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Traumatic corneal flap displacement is an uncommon complication followinglaser-assisted in situ keratomileusis (LASIK). Most reported traumatic flapdisplacements are partial and can subsequently be repositioned with satisfactoryresults.1-4 Occasionally,however, significant force may completely avulse the corneal flap, resultingin a lost flap.5,6 Completeloss of the flap may cause significant haze and loss of best spectacle-correctedvisual acuity.5 To our knowledge, no successfulreplacement of a lost corneal flap due to LASIK has previously been reported.In this case report, we describe a technique resulting in successful replacementof a lost corneal flap following LASIK.
Report of a Case.
A 59-year-old woman was referred following replacement of the cornealflap after complete flap avulsion 5 months after an uncomplicated LASIK procedure.Two days previously, she had been hit with a tree branch. She was immediatelyevaluated by her primary ophthalmologist who noted the absence of the cornealflap. The patient returned to the site of injury to look for the lost flap.The flap was found on the ground approximately 8 hours after the trauma andwas replaced by her primary ophthalmologist with a bandage contact lens. Shewas prescribed 0.3% ofloxacin (Allergan, Irvine, Calif) every hour and 0.5%loteprednol etabonate (Bausch & Lomb, Rochester, NY) every 6 hours andreferred to the Department of Ophthalmology at Stanford University (Stanford,Calif) the following day.
At her initial examination at Stanford University, the patient's uncorrectedvisual acuity was 20/200 in the affected eye. An anterior segment examinationrevealed a superior hinged flap that was misaligned nasally (90° off-axis).The bandage contact lens was in place. There was evidence of diffuse conjunctivalinjection, eyelid edema, grade 3 diffuse lamellar keratitis, interface debris,epithelial ingrowth, and diffuse macrostriae (Figure 1). There was no evidence of a focal infiltrate, ulceration,hypopyon, or melting.
Initial evidence of diffuse lamellarkeratitis and epithelial ingrowth.
The patient underwent flap lifting; removal of flap debris, interfaceinflammatory cells, and epithelial ingrowth; culture of the interface; flaprealignment; and flap suturing with 8 interrupted 10-0 nylon sutures (Figure 2). The bandage contact lens was replaced,and the patient was given 0.3% ofloxacin every 6 hours, 1.0% prednisoloneacetate every hour, and oral prednisone at a dosage of 50 mg/d for 3 days.There was no recurrence of epithelial ingrowth or diffuse lamellar keratitis.Culture results remained negative. All sutures were removed on postoperativeday 11. The prednisolone was tapered, and the ofloxacin treatment was discontinued.At postoperative month 8, there was mild interface haze (Figure 3). In the affected eye, the uncorrected visual acuity was20/25, and the best spectacle-corrected visual acuity was 20/20 with a refractiveerror of −0.50 D + 0.75 D × 72.
Suture of the flap with multipleinterrupted nylon sutures.
At postoperative month 8, theflap is well positioned with only mild interface haze.
Previous methods of correcting a completely avulsed corneal flap followingLASIK have been limited to epithelial supportive measures including applicationof a bandage contact lens, topical steroids to minimize haze, prophylactictopical antibiotics, lubrication, and vigilant observation to detect secondaryinfection. Although the lamellar flap is thought to be refractive neutral,secondary haze or irregular astigmatism may cause complications in these eyes.5,6 However, if the amputated flapis found, consideration can be given to replacement of the flap. The freecap should be carefully inspected to evaluate whether it is still viable.If the integrity of the free cap has been excessively compromised (ie, traumaticallyshredded) or it has become necrotic, it should not be replaced. If it remainsviable, any epithelialization of the stromal bed should be carefully removed,and the free corneal flap should be cultured, irrigated, and replaced withor without sutures. Suturing the flap may prevent epithelial ingrowth andassist in stretching the previously folded flap to prevent striae formation.Caution should be exercised to prevent misalignment of the flap or replacingthe flap with the epithelial side down. Misalignment of the flap may not onlyresult in irregular astigmatism but also predispose the patient to the developmentof epithelial ingrowth. Careful inspection of the flap under high magnificationwill demonstrate a smooth, shiny surface (Bowman membrane) and a slightlydull, rough surface (stroma). A bandage contact lens is placed over the eye.Prophylactic broad-spectrum antibiotics and topical steroids may also be indicated.During the postoperative period, the culture results should be monitored andthe patient should receive daily follow-up to provide the earliest diagnosisof a secondary infection.
The authors have no relevant financial interest in this article.
Corresponding author and reprints: Edward E. Manche, MD, StanfordUniversity, 900 Blake Wilbur Dr, W3053, Stanford, CA 94305 (e-mail: Edward.Manche@stanford.edu).
Haw WW, Manche EE. Successful Corneal Flap Replacement Following Complete Traumatic FlapAmputation After Laser-Assisted In Situ Keratomileusis. Arch Ophthalmol. 2004;122(2):275–276. doi:10.1001/archopht.122.2.275
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