Hassan Aboumerhi, Chad Shultz and SA Erzurum

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Traumatic Epithelial Ingrowth Despite Non-Displaced Lasik Flap

Hassan Aboumerhi1,3, Chad Shultz2 and SA Erzurum1,2,3

1Northeast Ohio Medical University, Rootstown, OH, 44272

2Eye Care Associates, Inc, Poland, OH, 44514

3St Elizabeth Health Center, Youngstown, OH 44501

*Corresponding Author:
Hassan Aboumerhi MD
St. Elizabeth Health Center, 1044 Belmont Ave, Youngstown, OH 44504
Tel: 440.292.7602
E-mail: [email protected]

Received Date: November 16, 2015; Accepted Date: December 04, 2015; Published Date: December 08, 2015

Citation: Aboumerhi H,Shult C, Erzurum SA (2016) Traumatic Epithelial Ingrowth Despite Non-Displaced Lasik Flap. J Eye Cataract Surg 1:5. doi: 10.21767/2471-8300.100005

Copyright: © 2016 Aboumerhi H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

 
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Abstract

A 50-year-old female developed significant aggressive epithelial ingrowth after a minor corneal abrasion to her left eye, which required surgical removal. On presentation, she exhibited no signs of corneal flap manipulation or displacement. This report exemplifies the latest presentation of traumatic epithelial ingrowth from initial LASIK surgery and the only case without flap displacement, emphasizing the need for close follow-up and examination of all LASIK patients even after minor trauma.

Keywords

LASIK; Epithelial ingrowth; Laser assisted in-situ keratomileusis

Abbreviations

LASIK: Laser Assisted In-situ Keratomileusis; UCVA: Uncorrected Visual Acuity; DLK: Diffuse Lamellar Keratitis; OCT: Optical Coherence Tomography

Introduction

Most patients undergoing laser in situ keratomileusis (LASIK) recover without issue. In certain cases, however, postoperative complications may threaten vision unless treated properly. One of these complications, corneal epithelial ingrowth, often occurs in the first day of 1-2% of LASIK cases [1]. Epithelial cell growth may encroach on the visual axis, impairing vision. These patients may develop corneal melt leading to permanent vision loss if not treated appropriately [2].

The formation of a corneal flap by LASIK leaves a potential space between the flap and the stroma. Etiologies for epithelial ingrowth are twofold: [1] cellular replication after introduction to the interface of the flap from the corneal periphery via cutting, lifting, or flap manipulation and [2] cellular migration from the flap border after surgery [3]. Risk factors for epithelial ingrowth include multiple LASIK procedures and hyperopic correction as opposed to myopic correction [4]. Case reports of traumatic incidents that have disrupted the corneal flap have also been reported, inducing epithelial ingrowth and, in one case, ingrowth was delayed 14 years after initial LASIK [5]. There are no reports of epithelial ingrowth after LASIK without corneal flap displacement. We report a case of epithelial ingrowth after minor corneal abrasion without manipulation or displacement of the LASIK flap 15 years after surgery.

Case Background

A 50-year-old woman with a history of LASIK 15 years ago presented to the emergency room after poking her eye with a twig in her garden. Physical exam demonstrated a corneal abrasion of the left eye. The patient was asked to follow up with her ophthalmologist the next morning. Ophthalmology evaluation demonstrated an uncorrected visual acuity (UCVA) of 20/20 in the right eye. The affected left eye was 20/40, improving to 20/25 on pinhole. The conjunctiva was mildly injected. Slit lamp examination revealed a corneal abrasion of the epithelium temporally at 3 o'clock surrounded by mild corneal edema. The flap was intact, in place, and its edges were uninvolved. The rest of the eye exam was unremarkable. The patient was started on tobramycin/dexmathesaone ophthalmic drops and was asked to return in 1 week.

During the patient's next visit, she described no discomfort and reported vision improvement and symptom resolution. She displayed UCVA of 20/20 in the right eye and 20/25- in the left eye. On slit lamp examination, her left eye exhibited resolution of the corneal abrasion and edema. There was, however, corneal haze noted in the interface directly under the area of the injury that extended toward the visual axis. The flap was still intact. Because of concern for disseminated lamellar keratitis (DLK), prednisolone acetate ophthalmic drops were prescribed for every two hours and the patient was referred to a refractive surgeon.

Five days later, UCVA was 20/20 in her left eye. Slit lamp examination demonstrated moderate epithelial ingrowth under the midperiphery of the flap with direct extension towards the visual axis, preserving a clear zone of interface temporally toward the edge of the flap (Figure 1).

eye-cataract-surgery-lamp-photograph

Figure 1: Slit lamp photograph of left cornea demonstrating epithelial ingrowth under the midperiphery of the LASIK flap with direct extension into the visual axis.

Because of significant epithelial organization and imposing threat to the visual axis, the ingrowth was surgically removed. After procedural consent, the flap was lifted after marking the forward edge with a pen. The ingrowth, which extended to the temporal edge of the visual axis, was then peeled away in one piece. After irrigation and careful inspection, the flap was then replaced (Figure 2).

eye-cataract-surgery-cornea-surgical

Figure 2: Slit lamp photograph of left cornea after surgical debridement of epithelial ingrowth and subsequent flap replacement.

