Epithelial ingrowth after laser in situ keratomileusis

Ocular Complications of Diabetes and Therapeutic Approaches

Diabetes mellitus (DM) is a metabolic disease defined by elevated blood glucose (BG). DM is a global epidemic and the prevalence is anticipated to continue to increase. The ocular complications of DM negatively impact the quality of life and carry an extremely high economic burden. While systemic control of BG can slow the ocular complications they cannot stop them, especially if clinical symptoms are already present. With the advances in biodegradable polymers, implantable ocular devices can slowly release medication to stop, and in some cases reverse, diabetic complications in the eye. In this review we discuss the ocular complications associated with DM, the treatments available with a focus on localized treatments, and what promising treatments are on the horizon.

Effect of a hyperosmotic agent on epithelial disruptions during laser in situ keratomileusis

PURPOSE

To evaluate the incidence of epithelial disruptions during primary laser in situ keratomileusis (LASIK) with the use of a preoperative hyperosmotic treatment comprising sodium chloride 5% ophthalmic ointment (Muro-128) and to identify the incidence of epithelial disruptions in various demographic populations.

SETTING

TLC Laser Eye Center, McLean, Virginia, USA.

DESIGN

Comparative case series.

METHODS

Using a matched-pair design, hyperosmotic treatment was randomized to 1 eye of patients having bilateral LASIK. The primary outcome measure, epithelial integrity, was assessed in each eye. Epithelial integrity was evaluated in groups defined by characteristics that included age, sex, ethnicity, skin type, presence or absence of rosacea, eye color, and hair color.

RESULTS

The study evaluated 496 eyes of 248 patients. The preoperative hyperosmotic treatment was associated with significantly less corneal epithelial disruption, as indicated by an epithelial integrity score. Compared with control eyes, the rate of corneal epithelial disruptions in the population of treated eyes decreased by 40% (relative risk, 0.60; 95% confidence interval [CI], 0.38-0.95). Among the characteristics studied, age was the best predictor of corneal epithelial disruptions; every 1-year increase in age was associated with a 9.0% increase in the risk for corneal epithelial disruptions (odds ratio [OR], 1.09; 95% CI, 1.05-1.13). Eyes of patients older than 34 years had a 4.4 times greater odds of being associated with epithelial disturbances than eyes of patients 34 years or younger.

CONCLUSIONS

The preoperative use of hyperosmotic agents can reduce the risk for intraoperative epithelial disruptions during LASIK. An increase in epithelial disruptions was associated with increasing age.

Ophthalmic use of blood-derived products

There is a wide spectrum of blood-derived products that have been used in many different medical and surgical specialties with success. Blood-derived products for clinical use can be extracted from autologous or allogeneic specimens of blood, but recombinant products are also commonly used. A number of blood derivatives have been used for a wide range of ocular conditions, from the ocular surface to the retina. With stringent preparation guidelines, the potential risk of transmission of blood-borne diseases is minimized. We review blood-derived products and how they are improving the management of ocular disease.

Regeneration of corneal epithelium utilizing a collagen vitrigel membrane in rabbit models for corneal stromal wound and limbal stem cell deficiency

PURPOSE

This study was performed to evaluate the potential of a collagen-based membrane, collagen vitrigel (CV), for reconstructing corneal epithelium in the stromal wound and limbal stem cell deficiency (LSCD) models.

METHODS

Three groups of rabbits were used in the stromal wound model: CV affixed using fibrin glue (CV + FG group, n = 9), fibrin glue only (FG group, n = 3) and an untreated control group (n = 3). In the LSCD model, one group received CV containing human limbal epithelial cells (CV + hLEC group, n = 2) and the other was an untreated control (n = 1). Gross observation, including fluorescent staining, pathological examination, immunohistochemistry and electron microscopy, was used to evaluate the effect of CV on the corneal epithelium.

RESULTS

In the stromal wound model, fluorescent staining showed that epithelial reconstruction occurred as rapidly in the CV + FG group as it did in the control group. The pathological examination proved that the CV supported a healthy corneal epithelium in the CV + FG group, whereas FG led to hypertrophy and inappropriate differentiation of corneal epithelium in the FG group. In the LSCD model, the corneas in the CV + hLEC group showed sustained tissue transparency with good epithelialization, low inflammatory response and reduced neovascularization. However, the control cornea was translucent and showed high amounts of inflammation and neovascularization.

