title: Fungal keratitis after photorefractive keratectomy: delayed diagnosis and treatment in a co-managed setting.
abstract: OBJECTIVE
  To report a case of fungal keratitis following photorefractive keratectomy (PRK) in a co-managed setting.
  
  
  METHODS
  A 35-year-old man with a preoperative refraction of -13.00 +3.75 x 18 degrees OD, and -12.50 +2.50 x 70 degrees OS underwent bilateral simultaneous PRK. On postoperative day 16, the patient presented with complaints of decreased vision and foreign body sensation. Examination by the co-managing optometrist revealed a visual acuity of 20/200, and a central corneal ulcer. Cultures were not taken and the patient was started on topical ofloxacin and prednisolone acetate 1% every hour. The patient was instructed to follow-up with another optometrist closer to the patient's home. Tobradex (tobramycin 0.3% combined with dexamethasone 0.1%) was added to the treatment regimen on postoperative day 23, but the ulcer continued to worsen. The patient was then referred to an ophthalmologist where corneal cultures were performed, but came back negative.
  
  
  RESULTS
  Despite treatment with fortified antibiotics, the ulcer perforated, requiring penetrating keratoplasty. Bacterial and fungal cultures were negative. Pathology examination of the specimen revealed fungal hyphae.
  
  
  CONCLUSIONS
  Although co-management of refractive patients may be a common practice, it is not without risks. In this case, delayed diagnosis and inappropriate treatment resulted in a poor final outcome.
authors.affiliation: Department of Ophthalmology, University of Washington, Seattle 98195-6485, USA.
authors.forename: Laura M
authors.initials: LM
authors.lastname: Periman
authors.forename: Devin A
authors.initials: DA
authors.lastname: Harrison
authors.forename: Jeehee
authors.initials: J
authors.lastname: Kim
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001228:Aspergillosis / Q000175:diagnosis* / Q000382:microbiology / Q000628:therapy; D003315:Cornea / Q000473:pathology; D003320:Corneal Ulcer / Q000175:diagnosis* / Q000382:microbiology / Q000628:therapy; D015821:Eye Infections, Fungal / Q000175:diagnosis* / Q000382:microbiology / Q000628:therapy; D006801:Humans; D015948:Keratoplasty, Penetrating; D054018:Lasers, Excimer; D008297:Male; D010348:Patient Care Team; D018903:Photorefractive Keratectomy / Q000009:adverse effects*; D011183:Postoperative Complications; D012422:Rupture, Spontaneous
chemical_list: D000900:Anti-Bacterial Agents