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Consultation section: Refractive

March consultation #2

Dua, Harminder Singh FRCOphth, FRCP(Edinburgh), MD, PhD

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Journal of Cataract & Refractive Surgery: March 2018 - Volume 44 - Issue 3 - p 410-411
doi: 10.1016/j.jcrs.2018.03.010
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Noteworthy features from the clinical examination are the wide area of ingrowth starting at the edge of the flap, indicating a limbal stem cell–driven epithelial ingrowth; a faint gray haze with a well-defined edge extending a millimeter or so beyond and parallel to the edge of the white patch, indicating the progressive nature of the ingrowth (it could be stationary at the sector, which is pigmented); and the marked flattening corresponding to the area of ingrowth. The AS-OCT confirms the interface location of the ingrowth. The multiple previous episodes indicate the recurrent and chronic nature of the pathology. Treatment is therefore warranted despite the UDVA and CDVA of 20/25.

Under topical anesthesia, at the slitlamp using broad-beam illumination, the edge of the flap should be visualized and the epithelium incised with a hypodermic needle, all along the edge. This allows lifting the flap without tearing the epithelium. Epithelial tear(s) is a risk factor for epithelial ingrowth. The flap should be undermined inferiorly, and the patient transferred to the operating room. A couple of radial ink marks should be made astride the flap-bed junction, and the flap lift should be completed to the hinge. All visible cell debris should be scraped gently off the undersurface of the flap and the bed. Trypan blue dye can help identify areas where the cells are not easily seen. Special attention should be given to the edges of the flap and the bed along 5 to 11 o'clock. Epithelial cells covering the sloping/vertical cut of the bed edge can be missed allowing regrowth to occur.

Similarly, cells from the surface of the flap can migrate around the edge; hence, this area too requires special attention. Dab alcohol 70% on the bed and undersurface of the flap, including the edges described above, for 15 seconds. This helps to kill any residual cells. In addition, mitomycin-C 0.02% (MMC) should be applied to the bed and flap stroma for 10 to 15 seconds. This dampens the keratocyte wound-healing response and reduces the risk for haze. After a thorough washing, a thin layer of fibrin glue should then be spread evenly on the entire bed (not just the edges) and the flap repositioned, aligning the ink marks. The flap should then be stroked gently from the center toward the edges to express any excess glue, which seeps out from the flap-bed junction and is wiped off. This seals the interface and mechanically prevents the epithelial cells from growing back. In some instances, it might cause the interface to become opalescent for a few days, but this invariably clears in 1 to 2 weeks. Sutures can be placed to anchor the flap to the bed. Tension of these sutures is important because tight sutures can cause striae or folds in the flap. Last, place a bandage contact lens. The patient should then be treated with antibiotic drops for a couple of weeks and steroid drops for 4 weeks.

© 2018 by Lippincott Williams & Wilkins, Inc.