CONCLUSION

We have demonstrated that CV supports corneal epithelial differentiation and prevents epithelial hypertrophy, in addition to serving as a scaffold for hLEC transplantation, without complications.

Etiopathogenesis and therapy of epithelial ingrowth after Descemet's stripping automated endothelial keratoplasty

Descemet's stripping endothelial keratoplasty is an emerging technique finalized to treat endothelial dysfunction replacing only the pathological portion of cornea. The advent of any new technique puts us in front of new complications. The epithelial ingrowth is a well-known complication already studied in case of ocular trauma and more recently in refractive surgery. This job analyzed the potential etiopathogenesis of epithelial ingrowth after DSAEK, reviewing the cases described in literature, and suggests the potential therapy.

Marginal ectropion induced by conjunctival ingrowth after levator resection surgery

BACKGROUND

Levator resection surgery is commonly performed to correct ptosis, and a large number of postoperative complications are well known. This report presents a previously unreported complication of marginal ectropion after levator resection surgery for congenital ptosis.

METHODS

The three patients with upper eyelid marginal ectropion in this observational case series previously had undergone levator resection surgery for congenital ptosis. The patients' medical records and clinical photographs were reviewed retrospectively. The patients underwent reoperations for ectropion correction. Unusual tissues identified during the surgery were excised and processed for histopathologic analysis.

RESULTS

The patients presented with upper eyelid marginal ectropion and had a history of levator resection surgery for congenital ptosis on the same eye. Ingrown tissues were observed during the second operations for ectropion correction in all three patients. Histopathologic analysis was performed for two of the patients, confirming that the tissue consisted of mucosa. The ectropions were corrected after surgical removal of the ingrown tissues.

CONCLUSIONS

Marginal ectropion can occur after levator resection surgery. In this study, the ectropion was attributed to mucosal ingrowth, a complication not previously reported. To improve the surgical outcomes, surgeons should be aware of this complication.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Management of residual refractive error after laser in situ keratomileusis and photorefractive keratectomy

PURPOSE OF REVIEW

To review the various steps and methods in managing residual refractive error after laser in situ keratomileusis and photorefractive keratectomy (PRK).

RECENT FINDINGS

Past studies have shown the efficacy and safety of flap relifts over recuts and for surface ablation over the flap. Other previous and also more recent studies show the use of a femtosecond laser for side cuts only. Recently, the creation of a femtosecond mini flap has been described. New studies also demonstrate the use of collagen cross-linking in postrefractive surgery ectasia.

SUMMARY

Residual refractive error is a known complication after both laser in situ keratomileusis and PRK. A systematic approach should be taken to manage this complication starting with a thorough evaluation to determine if an enhancement is indicated and if so, which method will be the safest and most efficacious for the patient.

Healthcare and a holiday: the risks of LASIK tourism

Medical tourism is the practice of travelling overseas for surgery. We describe a patient with low myopia who underwent laser in situ keratomileusis (LASIK) while on holiday in India. She presented to local hospital eye services six weeks post-LASIK with discomfort and reduced vision. She reported three previous LASIK flap lifts in the right eye. Clinical assessment, optical coherence tomography and confocal microscopy demonstrated moderate epithelial ingrowth and reduced visual acuity. Epithelial ingrowth after LASIK may be associated with visual impairment and management is determined by location, magnitude and effect on vision. LASIK tourism may mean patients are less well-informed of risks and lose continuity of professional care.

Spontaneous resolution of delayed epithelial ingrowth after LASIK

OBJECTIVE

Epithelial ingrowth is a known complication after laser in situ keratomileusis (LASIK), with a high incidence after repeat surgery or trauma. The authors report the occurrence of epithelial ingrowth 23 months after primary LASIK and its subsequent spontaneous resolution over the following 6 months.

