Treatment of epithelial ingrowth after LASIK enhancement with a combined technique of mechanical debridement, flap suturing, and fibrin glue application

Disruption of ingrown epithelium via Nd:YAG laser or DIEYAG. A retrospective case series of Post-LASIK patients

Purpose

To describe in detail the technique used and results of disruption of ingrown epithelium via Nd:YAG laser (DIEYAG) after LASIK treatment and enhancement.

Observations

Epithelial ingrowth following laser in situ keratomileusis (LASIK) enhancement has the potential to cause significant refractive error and discomfort when allowed to progress. This retrospective case series following seven eyes after LASIK enhancement and one eye with flap trauma, assessed the effectiveness and safety of the disruption of ingrown epithelium via Nd:YAG laser. In all cases, we found that the progression of ingrown epithelium was eliminated. Using best spectacle corrected visual acuity and topography as our main outcome measures, we found that refractive error and visual disturbance caused by ingrowth stabilized or improved, with no subsequent complications identified.

Conclusion and Importance

The disruption of ingrown epithelium via Nd:YAG laser offers a safe and effective alternative to other treatments for epithelial ingrowth after LASIK treatment and enhancement.

The best optical zone for small-incision lenticule extraction in high myopic patients

Small-incision lenticule extraction (SMILE) is an effective and safe procedure for the correction of myopia due to minimally invasive and noncorneal flap surgery. However, the SMILE procedure has certain requirements for corneal cap thickness, attempted refractive correction, residual stromal bed thickness, and optical zone diameter, which sometimes make surgeons hesitant to choose SMILE or other refractive surgeries. The requirements limit its use in patients with high myopia. The purpose of this review was to find the optimal parameters of SMILE through discussing the best optical zone for high myopic patients, the visual quality of different optical zones, the choice of corneal cap thickness, and their effects on corneal biomechanical parameters, so surgeons can provide reference recommendations for patients with high myopia in choosing a reasonable and safe procedure.

Comparison and application of commercially available fibrin sealants in ophthalmology

Fibrin glues carry many advantages over traditional suture as a tissue adhesive and have been increasingly used in a variety of ophthalmic procedures over the past 15 years. Several fibrin sealants are commercially available worldwide, each of which differs slightly in its composition and mechanism of delivery. The focus of our review is to briefly discuss the reported uses of fibrin in ophthalmic surgery and provide a broad overview of the properties associated with each commercially available fibrin sealant.

Hydrogel sealant to prevent recurrent epithelial ingrowth in the setting of a LASIK flap buttonhole

Purpose

To report the first case of hydrogel sealant to prevent the recurrence of epithelial ingrowth in a LASIK flap buttonhole.

Observations

A 67-year-old female presented ten years after undergoing bilateral LASIK with diffuse lamellar keratitis and flap dislodgement after blunt trauma to the right eye. She was found to have epithelial ingrowth with diffuse debris and striae, so her flap was lifted and the epithelial ingrowth was removed. However, a central buttonhole was noted intraoperatively. Once all the epithelium was removed, the flap was repositioned and hydrogel sealant (ReSure, Ocular Therapeutix, Bedford, MA) was used to fill the buttonhole as well as seal down the edges of the flap. Sixteen months postoperatively, the patient's uncorrected visual acuity was 20/50-2 and there was no recurrence of the epithelial ingrowth at the edges of the buttonhole.

Conclusions and importance

Preventing the recurrence of epithelial ingrowth is a challenging situation, especially in the setting of a LASIK flap buttonhole. The use of hydrogel sealant in the buttonhole and around the edges of the flap may offer an elegant and effective solution.

Management of Complex Epithelial Ingrowth After Laser In Situ Keratomileusis Using Fibrin Tissue Glue

OBJECTIVES

To evaluate the efficacy and safety of adjunctive fibrin tissue glue in the treatment of complex epithelial ingrowth after laser in situ keratomileusis (LASIK).

METHODS

A retrospective review was performed of 12 eyes in 12 patients treated for clinically significant epithelial ingrowth after LASIK with mechanical debridement of the ingrowth and placement of fibrin tissue glue. Primary outcome measurements including recurrence of ingrowth, visual acuity, and manifest refraction were evaluated at each postoperative examination. Changes in higher-order aberrometry were also evaluated.

