Discussion by Thomas E. Clinch, MD

Intraoperative management of partial flap during LASIK: a small case series report

PURPOSE

To report the intraoperative management of incomplete microkeratome LASIK flaps.

DESIGN

Small, retrospective, noncomparative, interventional case series.

PARTICIPANTS

Five outpatients.

METHODS

In 5 eyes of 5 patients, the premature stop of the microkeratome resulting from mechanical obstacles resulted in an incomplete flap that would not allow for the completion of the LASIK procedure. After the careful realignment of the partial flaps and the removal of the identified obstacles, the second pass of the microkeratome resulted in flaps of the intended size.

MAIN OUTCOME MEASURES

Final creation of a flap as intended, completion of the procedure, and visual and refractive outcome of the operative eyes.

RESULTS

The second pass of the microkeratome resulted in flaps as planned. All the procedures were completed, and the operative eyes that were followed up for at least 3 months had excellent visual and refractive results.

CONCLUSIONS

The second pass of the microkeratome can successfully manage incomplete flaps resulting from microkeratome premature stop as a result of mechanical obstacles.

Pathogenesis and management of laser in situ keratomileusis flap buttonhole

PURPOSE

To describe the clinical features and outcomes in patients who had a flap buttonhole during laser in situ keratomileusis (LASIK) and propose an etiopathogenic mechanism for this complication.

SETTING

University Eye Center, Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.

METHODS

Retrospective review of case records of 6 patients (6 eyes) who had a flap buttonhole during LASIK.

RESULTS

The mean patient age was 38.2 years +/- 4.1 (SD) and the mean preoperative spherical equivalent (SE) refraction, -8.13 +/- 4.04 diopters (D). Mean keratometry was 44.20 +/- 1.30 D. Retreatment was performed after a mean interval of 9.2 +/- 3.2 months. Final postoperative SE refraction was -0.44 +/- 0.58 D after a mean follow-up of 59.0 +/- 5.3 weeks. No patient experienced loss of best spectacle-corrected visual acuity.

CONCLUSIONS

Retreatment of eyes that have a flap buttonhole during LASIK is associated with good visual outcomes. Flap buttonholes can produce alterations in refraction, so retreatment is best performed after the refractive error has stabilized. Microkeratome malfunction may be responsible for the occurrence of a flap buttonhole during LASIK in eyes that do not have significant corneal steepening.