Epithelial invasion is a delicate complication to manage and requires a cautious approach, especially if it is a recurrence after multiple attempts to clean the interface. Even if it is not specified, how the various previous flap lifts and scrappings were managed and the reactivation of symptoms described 14 years after the last intervention are enigmatic in the absence of a triggering cause such as trauma or ocular surface disease (OSD). In general, the reactivation of the epithelial cells in the interface is expressed within the first months after the flap lift and not later in time.
The topographic and AS-OCT images show a thinning of the flap in relation to the invasion zone, probably as a result of successive scratches and collagenase activity produced by the active cells. The Schirmer test might be superimposed on the contralateral eye; however, it is likely that fluorescein evaluation would show an irregularity in the tear film associated with the patient's age (52 years), which combines factors of alteration of the ocular surface and induces OSD.
In my experience, the surgical resumption of an epithelial invasion is justified if the visual axis is affected and/or there is a loss of tissue and worse CDVA because of melting. In this case, the only sign of alarm is tissue damage because the UDVA of 20/25 shows that the induced astigmatism does not impact the central cornea. Therefore, a surgical procedure would only expose the patient to aggravation and not guarantee that improvement can be obtained.
I would introduce an antiinflammatory treatment with a preference for fluorometholone 0.1%, thus exposing the patient to minimal side effects and allowing very progressive tapering levels over 6 months, with the hypothesis of persistent cellular activity. I would combine it with a hyaluronic acid-based lubricant treatment to improve the regularity of the anterior cornea. One could also consider exploring the quality of the functional meibomian glands to explain the insidious recurrence of irritation and inflammation at such a long time after the initial invasion.
A surgical approach should be considered only in the event of visual and/or tissue aggravation. There is no guarantee that an eighth flap lift would be successful and would not ultimately lead to a superficial anterior lamellar graft. This last resort surgery warrants a good trustworthy patient–physician relationship because it will be followed by a subsequent refractive correction on the new alloflap for correction of secondary astigmatism. In general, the therapeutic choice must always lead to a benefit that exceeds the risk.