RESULTS

After epithelial ingrowth removal with adjunctive fibrin tissue glue, 11 eyes (91.7%) had no recurrence of ingrowth at the final follow-up examination. Uncorrected distance visual acuity changed from 20/20 or better in 3 eyes (25%) and 20/40 or better in 6 eyes (50%) preoperatively to 20/20 or better in 5 eyes (41.7%) and 20/40 or better in 10 eyes (83.3%) postoperatively. Nine eyes (75%) gained one or more lines of best-corrected distance visual acuity (CDVA). No eyes lost any lines of CDVA. There was no significant change in mean spherical equivalent (P=0.22) or mean cylinder (P=0.26) before and after surgery. Higher-order aberrations also remained stable with no significant change in root-mean-square error, coma, trefoil, and spherical aberration. There were no complications associated with the treatment.

CONCLUSIONS

Adjunctive fibrin tissue glue seems to be a safe and effective treatment for epithelial ingrowth after LASIK. This therapy may be particularly useful in managing challenging cases of complex or recalcitrant ingrowth.

Nd:YAG laser for epithelial ingrowth after laser in situ keratomileusis

PURPOSE

To evaluate the efficacy of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser for treatment of epithelial ingrowth after laser in situ keratomileusis (LASIK).

PATIENTS AND METHODS

Fifty-eight patients with epithelial ingrowth presented to Sohag refractive center, Sohag, Egypt, between January 2015 and March 2017. Only 41 patients (18 females and 23 males, mean age: 33.4 years) involving 41 eyes were indicated for treatment by Nd:YAG laser as the rest of the eyes were only under observation. Patients with epithelial ingrowth were recognized at a mean of 6 months after primary LASIK procedure (range: 2-16 months). Four eyes had undergone previous LASIK enhancements. Four eyes had the epithelial ingrowth removed by flap lift and scrapping. The mean intensity of the spots used was 0.8 mJ with variable number of shots depending on the size and density of the epithelial ingrowth area. Twenty-eight eyes showed complete regression after one session, while the rest necessitated 2-3 sessions for complete resolution. Mean follow-up period was 8 months (range 5-12 months).

RESULTS

Epithelial ingrowth was treated successfully in all 41 eyes. The uncorrected visual acuities were 20/20, and there was no evidence of recurrent epithelial ingrowth after 6 months with no complications reported.

CONCLUSION

YAG laser is a simple, effective outpatient procedure for the management of epithelial ingrowth after LASIK.

Epithelial ingrowth following laser in situ keratomileusis (LASIK): prevalence, risk factors, management and visual outcomes

The number of laser in situ keratomileusis (LASIK) procedures is continuing to rise. Since its first application for correcting simple refractive errors over 25 years ago, the role of LASIK has extended to treat other conditions, including postkeratoplasty astigmatism/ametropia, postcataract surgery refractive error and presbyopia, among others. The long-term effectiveness, predictability and safety have been well established by many large studies. However, due to the creation of a potential interface between the flap and the underlying stroma, interface complications such as infectious keratitis, diffuse lamellar keratitis and epithelial ingrowth may occur. Post-LASIK epithelial ingrowth (PLEI) is an uncommon complication that usually arises during the early postoperative period. The reported incidence of PLEI ranged from 0%–3.9% in primary treatment to 10%–20% in retreatment cases. It can cause a wide spectrum of clinical presentations, ranging from asymptomatic interface changes to severe visual impairment and flap melt requiring keratoplasty. PLEI can usually be treated with mechanical debridement of the affected interface; however, additional interventions, such as alcohol, mitomycin C, fibrin glue, ocular hydrogel sealant, neodymium:yttriumaluminum garnet laser and amniotic membrane graft, may be required for recurrent or refractory cases. The aims of this review are to determine the prevalence and risk factors of PLEI; to describe its pathogenesis and clinical features and to summarise the therapeutic armamentarium and the visual outcome of PLEI.

