Posttraumatic Flap Dislocation: A Walk In The Park?

To describe the management of a late traumatic flap dislocation, a possible postoperative complication of FemtoLASIK (Femtosecond Laser-assisted in situ Keratomileusis ) that every refractive surgeon should be able to manage.

FYEO, Private Refractive Clinic, the Netherlands

A 28-y-old male presented to his GP after blunt trauma by an encounter of his right eye and a lower hanging branch in the park 6 months after uneventfull femtoLASIK for myopia. Corneal erosion was diagnosed and treated with antibiotic oitment. 2 days later he was referred to our clinic with vision deterioration presenting with UCVA 20/400,a dislocated flap from inferior to superior and a taco folded flap centrally(fig1). AC was clear without perforation of the bulbus. Immediate surgical intervention occurred irrigating with BSS and cefuroxim. After cautious lifting the flap under the superior hinge with a blunt spatula, the taco flap unfolded. By unwrapping the flap,organic material was removed and the flap repositioned.Epithelium was removed around the edges of the flap. A bandage contact lens (BCL) was placed.Topical steroids (CS) and ofloxacin in high dose were started.Immediate postoperative flap examination (fig 2) had tight edges.UCDVA day 1 was 20/63 with quiet AC and flap in position without visible striae. Stromal opacities in the flap were scattered around.After 1 week the UCDVA was 20/40, the AC still quiet with a tight flap. The stromal infiltrates were not active. The BCL was removed. 2 weeks later a large epithelial island appeared inferior, starting to weaken the cornea (fig3).Immediate Nd:YAG (0.8 Mj) treatment of the island with continuation of high dose CS and oflaxcin drops resulted in local stromal haze(fig 4) at 6 weeks with UCVA 20/32.

A blunt trauma months after primary uneventfull FemtoLASIK can cause a serious flap dislocation. Surgical exploration should be as soon as possible to prevent scarring folds of the flap,infection delay from organic material and melting flaps which easily can tear.Make a surgical plan in advance thinking about instruments that could be necessary during surgery. Check the patient regularly in the first weeks for inflammation or epithelial islands after trauma. Do not hesitate to treat this immediately with ND:Yag laser to prevent further corneal weakening and abberrations.Inform health care workers to refer patients with blunt trauma after LASIK for thorough investigation.Our patient's walk in the park was at the end not ‘a walk in the park’.