Epithelial Ingrowth After LASIK

Delayed-onset pressure-induced interlamellar stromal keratitis (PISK) and interface epithelial ingrowth 10 years after laser-assisted in situ keratomileusis

Purpose

To report a case of pressure-induced interlamellar stromal keratitis (PISK) 10 years after laser assisted in situ keratomileusis (LASIK).

Observations

A case of a 36-year-old man who underwent LASIK and presented with PISK 10 years later. Before presenting to our department he consulted elsewhere for red eye, decreased visual acuity, foreign body sensation, and pain on the RE for 1 week. He was then prescribed topical prednisolone six times per day and was lost to follow-up. On examination and after 1 month of continuous use of steroids uncorrected distance visual acuity (UCDV) was 20/400 in the right eye (RE) and 20/20 in the left eye (LE). Best corrected visual acuity was 20/80 on the RE. The Goldmann intraocular pressure (IOP) was 26 and 17 mmHg in the RE and LE, respectively. Slit lamp biomicroscopy revealed fluid in the interface and epithelial ingrowth. Fundoscopic examination results were normal in both eyes. Treatment was initiated with topical brimonidine tartrate 0.2%, timolol 0.5%, and dorzolamide 2.0% BID. Once the pressure was controlled the patient was scheduled for mechanical debridement of the epithelial ingrowth with significant improvement of UCVA (20/25).

Conclusions

Refractive surgeons should be aware of PISK as a potential complication of LASIK even years after the procedure. Intraocular pressure can be misleading, and diligent and careful examination are key to diagnosis and treatment of this potentially blinding complication.

Bilateral post-LASIK exacerbation of granular corneal dystrophy with epithelial ingrowth

A male patient in his 30s, with a history of bilateral microkeratome-assisted myopic laser-assisted in situ keratomileusis (LASIK) 8 years ago at another centre, presented to us with gradually progressive diminution of vision and glare in both eyes for the last 4 years. On presentation, uncorrected distance visual acuity (UDVA) was 6/24 and 6/15 in the right eye and left eye, respectively, with normal intraocular pressures. Slit-lamp examination and anterior segment optical coherence tomography revealed well-defined white deposits, limited to an area within the LASIK flap. The deposits were confluent, at the level of the LASIK flap interface, and few discrete opacities were present in the posterior stroma. His father also had a similar clinical picture in both eyes. A diagnosis of both eyes post-LASIK exacerbation of granular corneal dystrophy with epithelial ingrowth was made. He underwent right eye femtosecond laser-assisted sutureless superficial anterior lamellar keratoplasty. At 6-month follow-up, UDVA improved to 6/12 with graft clarity of 4+ and coexistent grade 1 epithelial ingrowth.

Femtosecond Laser-Assisted Anterior Lamellar Keratoplasty as a Treatment Modality for Recalcitrant Post-Laser in situ Keratomileusis Epithelial Ingrowth

The purpose is to present the outcomes of anterior lamellar keratoplasty for a case of post-laser in situ keratomileusis (LASIK) epithelial ingrowth. A 40-year-old male patient presented with epithelial ingrowth 14 years after primary LASIK with a microkeratome blade in the right eye following trauma. Multiple stromal bed washing was done over a period of 3 years, but recurrence of epithelial ingrowth was seen every time. Femtosecond laser-assisted anterior lamellar keratoplasty was performed in the right eye. Twelve months after the procedure, the patient's corrected distance visual acuity improved to 6/9, and no recurrence was noted. Femtosecond laser-assisted anterior lamellar keratoplasty is an effective treatment modality in cases of recurrent recalcitrant epithelial ingrowth seen after LASIK.

Effect of Time Since Primary Laser-Assisted In Situ Keratomileusis on Flap Relift Success and Epithelial Ingrowth Risk

PURPOSE

To assess the association of time since primary laser-assisted in situ keratomileusis with flap relift success and risk of epithelial ingrowth in eyes undergoing flap relift after primary laser-assisted in situ keratomileusis.

SETTING

Hong Kong Sanatorium & Hospital, Hong Kong Special Administrative Region.

DESIGN

Retrospective, observational case series.