METHODS

A 35-year-old man underwent bilateral uneventful microkeratome-assisted LASIK in June 2008. The patient presented 23 months later after noticing a "white spot" in his left eye. Examination of the left eye showed an oval patch of epithelial growth in the superonasal quadrant. Uncorrected distance visual acuity (UDVA) was 1.0 OD and 0.6 OS. Topical fluorometholone 0.1% eye drops were prescribed four times a day. Over the next 2 weeks, the UDVA improved to 1.0 and the size of the interface opacities decreased slightly. However, no further change was observed with continuation of corticosteroid eye drops over the next 2 weeks. All treatment was stopped. Three months later, the epithelial ingrowth expanded toward the visual axis. An option of surgical intervention was refused by the patient.

RESULTS

Subsequent monthly follow-ups over another 3 months showed gradual decrease in the size of epithelial growth. Final slit-lamp examination showed complete clearance of the epithelial cells from the interface. The UDVA returned to 1.0 in the left eye.

CONCLUSIONS

Epithelial ingrowth can occur after a long interval after primary LASIK. In our case, the epithelial cells disappeared without any surgical intervention over a period of 6 months.

Laser in situ keratomileusis in 2012: a review

Laser in situ keratomileusis (LASIK) is a safe and effective treatment for refractive error. A combination of technological advances and increasing surgeon experience has served to further refine refractive outcomes and reduce complication rates. In this article, we review LASIK as it stands in late 2012: the procedure, indications, technology, complications and refractive outcomes.

Can intraoperative use of limbal stay suture in strabismus surgery cause epithelial ingrowth?

Epithelial ingrowth has been reported extensively as a result of some corneal procedures and secondary to trauma. The authors describe a case of epithelial ingrowth most likely caused by a limbal stay suture used during strabismus surgery. The pathophysiology of epithelial ingrowth and its differential diagnosis of fibrous downgrowth are discussed.

Fibrin glue for prevention of recurrent epithelial ingrowth under a LASIK flap with a central buttonhole defect

A 61-year-old woman presented with a paracentral buttonhole flap defect associated with a linear tear, extensive epithelial ingrowth, and macrostriae in the right eye. A laser in situ keratomileusis enhancement had been performed 3 weeks earlier. The epithelial ingrowth was removed after careful lifting of the flap, and tissue adhesive was used postoperatively as a barrier to further ingrowth. Six months postoperatively, the patient's corrected distance visual acuity had improved to 20/20 and the slitlamp examination showed no evidence of recurrent epithelial ingrowth. This case presents a novel approach to the management of a buttonhole defect.

Laser refractive surgery in diabetic patients: a review of the literature

BACKGROUND

The purpose of this study was to evaluate the current recommendations regarding laser refractive surgery in patients with diabetes mellitus and to assess whether these patients make appropriate candidates for laser vision correction.

METHODS

A literature search was conducted to identify current research on the ocular complications of diabetes and original publications on laser refractive surgery in diabetic patients.

RESULTS

Diabetes was associated with several ocular complications. Initially the US Food and Drug Administration listed these complications as justification to advise against refractive surgery in patients with diabetes. However, recent studies on laser in situ keratomileusis in diabetic patients indicate that this procedure may be safe in diabetic patients with very well controlled systemic disease and no ocular manifestations.

CONCLUSION

Laser refractive surgery may be performed safely in a very selected group of patients with diabetes.

LASIK interface complications: etiology, management, and outcomes

PURPOSE

To describe the etiology, diagnosis, clinical course, and management of LASIK interface complications.

METHODS

Literature review.

RESULTS

Primary interface complications include infectious keratitis, diffuse lamellar keratitis, central toxic keratopathy, pressure-induced stromal keratopathy (PISK), and epithelial ingrowth. Infectious keratitis is most commonly caused by Methicillin-resistant Staphylococcus aureus (early onset) or atypical Mycobacterium (late onset) postoperatively, and immediate treatment includes flap lift and irrigation, cultures, and initiation of broad-spectrum topical antibiotics, with possible flap amputation for recalcitrant cases. Diffuse lamellar keratitis is a white blood cell infiltrate that appears within the first 5 days postoperatively and is acutely responsive to aggressive topical and oral steroid use in the early stages, but may require flap lift and irrigation to prevent flap necrosis if inflammation worsens. In contrast, PISK is caused by acute steroid response and resolves only with cessation of steroid use and intraocular pressure lowering. Without appropriate therapy PISK can result in severe optic nerve damage. Central toxic keratopathy mimics stage 4 diffuse lamellar keratitis, but occurs early in the postoperative period and is noninflammatory. Observation is the only effective treatment, and flap lift is usually not warranted. Epithelial ingrowth is easily distinguishable from other interface complications and may be self-limited or require flap lift to treat irregular astigmatism and prevent flap melt.

