Consultation section. Refractive surgical problem.

A 29-year-old Hispanic man who had bilateral radial keratotomy (RK) and astigmatic keratotomy (AK) in his right eye 1 year previously went swimming in a lake. He subsequently developed foreign-body sensation and pain with a gradual decrease in vision over the following 5 weeks, despite treatment with ciprofloxacin hydrochloride (Ciloxan) and diclofenac sodium (Voltaren). The patient sought a second opinion. On examination, best corrected visual acuity was 20/40 in the right eye and 20/20 in the left. Slitlamp examination revealed mild conjunctival and scleral injection and a 3.5 mm diameter stromal infiltrate densest at the edges (Figure 1). The infiltrate involved one RK and one AK incision with gaping of both, approximately 90% depth incisions (Figure 2). The anterior chamber was deep and quiet. Examination was otherwise unremarkable. The cornea was scraped, but the smears were negative. The Ciloxan and Voltaren were stopped, and scopolamine four times a day was started. Cultures for aerobic, anaerobic, fungal, acid-fast bacilli, and Acanthamoeba were performed but showed no growth in the following week. Except for vascular ingrowth, there was no change in the appearance of the microbial keratitis during this week. An incisional biopsy and rescraping were performed, but there was again no growth of micro-organisms and no change in the microbial keratitis in the following 4 days. How would you manage this patient at this time?