A 39-year-old Caucasian female with a history of CF presented for a LASIK consultation. She was a very healthy marathon runner who was well-versed in her condition and its management. She had a history of dry eye disease (DED) and minor CF-related pulmonary issues, specifically exercise-induced bronchospasms. She was taking Kalydeco  (Vertex Pharmaceuticals Incorporated, Boston, MA, USA) 150 mg tablets PO BID and using inhaled and nebulized medications. Review of systems (ROS) was unremarkable for skin abnormalities, pancreatic insufficiency, vitamin A deficiency, hepatic issues, GI issues, and COPD. Manifest refraction was -6.25 D OD and -5.75 D OS with a mean corneal thickness of 540 mum OD and 535 mum OS. Upon examination, it was discovered that this patient had conjunctival staining and superficial punctate keratopathy. Her Schirmer's test was above 10 mm in 5 minutes and her tear break-up time (TBUT) was greater than 7 seconds. Refractive surgery was deferred. Treatment of DED consisted of punctal plugs and Refresh Plus Preservative Free (PF) Lubricant Eye Drops (AbbVie Inc., North Chicago, IL, USA). She showed significant clinical improvement after 6 months. Corneal staining was completely resolved but there was some conjunctival staining. She was started on Restasis  (AbbVie Inc., North Chicago, IL, USA) BID. She presented twice to the clinic with filamentary keratitis (FK) between 7-18 months after the initial visit, during which several corneal filaments were debrided using Jeweler's forceps. She was cleared for refractive surgery 12 months after starting Restasis . Due to concern for a high risk of postoperative ocular surface dryness, PRK was selected as the refractive surgery of preference for this patient.
Alcohol-assisted PRK monovision surgery was performed using an EX500 Wavelight Excimer Laser (Alcon Laboratories, Inc., Fort Worth, TX) using a 6.5 mm ablation zone with a transitional zone of 9.0 mm. The right eye was corrected for distance vision, and the left eye was under-corrected by 0.5 D. Mitomycin C was not used to avoid any risk of prolonged postoperative epithelial healing. An ACUVUE OASYS  bandage contact lens (Johnson & Johnson Vision Care, Inc., Jacksonville, FL) with a base curvature of 8.4 was applied postoperatively and removed after 5 days without any epithelial complications. The patient continued aggressive artificial tear treatment, topical moxifloxacin 0.5% QID OU for 8 days, and prednisolone acetate 1% OU QID for 4 weeks. Restasis  was restarted 8 days postoperatively after moxifloxacin was discontinued. Following 4 weeks of prednisolone acetate therapy, fluorometholone 0.1% was prescribed OU with a tapering regimen of TID for 3 weeks, BID for 3 weeks, and QD for 3 weeks.
During the first 6 months postoperatively, she presented twice to the clinic with FK. Several filaments were debrided from each eye using Jeweler's forceps. The patient was placed on 10% topical N-acetylcysteine made by a compounding pharmacy to be used QID for 2 months, BID for 2 months, and was discontinued after. Treatment resulted in the complete eradication of FK. The patient's postoperative refractive error was -0.25 D -0.5 D x170  OD with UDVA of 20/25, and -0.75 D -0.75 D x10  OS with UDVA of 20/50, correctable to 20/20 binocular vision. Conjunctival staining revealed minimal ocular surface irregularities. Her postoperative care otherwise was completely uneventful, and she continued using PF artificial tears and Restasis . At 1 year of postoperative care, the patient did not require additional medications. However, she continues to use her existing medications to manage her residual dry eye symptoms.