April 2020

IN FOCUS

Therapeutic Refractive Corneal Surgery
Management of rare post-LASIK complications


by Liz Hillman Editorial Co-Director


Eye with areas of epithelial ingrowth superior nasally and inferior nasally

Large area of epithelial ingrowth near inferior flap
margin; note the irregularity to flap margin that
commonly develops with epithelial ingrowth
Source (all): Francis Price Jr., MD

 

Post-LASIK complications are exceedingly rare. According to the American Refractive Surgery Council, less than 1% of LASIK patients experience surgical complications.
Though rare, EyeWorld spoke with experts on how to handle some of these complications. First, there’s the patient discussion.
“You don’t want to minimize the complication; you don’t want to ignore it,” said Michael Gordon, MD. “I think the best time to handle any complication is the moment you notice it because … quickly handled, quickly forgotten.”
The most common complication that requires a therapeutic intervention after LASIK, said Francis Price, MD, and Robert Maloney, MD, is the need for an enhancement. While a surgeon might not consider this a complication, per se, both Drs. Price and Maloney said the patient often sees it as such because they need to return the OR. Dr. Price said his enhancement rate is less than 1%; Dr. Maloney said the enhancement rate at his practice is 4%.
Outside of enhancements, the two most “common” reasons why a post-LASIK patient would need to return to the OR are a slipped flap or epithelial ingrowth. Overall, Dr. Maloney estimated that each occur in about 1% of cases.

Handling flap dislocations, striae

Slipped flaps usually occur within hours after surgery and are diagnosed on the first day postop. The exception is trauma, Dr. Maloney said.
“The key with repairing flap dislocations is after you lift and smooth it out, you’ll still have visible striae in it because the epithelium thickens and thins in response to the wrinkles. Even when you get rid of the stromal wrinkles, there are still epithelium wrinkles. The mistake new doctors make is they try and smooth out the epithelial wrinkles,” Dr. Maloney said. “Once the edges of the flap are lined up, the wrinkles will go away the next day, so you don’t have to remove any of the epithelial wrinkles.”

Tackling epithelial ingrowth

Overall, it would be rare to get primary epithelial ingrowth, Dr. Gordon said. The most common reason to get epithelial ingrowth, the doctors said, is from relifting the flap for enhancements.
Overall, Dr. Price said improved treatment with newer platforms is reducing the number of enhancements needed and thus cutting down on problems like secondary epithelial ingrowth. Dr. Gordon said if the ingrowth is at the edge and not impacting vision, he will monitor it. When it is impacting vision, go in and remove it, but he cautioned, “the problem is epithelial ingrowth in retreatment is difficult to eliminate.”
When epithelial ingrowth keeps occurring, Dr. Maloney said he sutures the flap tightly. Dr. Gordon mentioned glue and soft bandage contact lenses as options as well. Both said if there is a button hole in the flap or if it doesn’t go away despite these efforts, flap amputation might be necessary.
“The expression on [the patient’s] face is ‘What does that mean?’ The reality is the flap doesn’t do anything other than it’s a platform for the epithelium to sit on that has a Bowman’s membrane,” Dr. Gordon said. Removing the flap transitions the patient to a PRK-like condition. “You amputate the flap, let them heal, and frequently that’s all you need to do. … Treat them like a PRK with mitomycin. They usually heal fine. In 3–6 months, if the vision isn’t where you want it, fix it with a PRK.”
If a primary epithelium ingrowth occurs, Drs. Price and Gordon said it’s usually someone who had undiagnosed anterior membrane dystrophy.
“It’s not that you missed it, it just wasn’t present when you took a look at the patient,” Dr. Gordon said, explaining that its signs can be transient.
Dr. Price usually waits a couple of months to address ingrowth, depending on how bad it is, “because a lot of times it will resolve and get better, especially if it’s out at the edge.”
Dr. Maloney said epithelium ingrowth occurs within the first week of surgery, but it’s often not visible until later (it can be visible at 3 weeks postop but is easier to see at 5–6 weeks). Dr. Maloney addresses epithelium ingrowth as soon as he sees it because “the longer you leave it, the more likely it is to recur after surgery.”

Stopping recurrent erosions

Recurrent erosion is often associated with underlying basement membrane dystrophy, according to Drs. Gordon and Maloney.
“Usually in patients who get them later, they had epithelial defects at the time of surgery,” Dr. Maloney said. “If you’re working on a patient and the epithelium begins to slough, you can be sure they’ve got basement membrane dystrophy and at least recognize the possibility of recurrent erosions later. When recurrent erosions happen, it’s usually a month after the procedure and they generally tend to go away.”
Dr. Maloney said he treats recurrent erosion the same way he would for patients who hadn’t had LASIK.