The patient was prescribed ofloxacin and prednisolone acetate drops and was instructed to return for reevaluation in one day. She returned with a clear visual axis and a smooth flap. One month later, there was no return of epithelial ingrowth and the patient's vision was still 20/20 in both eyes.

Discussion

LASIK permanently changes the inherent anatomy of the cornea. Once a patient undergoes LASIK surgery, the cornea heals exclusively at the periphery of the microkeratome wound away from the visual axis, thereby leaving a persistent potential space under the flap. Even years after LASIK, only minimal adhesions may hold the flap to the stroma/strong>, leaving the rest of the interface patent and predisposing the flap to displacement after trauma [6].

Table 1 describes reported cases of traumatic LASIK flap epithelial ingrowth. Mean patient age was 36 and the female to male ratio was 1:0.67. Five cases in the series were caused by finger sticks to the eye and three were from a twig or branch. Seventy percent experienced full recovery of their vision; thirty percent of patients' visual deficits remained, despite improvement. Two cases did not require debridement of epithelial ingrowth; one case in the series involving corneal perforation mandated penetrating keratoplasty. Our case is the latest-onset of traumatic epithelial ingrowth, 15 years after initial LASIK, and the only case without flap displacement [5-19,20].

Cases of Traumatic LASIK Flap Epithelial Ingrowth
Author Year Published Patient Age Sex Time after LASIK Eye Etiology Flap Displacement VA, Before Treatment VA,
After
Lemley 2000 37 Yo F 17 m OS Airbag Yes 20/100 Debridement 20/20
Leung 2000 50Yo F 1 y OS Bird beak Yes 20/400 Debridement 20/30
Melki 2000 28Yo M 10d OS Basketball Yes   Flap Replacement 20/30
Melki 2000 21Yo M 24d OD Fingernail Yes 4/200 Debridement 20/20
Aldave 2001 29Yo M 18m OD Fingernail Yes 20/200 Debridement 20/40
Patel 2001 28Yo F 10m OS Fingernail Yes 20/200 Debridement 20/40
Sun 2001 26Yo M 10m OD Stone Yes   Penetrating Keratoplasty 20/20
Mifflin 2002 37Yo M 3 y OS Tree branch Yes 20/40 Debridement 20/20
Booth 2003 38Yo M 30m OS Football Yes 20/25 Debridement 20/20
Srinivasan 2004 23Yo F 4y OD Fingernail Yes 20/400 Flap Replacement 20/20
Cheng 2006 23Yo M 7 y OS Fingernail Yes 20/70 Debridement 20/20
Cheng 2006 33Yo F 1 y OS Broom stick Yes CF Debridement 20/20
Cheng 2006 38Yo F 2 y OD Folder Yes   Debridement 20/25
Yeh 2006 50Yo F 21m OD Bush Twig Yes 20/200 Debridement 20/70
Kim 2010 29Yo M 9y OS Dog paw Yes CF Debridement 20/25
Moshirfar 2011 48Yo F 7y OS Iron Cord Yes 20/40 Debridement 20/20
Holt 2012 59Yo F 14y OS Blunt wooden block Yes 20/30 Debridement 20/20
Lovieno 2012 45Yo F 2y OD Cupboard door Yes 20/40 Debridement 20/20
Sinha 2014 26Yo F 4y OS Wooden Splinter Yes 20/60 Debridement 20/20
Aboumerhi 2015 50Yo F 15y OS Twig No 20/40 Debridement 20/20

Table 1: "Cases of Traumatic LASIK Flap Epithelial Ingrowth." This case study is the latest-onset from initial LASIK and the only case without flap displacement.

In the current case, epithelial ingrowth resolved on slit lamp exam after flap lift, debridement, and drop treatment; her initial symptoms of blurry vision did not return. How the epithelial cells were introduced under the corneal flap remains unclear. Traumatic crystalline foreign bodies at the LASIK flap interface without flap displacement has been reported. Choi postulated that a sharp, high velocity, but weak ocular trauma could open the potential stromal space and leave debris without displacing the flap [21]. We speculate a similar mechanism occurred with this patient or that the twig may have microscopically penetrated to the interface, implanting surface epithelial cells into the potential space. Cellular proliferation may have given the patient their presenting symptoms.

Although corneal slit lamp examination is the standard for detecting epithelial ingrowth, anterior segment optical coherence tomography (OCT) may be a useful diagnostic tool. OCT may evaluate corneal structure changes related to disease before surgical debridement. After treatment, careful monitoring with close follow-up in these patients is necessary. Higher rates of recurrence even after surgical debridement have been reported [22].

Post-traumatic pithelial ingrowth introduces cells into the corneal flap interface and corneal disturbance is observed. In this report, however, epithelial ingrowth occurred beneath the flap without any sign of disruption. This report exemplifies the need for close follow-up and examination of all LASIK patients even after minor trauma, since corneal anatomy is indefinitely altered. Ophthalmologists should educate patients on epithelial ingrowth as a post-operative complication and carefully monitor patients for signs, regardless of observed flap disruption or distant chronology from the initial LASIK procedure.

Acknowledgement

This original research is not under consideration elsewhere; authors have no financial disclosures or conflict of interest. All authors have made contributions to this paper for authorship, including design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Authors have had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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