CONCLUSIONS

Differentiating between interface entities is critical to rapid appropriate diagnosis, treatment, and ultimate visual outcome. Although initial presentations may overlap significantly, the conditions can be readily distinguished with close follow-up, and most complications can resolve without significant visual sequelae when treated appropriately.

Laser confocal microscopy is a valuable, non-invasive tool for early diagnosis and characterisation of epithelial nests

A 22-year-old woman presented with blurred vision and glare in the right eye, which had been present for three months. The patient had undergone laser-assisted in situ keratomileusis nine months previously and enhancement three months thereafter. On ophthalmological examination, visual acuity was 6/8.6 in the right eye and 6/6 in the left eye. An opaque epithelial nest below the flap with a visible demarcation line was detected along the pupil margin in the right eye. Subsequent laser confocal microscopy revealed the presence of epithelial cells in a whorled pattern with irregular astigmatism on corneal topography. Three months later, the clinical symptoms had worsened and a denser and larger wedge-shaped epithelial nest was observed. The nest was scraped. Six months later, the patient exhibited restored visual acuity (6/6) without glare. Laser confocal microscopy is a valuable, non-invasive tool and provides in vivo pathological images for early diagnosis and localisation of lesion depth in epithelial nests to guide appropriate surgical management.

Femtosecond laser-assisted enhancements after laser in situ keratomileusis

We describe a technique of femtosecond laser-assisted enhancement after primary LASIK with a mechanical microkeratome-created flap. The vertical side-cut incision by the femtosecond laser creates a wound configuration that decreases mechanical trauma to the epithelium and prevents epithelial cell migration. These factors may decrease the risk for post-LASIK enhancement epithelial ingrowth.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Nd:YAG laser treatment for epithelial ingrowth after laser refractive surgery

Epithelial ingrowth under refractive surgery flaps occurs in primary treatment and in further flap lift. Nd:YAG treatment was first described in 2008. In the only series published to date, 100% of patients treated had topographic and symptomatic improvement. The authors pictorially illustrate two cases of epithelial ingrowth following laser in situ keratomileusis achieving complete symptomatic relief and marked microscopic improvement following Nd:YAG laser treatment.

Effects of fluorescein staining on laser in vivo confocal microscopy images of the cornea

This study was designed to identify whether topical fluorescein, a common ophthalmic tool, affects laser in vivo confocal microscopy of the cornea, a tool with growing applications. Twenty-five eye care specialists were asked to identify presence or absence of fluorescein in 99 confocal micrographs of healthy corneas. Responses were statistically similar to guessing for the epithelium (48% ± 14% of respondents correct per image) and the subbasal nerve plexus (49% ± 11% correct), but results were less clear for the stroma. Dendritic immune cells were quantified in bilateral images from subjects who had been unilaterally stained with fluorescein. Density of dendritic immune cells was statistically similar between the unstained and contralateral stained eyes of 24 contact lens wearers (P = .72) and of 10 nonwearers (P = .53). Overall, the results indicated that fluorescein staining did not interfere with laser confocal microscopy of corneal epithelium, subbasal nerves, or dendritic immune cells.

Removal of epithelial ingrowth via central perforating wound tract 6 years post LASIK

BACKGROUND

The purpose was to report a case of a novel approach for the removal of central interface epithelial ingrowth caused by a perforating corneal injury 6 years after laser-assisted in situ keratomileusis (LASIK).

METHODS

Access to a large central area of epithelial ingrowth under a LASIK flap was achieved through the wound tract from a perforating corneal injury. Suturing of the central LASIK flap in a similar manner commonly carried out peripherally was then performed to prevent recurrent epithelial ingrowth.

RESULTS

The offending epithelial ingrowth was removed with no recurrence over a 1-year follow-up.

CONCLUSIONS

This is, to our knowledge, the first reported case of central epithelial ingrowth removal from a LASIK interface by a perforating injury wound tract.

