Bilateral methicillin-resistant Staphylococcus aureus keratitis following hyperopic photorefractive surgery

Abstract

To report clinical manifestations of a female patient with bilateral bacterial keratitis following photorefractive keratectomy (PRK). Bilateral PRK was performed for moderate hyperopia. Bandage contact lenses were fitted at the conclusion of the surgery. Bilateral infectious keratitis with hypopion was diagnosed within 4 days after surgery. Smear and culture were obtained and showed the presence of methicillin-resistant Staphylococcus aureus (MRSA). The patient was treated with systemic prednisone and topical antibiotics (vancomycin, tobramycin and netylmicin) and betamethasone. After 1 month corneal leukoma was still present and remained unchanged during the following 7 months. Infectious keratitis is a rare complication of PRK that appears early in the postoperative period. MRSA keratitis may determine long-term visual impairment despite prompt therapeutic intervention.

Pharmacological treatment for infectious corneal ulcers

“…Either of these combinations would provide 100% coverage for MRSA, MRSE and at least 95% coverage of the most common isolates recovered from patients at the author's Institute and those reported in the ARMOR (Antibiotic Resistance Monitoring in Ocular micRorganisms) 2009 [22] and Ocular Antitrust Study [20,72]. Although these and other in vitro laboratory studies document lower MICs against common ocular pathogens, there are increasing reports of resistance and clinical failure, especially against Gram-positive isolates (Table 4) [25,26,59,87,88].…”

Methicillin-Resistant Staphylococcus aureus and the Eye: Current Concepts and Management Strategies

“…Reports of MRSA ophthalmic infections are numerous in the literature. They are more commonly seen in patients in neonatal ICUs [61][62][63], in post-ocular surgical patients [64][65][66][67][68][69][70][71][72][73][74][75], among healthcare workers [76,77] after corneal refractive surgery [77][78][79][80][81][82][83][84], in hospitalized pediatric patients [85], and in patients with chronic medical disease, immuno-suppression, or immunodeficiency [70,86].…”

“…Perhaps the most common are those reported after eye surgery and/or concerning post-operative endophthalmitis. Recent reports in the last decade on endophthalmitis or postoperative infection include small retrospective cases series or case reports following cataract surgery [65,70,83,98], after amniotic membrane transplantation [64], following scleral buckle placement [68], following PK [69], following Ahmed valve placement [71], and after cornea refractive surgery [77][78][79][80][81][82][83][84]. Other reports are frequently site-specific, including orbital cellulitis [99][100][101][102][103][104], lacrimal system involvement [91,[105][106][107], and, most recently, after brow epilation [108].…”

“…Published reports of MRSA infections specifically after refractive surgery and cataract surgery at that time raised an ominous specter concerning these infections, especially in light of the fact that many of the cultured organisms had been fluoroquinolone-resistant [75,[77][78][79][80][81][82][83][84]. However, many of the published small reports lack the study power to definitively illustrate the epidemiology of these infections.…”

“…FitzgeraldHughes et al [116] discussed cationic antimicrobial peptides and ''antipathogenic agents'' which interfere with bacterial virulence mechanisms (host binding, biofilm formation, evasion of phagocytosis, and toxin production) as novel therapies to combat MRSA. Cheung et al [120 • [71] Ocular surface reconstruction Hori et al [64] Cornea cross-linking Bödemann and Kohnen [66] Post refractive surgery Solomon et al [77] Woodward and Randelman [78] Nomi et al [80] Magli et a.l [79] Karth and Karth [83] an immunization therapy that potentially uses multiple antibodies directed against a series of genome-encoded toxins of MRSA. Suzuki discussed antibiotics such as targocil targeting wall teichoic acids (WTA).…”