LASIK和SBK术后外伤性角膜瓣移位的处理

目的:探讨准分子激光角膜原位磨镶术(laser in situ keratomileusis,LASIK)和准分子激光角膜前弹力层下磨镶术(Sub-Bowman’s keratomileusis,SBK)术后外伤性角膜瓣移位的处理。方法:对14例14眼LASIK和SBK术后因外伤导致角膜瓣移位的患者,经及时手术处理,合理用药,视力恢复良好。结果:选取的14例中13例治疗术后1wk视力均达到0.8以上,角膜透明,无1例患者角膜出现角膜瓣皱褶、上皮植入、角膜瓣溶解。1例患者因角膜瓣全部移位,治疗术后1wk视力0.1,角膜全层水肿,角膜瓣下皱褶不明显,下方瓣缘裂伤处有1～2mm宽的上皮植入。术后6mo,视力达到1.0,角膜完全透明。结论:及时正确处理LASIK和SBK术后外伤性角膜瓣移位均能获得良好视力。     

Late dislocation of LASIK flap following fingernail injury

A case of traumatic flap displacement with a fingernail injury four years after LASIK is reported.     

Traumatic flap dislocation 4 years after laser in situ keratomileusis

We present a case of late traumatic flap dislocation 47 months after laser in situ keratomileusis (LASIK). This is the latest reported case of traumatic LASIK flap dislocation to date. The patient was examined 5 days after being struck in the face and found to have a flap dislocation. The flap was repositioned surgically, and postoperatively the patient had 20/20 visual acuity and no visual complaints.     

Traumatic corneal flap avulsion and loss 13 years after LASIK

Postoperative flap displacements after Laser In Situ Keratomileusis (LASIK) are uncommon complications, and flap losses are even less frequent, occurring most commonly within 24 hours after the procedure. Although cases of late subluxation have been reported up to 14 years after the surgery, the longest reported time after surgery for late flap loss is four years after LASIK. We report a case of a 54-year-old man that presented a traumatic total flap avulsion and loss 13 years after LASIK. According to our knowledge, this is the longest time reported in such a case in the literature. Medical treatment yielded an acceptable visual result. This case reinforces the concept that there could be a lifelong potential risk of traumatic corneal flap loss after LASIK.     

Traumatic late flap dehiscence and Enterobacter keratitis following LASIK

PURPOSE: To report a case of traumatic flap dehiscence and Enterobacter keratitis 34 months after LASIK. METHODS: A 36-year-old man sustained a flap dehiscence following traumatic right eye gouging by a seagull claw. He presented the following day with uncorrected visual acuity (UCVA) in the affected eye of 3/200 and organic foreign body deposits underneath the flap. Systemic and topical antibiotics were administered and urgent surgical debridement and replacement of the LASIK flap was performed. An Enterobacter species was cultured from an intraoperative swab. RESULTS: After a prolonged postoperative course, including administration of topical ofloxacin, tobramycin, chloramphenicol, and dexamethasone, UCVA returned to 20/20. CONCLUSIONS: Good visual outcome after early debridement and appropriate antibiotics was achieved. Patients should be injury advised to seek prompt ophthalmic consultation after LASIK.     

Late-onset traumatic flap dislocation and diffuse lamellar inflammation after laser in situ keratomileusis

PURPOSE: To report a case of traumatic flap partial dislocation and subsequent diffuse lamellar inflammation 14 months after laser in situ keratomileusis (LASIK) retreatment. METHODS: Case report of a late flap dislocation that occurred during routine recreational activity (struck with a finger in the right eye while playing basketball). RESULTS: The partially dislocated LASIK flap was reflected nasally, and the stromal surfaces of the flap and bed were thoroughly scraped to remove debris and epithelial cells. The flap was repositioned, and a bandage contact lens was placed. Diffuse lamellar inflammation, which developed on post-trauma day number two, was successfully treated with frequent topical steroids. Three weeks after the injury, the patient had regained 20/20 uncorrected visual acuity. CONCLUSIONS: Patients should be appropriately warned of the possibility of late flap dislocation with traumatic forces encountered during routine recreational activities. Full visual recovery is possible if the dislocation is promptly diagnosed and appropriately managed.     

