topical fluoroquinolones may be used as antibacterial treatment and have been associated with corneal deposits [ 14 ] but nothing has been reported in surface laser ablations . one case of corneal deposits occurring after the use of topical ciprofloxacin in post - lasek treatment is presented . a 59-year - old man opted to be submitted to a lasek procedure in december 2008 . his best - corrected visual acuity ( bcva ) in the right eye ( re ) was 20/25 with + 3,75  sph = + 0,50  cyl at 30 and in the left eye ( le ) was 20/25 with + 3.25  sph . camellin guidelines , applying mytomicin c ( mmc ) 0.02% for two minutes at the end of the the laser - ablation . at the end , lidofilcon contact lenses ( actifresh 400  hydron  hamble , uk ) were placed to facilitate epithelial adhesion . alcon cusi  el masnou , spain ) was started two days earlier , while the postsurgical treatment resulted in ciprofloxacin 0.3% ( as above ) , diclofenac 0.1% four times / day ( diclofenaco lepori monodosis  angelini  barcelona , spain ) , polividone 5% ad libitum ( oculotect monodosis  novartis  barcelona , spain ) . debris from the deposit was analyzed with dark field microscopy and placed on a blood - agar plate seeded with a susceptible stain of staphylococcus aureus ( atcc 29213 ) . a standardized laboratory disk of ciprofloxacin containing 5  g / ml served as a control [ 3 , 4 ] . the follow - up during the three days after lasek was regular , so the patient was appointed to remove contact lenses ( cl ) after three days . at the scheduled visit , his cls were not  in situ  , although he could not explain when or how he had lost them . his le showed a microcistic  caramel - like  opacity of subepithelial , paraoptic , inferior corneal stroma with epithelial discontinuities , without any sign of ocular or periocular inflammation ( figures 1(a ) and 1(b ) ) . administration of ciprofloxacin and diclofenac in his le was stopped and substituted with tobramycin 0.3% ( tobrex  alcon cusi  el masnou , spain ) and dexamethasone 0.1% ( dexafree monodosis  thea  barcelona , spain ) six times / day . on the following day , re too showed initial opacities of the inferior cornea and was moved to the same treatment of le , which was gently scraped to analyze the debris as indicated in section 2 . after four days the gross opacity in le disappeared , although some minor subepithelial deposits and punctiform desepithelisation still persisted . tobramycin was then stopped bilaterally and dexamethasone was tapered in 2 weeks , switching to fluorometolone 0.1% ( fml drops  allergan  westport , ireland ) three times / day , tapered in 6 weeks bilaterally . during the whole period the iop did not show any hypertensive spike . after one month , le opacity was very similar to a vertex keratopathy ( figure 1(c ) ) , leading to a subepithelial inferior nubecula persisting for 6 months , with no influence on his best - uncorrected vision acuity ( bucva ) , which is 20/30 , nor on his bcva ( 20/25 with + 0.50  sph ) . the analysis of the images obtained with this technique revealed the precipitates to be polydisperse crystalline needles of 183  m average length ( sd = 54  m ) . the excised precipitate resulted in a zone of inhibition that measured 22.0  mm on atcc 29213 plate ; the control disk measured 17.0  mm after 24 hours . ciprofloxacin , a second - generation fluoroquinolone , is extensively used in bacterial keratitis , owing to its ease of availability , broad spectrum of activity , and lack of toxicity . although there are many reports of crystalline corneal deposits occurring with the use of topical ciprofloxacin 0.3% and norfloxacin 0.3% [ 17 ] ,   nothing has been reported after refractive surgery . in  in vitro  tear model , drug concentration of ciprofloxacin determined a rapid precipitation that starts at 8 postdose , producing turbidity and a significant decline in soluble drug concentration . scuderi et al . in 2003   incubated rabbit corneal epithelial cells with ofloxacin at different concentrations ( 1.5 , 3 , and 6  mg / ml ) and found in all the conditions tested a statistically significant dose- and time - dependent reduction in cell viability even after 8 hours . a large case - series of ofloxacin deposits after microbial keratitis has been presented by mitra et al . in 2007 . moreover gatifloxacin , a fourth - generation fluoroquinolone , has been reported to cause intrastromal crystalline deposits with a compromised corneal epithelium , in a similar manner to ciprofloxacin . although the use of ciprofloxacin alone seems to cause physicochemical changes in the tear film , combination therapy and other factors probably contribute to alter the ph thus causing or accelerating the precipitation process . such picture could be supported by our case , where le was more affected than re but further studies are needed to understand if cl loss , presurgical antibiotic treatment , lasek technique itself , or the application of mmc could have affected the re - epithelialisation in this case . accumulation of large numbers of dead cells and an altered general morphology may be further factors influencing the formation of deposits . with reference to the case here described , at the time of presentation to the corneal service , some of these topical medications ( oftacilox and tobrex ) contain benzalkonium chloride as preservative , which is known to disrupt cell walls by emulsifying membrane lipids , while decreasing epithelial microvilli , corneal wetting and inhibiting cell motility and surface healing . it is probable that the ph balance had been altered owing to the interaction of multiple medications which , in the presence of a compromised ocular surface and of a nonhealing epithelial defect ( due to the loss of the contact lenses ) , could result in ciprofloxacin precipitation and relative appearance of corneal deposits . discontinuation of ciprofloxacin and modification of topical therapy should aid the resolution of these deposits in most cases , as well as the promotion of epithelialisation , and the reduction of corneal and conjunctival toxicity . if deposits persist and prevent epithelialisation , they should be debrided to permit the cornea to epithelialise , as in this case , without any adverse outcome , although some deposits persisted subepithelially despite prolonged topical cortisone therapy . in any case , for the future it is hoped that more topical drugs are going to be available as unpreserved and/or with higher ph stability , in order to reduce at the lowest level any possible complication after local treatment , especially in refractive surgery where patients are very demanding for fast outcomes .
purpose . to report one case of corneal antibiotic deposition after ciprofloxacin administration in   laser assisted subepithelial keratomileusis ( lasek ) 
 . methods . 
 one case of post - lasek treatment resulted in corneal precipitates and poor wound healing . 
 debris was analyzed with dark field microscopy and placed on a blood - agar plate seeded with a susceptible stain of staphylococcus aureus ( atcc 29213 ) . 
 results . 
 the alterations resolved with discontinuation of ciprofloxacin treatment , although some residual deposits persisted subepithelially for 6 months . 
 analysis of precipitates revealed polydisperse crystalline needles of 183  m average length ( sd = 54  m ) and the excised precipitate demonstrated a zone of inhibition 
 . conclusions . 
 fluoroquinolone antibiotic drops have been used extensively in postsurgical treatment   of refractive surgery . 
 corneal precipitates have been previously reported in the literature , but up to now nothing has been documented after lasek . 
 polypharmacy during refractive surgery may impair epithelialisation , and clinical management should reduce toxic environment and promote ocular surface stability when performing surface ablations .