Refractive Surgery Grand Rounds: these cases illustrate why we must be prepared when things go wrong.(9th Annual Refractive Surgery Report)

Although we will focus on complications, this should not overshadow the satisfactory results that many patients achieve with LASIK. Improvements in patient selection, technique and equipment, and the advent of wavefront-guided ablations promise better results for our future patients.

Indeed, one 45-year-old patient's bilateral LASIK was successful at first. Acuity at one month post-op was 20/20 O.D. and 20/20 with -1.00D correction O.S. (perfect monovision). But a barroom brawl changed the course of his recovery.

During the fight, which occurred 10 weeks after the procedure, the other guy's fist and fingernail scraped across our patient's left cornea. That evening, an emergency room physician determined that he had a large abrasion with possible flap involvement.

When I saw him, visual acuity was still 20/20 O.D. and finger counting through pinhole at 5 feet O.S. Slit lamp exam, showed that the flap had dislodged superiorly with a large fold and striae. The stromal bed had already begun to have 3-4mm of epithelial ingrowth. The patient was in moderate pain and was photophobic.

Admittedly, most of our patients will avoid fights. But this case illustrates that we must know how to manage those complications that can occur during and after laser vision correction, and provide appropriate referral back to the surgeon when necessary.

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Case 1: What's the Big Flap?

The surgeon and I saw this patient together in the laser center. The surgeon replaced the flap and used a stretch-and-smooth technique to reduce the central striae that bisected the pupil. A soft bandage contact lens was placed on the eye, and I instructed the patient to use Pred Forte (prednisolone acetate, Allergan) qid and Ciloxan (ciprofloxacin, Alcon) q2-3h.

The next day the patient was more comfortable, and the epithelium was healing as expected. However, on the second day I observed a white haze on the corneal surface. I determined this to be Ciloxan precipitates, so I switched the patient to Ocuflox (ofloxacin, Allergan) qid as well as Bion preservative-free tears (Alcon) q2h.

On day 3, I removed the patient's contact lens. Visual acuity was now 20/60, and there was edema in the flap and a rough epithelial surface. I instructed him to continue using Ocuflox qid x 2 days.

A week later, visual acuity returned to 20/20 in the affected eye. I counseled the patient to avoid similar incidents in the future.

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Discussion. Traumatic flap dislodgment rarely occurs at more than one week post-op, though I have seen similar cases that resulted from cat and dog scratches or tree branches that hit the cornea. Visual acuity in each case returned to 20/20 after appropriate treatment.

Flap complications may occur during the LASIK procedure itself. Intraoperative flap complications occur during the 8-10 seconds when the microkeratome passes across the cornea, creating the LASIK flap. Loss of suction or inadequate suction can cause serious complications such as buttonholes, incomplete flaps or thin flaps. Patients at greater risk for these flap complications include those who have unusually steep corneas (K readings of 47.00D-48.00D, buttonholes), very flat corneas (39.00D-40.00D, free caps), as well as patients with small intrapalpebral fissures and a very prominent brow that makes for difficult placement of the microkeratome.

Whenever any flap complication other than free cap occurs, the surgeon must stop the procedure and replace the flap without ablating the tissue. After corneal topography and refraction stabilizes, usually within three months, the surgeon may complete the procedure by creating a newer, deeper flap.

Case 2: Abrasive Procedure

A 24-year-old male with -3.00D of myopia was referred for LASIK. On his initial exam he had signs of anterior epithelial basement membrane dystrophy in both eyes but no history of recurrent corneal erosion and no corneal staining. Also, he smoked one pack of cigarettes daily, which exacerbates poor epithelium. The surgeon discussed the possibility of corneal abrasion and extended healing with the patient, who still elected to undergo LASIK.

The procedure in the right eye was uneventful, but complete epithelial sloughing with a 7-8mm abrasion occurred in the left eye during the microkeratome pass.

The surgeon completed the procedure and placed a bandage soft contact lens in the patient's eye. He instilled a drop of Acular (ketorolac tromethamine, Allergan) and prescribed Ocuflox (ofloxacin, Allergan) and Pred Forte (prednisolone acetate 1%, Allergan), both qid.

I counseled the patient that the left eye would require extended epithelial healing (three days), and saw the patient each of those days.

Visual acuity was as follows:

* One day post-op: 20/2[0.sup.+] O.D., 20/200 blurry O.S.

* One week: 20/2[0.sup.+3] O.D., 20/50 O.S.

* One month: 20/15 -O.D., 20/25 O.S.

* Six months: 20/15 O.D, 20/20-with correction of +0.25 -0.75 x 180 O.S.

Discussion. Anterior epithelial basement membrane dystrophy is a relative contraindication for LASIK, due to the sloughing and recurrent corneal erosion that commonly occur with this condition. Many surgeons, when presented with a similar case of map-dot-fingerprint dystrophy, would opt for PRK as a reasonable choice to minimize the risk of DLK, ingrowth and …