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A suture technique to manage a case of severe early flap displacement after laser in situ keratomileusis

Leopoldo Spadea¹, Paola Pantaleoni¹, Guido Bianco¹

^{1 Ophthalmology, University of L'Aquila,  L'Aquila, Italy}

Correspondence to: Professor Leopoldo Spadea, Via B. Gozzoli n.34, 00142 Rome, Italy. E-mail: lspadea{at}cc.univaq.it

Accepted for publication:  May 1, 2004

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Introduction

The creation of corneal flap after Laser in situ Keratomileusis (LASIK) has been associated both with intraoperative (free-cap, button-hole) and postoperative (flap displacement, keratectasia) complications. We report a case of severe flap displacement that occurred 24 hours after LASIK and the suture technique to manage this complication.

Case Report

A 62 year old woman with moderate myopia underwent to bilateral LASIK. A standard procedure was performed without intraoperative complications, using a Hansatome microkeratome (Bausch & Lomb, Irvine, CA) with 160mm plate and 9.5mm suction ring to create a superior hinged flap. The estimated excimer laser ablation, by a Keracor 217 C instrument (Bausch & Lomb, Irvine, CA), was 127mm and 140mm for the OD and the OS respectively, with a 5.4mm and 5mm optical zone respectively.

After 24 hours the right eye showed a normal course; however, in the left eye a flap displacement occurred. The slit-lamp examination revealed in the left eye a flap totally folded up on itself, with bare stroma exposed and early signs of epithelialization of both the stromal bed and the back surface of the flap. Any attempt to reposition the flap in the conventional way failed because the tissue was folded and markedly edematous. The patient gave her consent for re-operation.

 

Technique Section

After application of topical anaesthesia (lidocaine 4%), the stromal bed and the back surface of the flap were thoroughly cleaned using a blunt spatula. Thereafter the flap was repositioned in its original location and then was refloated, irrigating with balanced saline solution (BSS) and flattened. The flap was secured with a partial thickness square continuous suture overlapping the flap, using 10-0 nylon with 150mm needle as shown in the video.

The day after the repositioning of the flap, the slit lamp exam showed in OS the corneal flap correctly positioned and engaged. At the fifth day the contact lens was removed, the corneal flap appeared correctly placed with good stability, and the interface was clean, so the suture was removed. During the follow-up at 12 months, BCVA remained 20/25 OD and 20/60 OS (OD plano, LE -0.75 sph).

 

Comment

Early-onset corneal flap displacement is a rare complication after LASIK surgery, and its incidence in literature varies from 0.00067% to 2.0%.[1-2] Authors recommend the use of soft contact lens, without patching, on all eyes for the first 24 hours after LASIK to reduce the incidence of flap displacement.1 A recent study of Lam et al. described management of four cases of flap slippage within the first 24 hours after the surgery.[3]

In this case it was the surgeon’s decision was to ensure that the flap was re-positioned by means of a suture, because he felt there was a high risk to have melting of the flap as final result of the conventional way to treat this complication (i.e. wearing a soft contact lens alone).

To avoid other corneal complications or recurrent flap dislocation in the present case, the stromal bed and underside of the flap were thoroughly cleaned, then a 10-0 nylon square continuous non-penetrating suture overlapping the flap was used. The suture was removed on the fifth day, when the edge of the flap was re-epithelialized. A non-penetrating overlapping the flap suture was chosen to avoid the possible induced astigmatism and the possible epithelialization of the interface. The follow-up period confirmed that non-penetrating suture did not alter the oblate topography pattern and did not produce any complication. Moreover the application of therapeutic contacts lens for few days provided added protection from pain due to suture trauma.

In conclusion a discussion of these potential early and late complications should be included in the informed consent process. Patients should be informed that excessive blinking and eye squeezing from pain, photophobia or other discomfort in the postoperative period can result in severe complications. However a correct surgical management of this complication allowed recovery of a normal outcome with good and stable result.

 

References

1. Ambrosio R, Wilson SE. Complications of laser in situ keratomileusis: etiology, prevention, and treatment. J Refract Surg 2001; 17: 350-79.

2. Stulting RD, Carr JD, Thompson KP, et al. Complications of laser in situ keratomileusis for the correction of myopia. Ophthalmology 1999; 106: 13-20.

3. Lam DSC, Leung ATS, Wu JT, et al. Management of severe flap wrinkling or dislodgement after laser in situ keratomileusis. J Cataract Refract Surg 1999; 25: 1441-47.