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.     

LASIK术后角膜上皮内生伴角膜瓣溶解

目的　认识ＬＡＳＩＫ 后角膜上皮内生伴角膜瓣溶解的临床规律。方法　观察分析７ 人１０ 眼ＬＡＳＩＫ 术后角膜上皮内生伴角膜瓣溶解的临床发展过程和表现以及处理方式和结果。结果　其临床表现为角膜瓣最远端层间混浊。逐渐扩大,浓密;角膜边缘缺损状如月蚀;内生上皮逐渐停止侵入并消退,角膜溶解停止。角膜溶解可造成散光,溶解范围不太大时可无最佳矫正视力的丢失。通过刀刮,ＰＴＫ 清扫内生上皮,可使上皮停止生长继而角膜溶解停止。结论　ＬＡＳＩＫ 后角膜上皮内生临床过程分为上皮内生,角膜瓣消溶,自限三个期,使上皮内生入停止的方法如手术可终止此过程     

Surgical management of epithelial ingrowth

In ten consecutive cases of epithelial ingrowth operated on during the past 33 months, therapy included photocoagulation of the iris followed by excision of involved iris tissue and vitreous gel by means of instruments designed for vitreous surgery. Epithelium remaining on the posterior surface of the cornea, ciliary body, and in the anterior chamber was destroyed by controlled transcorneal and transscleral cryotherapy. An intraocular air bubble was used to provide an insulating effect and a more effective, controllable freeze. All patients except two had improved vision postoperatively, and four of the ten patients had postoperative visual acuity of 6/12 (20/40) or better.     

准分子激光角膜原位磨镶术中游离瓣的形成及处理

目的：总结准分子激光角膜原位磨镶术（LASIK）术中出现游离瓣的原因及防治方法。方法：8眼LASIK术中出现的游离瓣，给予逐项分析，并对结果进行随访观察，结果：8眼游离瓣的患者术后第2天裸眼视力（OBCV）≥1．0者3眼，裸眼和≥0．6者5眼，术后3月视力明显提高，1年视力仍稳定，结果：LASIK术中出现游离瓣，只要及时处理，不影响疗效。     

Corneal iron line following LASIK with epithelial ingrowth

PURPOSE: To report a new corneal iron line following keratorefractive surgery. METHODS: Case report and review of the literature. A 51-year-old man developed epithelial ingrowth after otherwise uneventful LASIK surgery. The patient, satisfied with an uncorrected visual acuity of 20/25 and otherwise asymptomatic, declined to have his flap relifted to treat the ingrowth. RESULTS: Six months postoperatively a corneal iron line was noted at the leading edge of the epithelial ingrowth. Vision remained stable. CONCLUSIONS:: Epithelial iron lines have been reported with a number of conditions, including post-refractive procedures. This is the first report of an iron line associated with epithelial ingrowth following LASIK.     

LASIK术后角膜上皮内生的处理

目的：分析准分子激光原位角膜磨镶术(LASIK)后角膜上皮植入及内生发生的原因,总结治疗经验。

方法：回顾性分析2008-01/2012-12于我院行LASIK患者1 256例2 256眼,术后发生角膜上皮植入及内生18例30眼的临床资料。对所有患眼进行治疗后,对治疗前后患者整体视觉质量评分进行分析。

结果：行LASIK术后角膜上皮植入及内生18例30眼,发生率为1.3%。18例30眼患者中12眼为术后外伤致角膜瓣移位上皮内生,12眼为术中多次角膜瓣下冲洗,2眼为术中制作角膜瓣出现不规则瓣,4眼术中无特殊。30眼角膜上皮内生的程度：Ⅰ级11例18眼,Ⅱ级4例8 眼,Ⅲ级3例4眼。Ⅰ～Ⅱ级者予妥布霉素地塞米松滴眼液点眼并辅予降眼压药物治疗为主,Ⅲ级者先予药物治疗,若情况无好转,则予手术治疗。治疗后11例18眼Ⅰ级者中8例13眼内生均消失,3例5眼植入上皮灶缩小; 4例8眼Ⅱ级者中2例4眼上皮植入消失,2例4眼上皮植入程度减轻至Ⅰ级; 3例4眼Ⅲ级者中2 例2 眼角膜缘1mm处瓣缘有0.5～1mm宽瓣下浅灰白色带,视力0.8 ～1.2,1例2眼患者予刮除植入角膜上皮及内生上皮,随访无复发。治疗后18例角膜上皮内生患者整体视觉质量评分低于治疗前(Hc=10.511,P<0.01)。

结论：规范手术操作、术后及早发现并予积极治疗是对预防和治疗LASIK 术后并发症有重要意义。     

OCT visualization of corneal structural changes in traumatic dislocation of LASIK flap

A 45-year-old woman presented with a traumatic laser-assisted in situ keratomileusis (LASIK) flap dislocation in the right eye. Anterior segment optical coherence tomography (OCT) showed the presence of macrostriae, flap stromal edema, epithelial hyperplasia between the striae and epithelial ingrowth. The flap was surgically repositioned with optimal visual recovery. Anterior segment OCT can efficiently visualize corneal structural changes associated with LASIK flap dislocation.     

