Traumatic corneal flap avulsion and loss 13 years after LASIK

Late-onset traumatic corneal flap dislocation and secondary epithelial ingrowth 24 years after LASIK

Purpose

To analyze the diagnostic process, treatment, and post-operative outcomes of a unique case involving a late-onset (24 years post) traumatic corneal flap displacement after Laser-assisted in situ keratomileusis (LASIK) surgery due to a plant-related trauma. with an emphasis on the accompanying extensive epithelial ingrowth beneath the flap.

Observations

A 59-year-old male patient experienced corneal flap displacement 24 years post-LASIK due to a minor plant-related trauma. This case was complicated by extensive epithelial ingrowth beneath the flap, which was initially misdiagnosed with fungal keratitis. Upon identification of the actual cause, corneal flap repair surgery was performed, leading to partial vision recovery.

Conclusions and importance

This case signifies the potential for LASIK flap displacement even decades post-surgery due to minor traumas and highlights the need for vigilance in diagnosing associated complications like epithelial ingrowth. It indicates the importance of ophthalmologists and clinicians being vigilant for such complications and necessitates their familiarity with basic management techniques or quick referral to a corneal refractive surgery specialist. This report of a 24-year interval between LASIK and traumatic flap displacement with epithelial ingrowth is one of the longest known. The case also demonstrates that patients with late flap displacement can regain significant visual acuity with timely and appropriate management.

Flap-making patterns and corneal characteristics influence opaque bubble layer occurrence in femtosecond laser-assisted laser in situ keratomileusis

Background

Opaque bubble layer (OBL), which generates from photo-disruptive procedures on the cornea, has been a common phenomenon during femtosecond laser-assisted refractive surgeries and it would potentially impact eye tracking and flap lifting. And we have observed that an updated flap-making pattern could form less OBL clinically than the traditional pattern, which needed further approval. Thus, the purpose of this study is to prove our observation and investigate the possible risk factors related to the occurrence and type of OBL in laser in situ keratomileusis (LASIK) flaps using the Visumax laser system.

Methods

This prospective study included 167 eyes of 86 patients (mean age: 27.5 ± 6.1 years) undergoing bilateral femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia/myopic astigmatism by the same surgeon from April 2020 to August 2020. Preoperative data on refraction, central corneal thickness (CCT), and keratometry as well as intraoperative data were included for analysis. A new flap-making pattern creating an offset between flap-cut and side-cut was adopted to compare with the traditional pattern. The operation video of flap formation was analyzed to identify the existence and type of OBL. The area covered by OBL and the ratio of OBL to flap were calculated using Image J software.

Results

Among 167 eyes, 54 eyes (32.3%) developed OBLs, consisting of 31 as hard OBL coexisting with soft OBL, and 23 as soft OBL alone. The OBL incidence was significantly reduced in eyes with the new flap-making pattern compared with the traditional pattern (13.8% vs. 52.5%, P < 0.001). Hard OBLs had larger area ratios than soft OBLs (14.3 ± 8.3% vs. 1.1 ± 1.8%, P < 0.001). Univariate analyses revealed that eyes with more myopia, thicker CCT, and traditional flap-making patterns were more likely to develop OBLs. Multivariate analysis further confirmed that more myopia, thicker CCT, and traditional flap-making pattern were risk factors for OBLs. A Larger corneal diameter was associated with a higher incidence of hard OBL when applying the traditional flap-making process.

Conclusion

More myopia, thicker CCT, and larger corneal diameter were risk factors for OBL development during flap creation, whereas a flap-making pattern with an offset between flap-cut and side-cut could reduce the incidence of OBL.

Traumatic Flap Complications After Femtosecond LASIK

PURPOSE

The purpose of this article was to evaluate the prognosis of traumatic flap dislocation or avulsion in a large series of laser-assisted in situ keratomileusis (LASIK) cases.

METHODS

Retrospective, consecutive, noncomparative case series analyzes the visual and anatomical results after flap dislocation or avulsion, caused by trauma occurred at least 1 month after LASIK.

RESULTS

A total of 37,315 eyes of 19,602 patients were reviewed. A traumatic flap complication was observed in 9 eyes of 9 patients, with a maximum interval of 37 months after surgery. Flap dislocation with central full-thickness folds was found in 5 cases; flap lifting and repositioning achieved a full recovery of uncorrected visual acuity. In another case, a partially detached flap was repositioned by a microsponge without lifting; self-limiting localized epithelial ingrowth followed. In 3 eyes, a complete flap avulsion occurred and, after epithelialization, a moderate refractive change was observed, comprised between -0.25 and -1 diopters (D) of spherical equivalent, with astigmatism <1 D; in 1 eye, the resulting myopia was corrected by repeat femtosecond LASIK.

CONCLUSIONS

Traumatic flap complications after femtosecond LASIK are rare but can occur even in the long term; they have a favorable anatomic and visual prognosis.

Flap amputation for long-standing post-LASIK flap dislocation with epithelial ingrowth

A man aged 26 years presented with complaints of diminution of vision in his right eye for 1 year following a fist injury. He had a history of laser-assisted in situ keratomileusis in both eyes 5 years earlier. On examination, his uncorrected distance visual acuity (UDVA) in the right eye was 1.0 logMAR. Slit-lamp examination of the right eye revealed a superotemporal dislocation of the flap with coexisting epithelial ingrowth encroaching the pupillary area. Due to the presence of long-standing fixed flap folds, a flap amputation was performed along with removal of the epithelial ingrowth using 0.02% mitomycin C as adjunct. Postoperatively, the UDVA was 0.3 logMAR on day 1, which improved to 0.2 logMAR at 1 week. At 1 year, the UDVA was 0.2 logMAR improving to 0.1 logMAR with refraction, with minimal paracentral corneal haze and no signs of corneal ectasia.

Traumatic displacement of laser in situ keratomileusis flaps: an integrated clinical case presentation

Background

Traumatic dislocation of laser-assisted in situ keratomileusis (LASIK) corneal flaps is an uncommon postoperative complication that could occur any time after LASIK, and could be visually devastating. We evaluated the visual outcomes, corneal sensation, tear function, and dry eye questionnaire results of patients with traumatic dislocation of LASIK flaps, including one LASIK flap amputation.

Methods

This is a retrospective case series. Seven patients who were diagnosed with traumatic displacement of the LASIK flap and underwent flap replacement surgery between August 2014 and January 2019 were included.Patient’s visual acuity, refraction, corneal sensitivity, non-invasive tear breakup time (NIBUT), tear meniscus height (TMH), and ocular surface disease index (OSDI) results were evaluated.

Results

The patients’ mean age was 35.86 ± 5.84 years, and 42.9 % (3/7) were male. The mean duration from LASIK to trauma was 8.86 ± 2.48 years.The mean preoperative and postoperative six-month corrected distance visual acuity (CDVA) were 0.55 ± 0.34 and 0.02 ± 0.03, respectively. The mean spherical equivalent and astigmatism at six months postoperatively was − 1.0 ± 0.95 D and − 0.5 ± 0.25 D, respectively. The corneal flap was clear and well-positioned at the final follow-up (mean: 28.57 ± 6.9 months). 85.71 % (6/7) of the patients showed worse corneal sensation in the injured eye. Interocular OSDI discrepancy was less in those whose last visit was more than 30 months after the trauma.

Conclusions

Postoperative CDVAat six months was improved, and the refractive data also showed some improvement. The corneal nerve and tear function recovery peaked before 30 months, while the OSDI continued to show a strong trend of improvement beyond 30 months.