Inhibition of recurrence of epithelial ingrowth with an amniotic membrane pressure patch to a laser in situ keratomileusis flap with a central stellate laceration: a case report

Self-Retained, Sutureless Amniotic Membrane Transplantation for the Management of Ocular Surface Diseases

Amniotic membrane (AM) has anti-inflammation, anti-fibrotic, and regenerative effects. Sutureless cryopreserved AM transplantation, ProKera® (Bio-Tissue, Inc., Miami, FL, USA), is easily applied by ophthalmologists in the treatment of ocular surface diseases. This retrospective study included patients with ocular surface diseases who received ProKera® between January 2022 and May 2023. Six patients (9 eyes) with a mean age of 56.8 ± 20.8 years old (range 25-74) and a mean follow-up period of 7.8 ± 4.1 months (range 1-12) were included, including 2 of recurrent conjunctival tumors with limbal and corneal involvement (cases 1-2), 1 of pterygium with marked astigmatism (case 3) and 3 of Stevens-Johnson syndrome (SJS, cases 4-6). ProKera® was inserted after the lesion excision and deep keratectomy in cases 1-3, and no recurrence or corneal complication was noted. Cases 4-5 were discharged from the intensive care unit and presented with severe chronic SJS. Most ocular manifestations improved significantly after symblepharon release and ProKera® insertion, except for corneal conjunctivalization in 1 eye (case 5). Case 6 involved early ProKera® use at the bedside during acute SJS, resulting in complete resolution. We concluded that the adjunctive application of ProKera® can be effective for ocular surface reconstruction and provides options to intervene earlier for outpatients or patients unstable for invasive surgical intervention.

Management of recalcitrant epithelial ingrowth after laser in situ keratomileusis: A case report

RATIONALE

Surgically lifting and scraping, mitomycin C, fibrin glue, Nd:YAG laser, hydrogel ocular sealant, and amniotic membrane patch are the reported methods for treating epithelial ingrowth after laser in situ keratomileusis (LASIK). Here we report the management of a rare case of recalcitrant epithelial ingrowth using a combined scraping/laser ablation that occurred after LASIK.

PATIENT CONCERNS

A female patient underwent uncomplicated bilateral LASIK 10 years before incurring trauma to the right eye. Approximately 2.5 years later, she presented with a complaint of blurred vision and a foreign body sensation.

DIAGNOSES

The patient was diagnosed with epithelial ingrowth because of the presence of corneal melting, wrinkling, and scarring. Approximately 6 months after injury, the patient underwent corneal scraping to remove the epithelial ingrowth. Even after 2 more scraping procedures, the epithelial ingrowth recurred. Corneal densitometry was performed (Oculus Pentacam), which revealed a maximum corneal densitometry value of 87.4 gray scale units (GSUs) in the inferonasal quadrant. This reading highly elevated compared to readings from normal cornea (approximately 20 GSU).

INTERVENTIONS

We used a combination scraping/laser ablation procedure to correct astigmatism and eliminate any undetected residual corneal epithelial cells.

OUTCOMES

Two days following the procedure, the patient developed a mild corneal opacity in the area where the epithelial ingrowth had been located. At this time, visual acuity was 20/40, refractive error (manifest refraction) was -0.50 Diopter (D) sph, and the maximum corneal densitometry value was 79.2 GSU. After 2 months, the central cornea remained slightly blurred, but visual acuity was 20/25. No signs of recurrent epithelial ingrowth were present and the maximum corneal densitometry reading had decreased to 55.4 GSU.

LESSONS

This case demonstrates that epithelial ingrowth should be treated as soon as possible after trauma and that thorough scraping combined with laser ablation is effective for treating recalcitrant epithelial ingrowth. Additionally, corneal densitometry can be used to assess epithelial ingrowth severity and treatment efficacy.

Epithelial ingrowth following laser in situ keratomileusis (LASIK): prevalence, risk factors, management and visual outcomes

The number of laser in situ keratomileusis (LASIK) procedures is continuing to rise. Since its first application for correcting simple refractive errors over 25 years ago, the role of LASIK has extended to treat other conditions, including postkeratoplasty astigmatism/ametropia, postcataract surgery refractive error and presbyopia, among others. The long-term effectiveness, predictability and safety have been well established by many large studies. However, due to the creation of a potential interface between the flap and the underlying stroma, interface complications such as infectious keratitis, diffuse lamellar keratitis and epithelial ingrowth may occur. Post-LASIK epithelial ingrowth (PLEI) is an uncommon complication that usually arises during the early postoperative period. The reported incidence of PLEI ranged from 0%–3.9% in primary treatment to 10%–20% in retreatment cases. It can cause a wide spectrum of clinical presentations, ranging from asymptomatic interface changes to severe visual impairment and flap melt requiring keratoplasty. PLEI can usually be treated with mechanical debridement of the affected interface; however, additional interventions, such as alcohol, mitomycin C, fibrin glue, ocular hydrogel sealant, neodymium:yttriumaluminum garnet laser and amniotic membrane graft, may be required for recurrent or refractory cases. The aims of this review are to determine the prevalence and risk factors of PLEI; to describe its pathogenesis and clinical features and to summarise the therapeutic armamentarium and the visual outcome of PLEI.