March 2019


Research highlight
A stitch in time

by Maxine Lipner EyeWorld Senior Contributing Writer

57-year-old female; LASIK OU in 1994; enhancement OU 2012; EI OS

Lift/scrape/suture OS

6 months later
Source (all): Sonia Yoo, MD


Staving off epithelial ingrowth with suture technique

For patients with epithelial ingrowth, keeping recurrences at bay may mean suturing the flap after scraping. Study results1 published in Cornea indicate that while early visual results were better without suturing, long-term acuity was comparable, according to Sonia Yoo, MD, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami.
In a previous study, investigators examined outcomes of treating epithelial ingrowth in terms of vision, complications, and refractive error. In this second study, the idea was to compare two different techniques for removing epithelial ingrowth. “We looked at if we lifted, scraped, and put the flap back down versus if we lifted, scraped, and sutured the flap back down, how did the outcomes compare in these two groups,” Dr. Yoo said, adding that the study was a retrospective chart review of Bascom Palmer Eye Institute patients.

Evaluating two techniques

Those included underwent treatment for epithelial ingrowth at the center during a 15-year period between July 1999 and July 2014. “We looked at 67 eyes that had treatment for epithelial ingrowth, and about 84% of the eyes had a flap lift and scraping alone, while 16% had a flap lift, scraping, and suturing,” Dr. Yoo said. At 1 month, 44% of eyes with scraping alone achieved 20/20 or better uncorrected distance visual acuity, and 80% of eyes attained 20/20 corrected distance visual acuity or better, she reported.
Meanwhile, eyes that underwent both scraping and suturing did not fare as well initially from a visual perspective. “We found that at 1 month, patients who had the flap lift and scraping alone were seeing better and had less refractive error. But by the 1-year follow up, the vision and the refractive error in the two groups were comparable.”
At 1 month postoperatively, just 9% of eyes attained 20/20 uncorrected distance visual acuity or better and only 36% reached this level for corrected distance visual acuity, Dr. Yoo noted. However, by the 1-year mark, 82% of eyes had attained 20/20 corrected distance acuity with the suture technique as did 82% of those who underwent scraping alone. Likewise, 69% of eyes in the scraping group attained 0.5 D of cylinder or lower compared with 64% of eyes in which a suture was used, Dr. Yoo reported.
The initial issue here is the suture, which induces astigmatism. “We usually keep in sutures anywhere from 2 weeks to 2 months depending on the surgeon and the particular case,” Dr. Yoo said. “So at 1 month many of these patients still had the sutures in the flap, which would cause astigmatism and consequently reduce vision.” Many surgeons who are treating epithelial ingrowth might be reluctant to place sutures because they know that the visual recovery is slower, although the efficacy of preventing recurrence of epithelial ingrowth is higher, she explained.
Given the nature of retrospective studies where there can be some bias in the groups, Dr. Yoo was pleasantly surprised by the results. “The bias here is that generally the patients who had the flap suturing were ones who had more severe cases of epithelial ingrowth,” she said. “Because it wasn’t prospective, we didn’t grade these cases in a uniform way.”
In Dr. Yoo’s view, the results were encouraging for the flap-suturing group because this group of patients was likely to be more severely affected with epithelial ingrowth than the ones who were just lifted and scraped alone.

Clinical impact

Clinically speaking, the results indicate that suturing can be a viable option in the long run. “If a patient has significant epithelial ingrowth requiring flap lifting, scraping, and suturing, although their 1-month vision may be reduced, by 1 year they have a good prognosis in terms of their vision and refractive error,” Dr. Yoo said.
In cases where Dr. Yoo initially encounters epithelial ingrowth, she typically lifts the flap, scrapes, and puts the flap back down. If the case is a recurrent one, however, she takes a different approach. “I’ll lift the flap, remove the epithelium, not only from the bed but from the back of the flap, and I’ll additionally place sutures or some kind of tissue adhesive like fibrin glue or a tissue sealant,” she said, adding that she thinks that such adjunctive measures are needed in recurrent cases because once a patient has epithelial ingrowth, the risk of recurrence goes up.
Dr. Yoo hopes that physicians come away from the study with the understanding that the overall prognosis is good, even in cases where a suture must be placed. “Although the visual recovery is slower in patients who had their flaps sutured, by 1 year the vision and refraction are equally good whether or not you suture the flap,” Dr. Yoo said.

Editors’ note: Dr. Yoo has no financial interests related to her comments.


1. Yesilirmak N, et al. Post-laser in situ keratomileusis epithelial ingrowth: treatment, recurrence, and long-term results. Cornea. 2018;37:1517–1521.

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