Old Folded Lasik Flap

to show how to improve vision in such complicated situation using femto lasik. how to creat new flap and the too much challenges i faced to elevate this flap (as shown in video of this case) and the resurfacing of the cornea with marked improvement in its topography and refraction

the memorial institute for ophthalmic research (MIOR)

 30 y old male complaining of lt drop of vision after lasik 2 y ago by another doctor with history of deterioration of vision  directly after lasik. his 1st follow up was after lasik by 10 days , another surgery was done in the same day with no improvement in vision .  patient consult many doctors and all told him to do keratoplasty but he refused.when i examined him i see that the temporal 1/4 of the flap folded under the flap with elevation at this area and depression in the temporal part of flap with unaided VA 3/60 and refraction +6.00/-10.00 x 170 and best corrected 6/36 by +5.00/-8.00 x 170 and other eye 6/6 without glasses.

As the patient refuse to do keratoplasty, the Choices For Treatment are:

PRK 

Reposition of flap (epithelium removing and unfolding the flap then reposition it in its original place ) without doing excimer laser.

Create a new deep flap ( at a level deeper  to the folded part of flap ) .

i offered the patient  to give the eye a chance with femto lasik to try to resurface cornea to correct vision in this eye as much as i can and he accepted the idea. my plan was to create new flap more deep to 1st flap and use the following refraction +3.00/-6.00 x 170  to resurface cornea to improve vision. but i change the plan during surgery due to the too much challenges i faced during elevation of flap as  i found two planes one for old flap and other for new one and  i found sever adhesions  at multiple points  but finally i elevate flap and apply laser .

results :

post op.  marked improvement in corneal topography and refraction .

ref. of this eye become +2.50/-4.50x 155 (after 2 months) with uncorrected VA 0.4 correct by +1.00 /-3.00 x 155 to 0.7 

take home message:

• Early follow up after  surgery  is very important as it allows early intervention for post   operative complications and prevents further deterioration .
• In such challenging cases with irregular cornea , we can give a chance to Femto-lasik before we rush to keratoplasty .
• Although Femto-lasik is a valuable tool in these cases , as the idea of creating a deeper flap at this level cannot be done except with Femto-lasik ,but  sometimes - as in this case –        it can't cut all adhesions which make the surgery extremely difficult.