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Consultation section

Refractive surgical problem: Reply

Daya, Sheraz MD, FACP, FACS, FRCS (ED)

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Journal of Cataract & Refractive Surgery: May 2003 - Volume 29 - Issue 5 - p 864-865
doi: 10.1016/S0886-3350(03)00297-9
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This patient developed bilateral epithelial defects after LASIK. There is no information on the preoperative status of the corneas, specifically whether there was evidence of anterior basement membrane dystrophy, which can predispose to intraoperative epithelial defects and recurrent erosion syndrome. Another cause of the original defects is the device used to create the flap. The Hansatome has been implicated in the past; however, with the introduction of zero-compression heads, epithelial defects are now rare.

At present, the patient has recurrent erosion syndrome in both eyes and a recurrence of epithelial ingrowth in the right eye. The clinical image of the right eye reveals moderate ingrowth without evidence of flap melting.

In the right eye, corneal topography using elevation mapping would be useful. However, on the tangential keratometric map, the ablation appears to be decentered inferiorly. This is probably erroneous, and one must assume that the area of ingrowth is causing irregularity. That the patient historically has had good UCVA in this eye without epithelial ingrowth suggests that the ingrowth has induced refractive error. My approach would be to lift the flap and remove the epithelial ingrowth from the stromal bed and flap undersurface. I would also use 50% alcohol on a surgical spear and apply it to the area (bed and flap) for 30 seconds followed by vigorous irrigation with a balanced salt solution.

Epithelial ingrowth in the right eye occurred as a result of the original epithelial defect at the time of surgery, which was described as being inferior. Recurrence of ingrowth can be caused by loss of the “trap door” effect of the flap edge; this potential site of elevation must be addressed. The only solution is to place interrupted sutures at the site of ingrowth after epithelial removal. The sutures should be adjusted so they do not induce striae but with enough tension to ensure close apposition of tissue. The sutures would be removed after 1 month. This patient also has recurrent epithelial defects that can be managed with hypertonic sodium chloride 5% ointment in the manner described below.

At present, the left eye has recurrent erosions that may be related to underlying anterior basement membrane dystrophy or secondary to traumatic abrasion at the time of LASIK. Immediate management would be to ensure the epithelial defect heals. This can be achieved by patching with lubricants or by inserting a contact lens, which would provide comfort and promote epithelial healing. To prevent further recurrence, I would prescribe hypertonic sodium chloride 5% ointment at bedtime to deturgesce the epithelium and promote adherence to the underlying basement membrane. The ointment also lubricates, helping prevent epithelial removal on awakening.

I typically advise 6 months of treatment. If an erosion recurs despite the medication, I would consider PTK using a large optic zone and a depth of 10 μm to prevent future recurrence. Visual stability in both eyes is likely to be achieved once the epithelium is stable.

© 2003 by Lippincott Williams & Wilkins, Inc.