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Lasik Doctors


Diffuse Lamellar Keratitis (DLK)

Sands of Sahara after Lasik and All-Laser Lasik

Diffuse Lamellar Keratitis (DLK) is a postoperative complication of Lasik and All-Laser 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.

If you are ready to choose a doctor to be evaluated for conventional or custom wavefront Lasik, All-Laser Lasik, PRK, LASEK, Epi-Lasik, NearVision CK, RLE, or any refractive surgery procedure, we highly recommend you consider a doctor who has been evaluated and certified by the USAEyes nonprofit organization. Locate a USAEyes Evaluated & Certified Lasik Laser Eye Surgery Doctor.

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

Current DLK Medical Journal News...

Diffuse lamellar keratitis after small-incision lenticule extraction.

Related Articles

Diffuse lamellar keratitis after small-incision lenticule extraction.

J Cataract Refract Surg. 2015 Feb;41(2):400-7

Authors: Zhao J, He L, Yao P, Shen Y, Zhou Z, Miao H, Wang X, Zhou X

PURPOSE: To determine the incidence and clinical features of diffuse lamellar keratitis (DLK) after small-incision lenticule extraction (SMILE).
SETTING: Department of Ophthalmology, Eye and ENT Hospital of Fudan University, Shanghai, China.
DESIGN: Retrospective case control study.
METHODS: Small-incision lenticule extraction for myopia was performed from September 1, 2011, to October 31, 2013. Preoperative clinical characteristics; treatment parameters; and intraoperative and postoperative complications, including the incidence, severity, clinical outcome, and resolution of DLK, were recorded. The independent t test, chi-square test, univariate repeated measures, and multivariate linear regression analysis were used to make statistical comparisons between eyes that developed DLK and those that did not.
RESULTS: The study enrolled 1112 eyes (590 patients). Eighteen eyes (1.6%) (11 patients) developed DLK. These patients presented 1 to 3 days postoperatively with mild to moderate inflammation. Thirteen eyes (72.2%) had stage 1 DLK, 4 (22.2%) had stage 2, and 1 (5.6%) had stage 3. After intensive treatment with topical corticosteroids, the stage 1 and stage 2 cases resolved within 3 weeks and the stage 3 case resolved in 1 month. The postoperative corrected distance visual acuity was the same or better than preoperatively in all eyes. There was a statistically significant increase in the incidence of DLK with thinner lenticules (P = .02) and larger diameter lenticules (P = .01), although multifactorial analysis showed lenticule thickness to be the only factor (P = .03).
CONCLUSIONS: Diffuse lamellar keratitis is a potential complication after small-incision lenticule extraction, although it had a low incidence. The risk factors for DLK must be further elucidated.
FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

PMID: 25661134 [PubMed - indexed for MEDLINE]


Last updated Thursday, February 25, 2010

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