Cornea Roundtable: A Case-Based Discussion

Educational Objectives

The goal of this program is to improve the management of interface fluid syndrome in patients with prior laser-assisted in situ keratomileusis (LASIK) surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Identify interface fluid syndrome in patients with prior LASIK surgery.

Summary

Case study of a woman, 56 yr of age, referred for corneal transplantation: presented with poor vision in the left eye for 6 mo; she reported sudden onset of decreased vision with persistent pain and photophobia; she had received laser-assisted in situ keratomileusis (LASIK) 20 yr prior and developed corneal ectasia in both eyes (that was worse in the left eye); patient had previously used topical steroids, sodium chloride hypertonicity ophthalmic solution (Muro 128), and antibiotics; her best corrected visual acuity (VA) is 20/20 with a rigid gas-permeable lens OD and counting fingers OS

Case discussion: sudden onset of symptoms and current topical therapies are consistent with acute corneal hydrops; anterior segment optical coherence tomography can confirm the diagnosis; asymmetry in intraocular pressure (IOP) was observed (17 mm Hg OD and 6 mm Hg OS); epithelial defect should be investigated to help rule out infectious etiology; in this case, the patient had no epithelial defect or history of intraocular implants; the anterior chamber appeared to be formed, and the central 8 mm of cornea was edematous

Interface fluid syndrome (IFS): in patients with prior LASIK, examine flap for interface fluid if asymmetry in IOP is observed; steroid use in the treatment of diffuse lamellar keratitis causes increased IOP, leading to dysfunction of the endothelial pump and allowing passage of fluid into the interface; IFS is rare but vision-threatening; IOP may be underestimated when measured in the central cornea when the true IOP is significantly elevated (can be measured in the peripheral cornea); IFS is also known as pressure-induced stromal keratitis; clinical findings include asymmetric IOP, interface cleft, and interface haze; IFS has been reported with chronic steroid use and in patients with Fuchs endothelial dystrophy who undergo LASIK; in this patient, hydrops and fistula most likely led to IFS

Management: discontinue steroid and lower IOP; injecting air or gas into the anterior chamber is not indicated for IFS; primary treatment is endothelial keratoplasty or penetrating keratoplasty; in this patient, cutting into the interface and allowing removal of fluid resulted in partial clearing of the cornea and improved VA to 20/100 OS; the patient’s LASIK flap was removed and rotated such that the thicker, hinged portion was sealed over the fistula with fibrin glue; flap was then sutured into place, and amniotic membrane was placed on top; at 1 mo, the epithelium healed, and sutures were removed; at 3 mo, patient had best corrected VA of 20/25 OS with a scleral lens

Readings

Assayag E, Smadja D, Roditi E, et al. Interface fluid syndrome 2 decades after laser-assisted in situ keratomileusis. Eye Contact Lens. 2021 Jun;47(6):381-382; Galvis V, Berrospi RD, Tello A, et al. Interface fluid syndrome (IFS) following toxic anterior segment syndrome (TASS): not related to high intraocular pressure but to endothelial failure. Saudi J Ophthalmol. 2019 Jan-Mar;33(1):88-93; Shajari M, Rafiezadeh P, Pavlovic I, et al. Management of interface fluid syndrome after LASIK by Descemet membrane endothelial keratoplasty in a patient with Fuchs' corneal endothelial dystrophy. J Refract Surg. 2017 May;33(5):347-350.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Al-Hashimi, Dr. Fram, and Dr. Shamie were recorded at the Controversies in Ophthalmology: 89th Midwinter Conference, held January 8, 2022, in Universal City, CA, and presented by The Research Study Club of Los Angeles. For information about upcoming CME conferences from this presenter, please visit researchstudyclub.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

OP601404

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.