DLK is an uncommon complication after lasik. Various etiological agents have been implicated. Responds well to aggressive treatment and early diagnosis

1. Diffuse Lamellar Keratitis
(DLK)

2. What is it?
An inflammatory condition in which white blood
cells migrate along the stromal interface after
surgery
Incidence: 1.8-4% of cases.
May be sporadic or clustered.
Presents day 2-6 PO LASIK

3. “Sands of the Sahara”
DLK was originally termed "Sands of Sahara"
because of its characteristic wavelike
accumulation of infiltrating cells.
Advanced cases can cause a "shifting sands" or
wavelike appearance in the stromal bed, hence
the initial descriptive term.

4. Etiology
Microkeratome oil
Metallic debris from the microkeratome
blade
Meibomian secretions
Palmolive used to clean instruments
Heat-stable bacterial endotoxins
Epithelial defects

5. Etiology
Latex glove powder
Povidone-iodine applied to lids pre-op
Contaminated water in sterilizer
Underlying immune mechanism

6. Grade 1 DLK

7. Grade 2 DLK

8. Grade 3 DLK

9. Grade 4 DLK

10. If left untreated . . .
Stromal melt
Irregular astigmatism
Necrosis
Interface hazing
Change in refractive error

11. Symptoms
Photophobia
Hazy vision
Decreased vision
Gritty sensation

12. Management
Grade 1 is typically treated with Pred
Forte every hour with dexamethsone
ointment Qhs.
Patient should be seen every 24 hours
until the inflammation stabilizes, then slow
taper
Easily treated with little risk of vision loss

13. Management
Grade 2 is typically treated with Pred
Forte every hour with dexamethasone
ointment Qhs.
Patient should be seen every 24 hours to
monitor for increasing inflammation in the
central cornea
More risk for vision loss if not controlled

14. Management
Grade 3 & 4 are typically treated by lifting,
debulking, and aggressively irrigating the
bed and flap underside
Grade 4 may require stretching to
remediate the folds secondary to the
inflammatory cells in the center
High risk of permanent vision loss and
distortion due to irregular astigmatism

15. Oral Treatments?
Doxycycline to treat meibomanitis and
rosacea
Oral Prednisone (60 mg/day) with taper
after inflammation resolves

16. Late Onset
Reported in patients with epithelial defects
Resembles an ulcer with epithelial defect and
dense inflammation
Haw W, Manche E. “Late onset diffuse lamellar
keratitis associatied with an eiptiehrial defect in
six eyes” J Refr Surg, Vol 16, Nov/Dec 2000.

17. Intraoperative Complications
Flap defects increase the risk for DLK
Epithelial defects/abrasions
Button Holes
Treat the epithelial defects with antibiotics to
close the defect then increase steriods to treat
the imflammation