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January 12, 2026
3 min read
Eric Donnenfeld’s corneal health case presentations and panel discussion at OSN New York are always popular with meeting attendees and provide valuable clinical insights.
The cases presented in 2025 included infectious keratitis after PRK, lagophthalmos and corneal hypoesthesia with secondary dry eye. I will share a few comments on each of these topics.
Infectious keratitis is rare after LASIK when a femtosecond laser is used to create the flap, with a reported incidence of less than one case per 10,000. With surface ablation, in some reports, infectious keratitis incidence approaches one per 1,000, or 10 times more. Predisposing factors include dry eye, blepharitis and prior contact lens wear, which affects the microbiome of the ocular surface, increasing Pseudomonas keratitis risk. Most infections present in the first week postoperative, and the most common organism is staphylococci, including MRSA.
Many ophthalmologists use a fluoroquinolone antibiotic as prophylaxis, but with the rise in MRSA, Polytrim (AbbVie) eye drops with polymyxin B sulfate and trimethoprim, available at less than $10 per bottle in many pharmacies, may be a better choice. Once an infection is recognized, prompt Gram- and Giemsa-stained slides and a culture are appropriate. In the LASIK patient, this usually requires a flap lift, and once the flap is lifted, mechanical scraping of the flap undersurface and corneal bed followed by copious irrigation with balanced salt solution followed by placement of several drops of a broad-spectrum antibiotic in the interface make sense before repositioning the flap. Fortisite antibiotics from ImprimisRx (Harrow), which contain tobramycin 1.5% and vancomycin 5%, are a good choice for initial therapy in any sight-threatening infectious keratitis, and our group at Minnesota Eye Consultants keeps a few bottles on hand at all our clinical sites. In severe unresponsive cases, flap amputation may be necessary.
Late-onset infections are more likely to be secondary to mycobacteria, fungus, Nocardia or even Acanthamoeba. Many comprehensive ophthalmologists will choose to refer vision-threatening infectious keratitis cases to a fellowship-trained cornea specialist for treatment.
Lagophthalmos, including nocturnal lagophthalmos, results in corneal exposure that often induces secondary dry eye and keratitis. One study suggested that as many as 54% of patients, when carefully evaluated, show some sign of lagophthalmos. Risk factors include increased age; hospital-based patients, especially those in the ICU; sedated patients including those under general anesthesia; alcohol and drug intoxication; facial palsy; and lid laxity including floppy eyelid syndrome. Conservative treatment is with nonpreserved topical lubricants. Lacrimal outflow occlusion or treatments that increase natural tear production, including Tyrvaya (varenicline solution, Viatris) or Tryptyr (acoltremon ophthalmic solution 0.003%, Alcon), may also be helpful. For nocturnal lagophthalmos, a nonpreserved lubricating ointment and lid taping are useful. Transpore tape and Tegaderm (both 3M) work well, and for children, there is the Tarsus eyelid patch (Nictavi). Patients with chronic lagophthalmos may require eyelid surgery including the placement of gold or platinum implants, and of course, tarsorrhaphy is an option.
Reduced or absent corneal sensation is present in nearly 10% of the population, increasing the negative impact of dry eye and exposure of the ocular surface. Risk factors for corneal hypoesthesia include current or previous herpes simplex keratitis or herpes zoster keratitis, refractive corneal surgery, diabetes, chronic dry eye, lagophthalmos, penetrating and/or lamellar keratoplasty, trauma and any surgical procedure that affects the trigeminal nerve. Patients with significant corneal hypoesthesia are at risk for sight-threatening persistent epithelial defects, neurotropic keratitis and infection. Conservative treatment includes discontinuation of all toxic and preserved topical eye drops, frequent nonpreserved topical lubricants, lacrimal outflow occlusion, lid taping at night and tarsorrhaphy. Topical cyclosporine has shown efficacy in corneal hypoesthesia, and Vevye (cyclosporine ophthalmic solution 0.1%, Harrow), with its nonpreserved lubricious water-free semifluorinated alkane vehicle, is a good choice.
For patients who are unresponsive to conservative therapy, Oxervate (cenegermin-bkbj ophthalmic solution 0.002%, Dompé) is effective. Surgical options include amniotic membrane placement, and for severe recalcitrant cases, surgical neurotization is an option.
Infectious keratitis after corneal refractive surgery, lagophthalmos and reduced corneal sensation are important, potentially sight-threatening disorders of the cornea and ocular surface. Prompt, accurate diagnosis and treatment are indicated.
For More Information:
Richard L. Lindstrom, MD, can be reached at rllindstrom@mneye.com.
Sources/Disclosures
Source:
Expert Submission
Disclosures:
Lindstrom reports having financial disclosures for Alcon, Harrow, ImprimisRx, Minnesota Eye Consultants, Unifeye Vision Partners and Visant.
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