Transcript Late-Onset Dehiscence of LASIK Flap

Late-Onset
Dehiscence of LASIK
Flap
Poster Number: P-190
Authors: Hyunjin Jane Kim, Cary M. Silverman
Category: Keratorefractive
Authors have no financial interest or disclosures
Introduction
Corneal flap displacement within 1 to 2 days following laser in situ keratomileusis (LASIK) is a
well recognized complication.1-3 However, stability of the flap remains largely unknown as flap
dehiscence has been reported as late as 7 years after LASIK.4 We report cases of flap
dislocation 4 years and 9 years after laser LASIK, following trauma during routine domestic
activities. We also review 33 known case reports of late flap dehiscence, most of which are
single case reports. Largest case series described 4 patients with flap dislocadtion.5
Case 1
A 30-year-old Black man had a LASIK procedure on July 8, 2004. Patient had an uncomplicated
post operative course with uncorrected visual acuity (UCVA) of 20/20 in both eyes, and best
spectacle corrected vision (BSCVA) was 20/15 with refractive error of -0.25-1.00 x 165 and plano 0.75 x 170, respectively. On June 23, 2008, 4 years post LASIK, patient’s right eye was struck with
a piece of wood from a window trim. He presented two days after complaining of pain and slight
decrease in vision in the right eye. Exam showed UCVA of 20/25 with a mild displacement of flap
creating a fold and staining at the superior edge (Figure 1A).
Because the injury involved the periphery of the flap and vision was good, patient was treated
medically with Vigamox (Alcon, Fort Worth,Texas) and Lotemax (Bausch&Lomb, Tampa, Florida)
four times daily. Three days later, pain resolved and the UCVA was 20/30. By biomicroscopy,
patient had persistent folds but the staining had improved. Drops were discontinued a week later.
Five weeks after trauma, UCVA was 20/20-1 with no staining on slit lamp. Folds persisted as seen
on Figure 1B.
Figure 1A.
Color photos of right eye 2
days after being struck by a piece of wood
from a window trim. Note a mild displacement
of flap creating folds and staining at 12 o’clock
position.
Figure 1B. Color photo of right eye after
medical treatment of peripheral flap
dehiscence. Flap folds persist just superior to
the visual axis.
Case 2
A 29 year-old man underwent bilateral LASIK on February 1, 1999. Two years postoperatively, UCVA
was 20/30 and 20/40 and the BSCVA was 20/25 (plano -0.50 x 175) in the right eye and 20/20 (-0.50
-0.75 x165) in the left eye.
On March 18, 2008, after 9 years and 1.5 months since the uncomplicated LASIK, the patient
presented to emergency room 3 days after getting struck with a dog’s paw in his left eye. Patient
experienced a sharp pain and sudden decrease in vision. Patient was discharged from the
. emergency room on antibiotic drops as treatment for corneal abrasion, and was seen by an
optometrist the next day, who then referred the patient to the author (CMS).
Upon first visit to our service, 5 days after initial trauma, the UCVA was count fingers and the slit
lamp exam showed complete flap dislocation with mild flap edema without tears (Figure 2A). Stromal
bed of the flap was epithelialized and interface did not have debris. Immediate removal of epithelium
from stromal bed was completed under laser microscope. The flap interface was irrigated with
balanced salt solution and the flap was repositioned using irrigating cannula, Weck-Cel sponges and
a patent spatula. No alcohol glue or sutures were used.
The field was then irrigated with vancomycin fortified solution. A bandage contact lens secured the
flap (Figure 2B) and patient was maintained on Vigamox and Omnipred (Alcon, Fort Worth,Texas),
both at four times daily for 10 days. Patient was seen in follow up in 1 day, 1 week, and 1 month,
and 3, months. Final UCVA was 20/25, with no evidence of epithelial ingrowth, folds or diffuse
lamellar keratitis
Figure 2A. Color photo of left eye 3 days
after being struck by dog’s paw. Flap is totally
dislocated toward the nasal canthus, attached
at the nasal hinge without a tear. Whitish
debris represents epithelial ingrowth that is
encompassing about 30% of stromal bed
involving the visual axis.