Surgical adhesives in ophthalmology: history and current trends

Tissue adhesives are gaining popularity in ophthalmology, as they could potentially reduce the complications associated with current surgical methods. An ideal tissue adhesive should have superior tensile strength, be non-toxic and anti-inflammatory, improve efficiency and be cost-effective. Both synthetic and biological glues are available. The primary synthetic glues include cyanoacrylate and the recently introduced polyethylene glycol (PEG) derivatives, while most biological glues are composed of fibrin. Cyanoacrylate has a high tensile strength, but rapidly polymerises upon contact with any fluid and has been associated with histotoxicity. Fibrin induces less toxic and inflammatory reactions, and its polymerisation time can be controlled. Tensile strength studies have shown that fibrin is not as strong as cyanoacrylate. While more research is needed, PEG variants currently appear to have the most promise. These glues are non-toxic, strong and time-effective. Through MEDLINE and internet searches, this paper presents a systematic review of the current applications of surgical adhesives to corneal, glaucoma, retinal, cataract and strabismus surgeries. Our review suggests that surgical adhesives have promise to reduce problems in current ophthalmic surgical procedures.

Flap Amputation with Phototherapeutic Keratectomy (PTK) and Adjuvant Mitomycin C for Severe Post-Lasik Epithelial Ingrowth

Purpose

To report a patient with severe post–laser in situ keratomileusis (LASIK) epithelial ingrowth and keratolysis treated with flap amputation and phototherapeutic keratectomy (PTK) with adjuvant intraoperative mitomycin C (MMC).

Methods

Case report.

Results

A 55-year-old woman was referred to our department due to severe post-LASIK epithelial ingrowth with corneal melting 2 years after primary LASIK. The patient had had two previous attempts for epithelial ingrowth treatment (flap lift and epithelial ingrowth manual removal) that were unsuccessful. Slit lamp biomicroscopy and anterior segment optical coherence tomography showed extensive epithelial ingrowth and keratolysis (thinning of the LASIK flap) while the patient had photophobia and could not tolerate contact lenses. Flap amputation with subsequent PTK (in order to smooth out the corneal irregularities caused by the keratolysis and/or variations in flap thickness) and adjuvant intraoperative MMC application for 2 minutes was performed. There were no intra- or postoperative adverse events seen during the follow-up period. Six months after the procedure, uncorrected visual acuity improved to 20/40 compared with 20/50 preoperatively, while best spectacle-corrected visual acuity improved from 20/40 to 20/32. The topographic astigmatism was decreased from 3.24 diopters (D) to 1.00 D.

Conclusions

Flap amputation with PTK and adjuvant intraoperative MMC is an option for the management of severe post-LASIK epithelial ingrowth with keratolysis.

Contralateral Eye Comparison Between Femtosecond Small Incision Intrastromal Lenticule Extraction at Depths of 100 and 160 μm

PURPOSE

To compare the visual results, higher-order aberrations, and corneal biomechanical properties of femtosecond small incision lenticule extraction (SMILE) at depths of 100 and 160 μm.

METHODS

A prospective comparative interventional clinical trial of a series of patients who underwent SMILE. In the right eye, a refractive lenticule was created at a depth of 100 μm, and in the left eye, a depth of 160 μm was used. Manifest refraction, uncorrected visual acuity, total high-order aberrations (THOA), and corneal biomechanical properties of both eyes were evaluated 1 month postoperatively.

RESULTS

Thirty patients with bilaterally stable refractive errors were included in this study. One month postoperatively, mean corneal hysteresis was 9.71 ± 0.68 in the right eyes and 9.97 ± 0.77 in the left eyes, whereas the mean corneal resistant factor was 9.13 ± 1.04 and 9.31 ± 0.92 in the right and left eyes, respectively. Both corneal hysteresis and corneal resistant factor showed statistically significantly higher values in the left eyes (lenticule at a depth of 160 μm). No statistically significant differences were found between the right and the left eyes regarding manifest refraction, uncorrected visual acuity, and THOA.

CONCLUSIONS

Creating the refractive lenticule at a depth of 160 μm in SMILE had less effect on the corneal biomechanics than did creating a lenticule at a depth of 100 μm with no statistically significant differences in the refractive outcome and THOA between both groups.

Fibrin adhesive in conjunction with epithelial ingrowth removal after laser in situ keratomileusis: long-term results

PURPOSE

To describe the long-term results of fibrin adhesive use in the management of epithelial ingrowth after laser in situ keratomileusis (LASIK).