Comparison of laser in situ keratomileusis flaps created by 3 femtosecond lasers and a microkeratome

PURPOSE

To evaluate the thickness and side-cut angle of laser in situ keratomileusis (LASIK) flaps created by 1 of 3 femtosecond lasers or a microkeratome using Fourier-domain optical coherence tomography (OCT).

SETTING

Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea.

DESIGN

Comparative case series.

METHODS

Flap creation for bilateral LASIK was performed using an IntraLase (femtosecond group 1), VisuMax (femtosecond group 2), or Femto LDV (femtosecond group 3) femtosecond laser or an M2 microkeratome. Flap thickness was determined at 14 points. The side-cut angle was measured in 4 directions at the margin interface. Measurements were taken 2 months postoperatively using an RTVue Fourier-domain OCT device and integrated software.

RESULTS

Femtosecond group 1 comprised 50 eyes; femtosecond group 2, 40 eyes; femtosecond group 3, 64 eyes; and the microkeratome group, 52 eyes. Eyes in femtosecond groups 1 and 2 had relatively even flap configuration. Flaps in femtosecond group 3 and the microkeratome group had a meniscus shape. Flaps in femtosecond group 1 had the least difference between the mean peripheral and the central flap thickness (P<.001). The greatest flap thickness predictability (measured versus intended thickness) was in femtosecond group 3 (P<.001). Flaps in femtosecond group 1 had a side-cut angle closest to 90 degrees (P<.001).

CONCLUSIONS

Flap morphology differed according to the system used. The 3 femtosecond laser systems appeared to be superior to the microkeratome system generally. The 3 femtosecond laser systems also produced different flap configurations depending on their individual mechanisms.

Retreatment of residual refractive errors with flap lift laser in situ keratomileusis

PURPOSE

To investigate the outcomes of flap lift laser-assisted in situ keratomileusis (LASIK) for residual refractive errors.

METHODS

In this prospective study, 60 eyes of 48 patients (mean age 36 years; age range 23-53 years) underwent flap lift retreatment surgery following initial LASIK for the correction of residual refractive errors. All treatments were wavefront guided using the VISX S4 Star excimer laser. The main outcome measures were predictability, safety, efficacy, and stability.

RESULTS

Following retreatment, epithelial ingrowth occurred in 23.3% (n=14) of eyes, which required a flap lift and scrape procedure in 4 eyes and a second flap lift and scrape procedure in 2 eyes. De novo dry eye occurred in 8.3% (n=5) of eyes. At 6 months, the mean (±SD) post-retreatment Snellen decimal uncorrected visual acuity (UCVA), sphere, cylinder, spherical equivalent (SE), defocus equivalent (DE), and best corrected visual acuity (BCVA) was 1.03±0.23, 0.08±0.34 diopters (D) (range -0.75 to +1.25 D), -0.53±0.37 D (range 0 to -1.75 D), -0.04±0.34 D (range -1.11 to +1.04 D), 0.29±0.41 D (range 0 to 1.94 D), and 1.13±0.15 (range 0.5 to 1.5), respectively. Seventy-three percent (n=44) of eyes had an UCVA equal to or greater than 1 (6/6), 88.3% (n=53) and 98.3% (n=59) of eyes were within ±0.50 D and ±1.00 D of SE, respectively, and 3.3% (n=2) of eyes lost 1 line of BCVA.

CONCLUSIONS

A high incidence (23.3%, n=14) of epithelial ingrowth occurred following retreatment surgery and de novo dry eye occurred in 8.3% (n=5) of eyes. Despite this, reasonable visual and refractive outcomes were achieved at 6 months post-retreatment.

Flap lift and repair of postoperative laser in situ keratomileusis complications at the slitlamp

We describe a technique to treat flap complications after laser in situ keratomileusis while seated at the slitlamp biomicroscope. After topical anesthesia is applied to the cornea, a blunt corneal spatula is used to reflect the flap only to the extent necessary for epithelial debridement. A corneal rake or spatula is then used to remove retained epithelial cells from the stromal bed and underside of the flap. The epithelium is then debrided 1.0 mm to 2.0 mm outside the flap gutter. The increased depth perception with a slit beam greatly improves visualization and identification of the presence of residual epithelial cells or leftover debris after scraping. The slit beam also aids in proper repositioning of the flap after the procedure.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Incidence of epithelial ingrowth in primary and retreatment laser in situ keratomileusis

PURPOSE

To analyze the risk for clinically significant epithelial ingrowth after primary laser in situ keratomileusis (LASIK) and flap-lift retreatment LASIK.

