Incidence and Outcomes of Sterile Multifocal Inflammatory Keratitis and Diffuse Lamellar Keratitis After SMILE

J Refract Surg. 2018 Nov 1;34(11):751-759. doi: 10.3928/1081597X-20181001-02.


Purpose: To report the incidence outcomes of sterile multifocal inflammatory keratitis and diffuse lamellar keratitis (DLK) after small incision lenticule extraction (SMILE) in a large population.

Methods: This was a retrospective review of a population of 4,000 consecutive eyes treated by SMILE at the London Vision Clinic using the VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany). The inclusion criterion was to have presented with inflammatory keratitis after SMILE. In some cases after SMILE, the inflammatory keratitis presented as sterile multifocal interface keratitis uncharacteristic of classic DLK. The incidence was measured and categorized as primary or secondary by presenting appearance, grade, and time to presentation. Patients were observed for 1 year after surgery and standard outcomes analysis was performed.

Results: Of the 4,000 eye population, there were 18 cases (0.45%) of DLK grade 1 or 2. All cases were managed and resolved with topical steroid therapy. Of these, 12 cases (67%) were of classic appearance and 6 cases (33%) presented as sterile multifocal inflammatory keratitis. DLK was primary in nature in 11 cases (61%) and secondary in 7 cases (39%). Postoperative uncorrected distance visual acuity was 20/20 or better in 93% of eyes. No patients lost any lines of corrected distance visual acuity and there was no change in contrast sensitivity.

Conclusions: DLK occurred after SMILE with an incidence of 0.45% in this population. Topical steroid therapy resolved the DLK in all cases with no sequelae and no adverse effect on refractive or visual outcome at 1 year postoperatively. A unique type of DLK presentation can occur after SMILE, characterized by multiple focal sterile inflammatory spots. Management is the same as for classic DLK, but with a lower threshold for performing an interface washout. [J Refract Surg. 2018;34(11):751-759.].

MeSH terms

  • Adult
  • Female
  • Glucocorticoids / therapeutic use
  • Humans
  • Incidence
  • Inflammation / drug therapy
  • Inflammation / epidemiology
  • Keratitis / drug therapy*
  • Keratitis / epidemiology*
  • Keratomileusis, Laser In Situ / methods*
  • Lasers, Excimer / therapeutic use*
  • Male
  • Middle Aged
  • Myopia / physiopathology
  • Myopia / surgery
  • Postoperative Complications*
  • Retrospective Studies
  • Treatment Outcome
  • Visual Acuity / physiology
  • Young Adult


  • Glucocorticoids