Treatment of traumatic LASIK flap dislocation and epithelial ingrowth with fibrin glue

PURPOSE: To describe a case of a traumatic late dislocation of a laser-assisted in situ keratomileusis (LASIK) flap complicated by epithelial ingrowth. DESIGN: Interventional case report. METHODS: A 50-year-old woman presented 21 months after uncomplicated LASIK with painful vision loss in the right eye after minor trauma. RESULTS: A dislocation of the LASIK flap was noted at examination and was repositioned. One week later, epithelial ingrowth was detected in the flap interface. The ingrowth was treated with flap lifting, debridement, and sealing of the flap with fibrin glue. Visual acuity returned to baseline, and there was no recurrence after 20 months of follow-up. CONCLUSIONS: Traumatic dislocations of LASIK flaps may occur many months after uncomplicated surgery and may be associated with epithelial ingrowth after successful repositioning. The additional use of fibrin glue in conjunction with thorough debridement may be helpful in preventing the recurrence of epithelial ingrowth.     

Late-onset traumatic laser in situ keratomileusis (LASIK) flap dehiscence

PURPOSE: To report a case of laser in situ keratomileusis (LASIK) flap dehiscence following focal trauma six months after uneventful refractive surgery. METHODS: Case report. A 37 year old man was seen one day after a tree branch snapped tangentially against his left cornea causing a dehiscence of his LASIK flap. RESULTS: The flap was repositioned after treating the exposed flap stroma with a 50:50 mixture of distilled water and balanced salt solution. The patient regained 20/20 uncorrected visual acuity. CONCLUSIONS: Patients should be informed about the potential for traumatic flap dehiscence following LASIK surgery and advised to wear eye protection when appropriate. Due to minimal wound healing except at the edges of the flap, corneal flap dehiscence may occur months or years after uneventful LASIK.     

Surgical management of traumatic LASIK flap dislocation with macrostriae and epithelial ingrowth 14 years postoperatively

Fourteen years after uneventful laser in situ keratomileusis (LASIK), a 59-year-old woman presented after suffering blunt trauma to her left eye 5 weeks earlier. The injury resulted in traumatic flap dislocation, epithelial ingrowth, and significant macrostriae. Following epithelial removal, the flap was hydrated with sterile water, facilitating reduction of the macrostriae and reapproximation without the need for suture placement. The postoperative course was uneventful, and at 1 month, the epithelial ingrowth and macrostriae had resolved and the uncorrected distance visual acuity was 20/30. This case represents the longest documented interval from LASIK surgery to traumatic flap dislocation. We describe our surgical approach to the management of this type of injury and present a video illustrating the technique.     

Late traumatic displacement of laser in situ keratomileusis flaps

PURPOSE: To report the occurrence, management, and outcome of late-onset traumatic dehiscence and dislocation of laser in situ keratomileusis (LASIK) flaps. METHODS: Two interventional case reports of patients with late-onset LASIK corneal flap dislocation after ocular trauma occurring at 7 and 26 months after surgery, respectively. RESULTS: The flaps were lifted, stretched, and repositioned after irrigation and scraping of the stromal bed and the underside of the flap. A bandage contact lens was placed, and topical antibiotic and corticosteroids were given postoperatively. The dislocated corneal flaps were successfully repositioned in both cases. The patient whose dislocated flap was repositioned 4 hours after the trauma recovered his uncorrected visual acuity (UCVA) of 20/20 1 week after the procedure and had a well-positioned flap with a clear interface. The patient who was managed 48 hours after the injury required repeat flap repositioning at 10 and 24 days after the initial procedure for treatment of persistent folds and striae in the visual axis. His uncorrected visual acuity 2 weeks after the third flap repositioning was 20/40 + 2. Diffuse lamellar keratitis developed in both patients that resolved with the use of topical corticosteroids. CONCLUSION: Laser in situ keratomileusis corneal flaps are vulnerable to traumatic dehiscence and dislocation, which can occur more than 2 years after the procedure.     

Outcome of tarsoconjunctival flap dehiscence after eyelid reconstruction

PURPOSE: To report the outcome of eyelid reconstruction with a tarsoconjunctival flap complicated by premature flap dehiscence.DESIGN: Interventional case series.METHODS: In eight of approximately 100 patients who underwent unilateral lower eyelid reconstruction with a tarsoconjunctival (Hughes) flap during a 15-year interval, the procedure was complicated by premature flap dehiscence resulting from accidental trauma 1 to 11 days after the reconstructive procedure. Immediate surgical repair of the dehiscence was attempted in one case, but the tissues reopened within 1 day. Otherwise, the eyelids were permitted to heal spontaneously with the application of erythromycin ophthalmic ointment as the sole therapy.RESULTS: Although the reconstructed eyelids healed satisfactorily in each case, one patient, who had dry eyes from Sj?gren syndrome, required secondary surgery to treat mild lagophthalmos and lower eyelid retraction.CONCLUSIONS: The ultimate functional and esthetic outcomes after premature, traumatic dehiscence of a Hughes flap were generally satisfactory, suggesting that elective division of the conjunctival pedicle in uncomplicated cases may be performed relatively soon after the primary reconstructive procedure.     

