作者：刘兵，茹海霞
作者单位：100036中国北京市，解放军空军总医院眼科
【摘要】目的：报告1例LASIK术后11mo由于角膜损伤引起的弥漫性板层角膜炎（diffuse lamellar keratitis，DLK）。
方法：22岁女患者应用laser Sight SLX 准分子激光机和Moria II角膜板层刀行双眼原位角膜磨镶术（laser in situ keratomileusis，LASIK)，术中和术后早期未见并发症发生。
结果：LASIK术后11mo，由于书页损伤角膜上皮，右眼诊断为I级DLK。经局部应用皮质类固醇激素，2wk后DLK很快治愈，没有并发症发生。
结论：DLK经常发生于术后早期，但也可发生于术后数月，一旦确诊应迅速治疗，效果良好。
【关键词】 弥漫性板层角膜炎 原位角膜磨镶术
INTRODUCTION
Diffuse lamellar keratitis (DLK) is a common complication of laser in situ keratomileusis(LASIK), which typically develops early after LASIK. With appropriate diagnosis and treatment, DLK should be healed without sequelae. In this report, we described a delayed onset DLK in the right eye after uneventful bilateral LASIK in 11 months.
CASE REPORT
A 22yearold female patient was scratched in the right eye by the edge of a book paper 11 months after having LASIK using a laserSight SLX excimer laser and Moria II microkeratome. At that time, she felt slight pain, redness and tearing, and was unable to open eyes. The next day, she was well. But on the third day, she found a blurred vision in the right eye, and came to hospital. After examination, UCVA was 1.0 in the right eye, and 1.5 in the left. Slitlamp examination revealed stage I DLK with diffuse, dotlike, and granular haze in the low 1/3 interface(Figure 1) in the right eye. The DLK responded rapidly to hourly fluorometholone ophthalmic suspension within the first week and 4 times a day in the next week. It was healed in 2 weeks without complication. The patient had atopy to sulfa in the past.
DISCUSSION
Although DLK typically develops in the early postoperative period, more and more delayed onsets were found months or even several years[13] after LASIK. This case also indicated that DLK can occur 11 months after LASIK with an eye trauma，and has an obvious causative agent that the book paper hurt the eye that maybe defect corneal epithelium. Wilson[3] thought many cases of sporadic DLK, including cases were associated with epithelial trauma after LASIK, were likely attributable to endogenous factors that trigger inflammation. One trigger was the release of epitheliumderived cytokines such as interleukin1 that stimulated keratocytes to produce chemokines that were chemotactic to inflammatory cells. Cells likely accumulated at the interface because it was potential space, representing a path of least resistance for cell movement. Keszei[4] reported a DLK associated with iritis, no with manipulation of the flap or epithelium 10 months after LASIK, and supported the hypothesis that DLK was a nonspecific inflammatory response of the cornea rather than a specific agent causing the syndrome.
Boorstein [5] observed that the risk of DLK in untreated atopic patients was much greater than the risk of DLK among nonatopics (odds ratio, 5.85; 95% confidence interval, 2.8911.85; P=0.001). However, the risk of DLK among atopic patients taking an oral systemic nonsedating histamine receptor 1 antagonist and among nonatopic patients did not differ significantly (odds ratio, 0.54; 95% confidence interval, 0.122.46; P=0.43). He thought that atopy was a patientspecific risk factor for the development of diffuse lamellar keratitis after primary bilateral LASIK. Atopic individuals benefited from preoperative treatment to minimize the incidence of DLK and the potential for visual loss. More reports [69] showed corneal epithelial defects and erosions after LASIK can increase the risk DLK occurrence. On the other hand, some sporadic cases may also be related to exogenous factors such as Betadine[3], Ecballium elaterium herb[10], interface viral[11] or fungal infection[12], and traumatic flap displacement [13].
Treatment should begin as soon as DLK is diagnosed. Treatment protocols[14] included frequent topical steroids only, frequent topical steroids and oral steroids, or topical and oral steroids combined with lifting and irrigating beneath the flap to remove interface dense granules according to the extent. Treatment of severe DLK with highdose topical and oral corticosteroids also produced excellent results with flap lifting and interface irrigation [15].
Figure 1 Slitlamp photomicrograph of right eye revealed DLK I with diffuse, dotlike, and granular haze in the low 1/3 interface（略）
DLK is a common complication of the refractive procedure. If we detected and diagnosed it in a timely fashion, it can be treated and should be healed with minimal sequelae. If we untreated, or misdiagnosed and treated it incorrectly, there may be loss of visual acuity. Ophthalmologists should be familiar with DLK including its signs, symptoms and correct treatment protocol. As the number of cases of refractive surgery in china increases, ophthalmologists will encounter this condition more frequently.
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