The epidemiology of diffuse lamellar keratitis

Purpose: To report the incidence and outcomes of diffuse lamellar keratitis (DLK) after LASIK and to analyze potential causative factors. Methods: Retrospective review of 15,119 cases (11,232 primary procedures and 3887 enhancements) from 7168 patients undergoing LASIK from May 1995 through October 2002, comparing preoperative data and postoperative outcomes for each case developing DLK to patients in the study population and a control series of eyes that did not develop DLK. Results: We identified 61 eyes (0.40%) that developed DLK after LASIK. Three study groups were identified based on sterilization protocols used: (1) steam autoclave without reservoir (8348 cases), (2) cassette autoclave with reservoir (6771 cases), (3) steam autoclave without reservoir and new instrument cleaner (1758 cases). Significantly more eyes developed DLK with Protocol 2 (47 cases, 0.94%) than with Protocol 1 (11 cases; 0.1%; P < 0.0001) or Protocol 3 (3 cases, 0.2%; P < 0.0005). There was no significant difference in the incidence of DLK in Protocol 1 versus Protocol 3. DLK was significantly more common after primary procedures than with enhancement procedures only under Protocol 2. No individual developed DLK after more than 1 procedure. Treatment protocols included frequent topical steroids only (24 cases, 39.3%), frequent topical steroids and oral steroids (19 cases, 31.2%), or topical and oral steroids combined with lifting and irrigating beneath the flap (18 cases, 29.5%). Final refractions and visual acuities were not significantly different in eyes that developed DLK and those that did not. Conclusions: DLK is a nonspecific inflammatory response to multiple stimuli that cannot be attributed solely to individual variation in the inflammatory response, the microkeratome, or material deposited by the microkeratome. Sterilizers with reservoirs may cause some cases of DLK. With appropriate diagnosis and treatment, DLK should resolve without sequelae, yielding visual outcomes comparable to cases with uneventful postoperative courses.