guide to SMILE: Small Incision Lenticule Extraction. SLACK Inc. 2018. 2. Stuart A, et al. Atypical presen- tation of diffuse lamellar keratitis after small-incision lenticule extraction: Sterile multifocal inflammatory keratitis. J Cataract Refract Surg. 2018;44:774–779. 3. Reinstein DZ, et al. Incidence and outcomes of sterile multifocal inflammatory keratitis and diffuse lamellar keratitis after SMILE. J Refract Surg. 2018;34:751–759. Financial interests Reinstein: Carl Zeiss Meditec, ArcScan

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