FLAP LIFT AND REPAIR OF

POSTOPERATIVE LASER IN
SITU KERATOMILEUSIS
COMPLICATIONS AT THE
SLITLAMP
Richard S. Koplin, MD, David C.
Ritterband,MD, Olivia L. Lee,MD, John A.
Seedor,MD
J Cataract Refract Surg 2010;36:1069-1072

POST OPERATIVE COMPLICATION

OF LASIK

Epithelial ingrowth
Diffuse lamellar keratitis
Interface debris
Corneal striae
Flap injury

Require
intervention

Lifting the LASIK flap

ND:YAG LASER

Reported to successfully treat interface

epithelial ingrowth

COMPARED BETWEEN

Surgical microscope:
Lighting
Depth perception

Limit visualization
and precise flap
repositioning

Versus

Slit lamp
-width
-angulation

variative

OVERHEAD MICROSCOPE
Hinder identification of :
Leftover debris under the flap

The presence of residual epithelial cells after

stromal bed

Stromal underside of the flap have been

scraped

TO MANAGE THE
COMPLICATION:

Flap elevation and repair

Topical anesthesia

@ the slitlamp biomicroscope

Avoiding a return to the operating room

SURGICAL TECHNIQUE

Topical propacaine
anesthesia
Povidone-iodine
Stainlesss-steel lid speculum is placed
The patient is seated @ the slitlamp
Maintain the heads potition during the
procedure
The flap margin is identified by slitlamp
biomicroscopy.
A blunt flap elevator (eg, Machat LASIK
retreatment spatula, ASICO)is used to lift and
reflect the flap to the extent necessary for
epithelial debridement

The whole flap does not to be elevated

The epithelial side of the partially reflected
flap commonly adheres to the unexposed
corneal surface
providing visibility to the
surgical field
If the flap does not remain adherent a 2handed technique is used to maintain the
flap position
The surface is then examined by slitlamp
under high magnification
islands of
epithelial cells or interface debris

More extensive undermining of the flap

Mechanical debridement of epithelium from
the stromal bed
Underside of the flap is performed
Machat
spatula/ a corneal rake to peel and remove
any epithelial ingrowth
The slit beam lighting enhanches visibility in
fastidious & complete removal of cells and
debris.
The underside of the flap can be scrapped
using the spatula
The epithelium is then debrided 1-2mm
outside the flap gutter

Wet the surface of the flap after debridement

BSS
Reposition the flap in the stromal bed using the
spatula
A wet cellulose sponge to smooth and refine
the the flap position
The flap is allowed to dry for 60-90 seconds
Ensure proper removal of all epithelial cells
30 seconds prior to removing the lid
speculum
After the procedure topical AB and
corticosteroid agents 4 times daily for 1 week

RESULT
7 eyes of 6 patients were treated for
-clinically significant epithelial ingrowth (6)
-traumatic flap dislocation (1)
microkeratome LASIK
The same surgeons performing
The patients tolerated the procedure well
No intraoperative or postoperative
complication were experienced
Epithelial ingrowth did not recur
follow- up
period
UDVA of 20/20

Fig 1. A: flap lifter initiating elevation in area to be treated.

B: The LASIK flap reflected back and adherent to surface while the
corneal rake is used to scrape the stromal bed. Only the flap area with
epithelium ingrowth has to be elevated.
C: Higher magnification image of the corneal rake

REPRESENTATIVE CASE
HISTORIES I

A 34-year old man

bilateral LASIK

4 years later

UDVA LE=RE

Struck in RE with barbed wire

Pain
Decreased vision
D/ Corneal abrasion
Th: Gentamicin eo
Referred

Emergency room

48 HOURS AFTER THE TRAUMA

UDVA 20/200
Lasik flap was dislocated from 5-10 oclock
The flap folded on itself
The exposed stromal bed in the
inferotemporal quadrant
- epithelized
- did not stain with fluoresin
Epithelial ingrowth extended into the flap
stromal interface
The flap hinge appeared to be intact

4 DAYS AFTER THE TRAUMA

Slitlamp repair
- flap lifting
- epithelial debridement of the stromal
interface and underside of the flap
- flap repositioning

1 day after repair:

UDVA : 20/30
The flat was noted
-to be flat
- in place
No epithelial debris

2 WEEKS AFTER THE INJURY

UDVA 20/20
Trace subepithelial haze remained inferiorly

CASE HISTORY II

A 42 year- oldman with myopia

-2,00 RE , -1,75 LE
Noncustomized LASIK in both eyes
Mechanical microkeratome with 8,5 mm ring
Ablationed was performed
Optical zone of 5,5 mm, transition zone of
7,7mm

6 YEARS LATER

To correct residual myopic astigmatism:

flap lift and enhancement was performed
Epithelial ingrowth (+) under both flaps
Extended close to the visual axis :3 weeks
Patient complaint :fluctuating and blurry
vision
UDVA 20/25 in both eyes
5 weeks after enhancement:
- both flap was lift
-epithelial ingrowth was scrapped

5 WEEKS AFTER THE ENHANCEMENT

CDVA improved to 20/20 RE and 20/15 LE
First day following flap lift
@4 months :
-linear area of epithelial ingrowth at the flap
edge RE
- no progression and no epithelial cells were seen
in LE

DISCUSSION

Flap lift with the aid of slitlamp

biomicroscopic for repair of post-LASIK
complication
distinct advantage
The surgeon can actively
-alter the slitlamps light intensity
- depth of focus
- beam width
- angle
visualize of the lap interface during
procedure

OPERATING MICROSCOPE

Fixed wide beam of the light source

Cornea cannot be viewed in a cross section
with dynamic manipulation of the light
source

SLITLAMP BIOMICROSCOPIC

Recommended
To ensure that all traces of epithelium are
removed
Little risk for regrowth of cells
In the case of debris remnant that might
induce haze ( as might be seen in Nd:YAG
Laser treatment of interface cells)
Simple and efficient
Immediate
Cost effective repair

Thank you very much