METHODS

Seventy-three eyes with flaps relifted for refractive enhancement laser-assisted in situ keratomileusis were included. Main outcome measures included rate of relift success and epithelial ingrowth; associations of time since primary laser-assisted in situ keratomileusis, sex, age at relift, year of relift, and flap creation method in primary laser-assisted in situ keratomileusis with relift success and epithelial ingrowth.

RESULTS

Relifting was successful in 71 eyes (97.3%). Among the successfully relifted eyes, 12 (16.9%) developed epithelial ingrowth, of which 3 (4.2%) were clinically significant. No eyes lost more than one line of corrected distance visual acuity. The time since primary laser-assisted in situ keratomileusis (up to 22 years), sex, age at relift, year of relift, and flap creation method in primary laser-assisted in situ keratomileusis were not associated with relift success or epithelial ingrowth.

CONCLUSIONS

With our described surgical technique, flaps could be successfully relifted without much difficulty up to 22 years after primary laser-assisted in situ keratomileusis with a low incidence of epithelial ingrowth.

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.

Postoperative Corneal Complications in Small Incision Lenticule Extraction: Long-Term Study

PURPOSE

To investigate the incidence and clinical results of corneal complications after small incision lenticule extraction (SMILE).

METHODS

A retrospective cohort study including 3,223 patients (6,373 eyes) who were treated for myopia or myopic astigmatism was conducted. Postoperative corneal complications were recorded. Postoperative follow-up visits were scheduled on days 1 and 7 and months 1, 3, 6, and 12.

RESULTS

Of the 6,373 cases, 432 eyes (6.8%) developed at least one corneal complication postoperatively. These included punctate epithelial erosions (3.26%), diffuse lamellar keratitis (DLK) (2.17%), corneal infiltrates (0.39%), interface debris/secretion (0.30%), interface haze (0.17%), interface foreign body (0.24%), corneal striae (0.14%), corneal edema (0.09%), and epithelial ingrowth (0.02%). Of cases with corneal complications, 308 (71.3%) had an uncorrected distance visual acuity (UDVA) of better than 20/25 and 49 (11.3%) eyes lost two or more lines of corrected distance visual acuity (CDVA) on the first day after surgery. By 3 months, only 2 eyes (0.9%) had lost two or more lines of CDVA. At 6 months, 1 eye (1.0%) did not achieve a UDVA of 20/25 as a result of stage 3 DLK, but achieved 20/20 by 1 year. The postoperative spherical equivalent in cases without complications was lower than that in cases with complications at 1 day and 1 and 3 months (P = .001, .011, and .001, respectively), but there was no statistical difference at 6 and 12 months.

CONCLUSIONS

In this large cohort study, a variety of corneal complications were noted after SMILE. Although some of these complications may temporarily affect visual recovery, most resolve with appropriate treatment. [J Refract Surg. 2019;35(3):146-152.].

Post-Laser In Situ Keratomileusis Epithelial Ingrowth: Treatment, Recurrence, and Long-Term Results

PURPOSE

To study outcomes after surgical removal of epithelial ingrowth (EI) in post-laser in situ keratomileusis patients, specifically comparing visual results and recurrence rates between 2 different EI management techniques.

METHODS

In this retrospective chart review of 67 eyes of 54 patients who underwent surgical treatment for EI after laser in situ keratomileusis between July 1999 and July 2014 at the Bascom Palmer Eye Institute, Miami, FL, surgical techniques, recurrence rates, visual acuity (VA), and refractive error were assessed.

RESULTS

Of the 67 eyes, 56 eyes (83.6%) had flap lift + scraping alone, and 11 eyes (16.4%) had flap lift + scraping + suturing. After mean follow-up of 2.5 years, 11 of 56 eyes (19.6%) treated with flap lift + scraping alone had EI recurrence, whereas no eyes treated with flap lift + scraping + suturing had EI recurrence. VA results and refractive errors were better in eyes treated with lift + scraping alone compared with lift + scraping + suturing at 1 month. In the 67 eyes with 1-year follow-up, VA and refractive errors improved from preoperative values and were comparable between groups.

CONCLUSIONS

Scraping alone provides significantly better initial visual outcomes but higher EI recurrence rates compared with scrape-suturing. Long-term visual outcomes are comparable between 2 techniques.

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.