Nodular episcleritis after laser in situ keratomileusis in patient with systemic lupus erythematosus.

Sir,

Laser in situ keratomileusis (LASIK) is safe and efficacious for the treatment of refractive error. However, controversy remains regarding LASIK for patients with autoimmune disorders.[1-3] Episcleritis is a manifestation of systemic lupus erythematosis (SLE), which can be successfully managed by observation and topical lubricants. However, some cases may warrant the use of topical corticosteroids.

A 28-year-old female with an established well controlled SLE underwent uneventful bilateral LASIK for myopic astigmatism. A mechanical microkeratome was used to perform the keratectomy. One week post-operatively the patient presented with tearing, moderate pain, and redness in the lateral aspect of her left eye. On examination, her vision was 20/20 and the Slit lamp examination indicated a nodular episcleritis surrounded by engorged episcleral blood vessels [Figure 1]. The posterior segment examination was unremarkable.

Figure 1

Nodular episcleritis 1 week after laser in situkeratomileusis in a patient with well controlled systemic lupus erythematosus

Topical prednisolone acetate 1%, and diclofenac sodium 1%, 4 times a day was started. The episcleritis was completely resolved within 2 weeks and the patient has remained free of systemic or ocular reactivation over the last 3 years [Figure 2].

Figure 2

Complete resolution of episcleritis after topical corticosteroid therapy in a patient with well controlled systemic lupus erythematosus who had undergone laser in situkeratomileusis

Ophthalmic manifestations occur through immune vasculitis and/or thrombosis and immune complex deposition with wide range of clinical presentation including, scleritis and episcleritis.[4] Episcleritis is an acute self-limited inflammation of the episclera that frequently affects young and middle aged individuals. It occurs in association with SLE in one-third of the cases.[4]

SLE is a chronic, systemic autoimmune disease, occur 9 times more frequently in typically young, middle-aged women. Some have postulated that estrogens enhance the immune response.[5]

LASIK is suitable in well controlled autoimmune disorders such as SLE. Smith and Maloney[1] performed LASIK in 49 eyes of 26 patients with autoimmune diseases, 7 of whom had SLE and reported no complications. We recommend judicious use of topical steroids in cases of episcleritis due to the attendant risks of steroid use. SLE patients have an altered autoimmune system. Even when they are symptom-free, the disease may not be inactive; this makes them susceptible to the risk of post-operative inflammation. This possibility should be explained to the patient pre-operatively.