SETTING

Private practice, Beverly Hills, California, USA.

METHODS

All cases of primary and flap-lift retreatment LASIK performed by the same surgeon in a single surgical center between January 2004 and June 2007 were retrospectively reviewed. Cases that subsequently developed clinically significant epithelial ingrowth, defined as epithelial ingrowth impeding on the visual axis and negatively affecting uncorrected or corrected distance visual acuity, were identified and analyzed.

RESULTS

Clinically significant epithelial ingrowth occurred in none of the 3866 primary LASIK cases and in 15 (2.3%) of the 646 flap-lift retreatment cases (P<.0001). Clinically significant ingrowth was more frequent when flap-lift retreatment was performed 3 or more years after primary LASIK (7.7% versus 1.0%) (P = .0001). Patient age and sex did not have a statistically significant effect on the epithelial ingrowth rate. There was a nonsignificant trend toward increased epithelial ingrowth after flap-lift retreatment of Automated Corneal Shaper (ACS) microkeratome flaps.

CONCLUSION

Flap-lift retreatment performed 3 or more years after primary LASIK led to a higher risk of clinically significant epithelial ingrowth than primary LASIK or earlier flap-lift retreatment.

FINANCIAL DISCLOSURE

The author has no financial or proprietary interest in any material or method mentioned.

Influence of original flap creation method on incidence of epithelial ingrowth after LASIK retreatment

PURPOSE

To compare the rate of epithelial ingrowth after LASIK retreatment among eyes with flaps created by femtosecond laser and those created by mechanical microkeratome.

METHODS

Postoperative results from 272 consecutive LASIK retreatments performed by a single surgeon over a 4-year period were reviewed retrospectively to identify cases that developed clinically significant epithelial ingrowth, defined as that which required surgical removal. Flaps for the original LASIK treatments were created using a mechanical microkeratome or femtosecond laser. The same technique to lift the flap at the time of retreatment was used in all eyes included in this study.

RESULTS

LASIK retreatment was performed in 132 eyes that had the initial flap created using a mechanical microkeratome (microkeratome group). Epithelial ingrowth was identified in 11 eyes of 9 patients. Surgical intervention to remove the epithelium from the stromal interface was required in 8 (6.1%) eyes. Femtosecond laser was used to create the initial LASIK flap in 140 eyes that required retreatment (femtosecond group). Epithelial ingrowth after LASIK retreatment was identified in 2 eyes of 1 patient in the femtosecond group (P=.004). Neither of these 2 eyes required surgical intervention to remove the epithelium from the stromal interface (P=.017).

CONCLUSIONS

Eyes with femtosecond laser-created flaps may be less likely to develop significant epithelial ingrowth after LASIK retreatment when compared with eyes in which the flap was created using a mechanical microkeratome. The difference in rate of epithelial ingrowth may be related to the geometry of the flap edge.

Intracorneal epithelial ingrowth after descemet stripping endothelial keratoplasty and stromal puncture

PURPOSE

To report a case of intracorneal epithelial ingrowth after Descemet stripping endothelial keratoplasty (DSEK) with stromal puncture for phakic bullous keratopathy.

METHODS

A 35-year-old man underwent DSEK for phakic bullous keratopathy in his right eye after an episode of trauma some years ago. Intraoperative drainage of interlamellar fluid was assisted by stromal punctures. Postoperatively, the patient had a best-corrected visual acuity of 20/40 in his right eye. A small area of epithelial ingrowth appeared in the corneal intrastromal interface inferiorly as an irregular flat haze about a month after surgery. It was in continuity with the inferior stromal puncture incision made intraoperatively. By 10 months, the epithelial pearls became confluent and homogenously white with a sharp demarcation.

