Journal of the Formosan Medical Association
Volume 108, Issue 12 , Pages 967-972, December 2009

Ring Keratitis Associated With Topical Abuse of a Dilute Anesthetic After Refractive Surgery

  • Yu-Chih Hou
    • ,
  • I-Jong Wang
    • ,
  • Fung-Rong Hu

      Affiliations

    • Corresponding Author InformationCorrespondence to: Dr Fung-Rong Hu, Department of Ophthalmology, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei 100, Taiwan

Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan

Received 27 November 2007; received in revised form 2 April 2008; accepted 2 June 2008.

Article Outline

Anesthetic toxic keratitis is rare and presents as a ring keratitis, which is often misdiagnosed as Acanthamoeba keratitis. Here, we report an unusual case of toxic keratitis caused by topical abuse of a dilute anesthetic. A 26-year-old woman presented with bilateral corneal edema, ring infiltrates, pigmented keratic precipitate, Descemet's membrane folding, and strong anterior chamber reactions 2 weeks after laser subepithelial keratomileusis surgery. Tracing back her medical history, topical dilute 0.1% proparacaine was prescribed and frequently used for 1 month. Toxic keratitis was suspected. After discontinuation of the topical anesthetic and initiation of treatment with topical 20% autologous serum, complete corneal epithelialization was achieved within 1 week. Corneal infiltrates and anterior chamber reaction gradually subsided. Vision improved from finger counting to 20/20 in the right eye and 20/25 in the left eye, but confocal microscopy showed decreased corneal endothelial cells. Topical abuse of a dilute topical anesthetic can cause severe toxic keratitis and endothelial cell loss. The physician must be aware of the signs of topical anesthetic abuse and should not prescribe even a dilute anesthetic for long-term use. Autologous serum can help in the recovery of toxic keratitis.

Key Words:  autologous serum , endothelial cell loss , topical anesthetic abuse , toxic keratitis

No full text is available. To read the body of this article, please view the PDF online.

 

Back to Article Outline

References 

  1. Penna EP , Tabbara KF . Oxybuprocaine keratopathy: a preventable disease . Br J Ophthalmol . 1986;70:202–204
  2. Varga JH , Rubinfeld RS , Wolf TC , et al.   Topical anesthetic abuse ring keratitis: report of four cases . Cornea . 1997;16:424–429
  3. Rosenwasser GOD . Complications of topical ocular anesthetics . Int Ophthalmol Clin . 1989;29:153–158
  4. Rosenwasser GOD , Holland S , Pflugfelder SC . Topical anesthetic abuse . Ophthalmology . 1990;97:967–972
  5. Dass BA , Soong HK , Lee B . Effects of proparacaine on actin cytoskeleton of corneal epithelium . J Ocul Pharmacol . 1988;4:187–194
  6. Risco JM , Millar LC . Ultrastructural alterations in the endothelium in a patient with topical anesthetic abuse keratopathy . Ophthalmology . 1992;99:628–633
  7. Gasset AR , Ishii Y , Kaufman HE , et al.   Cytotoxicity of ophthalmic preservatives . Am J Ophthalmol . 1974;78:98–105
  8. Lemp MA , Zimmerman LE . Toxic endothelial degeneration in ocular surface disease treated with topical medications containing benzalkonium chloride . Am J Ophthalmol . 1988;105:670–673
  9. Gurelik G , Bilgihan K , Sezer C , et al.   Effect of mechanical vs dilute ethanol epithelial removal on keratocyte apoptosis and polymorphonuclear leukocyte migration . Eye . 2002;6:136–139
  10. Kim TI , Tchah H , Cho EH , et al.   Evaluation for safety of cultured corneal fibroblasts with cotreatment of alcohol and mitomycin C . Invest Ophthalmol Vis Sci . 2004;45:86–92
  11. Pfister RR . Permanent corneal edema resulting from the treatment of PTK corneal haze with mitomycin: a case report . Cornea . 2004;23:744–747
  12. Majmudar PA , Forstot SL , Dennis RF , et al.   Topical mitomycin-C for subepithelial fibrosis after refractive corneal surgery . Ophthalmology . 2000;107:89–94
  13. Rubinfeld RS , Pfister RR , Stein RM , et al.   Serious complications of topical mitomycin-C after pterygium surgery . Ophthalmology . 1992;99:1647–1654
  14. Chang SW . Early corneal edema following topical application of mitomycin-C . J Cataract Refract Surg . 2004;30:1742–1750
  15. Tsubota K , Goto E , Fujita H , et al.   Treatment of dry eye by autologous serum application in Sjogren's syndrome . Br J Ophthalmol . 1999;83:390–395
  16. Collins MK , Perkins GR , Rodriguez Tarduchy G , et al.   Growth factors as survival factors: regulation of apoptosis . Bioessays . 1994;16:133–138
  17. Fredj-Reygyrobellet D , Plouet J , Delayre T , et al.   Effects of aFGF and bFGF on wound healing in rabbit corneas . Curr Eye Res . 1987;6:1205–1209
  18. Phan TM , Foster CS , Boruchoff SA , et al.   Topical fibronectin in the treatment of persistent corneal epithelial defects and trophic ulcers . Am J Ophthalmol . 1987;104:494–501
  19. Berman MB . Collagenase inhibitors: rationale for their use in treating corneal ulceration . Int Ophthalmol Clin . 1975;15:49–66
  20. Matsumoto Y , Dogru M , Goto E , et al.   Autologous serum application in treatment of neurotrophic keratopathy . Ophthalmology . 2004;111:1115–1120
  21. Chen HT , Chen KH , Hsu WM . Toxic keratopathy associated with abuse of low-dose anesthetic: a case report . Cornea . 2004;23:527–529

PII: S0929-6646(10)60011-3

doi:10.1016/S0929-6646(10)60011-3

Journal of the Formosan Medical Association
Volume 108, Issue 12 , Pages 967-972, December 2009

Article Tools