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Consultation section

Refractive surgical problem

Section Editor(s): Kohnen, Thomas MD

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Journal of Cataract & Refractive Surgery: May 2003 - Volume 29 - Issue 5 - p 863
doi: 10.1016/S0886-3350(03)00295-5
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A 43-year-old woman had bilateral laser in situ keratomileusis (LASIK). The preoperative subjective manifest refraction was −6.25 −0.75 × 70 in the right eye and −7.00 −0.50 × 30 in the left eye. Preoperative examination revealed a 5.0 mm scotopic pupil in both eyes measured with a Colvard pupillometer, a corneal thickness of 604 μm and 610 μm in the right and left eye, respectively, and uneventful corneal topographies with a mean corneal power of 45.6 diopters (D) and 45.4 D, respectively. In both eyes, the uncorrected visual acuity (UCVA) was 20/200 and the best corrected visual acuity (BCVA) was 20/20. The anterior and posterior segments were normal, and the patient did not report past eye problems.

Wavefront-guided LASIK was performed with a Hansatome microkeratome (9.5 mm suction ring, 180 μm blade) and a Bausch & Lomb 217z scanning-spot excimer laser (optical zone, 6.5 mm; central ablation, 122 μm right eye and 116 μm left eye). In the left eye, which was operated on first, an inferior large peripheral epithelial defect extending from the flap margin 1.5 mm into the central flap area was present. In the right eye, a large central epithelial defect occurred. A therapeutic contact lens was inserted in the right eye for 1 day; the left eye received no contact lens. In both eyes, the epithelial defects healed in 4 days. The patient was treated with antibiotic–steroid eyedrops 4 times daily and artificial tears hourly for 2 weeks. Stage 2 diffuse lamellar keratitis (DLK) developed that resolved with the topical therapy.

The BCVA slowly recovered and was 20/40 in both eyes after 2 months. The patient had several attacks of epithelial defects in both eyes postoperatively and epithelial ingrowth in the right eye that developed after 10 months. Retreatment for a residual refractive error (+0.50 −1.25 × 0) was combined with epithelial removal in the right eye. Two months later, the UCVA was 20/20 in both eyes.

Now, 18 months after the primary procedure, the patient returns with pain in the left eye with a recurrent erosion (Figure 1, right) and an epithelial ingrowth in the right eye (Figure 1, left). Both flaps are attached. In the right eye, the UCVA is 20/30 and the BCVA is 20/20 with +0.50 −0.50 × 170. The UCVA is 20/100 in the left eye and does not improve with glasses. Figure 2 shows corneal evaluation of the right eye; a sufficient image of the left eye was not possible at this time.

Figure 1.
Figure 1.:
(Kohnen) Slitlamp image of the right eye (left) and left eye (right) 18 months after LASIK for myopia.
Figure 2.
Figure 2.:
(Kohnen) Topography images of the right eye (tangential map) 2 weeks (left) and 18 months (right) after LASIK for myopia.

How would you now manage this case?

© 2003 by Lippincott Williams & Wilkins, Inc.