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Photorefractive Keratectomy for Treatment of Flap Complications in Laser In Situ Keratomileusis

Weisenthal, Robert W. MD; Salz, James MD; Sugar, Alan MD; Mandelberg, Alan MD; Furlong, Michael MD; Bagan, Steven MD; Kandleman, Sergio MD

Clinical Science

Purpose. To present the results of photorefractive keratectomy (PRK) for treatment of laser in situ keratomileusis (LASIK) flap complications.

Methods. Compilation of case reports through solicitation on Kera-net, an Internet surgery discussion site.

Results. PRK was performed on 13 patients from 2 weeks to 6 months after LASIK flap complications. The technique used for the PRK varied. Epithelial removal was performed using no-touch phototherapeutic keratectomy (PTK) in six of the 13 patients and manual debridement in the other seven patients. A dilute solution of 20% ethanol was used to facilitate manual debridement in five of the seven patients. In two of these five patients, the epithelium was replaced as in laser-assisted subepithelial keratomileusis (LASEK). A solution of 0.02% mitomycin C was used after laser ablation to prevent haze formation in three patients. After an average 7 months of follow-up, uncorrected visual acuity was 20/20 in six patients, 20/25 in four patients, and 20/30 in two patients. The visual acuity in one patient was 20/80, purposely left undercorrected for monovision. Best spectacle-corrected visual acuity was 20/20 in 10 of 13 patients. Three patients were 20/25, losing one line of best spectacle-corrected visual acuity. On slit-lamp examination, at last follow-up appointment, stromal haze was graded from trace to none in all patients.

Conclusions. Photorefractive keratectomy is a safe and effective technique for treatment of patients with LASIK flap complications.

Laser in situ keratomileusis (LASIK) offers rapid visual recovery, minimal postoperative discomfort, predictable refractive results, and a low complication rate. Improved microkeratome design has enhanced the success rate and safety of the procedure. Though rare, flap problems remain a vexing problem for the surgeon. A poor-quality flap usually requires delaying the laser treatment, creating disappointment and hardship for the patient.

Flap complications are typically managed by repositioning of the flap without laser treatment. Slade 1 recommends at least a 3-month interval before the second surgery to allow the stromal tissue to solidify. However, if the patient has significant anisometropia and is contact lens intolerant, waiting 3 months may be intolerable. The surgeon may also prefer to avoid using a microkeratome if the patient's orbital anatomy made the initial resection difficult. The flap complication may also induce an irregular corneal surface or allow epithelial ingrowth. Phototherapeutic keratectomy (PTK) combined with photorefractive keratectomy (PRK), as first described by Wilson, offers the advantages of reducing the time interval to the second procedure, treating the corneal irregularity, and eliminating the need for a microkeratome resection. 2–4 The purpose of this paper is to present a heterogeneous group of patients who underwent PRK for treatment of flap complications in LASIK.

From the Department of Ophthalmology (R.W.W.), Upstate Medical Center, Syracuse, New York, U.S.A.; Department of Ophthalmology (J.S.), University of Southern California, Los Angeles, California; Kellogg Eye Center (A.S.), University of Michigan Medical School, Ann Arbor, Michigan, U.S.A.; COM Laser Barra Square (S.K.), Rio de Janeiro, Brazil.

Submitted June 21, 2002.

Revision received January 14, 2003.

Accepted March 11, 2003.

Address correspondence and reprint requests to Robert W. Weisenthal, MD, P.O. Box 48, 5770 Towpath Commons, DeWitt, NY 13214-0048, U.S.A.; E-mail:

© 2003 Lippincott Williams & Wilkins, Inc.