Eyeworld

MAY 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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30 30 EW REFRACTIVE SURGERY May 2012 Early answers for late flap dislocation by Maxine Lipner Senior EyeWorld Contributing Editor How to beat back stria and ingrowth A patient who underwent LASIK back in the late 1990s gets hit in the eye—should you still be concerned about a flap dislocation? This should absolutely be on the radar, according to Mark D. Mifflin, M.D., associate professor of ophthalmology, John A. Moran Eye Center, University of Utah, Salt Lake City. Dr. Mifflin reported on such a case of blunt trauma, which occurred 14 years after LASIK, in the November 2011 issue of the Journal of Cataract & Refractive Surgery. Currently, this is the longest flap dislocation case on record. One of the main difficulties in such instances is that because the LASIK procedure may have been per- formed so long before, no thought is given to the idea of a flap disloca- tion. "People will think, 'My eye got scratched,' and they'll go see an emergency room provider and the problem won't be correctly diag- nosed," Dr. Mifflin said. "If it's not diagnosed correctly the flap tends to get folds in it, and the longer these stay in the flap, the harder they are to get out." In addition, he finds epithelial ingrowth can become a factor when flap dislocation is not noted early on. Indeed, by the time Dr. Mifflin's patient came to him for care she had both epithelial ingrowth and thick striae. "The patient actually had pretty good vision, but she did have a broad area of epithelial ingrowth, which is concerning because that will progress over time," Dr. Mifflin said. "If the epithelium is not re- moved over time you may get melt- ing of the flap, and that can make it harder to fix." Treating ingrowth and stria To treat the patient, Dr. Mifflin first marked the portion of the flap that was still aligned and then lifted about three-quarters of the way. The ingrowth here was visible. "I could see the sheet," he said. "So it was very carefully removed and scraped and dried back from the bed and the underside of the flap." It was also clear that there was thick stria there. "It was kind of like a washboard," Dr. Mifflin said. He felt that the best technique would be to scrape the epithelium from the surface to get rid of the washboard-type folds. "The epithelium acts like a casting of those folds—it will grow and mold to what's on the surface," he said. To combat this, Dr. Mifflin recommended gently scraping off the surface epithelium and then using sterile water to make the flap swell, the idea being that this will get rid of some of the stria. The next stage is to carefully Introduction to Phacoemulsification and IOLs Saturday, June 2, 2012 New York Eye & Ear Infirmary and the Jorge N. Buxton Microsurgical Education Foundation will hold its 2nd annual unique, intensive course taught by expert cataract faculty. Didactic and wet lab introduction to critical skills in our state-of-the-art facility with one-to-one instruction, including a new, advanced lab dissection system and live simul- cast of cataract surgery. Offered free (with a $50 refundable deposit) as a service to 2nd year eye residents. Registration is limited. For more details or to Register contact: Deirdre Behan, CME Coordinator Institute for Continuing Medical Education New York Eye & Ear Infirmary 310 East 14th Street New York, NY 10003 212-614-8269 or dbehan@nyee.edu Sponsored by an educational grant from Abbott Medical Optics manage the interface. "Make sure that all of the epithelium is well away from the edge of the flap by gently scraping again, and then lay the flap down, irrigate and smooth it," Dr. Mifflin said. "Our plan was to suture it initially, but it seemed to oppose so well that we decided to leave it and put on a bandage con- tact lens, and that worked great." He found that there was no epithelial ingrowth and that the folds were markedly better even the next day. Suturing issues While suturing the flap down with 10-0 nylon can be helpful, this can also cause problems at times. "This tissue is only about 100 or 150 mi- crons, so it's very thin and flimsy," Dr. Mifflin said. "Trying to put a su- ture in that [tissue] without causing some wrinkling of the edge or dis- rupting the edge can be tricky." Dr. Mifflin finds that in some cases the suture can actually create stria or promote regrowth of the epithelial ingrowth. "It's one of those things where sometimes less is more; if you put a suture on one side and you're really tugging the flap over to seal a gap on one side, you may be stretch- ing the flap so you might be at risk of getting epithelial ingrowth some- where else," he said. "I believe that if you can do it without sutures, it's better—you're less likely to have secondary problems." In his career he has encountered approximately four late flap disloca- tions, and Dr. Mifflin has used the same technique on all of them. "I have only sutured one of them," he said. "The other three or so I have managed in a similar fashion by carefully removing the epithelium and not using sutures." Another possibility for remov- ing the epithelial ingrowth is to use the YAG laser to kill this off. How- ever, Dr. Mifflin does not favor that approach. "I have not had good suc- cess with that technique," he said. "I prefer surgical management, taking the patient back to the operating room and physically removing the epithelial ingrowth by retracting the flap and scraping off the ingrowth, and then either replacing the flap if you can get it back in its normal position or using sutures." The patient in this case fared very well. "She had noticeable visual improvement within a few days of the surgery," Dr. Mifflin said. He found that her vision jumped from 20/20 to 20/30 and her topography improved greatly. "The irregular astigmatism that was there after the injury was basically gone," he said. "It had come back to the pre-injury state so she was very happy." Overall, Dr. Mifflin stressed the importance of educating LASIK pa- tients on the need to seek care from a specialist even when faced with what seems to be an insignificant in- jury years after the surgery. "I think that LASIK patients need to under- stand this is a possibility, even years out, and they need to get their eye checked carefully within a couple of days if they have an eye injury," he said. He also feels that it's vital to teach other practitioners who are not well-versed in dealing with LASIK patients what to do in such cases. "If you're not experienced in looking under a slit lamp with this kind of injury, make sure that you refer the patient," he said. EW Editors' note: Dr. Mifflin has no finan- cial interests related to this article. Contact information Mifflin: mark.mifflin@hsc.utah.edu

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