Epithelial remodeling in correction of irregular astigmatism caused by irregular LASIK flap and epithelial ingrowth
First Author: VladimirSuvajac SERBIA
Co Author(s): Gordana Suvajac Kristina Savic Jovana Suvajac Vesna Novakovic Branislav Djurovic
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To report a case of patient who had LASIK surgery in his left eye, with irregular flap creation and postoperative epithelial ingrowth. After surgical removal of epithelial ingrowth, patient had significant irregular astigmatism, with pronounced loss of BCVA. In the first 3 months after epithelial ingrowth removal, epithelial remodeling gradually compensated for the significant amount of corneal irregularity and lead to complete recovery of preoperative BCVA.
: Eye Clinic ,,Profesional – dr Suvajac’’, Belgrade, Serbia
Case report of 31 year old patient who underwent LASIK procedure in his left eye for the correction of myopic astigmatism. During the passage of microkeratome (Moria M2, 90 micron head), irregular flap was created, with residual uncut slit of tissue remaining inferonasally, extending from flap margin to the edge of the optical zone. Since ablation depth was low, we proceeded with EXCIMER ablation. Three months after LASIK, patient started complaining on severe diplopia in his left eye. On slit lamp examination, significant epithelial ingrowth in the flap area surrounding the uncut slit of tissue was diagnosed. On corneal tomography, localized corneal flattening was seen in the area of ingrowth. Epithelial ingrowth was removed by flap lift and scraping, but postoperatively the slip of uncut tissue was much more pronounced, causing significant irregular astigmatism and loss of BCVA. Postoperative objective refraction (Huvitz HRK 8000A), manifest refraction, slit lamp examinations, as well as corneal tomography measurements (Wavelight Oculyzer) were taken monthly, until full recovery of BCVA occurred.
Preoperative left eye UCVA was 0.6 and preoperative manifest refraction was -1.25 Dcyl ax 85, for the BCVA of 1.0.One month after LASIK surgery, UCVA was 1.0, despite irregular flap creation. Three months after LASIK, due to the epithelial ingrowth, patient started complaining on severe diplopia in his left eye, while the UCVA still remained 1.0. One month after epithelial ingrowth removal, diplopia were absent, but due to highly irregular cornea, there was significant loss of UCVA and BCVA. UCVA was 0.2 and BCVA was 0.5 with manifest refraction of -0.50/-3.0 x 85. Corneal astigmatism measured by corneal tomography was 3.9 diopters. We decided to observe the patient and prescribed him artificial tears only. Two months after epithelial ingrowth removal, corneal surface was much more regular and corneal astigmatism was 1.9 diopters, UCVA was 0.7 and BCVA was 1.0 with manifest refraction of -1.0 Dcyl ax 40. Three months later, corneal surface continued to regularize, corneal astigmatism improved to 1.0 diopter, UCVA was 0.9, and BCVA was 1.0 with manifest refraction of 0.0/-0.50 x 40. In the following months there was no change in corneal curvature, and corneal surface appeared stabile.
It is well known fact that corneal epithelium has a tendency to regularize the irregular corneal surface. This is best seen in patients with keratoconus and other ectatic corneal disorders. Epithelial remodeling and hyperplasia are also, at least partially, responsible for refractive regressions after EXCIMER refractive treatments. In our patient, epithelial remodeling contributed to significant corneal surface regularization after irregular LASIK flap creation with postoperative epithelial ingrowth and irregular astigmatism, and led to UCVA and BCVA recovery. Although we did not measure the epithelial profile with anterior segment OCT (or other device), regularization of corneal surface could be contributed to epithelium remodeling since gradual curvature changes were seen on corneal tomography maps during several months period, with no other therapeutic measures taken, except for the use of lubrication eye drops. Also, in case of significant LASIK flap abnormalities, EXCIMER ablation should not be undertaken, due to possible postoperative complications, such as epithelial ingrowth. FINANCIAL INTEREST: NONE