Facing post-LASIK ectasia

Post-LASIK ectasia is estimated to occur in a range of 0.04–0.6% of cases.1 Better screening methods have reduced incidents of post-LASIK ectasia. In fact, Dr. Price said, screening in some cases, is “too good,” screening out too many possible candidates who would have otherwise done well with LASIK.
“I think the biggest problem are people who rub their eyes,” Dr. Price said. “Most of the people I’ve had to do crosslinking on who are sent in for post-LASIK ectasia have a history of rubbing their eyes.”
As such, Dr. Price said they make a point in his practice of telling patients not to rub their eyes now or later.
“Early on, don’t rub your eyes because the flap can come off or wrinkle. Thirty years from now don’t do hard eye rubbing or pushing on your eyes because the cornea can bulge out,” Dr. Price said. “It’s important to be proactive and remind them about behavioral things that can cause them to have problems later.”

At a glance

• Post-LASIK complications, such as flap dislocation, recurrent erosion, epithelial ingrowth, and ectasia are extremely rare. The most common post-LASIK complication is the need for enhancement, doctors said.
• When addressing striae in a flap, note that epithelial wrinkles might still be visible after smoothing the stroma; they will disappear with time.
• Epithelial ingrowth is more common after lifting the flap for an enhancement.
• Recurrent erosion is often associated with underlying basement membrane
dystrophy.

About the doctors

Michael Gordon, MD
Gordon Schanzlin New Vision Institute
La Jolla, California

Robert Maloney, MD
Maloney-Shamie Vision Institute
Los Angeles, California

Francis Price Jr., MD
Price Vision Group
Indianapolis, Indiana


Localized nest of epithelial ingrowth extending in from wound margin at 10:00
Source: Francis Price Jr., MD

Dr. Price said January 2020 marked 25 years that he’s been performing LASIK, and he discussed with EyeWorld how far the procedure has come in that time, making surgical complications exceedingly rare. One of the major advances was the switch from microkeratome to laser. He also mentioned the PROWL-1 and PROWL-2 studies, which looked at patient-reported outcomes with LASIK, finding that more than 95% of patients were satisfied with their procedure.2,3 Dr. Price and coresearchers separately published a study in 2016 that compared visual satisfaction with LASIK and contact lenses.4 To assess satisfaction with patients’ method of vision correction, Dr. Price said they posed the statement: “I would recommend my current method of vision correction to a close friend or family member.” At 3 years after baseline the percent of people who “strongly agreed” with this statement were as follows: 88% for LASIK after contact lens wears, 77% for LASIK after glasses wearing, and 54% for those staying in contact lenses. When adding the percent who also just “agreed” with the statement the percentages were 98%, 99%, and 97%, respectively, so that overall both the contact lens and LASIK group would recommend their current form of visual correction, Dr. Price said, adding that the very satisfied percentages were significantly higher in the LASIK group compared to the contact lens group. LASIK was also found to reduce difficulty with night driving and other nighttime visual disturbances in the former contact lens and glasses wearing groups. Those in the LASIK group also had fewer self-reported eye infections, ulcers, and abrasions, compared to contact lenses wearers.

References

1. Wolle MA, et al. Complications of refractive surgery: ectasia after refractive surgery. Int Ophthalmol Clin. 2016;56:129–139.
2. Eydelman M, et al. Symptoms and satisfaction of patients in the Patient-Reported Outcomes With Laser In Situ Keratomileusis (PROWL) studies. JAMA Ophthalmol. 2017;135:13–22.
3. Hays RD, et al. Assessment of the psychometric properties of a questionnaire assessing Patient-Reported Outcomes With Laser In Situ Keratomileusis (PROWL). JAMA Ophthalmol. 2017;135:3–12.
4. Price MO, et al. Three-year longitudinal survey comparing visual satisfaction with LASIK and contact lenses. Ophthalmology. 2016;123:1659–1666.

Relevant disclosures

Gordon
: None
Maloney: None
Price: Alcon, STAAR Surgical

Contact

Gordon
: mgordon786@gmail.com
Maloney: info@maloneyshamie.com
Price: frankprice@pricevisiongroup.net

Management of rare post-LASIK complications Management of rare post-LASIK complications
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