Mixed Acanthamoeba and multidrug-resistant Achromobacter xyloxidans in late-onset keratitis after laser in situ keratomileusis

A 31-year-old woman developed a spontaneous flap interface keratitis in the left eye 6 years after a laser in situ keratomileusis (LASIK) enhancement. Cultures and polymerase chain reaction (PCR) were positive for Achromobacter xyloxidans resistant to first- and second-generation cephalosporin, aminoglycosides, and quinolones and also positive for Acanthamoeba T4. Treatment with topical fortified ceftazidime, topical chlorhexidine, and voriconazole and oral voriconazole did not stop the progression of the disease. Flap amputation revealed persistence of Acanthamoeba but not Achromobacter. Six weeks after flap amputation, the infiltrate had resolved, PCR was negative for Acanthamoeba, and the cornea had fully epithelialized. To our knowledge, this is the first report of post-LASIK infectious keratitis caused by mixed infection of Achromobacter xyloxidans and Acanthamoeba occurring years after the procedure without apparent ocular trauma. It is also the first report of the use of combined systemic and topical voriconazole as a therapy for Acanthamoeba keratitis after LASIK.