SETTING

Private practice, Minneapolis, Minnesota, and an academic medical center, Durham, North Carolina, USA.

DESIGN

Retrospective case series.

METHODS

Patients with a history of LASIK had epithelial ingrowth removal with mechanical debridement and fibrin glue application. Visual outcomes and the presence or absence of epithelial ingrowth were evaluated again after 3 months and at the last follow-up. The main outcome measures were recurrence of epithelial ingrowth and visual acuity.

RESULTS

Thirty-nine eyes of 38 patients were evaluated. After epithelial ingrowth removal and application of fibrin glue, 31 eyes (79.5%) had no recurrence of ingrowth at the final follow-up and 5 eyes (12.8%) had mild epithelial ingrowth not requiring removal. Three eyes (7.7%) had significant epithelial ingrowth at the 3-month follow-up that required subsequent removal and fibrin application. At the 3-month follow-up visit, 76.9% of eyes achieved 20/25 or better corrected distance visual acuity (CDVA) and 69.2% of eyes achieved 20/40 or better uncorrected distance visual acuity (UDVA). At the last follow-up visit (mean 26.6 ± 17.0 months [SD]), 84.6% of eyes had 20/25 or better CDVA and 74.4% of eyes had 20/40 or better UDVA.

CONCLUSIONS

Fibrin adhesive in conjunction with manual epithelial removal prevented a clinically significant recurrence of epithelial ingrowth in the majority of eyes. Larger randomized studies are needed to compare the success of this technique with that of others.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Ophthalmic use of blood-derived products

There is a wide spectrum of blood-derived products that have been used in many different medical and surgical specialties with success. Blood-derived products for clinical use can be extracted from autologous or allogeneic specimens of blood, but recombinant products are also commonly used. A number of blood derivatives have been used for a wide range of ocular conditions, from the ocular surface to the retina. With stringent preparation guidelines, the potential risk of transmission of blood-borne diseases is minimized. We review blood-derived products and how they are improving the management of ocular disease.

Small-incision, sutureless repair of subconjunctival fat prolapse

PURPOSE

To present a new, small-incision, sutureless surgical technique for the repair of subconjunctival fat prolapse.

METHODS

This is a retrospective interventional case series. Four eyes of 3 patients who presented with prolapsed subconjunctival fat were surgically repaired using a small-incision, sutureless technique with fibrin glue. No prolapsed subconjunctival fat was excised.

RESULTS

The surgical treatment of prolapsed subconjunctival fat using a small-incision, sutureless technique with fibrin glue was successful in all 4 eyes. There have been no cases of recurrence of the prolapsed subconjunctival fat with a mean follow up of 31 months.

CONCLUSIONS

Small-incision, sutureless repositioning of subconjunctival fat using fibrin glue is an effective new surgical technique for the management of prolapsed subconjunctival fat.

Cut and paste: sutureless conjunctival closure in strabismus surgery

PURPOSE

This study investigated the use of fibrin glue and compared its effect with traditional sutures for conjunctival closure in strabismus surgery.

METHODS

The study included 12 patients undergoing horizontal strabismus surgery, of whom 5 underwent bilateral medial rectus muscle recessions and 7 underwent bilateral lateral rectus muscle recessions. For each patient, fibrin glue was used to close the conjunctiva of one eye and 6-0 plain sutures were used to close the other.

RESULTS

All eyes maintained adequate closure of the conjunctiva postoperatively and there were no intraoperative or postoperative complications for an eye. However, the average surgical time needed to apply fibrin glue was considerable less than that required for closure with sutures. Furthermore, eyes closed with fibrin glue were associated with significantly less postoperative inflammation and patient discomfort than those closed with sutures. All patients and parents reported significantly less discomfort from the eyes treated with fibrin glue.

CONCLUSION

These results are promising and demonstrated a safe and effective alternative to traditional suture closure in strabismus surgery. When compared to traditional suture closure, conjunctival closure with glue includes the following advantages: less postoperative patient discomfort, diminished postoperative inflammation, and potentially reduced surgical time with corresponding reduced time under general anesthesia.

