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FLAP LIFT AND REPAIR OF
POSTOPERATIVE LASER IN
SITU KERATOMILEUSISCOMPLICATIONS 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
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POST OPERATIVE COMPLICATION
OF LASIK
Epithelial ingrowth
Diff!e la"ellar #eratiti!
$nterface debri! Corneal !triae
%lap in&r'
Re(ireintervention
Lifting the LAS$K flap
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ND:YAG LASER
Reported to !cce!!fll'treat interface
epithelial ingrowth
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COMPARED BETWEEN Srgical "icro!cope)
Lighting
Depth perception
*er!!
Slit la"p
+width variative
+anglation
Li"it vi!aliation
and preci!e flap
repo!itioning
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OVERHEAD MICROSCOPE
-inder identification of )
Leftover debri! nder the flap
he pre!ence of re!idal epithelial cell! after!tro"al bed
Stro"al nder!ide of the flap have been
!craped
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TO MANAGE THE
COMPLICATION: %lap elevation and repair
opical ane!the!ia
/ the !litla"p bio"icro!cope
Avoiding a retrn to the operating roo"
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SURGICAL TECHNIQUE
opical propacaine ane!the!ia 0ovidone+iodine
Stainle!!!+!teel lid !pecl" i! placed
he patient i! !eated / the !litla"p
Maintain the head1! potition dring theprocedre
he flap "argin i! identified b' !litla"p
bio"icro!cop'.
A blnt flap elevator 2eg, Machat LAS$K
retreat"ent !patla, AS$CO3i! !ed to lift and
reflectthe flap to the e4tent nece!!ar' for
epithelial debride"ent
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he whole flap doe! not to be elevated
he epithelial !ide of the partiall' reflectedflap co""onl' adhere! to the ne4po!ed
corneal !rface providing vi!ibilit' to the
!rgical field
$f the flap doe! not re"ain adherent a 5+handed techni(e i! !ed to "aintain the
flap po!ition
he !rface i! then e4a"ined b' !litla"p
nder high "agnification i!land! ofepithelial cell! or interface debri!
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More e4ten!ive nder"ining of the flap
Mechanical debride"ent of epitheli" fro"
the !tro"al bed
6nder!ide of the flap i! perfor"ed Machat
!patla7 a corneal ra#e to peel and re"ove
an' epithelial ingrowth
he !lit bea" lighting enhanche! vi!ibilit' in
fa!tidio! 8 co"plete re"oval of cell! and
debri!.
he nder!ide of the flap can be !crapped!ing the !patla
he epitheli" i! then debrided 9+5""
ot!ide the flap gtter
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:et the !rface of the flap after debride"ent
;SS Repo!ition the flap in the !tro"al bed !ing the
!patla
A wet celllo!e !ponge to !"ooth and refine
the the flap po!ition he flap i! allowed to dr' for = !econd!
En!re proper re"oval of all epithelial cell!
?= !econd! prior to re"oving the lid
!pecl" After the procedre topical A; and
cortico!teroid agent! @ ti"e! dail' for 9 wee#
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RESULT e'e! of < patient! were treated for
+clinicall' !ignificant epithelial ingrowth 2
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%ig 9. A) flap lifter initiating elevation in area to be treated.
;) he LAS$K flap reflected bac# and adherent to !rface while the
corneal ra#e i! !ed to !crape the !tro"al bed. Onl' the flap area with
epitheli" ingrowth ha! to be elevated.
C) -igher "agnification i"age of the corneal ra#e
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REPRESENTATIVE CASE
HISTORIES I A ?@+'ear old "an bilateral LAS$K
@ 'ear! later
Strc# in RE with barbed wire
0ain
Decrea!ed vi!ionE"ergenc' roo"
6D*A LERE
D7 Corneal abra!ion
h) enta"icin eo
Referred
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48 HOURS AFTER THE TRAUMA
6D*A 5=75== La!i# flap wa! di!located fro" +9= o1cloc#
he flap folded on it!elf
he e4po!ed !tro"al bed in the
inferote"poral (adrant + epithelied
+ did not !tain with flore!in
Epithelial ingrowth e4tended into the flap!tro"al interface
he flap hinge appeared to be intact
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4 DAYS AFTER THE TRAUMA Slitla"p repair
+ flap lifting
+ epithelial debride"ent of the !tro"al
interface and nder!ide of the flap
+ flap repo!itioning
9 da' after repair)6D*A ) 5=7?=
he flat wa! noted
+to be flat+ in place
Bo epithelial debri!
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2 WEEKS AFTER THE INJURY
6D*A 5=75=
race !bepithelial hae re"ained inferiorl'
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CASE HISTORY II
A @5 F'ear+ old"an with "'opia +5,== RE , +9, LE
Bonc!to"ied LAS$K in both e'e!
Mechanical "icro#erato"e with G, "" ring
Ablationed wa! perfor"ed
Optical one of , "", tran!ition one of
,""
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6 YEARS LATER o correct re!idal "'opic a!tig"ati!")
flap lift and enhance"ent wa! perfor"ed
Epithelial ingrowth 2H3 nder both flap!
E4tended clo!e to the vi!al a4i! )? wee#! 0atient co"plaint )flctating and blrr'
vi!ion
6D*A 5=75 in both e'e!
wee#! after enhance"ent)
+ both flap wa! lift
+epithelial ingrowth wa! !crapped
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5 WEEKS AFTER THE ENHANCEMENT
CD*A i"proved to 5=75= RE and 5=79 LE
%ir!t da' following flap lift
/@ "onth! )
+linear area of epithelial ingrowth at the flapedge RE
+ no progre!!ion and no epithelial cell! were !een
in LE
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DISCUSSION %lap lift with the aid of !litla"p
bio"icro!copic for repair of po!t+LAS$K
co"plication di!tinct advantage
he !rgeon can activel'+alter the !litla"p1! light inten!it'
+ depth of foc!
+ bea" width
+ angle
vi!alie of the lap interface dring
procedre
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OPERATING MICROSCOPE %i4ed wide bea" of the light !orce
Cornea cannot be viewed in a cro!! !ection
with d'na"ic "aniplation of the light
!orce
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SLITLAMP BIOMICROSCOPIC Reco""ended
o en!re that all trace! of epitheli" are
re"oved
Little ri!# for regrowth of cell! $n the ca!e of debri! re"nant that "ight
indce hae 2 a! "ight be !een in Bd)IA
La!er treat"ent of interface cell!3
Si"ple and efficient $""ediate
Co!t effective repair
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