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Consultation section: Refractive

March consultation #9

Stival, Larissa R. MD; Santhiago, Marcony R. MD, PhD

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Journal of Cataract & Refractive Surgery: March 2018 - Volume 44 - Issue 3 - p 413-414
doi: 10.1016/j.jcrs.2018.03.017
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The preoperative approach should start with a thorough check at the slitlamp to identify possible entry bridges for epithelial cells that will guide a specific scrape at the LASIK bed margin, intraoperatively.

For recurrent cases like the one described here, the intraoperative approach should include a very efficient removal of epithelial cells followed by strategies that would inhibit any cell growth with the application of antimitotic agents and, subsequently, a method that would prevent new epithelial cells to go under the flap again.

Therefore, our suggestion would start with a complete scrape of both the stromal and LASIK flap bed, including the LASIK bed margin to remove any entry sites. Then we would apply MMC for 20 seconds after scraping to limit the growth of any remnant cells, and an after complete wash out of MMC, would use a subsequent layer of fibrin glue across the LASIK bed and at the flap edge to block the entrance of new cells.1–3

A possible adjuvant therapy would combine alcohol,2 which could have been applied before MMC, in an attempt to devitalize any residual epithelial cells. If possible, depending on the integrity of the flap edge, flap suturing is an alternative to, or in association with, fibrin glue.4 Any further treatment would depend on the outcomes. The corneal topography will probably regularize after the epithelial removal because the AS-OCT shows that the epithelium underneath the LASIK flap seems to be responsible for irregular astigmatism. If the corneal topography is still irregular after this treatment, a topography-guided surgery might be an option to regularize the cornea and improve image quality.

Epithelial ingrowth after LASIK is rare and frequently self-limited but might become challenging if overlooked. As important as its treatment, its prevention through adequate techniques to lift the flap for retreatment limits the occurrence of epithelial ingrowth5,6 through a smooth tearing of the epithelium, overlying the flap edge over the entire periphery of the flap. The flap edge should be opened with a Sinskey hook and the flap peeled back after the exposed edge is grasped with forceps. That would limit passage of instruments through the epithelium, which would leave epithelial fragments and overhangs that could be caught in the interface when the flap is returned to its position.5,6

REFERENCES

1.Santhiago MR, Netto MV, Wilson SE. Mitomycin C: biological effects and use in refractive surgery. Cornea. 2012;31:311-321.
2.Wilde C, Messina M, Dua HS. Management of recurrent epithelial ingrowth following laser in situ keratomileusis with mechanical debridement, alcohol, mitomycin-C, and fibrin glue. J Cataract Refract Surg. 2017;43:980-984.
3.Hardten DR, Fahmy MM, Vora GK, Berdahl JP, Kim T. Fibrin adhesive in conjunction with epithelial ingrowth removal after laser in situ keratomileusis: long-term results. J Cataract Refract Surg. 2015;41:1400-1405.
4.Güell JL, Verdaguer P, Mateu-Figueras G, Elies D, Gris O, Manero F, Morral M. Epithelial ingrowth after LASIK: visual and refractive results after cleaning the interface and suturing the lenticule. Cornea. 2014;33:1046-1050.
5.Wilson SE, Santhiago MR. (2012). Flaporhexis: rapid and effective technique to limit epithelial ingrowth after LASIK enhancement. J Cataract Refract Surg, 38, 2-4, Available at: http://www.jcrsjournal.org/article/S0886-3350(11)01571-9/pdf.
6.Santhiago MR, Smadja D, Zaleski K, Espana EM, Armstrong BK, Wilson SE. Flap relift for retreatment after femtosecond laser-assisted LASIK. J Refract Surg. 2012;28:482-487.
© 2018 by Lippincott Williams & Wilkins, Inc.