Incidence of epithelial ingrowth in primary and retreatment laser in situ keratomileusis

PURPOSE

To analyze the risk for clinically significant epithelial ingrowth after primary laser in situ keratomileusis (LASIK) and flap-lift retreatment LASIK.

SETTING

Private practice, Beverly Hills, California, USA.

METHODS

All cases of primary and flap-lift retreatment LASIK performed by the same surgeon in a single surgical center between January 2004 and June 2007 were retrospectively reviewed. Cases that subsequently developed clinically significant epithelial ingrowth, defined as epithelial ingrowth impeding on the visual axis and negatively affecting uncorrected or corrected distance visual acuity, were identified and analyzed.

RESULTS

Clinically significant epithelial ingrowth occurred in none of the 3866 primary LASIK cases and in 15 (2.3%) of the 646 flap-lift retreatment cases (P<.0001). Clinically significant ingrowth was more frequent when flap-lift retreatment was performed 3 or more years after primary LASIK (7.7% versus 1.0%) (P = .0001). Patient age and sex did not have a statistically significant effect on the epithelial ingrowth rate. There was a nonsignificant trend toward increased epithelial ingrowth after flap-lift retreatment of Automated Corneal Shaper (ACS) microkeratome flaps.

CONCLUSION

Flap-lift retreatment performed 3 or more years after primary LASIK led to a higher risk of clinically significant epithelial ingrowth than primary LASIK or earlier flap-lift retreatment.

FINANCIAL DISCLOSURE

The author has no financial or proprietary interest in any material or method mentioned.

Influence of original flap creation method on incidence of epithelial ingrowth after LASIK retreatment

PURPOSE

To compare the rate of epithelial ingrowth after LASIK retreatment among eyes with flaps created by femtosecond laser and those created by mechanical microkeratome.

METHODS

Postoperative results from 272 consecutive LASIK retreatments performed by a single surgeon over a 4-year period were reviewed retrospectively to identify cases that developed clinically significant epithelial ingrowth, defined as that which required surgical removal. Flaps for the original LASIK treatments were created using a mechanical microkeratome or femtosecond laser. The same technique to lift the flap at the time of retreatment was used in all eyes included in this study.

RESULTS

LASIK retreatment was performed in 132 eyes that had the initial flap created using a mechanical microkeratome (microkeratome group). Epithelial ingrowth was identified in 11 eyes of 9 patients. Surgical intervention to remove the epithelium from the stromal interface was required in 8 (6.1%) eyes. Femtosecond laser was used to create the initial LASIK flap in 140 eyes that required retreatment (femtosecond group). Epithelial ingrowth after LASIK retreatment was identified in 2 eyes of 1 patient in the femtosecond group (P=.004). Neither of these 2 eyes required surgical intervention to remove the epithelium from the stromal interface (P=.017).

CONCLUSIONS

Eyes with femtosecond laser-created flaps may be less likely to develop significant epithelial ingrowth after LASIK retreatment when compared with eyes in which the flap was created using a mechanical microkeratome. The difference in rate of epithelial ingrowth may be related to the geometry of the flap edge.

Fibrin glue in ophthalmology

Suturing is a time consuming task in ophthalmology and suture induced irritation and redness are frequent problems. Postoperative wound infection and corneal graft rejection are examples of possible suture related complications. To prevent these complications, ophthalmic surgeons are switching to sutureless surgery. A number of recent developments have established tissue adhesives like cyanoacrylate glue and fibrin glue as attractive alternatives to sutures. A possible and promising new application for tissue adhesives is to provide a platform for tissue engineering. Currently, tissue glue is being used for conjunctival closure following pterygium and strabismus surgery, forniceal reconstruction surgery, amniotic membrane transplantation, lamellar corneal grafting, closure of corneal perforations and descematoceles, management of conjunctival wound leaks after trabeculectomy, lid surgery, adnexal surgery and as a hemostat to minimise bleeding. The purpose of this review is to discuss the currently available information on fibrin glue.

Epithelial ingrowth after femtosecond laser-assisted in situ keratomileusis

PURPOSE

To describe the incidence and clinical features of epithelial ingrowth after femtosecond laser-assisted in situ keratomileusis (LASIK).

