Fungal keratitis after photorefractive keratectomy: delayed diagnosis and treatment in a co-managed setting.

ABSTRACT

PURPOSE: To report a case of fungal keratitis following photorefractive keratectomy (PRK) in a co-managed setting. METHODS: A 35-year-old man with a preoperative refraction of -13.00 +3.75 x 18 degrees OD, and -12.50 +2.50 x 70 degrees OS underwent bilateral simultaneous PRK. On postoperative day 16, the patient presented with complaints of decreased vision and foreign body sensation. Examination by the co-managing optometrist revealed a visual acuity of 20/200, and a central corneal ulcer. Cultures were not taken and the patient was started on topical ofloxacin and prednisolone acetate 1% every hour. The patient was instructed to follow-up with another optometrist closer to the patient's home. Tobradex (tobramycin 0.3% combined with dexamethasone 0.1%) was added to the treatment regimen on postoperative day 23, but the ulcer continued to worsen. The patient was then referred to an ophthalmologist where corneal cultures were performed, but came back negative. RESULTS: Despite treatment with fortified antibiotics, the ulcer perforated, requiring penetrating keratoplasty. Bacterial and fungal cultures were negative. Pathology examination of the specimen revealed fungal hyphae. CONCLUSIONS: Although co-management of refractive patients may be a common practice, it is not without risks. In this case, delayed diagnosis and inappropriate treatment resulted in a poor final outcome.