LASIK interface-captured foreign bodies after mild traumatic corneal scratch without flap displacement

A 38-year-old woman developed diffusely distributed opacities with crystalline materials in the laser in situ keratomileusis (LASIK) interface of her eye after she was scratched by a sprig during mountain climbing. No sign of flap displacement was noted. Despite two days of topical and systemic antibiotics therapy, the corneal infiltration with interface opacities persisted. The following day, the distribution of the crystalline materials had rotated in a counterclockwise direction. Flap lifting and foreign body removal using sufficient irrigation were performed. One month after surgery, the patient's postoperative uncorrected visual acuity was 0.8 with cleared interface. No signs of epithelial ingrowth or flap striae were noted. Mild traumatic corneal scratching without flap displacement may threaten the integrity of the LASIK interface. If foreign bodies are suspected to be the cause of inflammation, early flap lifting with irrigation is imperative for successful treatment.     

Late traumatic dislocation of laser in situ keratomileusis corneal flaps

PURPOSE: To report the management and outcome of late-onset traumatic dislocation of laser in situ keratomileusis (LASIK) flaps. DESIGN: Retrospective, observational case series. PARTICIPANTS: Four patients with late-onset LASIK flap dislocation occurring after mechanical trauma at various intervals (10 days-2 months) after the procedure. INTERVENTION: In all cases of postoperative traumatic LASIK flap dislocation, the flap was refloated with scraping and irrigation of the underlying stromal bed within 12 hours of the injury. A bandage contact lens was placed, and a regimen including topical antibiotics and corticosteroids was instituted in all cases. MAIN OUTCOME MEASURES: Best spectacle-corrected visual acuity and complications associated with the surgery were monitored. RESULTS: Postoperative follow-up ranged from 4 to 21 months. Nonprogressive epithelial ingrowth was noted in one patient and diffuse lamellar keratitis developed in another patient. All patients recovered pretrauma spectacle-corrected visual acuity. CONCLUSIONS: Corneal LASIK flaps are prone to mechanical dislocation as late as 2 months after the procedure. Appropriate management results in recovery of optimal visual outcomes.     

Cases of eye trauma after laser keratomileusis

Variants of corneal injuries and their complications in various periods after laser keratomileusis are described. The causes and probable mechanisms of injuries are analyzed with consideration for pathohistological findings. A total of 3507 operations were performed in 1796 patients with myopia of 1.5-14.5 diopters. Hansatome microkeratotome was used for lamellar section of the cornea and EC 500 eximer laser (Nidek) for laser keratoablation. According to the consultation rate, the incidence of injuries was 0.45% (16 eyes). The injuries occurred 1 week to 6 months after the operation and were as follows: epithelial injuries (10 cases), foreign bodies in the cornea (4 cases), and displacement of corneal flap (2 cases). The causes of injuries were mainly communal, the outcomes were favorable, microsurgical reoperation was needed in 3 cases. The mechanisms of injuries were analyzed with consideration for the histology of human cornea. The most complete fixation of corneal flap after laser keratomileusis was attained in the wound channel and at the site of the flap stromal apposition. Mechanical displacement of the corneal flap resultant from the injury is the most probable during the 4-week formation of cicatricial tissue in the wound; later the direction of the traumatic agent is significant. Prevention of corneal injuries after laser keratomileusis is important.     

LASIK术后外伤性角膜瓣移位的治疗观察

目的:探讨准分子激光原位角膜磨镶术(laser in situkera-tom ileusis,LASIK)术后眼外伤角膜瓣移位的治疗。方法:对11例因外伤导致LASIK术后角膜瓣移位的患者,充分瓣下冲洗,准确对位角膜瓣,术毕戴绷带片。结果:9例1wk后视力提高0.6～1.0,1例前房积血伴继发性青光眼,外伤性瞳孔散大及视网膜震荡,8mo后小孔视力达0.8,1例伴石灰灼伤,1mo后视力达0.6。无1例出现上皮内生、角膜融解等严重并发症。随访3～12mo。结论:及时有效地处理LASIK术后角膜瓣移位,可以恢复良好视力。     

Accidental self-removal of a flap--a rare complication of laser in situ keratomileusis surgery.