LASIK术后角膜上皮植入的原因及分型

目的分析准分子激光原位角膜磨镶术（LASIK）后角膜上皮植入的原因及分型。设计回顾性病例系列。研究对象45例LASIK术后角膜上皮植入处理后随诊半年以上患者共49眼。方法分析北京协和医院门诊收治的外院转来时角膜上皮植入患者,上皮植入时间6～31天,最佳矫正视力为手动-0．6,除眼部刺激症状外,多数患者伴有不同程度的角膜瓣水肿、混浊、融解。掀开角膜瓣治疗43眼。根据上皮植入的位置、发展速度进行分类。按上皮植入距角膜中央的距离和范围分为周边型、旁中央型、中央型,分别为7眼、32眼、10眼。按照发展的速度分为进展性、稳定性、静止性,分别为31眼、4眼、4眼。主要指标LASIK术后角膜上皮植入手术史、视力、角膜瓣对合、伤口愈合情况。结果引起上皮植入的主要原因：（1）角膜上皮水肿、剥脱;（2）角膜瓣状况不良;（3）角膜瓣对合异常,分别为15眼、21眼、13眼。对视力影响程度由重到轻依次为中央型〉旁中央型〉周边型;进展的旁中央和中央型上皮植入超过1周者,92％可导致角膜瓣基质融解,严重影响视力。治疗方案：密切观察,原瓣掀开刮除植入上皮29眼,上皮刮除联合治疗性角膜屈光手术（PTK）14眼,非掀瓣保守观察治疗6眼。角膜瓣再次掀开者角膜伤口均一期愈合,未见再次植入病例。34眼达到了术前预期视力,7眼低于术前视力1行以内,8眼低于术前预期视力2行及其以上。结论角膜上皮和角膜瓣水肿是导致LASIK术后角膜上皮植入的主要原因,92％进展的中央型和旁中央型的上皮植入者,1周左右可致角膜瓣融解,严重影响视力。积极掀瓣刮除植入上皮和局部PTK治疗是使患者恢复视力的首选治疗手段。     

Laceration and partial dislocation of LASIK flaps 7 and 4 years postoperatively with 20/20 visual acuity after repair

PURPOSE: To report two cases of late ocular trauma resulting in laceration of corneal flaps 7 and 4 years (cases 1 and 2, respectively) after LASIK. METHODS: A 49-year-old man sustained laceration of the flap and interface foreign body debris from construction material in the right eye 7 years after uneventful LASIK (case 1). A 33-year-old man had partial dislocation of the flap 4 years after LASIK in the left eye (case 2) due to a penetrating wood chip accident. Surgical procedures were performed to remove the foreign bodies and reposition the flaps. RESULTS: In case 1, postoperative uncorrected visual acuity (UCVA) was 20/25 with manifest refraction of -0.50 -0.50 x 110 corrected to 20/20. In case 2, UCVA was 20/20 with piano refraction after LASIK retreatment. CONCLUSIONS: Corneal LASIK flaps are susceptible to penetrating trauma, which can occur >7 years after the procedure. Proper everamanage ment of the trauma and LASIK flap can restore excellent visual acuity.     

Traumatic flap dislocation 4 years after LASIK due to air bag injury

PURPOSE: To report a patient who developed corneal flap dislocation following air bag injury 48 months after LASIK. METHODS: Evaluation by slit-lamp microscopy and fluorescein angiography. RESULTS: A 29-year-old man was treated after air bag injury that occurred 48 months after LASIK. Examination revealed corneal flap dislocation, with severe folds and flap edema. Preoperative visual acuity was finger counting at 1 m. Visual acuity was 20/400 24 hours after repositioning the corneal flap. Retinal angiography revealed Berlin macular edema, which was injected with periocular steroids. Five days after injection, visual acuity remained 20/400, but improved to 20/40 1 month after injection. CONCLUSIONS: Significant trauma can dislocate a corneal flap many months after surgery.     

Application of two-part glue technique in epithelial ingrowth after laser in situ keratomileusis flap dislocation

A 59-year-old woman who underwent uneventful laser in situ keratomileusis surgery 16 years ago presented with traumatic flap dislocation complicated by an epithelial ingrowth in the right eye. The epithelial ingrowth was managed with re-lifting the flap, mechanical debridement, soaking with 70.0% alcohol, and irrigation. The flap was repositioned and secured with a two-part glue technique. Serial anterior segment-optical coherence tomography demonstrated a well-attached flap with no gap or haze in the flap-stromal interface. Three weeks postoperatively, the patient returned to emmetropia and the uncorrected distance visual acuity improved to 20/20. Twelve months postoperatively, the patient''s visual acuity remained 20/20, and there was no evidence of recurrent epithelial ingrowth.     

LASIK后严重角膜上皮植入并角膜瓣融解的处理

目的：探讨ＬＡＳＩＫ术后严重角膜上皮内生所致角膜瓣融解缺损的治疗方法。病例和方法：ＬＡＳＩＫ术后经本院确诊为角膜上皮内生合并角膜瓣融解的１２例１３眼,根据角膜瓣厚度及角膜瓣融解的程度,９眼接受翻开角膜瓣清除层间上皮的治疗,３眼行异体角膜磨镶术,１眼去除角膜瓣。结果：翻开角膜瓣清除膜上皮的９眼中,２眼复发,但再次治疗后正常愈全。异体角膜磨镶术组的３眼角膜瓣均正常愈合。去除角膜瓣的１眼角膜上皮正常,但     

Late dislocation of LASIK flap following fingernail injury

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