Figure 2B. Color
photo of left eye with
bandage contact lens after surgical repair of
the flap dislocation and epithelial ingrowth.
There was no residual epithelial ingrowth and
cornea was clear (note photographic artifact
on inferonasal cornea).
Discussion
Absence of scar formation in the lamellar interface explains rapid restoration and persistence of
post-LASIK visual acuity.6, 7 Consequently, early displacement of LASIK is a well known
phenomenon documented in large studies. Gimbel and associates reported 12 eyes of 1000 (1.2%)
that had slipped flap within a day postoperatively.1 Similarly, Lin and Maloney reported 20 eyes out
of 1019 (2.0%) that had displaced flap within 24 hours of LASIK.2 Stulting and associates
repositioned 13 eyes out of 1062 (1.2%) within 2 days of surgery for dislocated flaps.3 Smaller case
reports and series have been published on late (postoperative week one or more) presentation of
flap dislocation. Our case is the first report in the English literature of flap displacement after over 9
years following LASIK, and a second report of late flap dehiscence treated medically without
surgical repair.
33 cases have been reported on late onset unilateral flap displacement.4-26 Mean age was 35 years
and there were 19 men and 15 women. Mechanisms of flap displacement ranged from
spontaneous8, iatrogenic9, to traumatic displacement due to domestic tools4, 10-13, finger injury4, 5, 14,
15, airbag12, 16, 17, ball5, 18, 19, and animals5, 20, 21. The onset of flap slippage ranged from 10 days to 7
years. Most common presentation was immediate visual loss associated with pain. Slit lamp
biomicroscopy revealed partial dehiscence of the flap in all but one case in which there was a total
loss of flap.15 Sixteen cases (48%) presented with flap folds, and 10 cases had epithelial ingrowth,
which was associated with delayed presentation after injury.
Discussion Continued
Only 2 cases of epithelial ingrowth were seen within 24 hours of injury and the rest presented 2 to
26 days after the injury. Twenty-two cases (67%) achieved final uncorrected or best spectacle
corrected visual acuity of 20/20. Seven eyes (21%) went down in vision with the worst visual loss of 3
lines corresponding to the total loss of LASIK flap.15 All but 4 eyes underwent surgical repair at the
first presentation following trauma. Two of the 4 cases underwent surgery later21, 22, one case was
treated medically only22, and the last case had total flap loss.15 After initial treatment, 11 eyes
developed diffuse lamellar keratitis, and 14 eyes epithelial ingrowth. Eleven of the 14 cases required
additional surgery to remove epithelium ingrowth.
Lack of stability of the flap can be attributed to the same reasons that give rise to the optical clarity of
flap. Animals as well as human studies have shown that adhesion between the flap-stromal bed
interface is limited to the edge of the wound.6-7 We postulate that if enough force is applied tangential
to the flap undermining tissue adhesions at the edge of the flap, the rest of the flap is then at risk of
partial or total dislocation. This phenomenon is observed when the author (CMS) lifts the flaps more
than 10 years following the original LASIK to perform enhancement surgeries.
Discussion
continued
We herein report the latest presentation of traumatic flap dislocation, emphasizing the fact that flap
interface is vulnerable to traumatic dehiscence for up to 9 years following LASIK. The cases reported
are comparable to 33 cases in literature. Case 2 presented 3 days after being struck with dog’s paw,
and had extensive epithelial ingrowth. Despite delayed presentation and the extent of the injury, he
was successfully treated and enjoyed good visual outcome. On rare occasions, peripheral flap
dehiscence may be treated medically without surgical intervention as shown in Case 1 and in a case
reported by Heickell and associates.22 In both cases, patient achieved final BSCVA of 20/20 after
treatment
with
topical
medications.
All patients undergoing LASIK should be educated about this possible complication associated with
lamellar corneal wound and instruct patients to seek ophthalmologic attention immediately to avoid
other complications associated with flap dehiscence. The surgeon may also urge patients to use
protective eye wear or even consider an alternative refractive procedure for patients with increased
occupational hazard to blunt eye trauma, such as those who work in the military or law enforcement,
or contact sport. Prompt surgical invention, however, is effective in restoring visual acuity in case of
flap
displacement.
References
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