Refractive Surgical Question
September consultation #1
In June 2004, a 48-year-old man had laser in situ keratomileusis (LASIK) in both eyes. According to the patient’s charts, the preoperative corrected distance visual acuity (CDVA) was 20/25 with +1.00 −3.25 × 175 in the right eye and 20/25 with +0.75 −3.00 × 165 in the left eye. In July, he had an enhancement in the right eye because of undercorrection (+0.25 −2.25 × 180). Postoperatively, the refraction in the right eye was +1.00 −1.25 × 171. In August 2005, the patient had a second enhancement. In May 2009, the residual refraction was +2.00 −1.75 × 7. In June 2011, a flap lift was performed in the right eye with additional use of mitomycin-C (MMC) because of progressive epithelial ingrowth. Afterward, the patient could function adequately with the use of a contact lens.
In August 2013, the patient scheduled a consultation at another hospital in the Netherlands because of a corneal ulcer with a positive Pseudomonas culture in the right eye.
In February 2014, the patient was referred to our department and the CDVA was 20/100 with +8.00 −6.00 × 150 in the right eye and the uncorrected distance visual acuity (UDVA) was 20/25 in the left eye. Slitlamp examination showed epithelial ingrowth at the periphery of the flap at 3 o’clock and 7 o’clock (Figures 1 and 2). The flap diameter appeared to be 9.5 mm. There was an extensive stromal scar with stromal thinning in the temporal lower quadrant of the cornea. Figure 3 shows anterior segment optical coherence tomography (AS-OCT) of the right eye. Scheimpflug photography showed irregular astigmatism and a minimum corneal thickness of 463 μm (Figure 4). A trial with scleral contact lenses was not successful because of contact lens intolerance and practical issues stemming from the patient’s work as a police officer.
How would you treat the epithelial ingrowth and stromal scar in the right eye? Would you perform a flap amputation and wait for reepithelialization with a postoperative contact lens fitting? Could one still use a topography-guided excimer laser technique to remove the scar in combination with an anterior lamellar procedure? Would you perform an anterior lamellar keratoplasty or deep anterior lamellar keratoplasty (DALK)? If yes, how would you handle the preexisting flap dimensions and epithelial ingrowth in the periphery? Or would you perform an excimer laser and femtosecond laser–assisted (mushroom-shaped) keratoplasty?© 2014 by Lippincott Williams & Wilkins, Inc.