Confocal microscopy of stage 4 diffuse lamellar keratitis with spontaneous resolution

To report confocal microscopic findings at the onset of stage 4 diffuse lamellar keratitis and after its resolution. Stage 4 is the most severe form of diffuse lamellar keratitis. Its incidence is approximately 1 in 5000 and is associated with stromal melting, deep flap folds, central haze, hyperopic shift, irregular astigmatism, and severe decrease in visual acuity.

A 22-year-old woman underwent bilateral uncomplicated laser in situ keratomileusis (LASIK) for myopia. Postoperative course in the right eye was uneventful; however, in the left eye, stage 4 diffuse lamellar keratitis developed. Confocal microscopy examination was performed in both eyes at the onset of the syndrome and after its resolution. Findings in the eye with diffuse lamellar keratitis (left eye) were compared with the uninvolved (right) eye.

The condition improved spontaneously and 2 years later, slit-lamp microscopy showed resolution of the folds and haze with subsequent improvement of visual acuity. However, confocal microscopic examination in the left eye revealed a persistent stromal subclinical haze on both sides of the lamellar cut and prominent folds that extended into the anterior stroma.

Confocal microscopy revealed that in spite of normal appearance on slit-lamp microscopy, micromorphological alterations persisted after spontaneous resolution of stage 4 diffuse lamellar keratitis.