METHODS

All eyes with clinically significant epithelial ingrowth were identified from patients who underwent primary femtosecond laser-assisted LASIK and their subset of patients who underwent enhancement procedures from January 2005 to March 2007 at Kudret Eye Hospital. Clinical course in terms of severity, type of epithelial ingrowth, time of appearance, effect on visual acuity, and treatment was described for each patient.

RESULTS

Two eyes of 6415 eyes after primary procedure and 2 eyes of 108 eyes after enhancement procedure developed clinically significant epithelial ingrowth. All eyes were treated with surgical removal of epithelial ingrowth. The epithelial ingrowths in all the patients were seen as solitary islands of cells, with a size ranging between 1 and 3 mm, beneath the flap with no connection with the surface epithelium. There was recurrence of ingrowth in 1 eye.

CONCLUSIONS

Visually significant epithelial ingrowth after femtosecond laser-assisted LASIK is an infrequent complication. The lower incidence of epithelial ingrowth after femtosecond LASIK surgery compared with mechanical microkeratome-assisted LASIK may be attributed to the anatomy of the femtosecond laser-created side cut in contrast to that created with a mechanical microkeratome and the creation of less peripheral trauma at the time of flap creation.

Sutureless amniotic membrane transplantation for partial limbal stem cell deficiency

PURPOSE

To evaluate the results of sutureless amniotic membrane (AM) transplantation using fibrin glue for reconstructing corneal surfaces with partial limbal stem cell deficiency (LSCD).

DESIGN

Retrospective noncomparative interventional case series.

METHODS

Eleven eyes of nine patients that had LSCD with 120 degrees to almost 360 degrees of limbal involvement underwent superficial keratectomy to remove the conjunctivalized pannus followed by AM transplantation using fibrin glue. Additional sutureless AM patch (ProKera; Bio-Tissue, Inc, Miami, Florida, USA) was used in seven patients, and mitomycin C was applied on the cornea in four eyes and during fornix reconstruction in seven eyes. The surgery was repeated in three eyes for residual pannus.

RESULTS

During a mean follow-up of 14.2 +/- 7.7 months (range, six to 26 months), all eyes maintained a smooth and stable corneal epithelial surface without recurrent erosion or persistent epithelial defect, and showed less stromal cloudiness and vascularization. Best-corrected visual acuity improved in nine eyes (81.8%). Corneal epithelialization proceeded by epithelial growth over AM (n = 4), accompanied by dissolution of AM (n = 4) or a combination of both (n = 3). No complication was noted regarding initial or repeated uses of fibrin glue.

CONCLUSION

AM transplantation using fibrin glue appears to be a safe and effective method of restoring a stable corneal epithelium for cases with partial LSCD. This approach avoids the need of transplanting limbal epithelial stem cells.

Treatment of laser in situ keratomileusis interface epithelial ingrowth with neodymium:yytrium-aluminum-garnet laser

PURPOSE

To evaluate the results obtained with the treatment for interface epithelial ingrowth after laser in situ keratomileusis (LASIK) with neodymium:yytrium-aluminum-garnet (Nd:YAG) laser.

DESIGN

Retrospective, interventional, noncomparative, consecutive case series.

METHODS

Thirty eyes were treated with Nd:YAG laser for clinically significant epithelial ingrowth developed after LASIK. Each impact produced an explosion with evaporation of epithelial cells giving rise to bubbles. The mean intensity of the spots was 0.6 mJ, and they were variable in quantity depending on the size of the epithelial ingrowth area. The patients were followed up for two years.

RESULTS

The opacities caused by the epithelial ingrowth disappeared in 80% of the cases with the Nd:YAG laser treatment. In 40% of the cases, two or more sessions of Nd:YAG laser treatment were necessary to eliminate the epithelial ingrowth areas entirely. In 60% of the cases, visual acuity improved by one or more lines of vision and the corneal topography was more regular. After the treatment, symptoms like glare and halos improved in all cases. The intensity of the laser was adjusted in each case and was focused perfectly on the epithelial ingrowth areas. There were no complications.

CONCLUSIONS

Nd:YAG laser, in our experience, is an easy and effective technique for the treatment of epithelial ingrowth after LASIK.