Fixing a lost or slipped flap

Advice for how to treat a patient suffering from a rare occurrence

Having a flap slip after LASIK occurs very rarely, around 2% of cases, and losing a free flap is an even rarer occurrence — something that most surgeons may never experience during their careers.
In his lecture at the American Academy of Ophthalmology (AAO) annual meeting in Las Vegas titled “Lost Flap and Slipped Flap: Treatment Options” during the meeting’s refractive subspecialty day, Harry S. Geggel, M.D., Seattle, will provide tips on how to best help patients when these rare complications arise.

Lost flaps

Dr. Geggel said there have been a few isolated cases of patients having a flap amputated with severe trauma. However, a flap is more likely to be lost during surgery. This can occur if patients have a flat cornea (K readings less than 41 D), if suction is lost during the pass of the microkeratome, or if there is an incorrect coupling of the blade head with the gears.
“Lost flaps usually will occur in the operating room where the microkeratome just made too superficial a cut,” Dr. Geggel said. “Surgeons have to be comfortable knowing how to take the microkeratome apart, because the lost flap is usually going to be somewhere within the machine.”
After the flap is found, Dr. Geggel said that toothless forceps should be used to handle the flap so as to avoid tissue damage. Ideally, the flap should be stored in a desiccation chamber to avoid drying while the patient’s eye is examined to determine whether LASIK can still be performed.
Dr. Geggel said if the bed diameter is adequate and not too much time has elapsed, LASIK could still be performed and then the flap would be replaced.
“It’s a little controversial what the standard of care is, and whether or not one should simply replace the flap and reevaluate or perform the actual LASIK surgery,” he said. “If it’s been less than five minutes, you could possibly perform LASIK, but my bias would be not to do it unless it’s been less than three or four minutes. It comes down to clinical judgment.”
Dr. Geggel said that it is important for the surgeon to pause to examine the flap under high magnification to ensure proper flap orientation. Usually the lost flap is slightly irregular, and the surgeons can put it together like a jigsaw puzzle.
“With these lost flaps, there’s an increased risk for epithelial ingrowth, so you want to make sure that there’s been no epithelium that’s been pushed down onto the stroma of the patient’s cornea or the back of the flap,” he said. A cellulose sponge can be used to remove the epithelium on both sides of the stroma.
He also recommends air drying the flap for a longer amount of time once it’s reattached just to make sure it is adherent. He said that in this case he would air dry the flap for five to 10 minutes instead of two minutes as he usually does for a routine LASIK procedure.
Dr. Geggel said that a bandage contact lens should be used and that the patient should be examined for up to two hours after surgery. He also recommends seeing the patient regularly for a week to make sure that the flap is not slipping and that there is no sign of infection.
If the lost flap slips after the first day, Dr. Geggel recommends suturing the flap and using frequent antibiotic and steroid drops to prevent infection and the formation of diffuse lamellar keratitis (DLK).

Slipped flaps

In the second part of his talk, Dr. Geggel said he will be discussing slipped flaps.
“Slipped flaps are more common [than lost flap],” he said. “Usually, in my experience, it happens within the first 24 hours, which is why you see the patient [for an appointment] the next day. In my experience, if the flap is in proper position on day one, it doesn’t slip unless someone gets hit in the eye.”
The sooner the flap is fixed the better. Therefore, Dr. Geggel recommends fixing it that afternoon or the next day because if the flap slips, it can get macrostriae, which can get harder to remove as the days go by.
Dr Geggel said there are different techniques for putting a slipped flap back in proper position.
The ophthalmologist has to make the decision whether or not to remove the central 4 mm of the epithelium, because the epithelium can hold the folds in the fixed position. In his opinion, removing the epithelium will lead to removing the macrostriae with greater ease.

Caring for lost or slipped flaps

Dr. Geggel said the procedure after the flap is re-adhered is the same for both lost and slipped flaps.
He said, “I air dry it a little bit longer. I use a bandage contact lens. If it becomes redislocated the next day, I’ll consider suturing. And you really have to worry about DLK, so I will give the patients more topical steroids than I normally do. In these cases I do usually give them two to three days of oral steroids to minimize DLK, and again the usual topical antibiotics.”
Dr. Geggel noted that patients will notice immediately that something has happened if they have a lost or slipped flap but that in 999 times out of 1,000 of these cases, the flap will have been dislocated, not amputated.
To his knowledge there have been only two case reports of amputated flaps, so slipped flaps are a more common concern for the surgeon performing refractive surgery.

Editors’ note: Dr. Geggel has no financial interest related to his comments.

Contact Information
Geggel: 206-223-6840, harry.geggel@vmmc.org