flap lift and repair of postoperative laser in

7/24/2019 Flap Lift and Repair of Postoperative Laser In

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FLAP LIFT AND REPAIR OF

POSTOPERATIVE LASER IN

SITU KERATOMILEUSISCOMPLICATIONS AT THE

SLITLAMP

Richard S. Koplin, MD, David C.

Ritterband,MD, Olivia L. Lee,MD, John A.

Seedor,MD

J Cataract Refract Surg 2010;36:1069-1072


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POST OPERATIVE COMPLICATION

OF LASIK

Epithelial ingrowth

Diff!e la"ellar #eratiti!

$nterface debri! Corneal !triae

%lap in&r'

Re(ireintervention

Lifting the LAS$K flap


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ND:YAG LASER

Reported to !cce!!fll'treat interface

epithelial ingrowth


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COMPARED BETWEEN Srgical "icro!cope)

Lighting

Depth perception

*er!!

Slit la"p

+width variative

+anglation

Li"it vi!aliation

and preci!e flap

repo!itioning


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OVERHEAD MICROSCOPE

-inder identification of )

Leftover debri! nder the flap

he pre!ence of re!idal epithelial cell! after!tro"al bed

Stro"al nder!ide of the flap have been

!craped


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TO MANAGE THE

COMPLICATION: %lap elevation and repair

opical ane!the!ia

/ the !litla"p bio"icro!cope

Avoiding a retrn to the operating roo"


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SURGICAL TECHNIQUE

opical propacaine ane!the!ia 0ovidone+iodine

Stainle!!!+!teel lid !pecl" i! placed

he patient i! !eated / the !litla"p

Maintain the head1! potition dring theprocedre

he flap "argin i! identified b' !litla"p

bio"icro!cop'.

A blnt flap elevator 2eg, Machat LAS$K

retreat"ent !patla, AS$CO3i! !ed to lift and

reflectthe flap to the e4tent nece!!ar' for

epithelial debride"ent


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he whole flap doe! not to be elevated

he epithelial !ide of the partiall' reflectedflap co""onl' adhere! to the ne4po!ed

corneal !rface providing vi!ibilit' to the

!rgical field

$f the flap doe! not re"ain adherent a 5+handed techni(e i! !ed to "aintain the

flap po!ition

he !rface i! then e4a"ined b' !litla"p

nder high "agnification i!land! ofepithelial cell! or interface debri!


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More e4ten!ive nder"ining of the flap

Mechanical debride"ent of epitheli" fro"

the !tro"al bed

6nder!ide of the flap i! perfor"ed Machat

!patla7 a corneal ra#e to peel and re"ove

an' epithelial ingrowth

he !lit bea" lighting enhanche! vi!ibilit' in

fa!tidio! 8 co"plete re"oval of cell! and

debri!.

he nder!ide of the flap can be !crapped!ing the !patla

he epitheli" i! then debrided 9+5""

ot!ide the flap gtter


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:et the !rface of the flap after debride"ent

;SS Repo!ition the flap in the !tro"al bed !ing the

!patla

A wet celllo!e !ponge to !"ooth and refine

the the flap po!ition he flap i! allowed to dr' for = !econd!

En!re proper re"oval of all epithelial cell!

?= !econd! prior to re"oving the lid

!pecl" After the procedre topical A; and

cortico!teroid agent! @ ti"e! dail' for 9 wee#


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RESULT e'e! of < patient! were treated for

+clinicall' !ignificant epithelial ingrowth 2


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%ig 9. A) flap lifter initiating elevation in area to be treated.

;) he LAS$K flap reflected bac# and adherent to !rface while the

corneal ra#e i! !ed to !crape the !tro"al bed. Onl' the flap area with

epitheli" ingrowth ha! to be elevated.

C) -igher "agnification i"age of the corneal ra#e


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REPRESENTATIVE CASE

HISTORIES I A ?@+'ear old "an bilateral LAS$K

@ 'ear! later

Strc# in RE with barbed wire

0ain

Decrea!ed vi!ionE"ergenc' roo"

6D*A LERE

D7 Corneal abra!ion

h) enta"icin eo

Referred


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48 HOURS AFTER THE TRAUMA

6D*A 5=75== La!i# flap wa! di!located fro" +9= o1cloc#

he flap folded on it!elf

he e4po!ed !tro"al bed in the

inferote"poral (adrant + epithelied

+ did not !tain with flore!in

Epithelial ingrowth e4tended into the flap!tro"al interface

he flap hinge appeared to be intact


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4 DAYS AFTER THE TRAUMA Slitla"p repair

+ flap lifting

+ epithelial debride"ent of the !tro"al

interface and nder!ide of the flap

+ flap repo!itioning

9 da' after repair)6D*A ) 5=7?=

he flat wa! noted

+to be flat+ in place

Bo epithelial debri!


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2 WEEKS AFTER THE INJURY

6D*A 5=75=

race !bepithelial hae re"ained inferiorl'


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CASE HISTORY II

A @5 F'ear+ old"an with "'opia +5,== RE , +9, LE

Bonc!to"ied LAS$K in both e'e!

Mechanical "icro#erato"e with G, "" ring

Ablationed wa! perfor"ed

Optical one of , "", tran!ition one of

,""


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6 YEARS LATER o correct re!idal "'opic a!tig"ati!")

flap lift and enhance"ent wa! perfor"ed

Epithelial ingrowth 2H3 nder both flap!

E4tended clo!e to the vi!al a4i! )? wee#! 0atient co"plaint )flctating and blrr'

vi!ion

6D*A 5=75 in both e'e!

wee#! after enhance"ent)

+ both flap wa! lift

+epithelial ingrowth wa! !crapped


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5 WEEKS AFTER THE ENHANCEMENT

CD*A i"proved to 5=75= RE and 5=79 LE

%ir!t da' following flap lift

/@ "onth! )

+linear area of epithelial ingrowth at the flapedge RE

+ no progre!!ion and no epithelial cell! were !een

in LE


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DISCUSSION %lap lift with the aid of !litla"p

bio"icro!copic for repair of po!t+LAS$K

co"plication di!tinct advantage

he !rgeon can activel'+alter the !litla"p1! light inten!it'

+ depth of foc!

+ bea" width

+ angle

vi!alie of the lap interface dring

procedre


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OPERATING MICROSCOPE %i4ed wide bea" of the light !orce

Cornea cannot be viewed in a cro!! !ection

with d'na"ic "aniplation of the light

!orce


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SLITLAMP BIOMICROSCOPIC Reco""ended

o en!re that all trace! of epitheli" are

re"oved

Little ri!# for regrowth of cell! $n the ca!e of debri! re"nant that "ight

indce hae 2 a! "ight be !een in Bd)IA

La!er treat"ent of interface cell!3

Si"ple and efficient $""ediate

Co!t effective repair


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T!"# $%& '()$ *&+

flap lift and repair of postoperative laser in

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