We present a case of an iatrogenic double flap created during laser in situ keratomileusis using a femtosecond laser microkeratome that resulted in development of severe diffuse lamellar keratitis (DLK). The DLK occurred mainly in the second interface, made by the spatula accidentally and not exposed to femtosecond or excimer lasers. Because of differences in the severity of the interface inflammatory reactions between the two layers exposed to the same spatula, an allergic reaction to detergent, bacteria, or other chemicals could not be assumed to be the main cause of DLK. Our observations in this case may suggest an important association of neural factors with DLK, because the inflammatory reaction occurred mainly in the deep stromal layer at the thick corneal nerves.
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