Case report

Flap interface precipitates after antibiotic–steroid suspension administration

Paciuc-Beja, Miguel MD*; Galicia Alfaro, Victor H. MD; Retchkiman-Bret, Myriam MD; Santos-Cantu, Daniela MD; Quiroz-Mercado, Hugo MD

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Journal of Cataract and Refractive Surgery Online Case Reports: July 2015 - Volume 3 - Issue 3 - p 57-58
doi: 10.1016/j.jcro.2015.05.004
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The healing process after laser in situ keratomileusis (LASIK) surgery requires the use of antibiotic drops, topical steroids, and preservative-free lubricants. A drop of antibiotic and steroid is usually instilled at the end of the procedure. Prednisolone acetate 1.0% suspension, which is a commonly used topical steroid, requires vigorous shaking to thoroughly mix the bottle contents.A


A 37-year-old woman with myopia in both eyes since 17 years of age was scheduled for LASIK. There had been no change in her refraction in the previous 10 years. The refraction was −2.00 diopters (D) sphere in both eyes; topography was normal. The central corneal pachymetry was 560 μm in the right eye and 539 μm in the left eye.

Uneventful LASIK was performed using the Hansatome microkeratome (Bausch & Lomb) and the Visx Star S4 (Abbott Medical Optics, Inc.). At the end of the procedure, a combination of gatifloxacin 0.3% and prednisolone acetate 1.0% suspension drops was applied to each eye. Twenty-four hours postoperatively, the patient presented with increased tearing and ciliary injection in the left eye. Both flaps were well centered. White granular-like paracentral precipitates were found under the flap at 8 o'clock in the left eye (Figure 1).

Figure 1.
Figure 1.:
White solid precipitates under the flap (arrow).

The flap was lifted, and the white deposits, which were solid and lying on the flap side (Figure 2), could not be removed with irrigation but were removed using a 0.12 forceps. After 1 week, the patient remained asymptomatic with an uncorrected distance visual acuity of 20/20 in both eyes.

Figure 2.
Figure 2.:
After the flap was lifted, the white precipitates were seen on the flap side (arrow).


Fahd and Fahed1 reported prednisolone acetate crystal deposits under the flap in 1 of 425 eyes. They had used prednisolone acetate 1.0% to fill the gutters, creating a white circumferential ring to confirm that the flap was centered. Their case resolved after 48 hours. The amount of precipitates in their case was less than the amount in our case. Campos et al.2 found no inflammation or flap interface precipitates in 100 eyes that had LASIK and a combination of gatifloxacin 0.3% and prednisolone acetate after surgery.

In the case we report, the white deposits under the flap showed that the antibiotic–steroid drops instilled at the end of the procedure reached the flap interface not from absorption through the corneal epithelium, but from the edges of the flap.


1. Fahd DC, Fahed SD. Delineation of LASIK flaps with prednisolone acetate eye drops. J Ophthalmic Vis Res 2014; 9:116-118. Available at:
2. Campos M, Muccioli C, Malta JBNS, Gerade RA, Salame ALA, Belfort R Jr. Efficacy and tolerability of a combined gatifloxacin plus prednisolone formulation for topical prophylaxis after LASIK. Clin Ophthalmol 2011; 5:209-214. Available at: Accessed March 26, 2015.


A. Hovanesian JA, Encourage Patients to do the “Eye Drop Shake,” Primary Care Optometry News June 12, 2013. Available at: Accessed March 26, 2015
© 2015 by Lippincott Williams & Wilkins, Inc.
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