Eyeworld

How one practitioner handled the longest case W hen it comes to flap striae, just because a certain length of time has passed does not mean that patients are out of the woods, according to Roxana Ursea, M.D., assistant pro- fessor of ophthalmology, and direc- tor, cornea and refractive surgery division, University of Arizona, Tuc- son. In the November 2010 issue of the Journal of Refractive Surgery, Dr. Ursea reported on a case of trau- matic flap striae, which occurred a record 6 years after LASIK. The case involved a 28-year-old patient who was referred to Dr. Ursea by a colleague. "The patient had trauma and poor vision and was referred to me for evaluation," Dr. Ursea said. "Seven years prior to his presentation, he had LASIK for my- opia and astigmatism—in fact, he was initially seen as a post-trauma patient with microhyphema." At that point the flap striae were not yet detected. While the patient was put on anti-inflammatory drops and his hyphema cleared up, his vision did not improve much. It was then that the patient was referred for a second opinion to Dr. Ursea, who is a corneal specialist. At that point, Dr. Ursea detected the striae and proceeded to treat these. "Initially I tried a conservative approach with a lot of lubrication," Dr. Ursea said. "There was no im- provement, and after talking to the patient he agreed to have the flap lifted and irrigated and then reposi- tioned." Dr. Ursea found that she had remarkably little trouble accom- plishing this. The patient's vision then returned to 20/20. "Looking back at the literature, it was the longest interval of time after the ini- tial refractive surgery procedure that there was an occurrence of flap striae," Dr. Ursea said. Smoothing techniques This was one of many different ap- proaches that could have been taken. "There are a lot of approaches that were described before," Dr. Ursea said. "Some involve using arti- ficial tears, some involve lifting the flap and irrigating with a hyposaline solution." In some cases a hypother- mic spatula is tried. "A spatula is warmed up to try to smooth the striae in the flap," Dr. Ursea said. Likewise, others use a Caro iron to warm up and smooth the tissue. Yet another tact is repeated stretching followed by smoothing. Dr. Ursea bases her chosen tech- nique on whether or not vision is af- fected. "I tend to lift the flap and find that it's better to lift it sooner rather than later if the vision is af- fected," she said. "This is better visu- alized by the red reflex so that when I do a retinoscopy I can actually see the striae—I know that the vision is affected." Another modality Dr. Ursea sometimes uses is sodium flu- orescein at the slit lamp. She finds this to be a more sensitive method for detecting striae. Usually Dr. Ursea then lifts and hydrates the flap and stretches it manually. Perpetual weakness Dr. Ursea hopes that practitioners come away with the understanding that this can happen at any time down the line—at no point are they safe. "The lesson is related to the sealing of the flap the first time be- cause surgeons think that as time passes, they are safe and there is no problem," she said. "But in all of the reports previously and also in this particular case, the message is that if there is trauma, the flap dislocates because it is never actually 100% healed like an intact cornea that has not undergone this procedure." Looking at the histopathology it appears to Dr. Ursea that the strength of the post-LASIK cornea is better in the periphery of the flap than in the center. "The healing in the center is not so good because there are no bridging collagen fibers," Dr. Ursea said. "It takes about 6 months for that primitive scarring to occur." When it does, the collagen in the flap margins tends to be stronger. Dr. Ursea stressed that LASIK is not for everyone, which she urges practitioners to keep in mind. "De- pending on the lifestyle and hobbies of the patient, you might think twice about what kind of procedure to perform because this can happen at a very late stage and many years after the procedure," she said. "Let's say that the patient does active sports or is in the military or police enforcement where there is a chance that something may happen—you might prefer a surface procedure rather than a flap." EW Editors' note: Dr. Ursea has no finan- cial interests related to her comments. Contact information Ursea: rursea@eyes.arizona.edu EW REFRACTIVE SURGERY 85 March 2011 by Maxine Lipner Senior EyeWorld Contributing Editor Stressing over striae www.WinterUpdate.org

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