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Consultation section: Refractive

March consultation #8

Slade, Stephen MD

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Journal of Cataract & Refractive Surgery: March 2018 - Volume 44 - Issue 3 - p 413
doi: 10.1016/j.jcrs.2018.03.016
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My first goal would be to establish whether the epithelial ingrowth is indeed the reason for the redness and irritation of the eye rather than dry-eye syndrome, an inflammatory condition, or a foreign body or other cause. At present, the patient has good, equal uncorrected vision, surprisingly despite 4.0 D of oblique uncorrected astigmatism. However, if the epithelium is proven to be the reason for the reported redness and irritation, how do we address the ingrowth? Not all epithelium ingrowth requires removal; it can exist quietly under a flap, especially in small isolated nests of cells. The 4 main reasons I recognize to treat ingrowth are (1) the epithelium is progressing, (2) the epithelium is causing a melting and/or irregularity of the flap, (3) the epithelium is blocking the vision or creating astigmatism, and (4) the epithelium is causing a noticeable cosmetic defect or irritation for the patient.

In most cases, I begin with simply lifting the flap using a “flapsulorhexis” technique as described by John Doane.1 This method gives a near perfect “cut” edge and lowers the chances for future ingrowth. After having lifted the flap, I always meticulously clean the bed and the undersurface of the flap, which is sometimes ignored. I would also check the actual margin of the flap for any rolled edges. A rolled edge of the flap can be seen under high magnification and must be unrolled by teasing it apart. An elevated rolled edge provides a much easier pathway for more ingrowth.

Of course, if any refractive treatment is being planned, one should wait until after the epithelium is removed because it is likely the cause of this astigmatism. Indeed, I will rarely treat epithelium and a refractive error at the same time.

For this case, after the flap is repositioned, I would suture it. I believe the best option is an 8-bite Barraquer antitorque pattern. I would place 3 cardinal sutures, using the hinge of the flap as the fourth fixation point. Then, place the running 8-bite suture followed by a second evenly spaced suture throughout the first. Ignore the hinge, placing the sutures evenly around the cornea. The first suture can come out at 2 weeks, then the second one, 1 or 2 weeks later. I have not seen epithelium reoccur after this suturing protocol.

In extreme cases, a flap can be removed. You would essentially have a PRK in deeper, coarser stroma than usual. When I remove a flap, I like to smooth the bed with phototherapeutic keratectomy and I do apply MMC because the chances for haze are greater. Nevertheless, most such cases do well.


1.Doane JF., course faculty., 1998. “LASIK II – Complication Management and New International Directions. Subject: Lasik Enhancement by Epitheliorrhexis,” presented at the ASCRS Symposium on Cataract IOL and Refractive Surgery (San Diego, California, USA, April).
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