PURPOSE: To report a rare complication in which the patient accidentally removed the laser in situ keratomileusis corneal flap. METHODS: Interventional case report. A 35-year-old woman underwent uncomplicated laser in situ keratomileusis surgery. Ten days after surgery, she inserted a soft contact lens into the right eye to improve her vision. She tried to remove the contact lens, but had pain and bleeding. She was referred 10 days later with a diagnosis of loss of flap. RESULTS: On examination, she had a best-corrected visual acuity of 20/70 in the right eye. The right eye examination revealed no corneal flap, mild corneal edema, and significant haze. A central epithelial defect was found. CONCLUSION: Accidental corneal flap removal can rarely follow laser in situ keratomileusis surgery. This complication provides insight into the weak adhesion of the flap onto the stromal bed after laser in situ keratomileusis surgery and, hence, the inherent risk of traumatic flap dislocation or amputation, which needs to be explained to the patient.     

Dislocated laser in situ keratomileusis flap visualized by cross-polarized filtration

We report a case of a displaced laser in situ keratomileusis flap. The flap displacement was enhanced by using cross-polarized filters.     

角膜屈光术后角膜瓣下上皮细胞植入的研究进展

角膜瓣下上皮细胞植入或内生是角膜屈光术后并发症之一,近年来随着手术设备和技术的提高,其发生率已经明显降低。但外伤致角膜瓣移位发生角膜瓣下上皮植入病例仍时有报道。若上皮细胞植入处理不及时可引起患者屈光状态改变、角膜瓣融解等严重并发症。故本文对角膜屈光术后角膜层间上皮植入研究进展予以综述。     

Detection of neutrophils in late-onset interface inflammation associated with flap injury after laser in situ keratomileusis

OBJECTIVE: To report a case with late-onset interface inflammation associated with traumatic flap injury at 7 months after laser in situ keratomileusis (LASIK) and to describe the type of infiltrating cells in the tears of the patient. METHODS: Interventional case report. A 24-year-old male patient who underwent uneventful LASIK on both eyes received blunt trauma from the tip of a shoe in the left eye 7 months after surgery. The corneal flap of his left eye was lacerated across the pupillary area. Inflammatory cells were observed under the lacerated flap segment. Tear fluid was collected from his left eye 3 days after the injury and assessed by tear cytology. For controls, tears of 2 patients who underwent LASIK and developed no interface inflammation were collected the next day after their surgeries and examined. RESULTS: Tear fluid of the patient with interface inflammation contained numerous neutrophils. Tears of control patients contained only a few epithelial cells and cell debris but no inflammatory cells. The inflammation was decreased by systemic and topical steroids. However, irregular astigmatism caused by stromal scarring remained, resulting in decreased best-corrected visual acuity. CONCLUSIONS: Interface inflammation can be caused by late-onset flap injury. Neutrophils detected in the tears may reflect a major component of cells infiltrating the interface after LASIK.     

结膜瓣遮盖术治疗难治性角膜溃疡

目的观察应用结膜瓣遮盖术治疗难治性角膜溃疡的临床疗效。方法回顾分析2003年1月至2006年4月在青岛眼科医院和山东省眼科医院行结膜瓣遮盖术治疗的难冶性角膜溃疡患者30例30眼。其中感染及外伤性角膜溃疡10眼，穿透性角膜移植术后植片溃疡16眼，板层角膜移植术后植片溃疡4眼。30眼中，出现角膜溃疡穿孔9眼。对上述患者行病灶清除＋结膜瓣遮盖术治疗，合并穿孔者术中行双层结膜瓣遮盖或重缝植片，术后针对原发病进一步进行药物治疗。结果27例27眼患者1次手术治愈角膜溃疡。3眼术后结膜瓣回退，再次行结膜瓣遮盖加睑裂缝合术，1眼溃疡修复；1眼结膜瓣再次脱落，改行板层角膜移植术；1眼反复行结膜瓣遮盖术3次，最终角膜植片完全自溶。28眼通过结膜瓣遮盖术达到治愈角膜溃疡，保存眼球的目的。结论对于药物治疗无效的难治性角膜溃疡，结膜瓣遮盖术仍是有效的治疗方法，并可作为应急方法治疗角膜穿孔、控制炎症．从而保存眼球，为进一步行角膜移植术提供条件。[眼科新进展2．007；27（3）：204-207]