USAEyes Lasik grant application.
How to Choose
A Lasik Doctor
Find Certified Surgeon
50 Tough Lasik Questions
Ask Lasik Expert
Lasik Q&A Forum
Top Articles
What is Lasik?
Lasik Cost
Lasik Results
Wavefront Custom iLasik
Bladeless Lasik
Lasik Patient Survey
Lasik Alternative
Top Articles
Monovision Lasik
PRK, LASEK, Epi-Lasik
RLE Lens Exchange
Lasik Groupon
$1,500 Off Lasik

Image of Lasik doctors certification logo.

This website is accredited by Health On the Net Foundation. Click to verify.   The website complies with the HONcode standard for trustworthy health information: verify here.

Diffuse Lamellar Keratitis (DLK)

Sands of Sahara after Lasik and Bladeless Lasik

Slit lamp image of DLK.  
The white infiltrates associated with Diffuse Lamellar Keratitis (DLK) are shown in an image of a cornea.  

Diffuse Lamellar Keratitis (DLK) is a postoperative complication of Lasik and Bladeless Lasik that occurs when foreign cells (infiltrates) are introduced into the interface between the corneal flap and underlying stroma. DLK can occur with any flap manipulation including initial surgery, enhancement, removal of epithelial ingrowth, etc. There is often pain, blurred vision, foreign body sensation, and sensitivity to light but some patients have no symptoms other than rapid onset of hazy vision. DLK most often is present within one to six days after surgery however DLK has occurred months and years after surgery and can threaten an otherwise successful visual outcome if not properly treated.

DLK causes the creation of fine white grainy cells that when viewed through a slit-lamp appear like waves of sand, hence the nickname Sands of Sahara. Although the infiltrates are sterile, the cornea attacks them and if left unchecked will destroy itself causing serious damage and permanent reduction in visual acuity.

DLK had been a very mysterious problem when it first started to occur and is still not completely understood. DLK tends to happen in "runs" of several patients in a row. It appears that there are several causes or that multiple conditions must exist for DLK to occur.

Surgeons verify that all tools are properly sterilized, but the problem has persisted in-part because the infiltrates are not alive; they are actually dead and sterile cells. DLK is not caused by the infiltrates making trouble. It is caused by the cornea reacting to the presence of the infiltrates even if they are dead.

The most common used sterilizers utilize steam from distilled water to cause sterilization. This water would collect in a drain pan that was difficult to empty completely. If the water was not drained, the dead infiltrates would collect in the water and then be readmitted to the next batch of items being sterilized in the steam. The sterilizer became an efficient method of sterile infiltrate distribution. Now, doctors empty the sterilizer pans completely, use new sterile distilled water, and clean the sterilizers often. Much more than normal protocol. Also, dry sterilizers are used.

DLK is defined in four stages beginning with Stage 1 where DLK is first present through Stage 4 where the cornea is destroying itself.

    Stage 1 consists of infiltrates in the periphery of the flap without involvement of the central cornea. This stage most commonly presents on the day after surgery.

    Stage 2 occurs as a result of central migration of cells to involve the visual axis. Stage 2 most frequently presents on day two or three. Progression to stage 3 occurs when dense clumps of cells aggregate in the central visual axis. Relative clearance of the periphery is also seen.

    Stage 3 usually appears 48 to 72 hours after surgery, and can be associated with a 1- or 2-line loss of visual acuity. Stage 3 has been referred to as "threshold" DLK because many of these eyes will develop permanent scarring if not appropriately treated.

    Stage 4 is severe lamellar keratitis resulting in stromal melting and permanent scarring. Central tissue loss causes a hyperopic shift. The incidence of Stage 4 is estimated at one in 5,000 Lasik cases.

Treatment is normally topical and oral medication. Sometimes it is necessary to lift the flap, remove some of the infiltrates, irrigate the area, and reposition the flap. Quick diagnosis and treatment is a must Something important to remember is that DLK can occur months, even years, after surgery if there is sufficient trauma or disruption to the Lasik flap. If you ever have trauma to the eye after having Lasik, it is always good to be evaluated by a refractive surgeon.

Looking For Best Lasik Surgeon?

If you are ready to choose a doctor to be evaluated for conventional or custom wavefront Lasik, Bladeless Lasik, PRK, or any refractive surgery procedure, we recommend you consider a doctor who has been evaluated and certified by the USAEyes nonprofit organization. Locate a USAEyes Evaluated & Certified Lasik Doctor.

Personalized Answers

If this article did not fully answer your questions, use our free Ask Lasik Expert patient forum.

Recent Diffuse Lamellar Keratitis Medical Journal Articles...

Related Articles

Diffuse lamellar keratitis in the femtosecond-assisted LASIK flap tunnel.

Clin Ophthalmol. 2014;8:1065-7

Authors: Kymionis GD, Tsoulnaras KI, Tsakalis NG, Grentzelos MA

Here we report a case of a 29-year-old myopic female who underwent femtosecond laser-assisted in situ keratomileusis (LASIK) and, on the first postoperative day slit-lamp examination revealed a dense, white, granular reaction with the presence of some blood droplets (stage I diffuse lamellar keratitis [DLK]) in her left eye, specifically localized into the femtosecond LASIK flap tunnel (not extended to the flap interface). The patient received intensive treatment with topical corticosteroids and 5 days later the granular reaction had completely resolved. A new site of DLK, ie, the flap tunnel, in femtosecond-assisted LASIK is presented. DLK into the flap tunnel could be managed with corticosteroids if detected early, without affecting the flap interface.

PMID: 24940043 [PubMed]


Last updated

"Consider and Choose With Confidence"TM

A few of the communities where Lasik doctors are certified by USAEyes :