Consultation section: Refractive
This is a clear case of recurrent epithelial ingrowth. Usually, one would expect melting of the flap edge at the entrance of the ingrowth to a certain degree. The resulting gap between the flap edge and corneal bed edge that forms the port of entry for the epithelial cells is hard to close. The vault over the ingrowth area produces a flattening of the area toward the center and results in irregular astigmatism.
My approach is to perform a 2- to 3-step procedure. First, I would create a flap lift with a standard cleaning of the ingrowth area with dry sponges and a hockey knife, also cleaning the edges of the flap and stromal bed meticulously. Then, I would use a sponge soaked in 20% ethanol and apply it to the stromal surface, as well as on the back surface of the flap (I would close the flap over the sponge), for 20 seconds limited to the ingrowth area. Flushing with a balanced salt solution and repositioning and placing a bandage contact lens finishes this first step. Fairly often, the alcohol-induced inflammatory reaction of the stroma glues the surfaces together, preventing further epithelial ingrowth.
If this technique does not work sufficiently, suturing the flap to the stroma with 10–0 nylon sutures every 2.0 mm at the port of ingrowth has been shown to resolve such cases. Sutures can be removed after 2 to 3 weeks.
Regarding the refraction and irregular surface, a topography-guided surface ablation (photorefractive keratectomy [PRK]) should follow, although no sooner than after 3 months.© 2018 by Lippincott Williams & Wilkins, Inc.