RESULTS

Because the epithelial ingrowth remained stationary till the last follow-up (13 months), no surgical intervention was planned. The central visual axis was clear and the best-corrected visual acuity was 20/40.

CONCLUSIONS

Epithelial ingrowth into the cornea may occur after an uncomplicated DSEK with stromal puncture. Patients undergoing DSEK should be closely monitored for development and progression of intracorneal epithelial ingrowth, especially when stromal punctures have been made to drain interface fluid.

Epithelial ingrowth after femtosecond laser-assisted in situ keratomileusis

PURPOSE

To describe the incidence and clinical features of epithelial ingrowth after femtosecond laser-assisted in situ keratomileusis (LASIK).

METHODS

All eyes with clinically significant epithelial ingrowth were identified from patients who underwent primary femtosecond laser-assisted LASIK and their subset of patients who underwent enhancement procedures from January 2005 to March 2007 at Kudret Eye Hospital. Clinical course in terms of severity, type of epithelial ingrowth, time of appearance, effect on visual acuity, and treatment was described for each patient.

RESULTS

Two eyes of 6415 eyes after primary procedure and 2 eyes of 108 eyes after enhancement procedure developed clinically significant epithelial ingrowth. All eyes were treated with surgical removal of epithelial ingrowth. The epithelial ingrowths in all the patients were seen as solitary islands of cells, with a size ranging between 1 and 3 mm, beneath the flap with no connection with the surface epithelium. There was recurrence of ingrowth in 1 eye.

CONCLUSIONS

Visually significant epithelial ingrowth after femtosecond laser-assisted LASIK is an infrequent complication. The lower incidence of epithelial ingrowth after femtosecond LASIK surgery compared with mechanical microkeratome-assisted LASIK may be attributed to the anatomy of the femtosecond laser-created side cut in contrast to that created with a mechanical microkeratome and the creation of less peripheral trauma at the time of flap creation.

Delayed epithelial ingrowth caused by viral conjunctivitis after LASIK

To report a patient who presented with epithelial ingrowth caused by viral keratoconjunctivitis 3 months after LASIK surgery. A 41-year-old man presented with decreased visual acuity in the right eye, which had developed about 3 weeks before. He had undergone LASIK surgery 3 months prior without complications. Two months after the surgery, he was treated for viral conjunctivitis. During the treatment period, filamentary keratitis developed, and a therapeutic bandage contact lens was applied for 2 weeks. Upon presentation, examination revealed a corrected visual acuity of 20/100 and irregular epithelial sheets under the edematous flap. The flap was lifted, and the in-grown epithelium was removed. The flap was repositioned with double continuous 10-0 nylon sutures. Post-operatively, the patient developed a mild diffuse lamellar keratitis that resolved rapidly with topical corticosteroid treatment. At 2 months, the corrected visual acuity was 20/20 without interface opacities. As the patient showed no complications prior to viral conjunctivitis, we suspect that the viral infection caused edema of the corneal flap, which caused epithelial ingrowth under the flap. Patients who have viral conjunctivitis after LASIK surgery should be examined carefully and managed with consideration of flap complications.

Recalcitrant epithelial ingrowth in patients with compromised eyelid function

PURPOSE

To report recalcitrant unilateral epithelial ingrowth in two patients with ipsilateral weak eyelid closure.

METHODS

Two patients with weak eyelid closure who underwent simultaneous, uncomplicated LASIK developed unilateral epithelial ingrowth.

RESULTS

Eight months postoperatively, one patient presented with right-sided epithelial ingrowth. One month after removal, more extensive epithelial ingrowth was noted and removed, and the flap gutters were sealed with fibrin adhesive. Epithelial ingrowth recurred 1 week later. The epithelial ingrowth was removed and the flap was secured with concurrent placement of radial 10-0 nylon sutures. No further epithelial ingrowth recurred. In the second patient, epithelial ingrowth was noted in the left eye 4 months postoperatively. Eight months later, the ingrowth was removed with subsequent recurrence in 2 weeks.

CONCLUSIONS

Weak eyelid closure may be a predisposing factor to poor flap adhesion and epithelial ingrowth. Close attention to lid function may be of importance in deciding between LASIK and photorefractive keratectomy, particularly in patients with other risk factors for epithelial ingrowth.