Case Presentation
A 23-year-old white female underwent routine bilateral myopic astigmatic LASIK without complication. A nasal hinge position was employed for both eyes. At her 6-month postoperative visit, visual acuity without correction was 20/20 in the right eye and 20/20 in the left eye.
Eleven months after the procedure, the patient sustained a traumatic flap laceration in her right eye from contact with the edge of a cardboard box. Shortly thereafter, the patient's father, an optician, advised her that it was just a corneal abrasion, and she did not seek formal eye care for 6 hours.
At the time of her initial posttraumatic evaluation, the patient complained of blurred vision and only mild discomfort (Figure 1). Her visual acuity in the right eye was count fingers at 6 feet. A slit lamp examination revealed a curvilinear flap laceration combined with a 3-clock hour inferior flap edge dehiscence. This new traumatic flap was elevated, folded upon itself, and reflected nasally.
How would you proceed?1. Begin prophylaxis for the infection?
2. Amputate the flap?
3. Administer hypotonic BSS for the fixed fold?
4. Which basic surgical principles would you use?
Surgical Course
During the initial slit lamp examination, it was not immediately discernable if any flap tissue had been lost. After copious topical ciprofloxacin prophylaxis treatment, I evaluated the flap to assess the viability and continuity of the remaining tissue. I used a blunt instrument to unfold and reposition the flap. There was no significant stromal loss, however there was diffuse mucinous and cellular debris adherent to the stroma, and epithelial defects were present.
The eyelid skin was then prepared with povidone-iodine, the patient was placed under the microscope, and the lashes and lids were draped from the field. I applied topical anesthetic and additional ciprofloxacin, and performed copious irrigation to decrease any bacterial cell-load associated with prolonged exposure of the stromal bed prior to surgical intervention. Irrigating is also helpful in removing mucinous tear film debris, as well as any cellular material associated with early healing which may already be adherent to the stromal bed and undersurface of the flap.
I mechanically removed potential epithelial debris on the stromal bed with a blunt spatula and a dry polyvinyl chloride spear to reduce the risk of epithelial ingrowth. I then hydrated and repositioned the traumatized flap. A fixed fold persisted where the flap had folded upon itself (Figure 2), and I treated this by applying hypotonic BSS (80%) directly to the fold on the undersurface of the flap with a saturated polyvinyl chloride spear. I used this technique to minimize the application of the hypotonic saline to other areas of the flap and the stromal bed.
I repositioned the flap, meticulously realigning the edge. Areas of the laceration were biplanar and required both stromal and epithelial alignment. In addition, I identified multiple epithelial abrasions. I applied a bandage contact lens and placed the patient on tobramycin/dexamethasone and ciprofloxacin, and conducted a close follow-up.
OUTCOME
On the first postoperative day, the visual acuity of the eye was 20/30 with a -0.50 sphere soft contact lens. The bandage contact lens was left in place for 1 week. The patient developed grade 1 DLK and epithelial ingrowth along the edge of the dehiscence and flap laceration, but neither were visually significant. The visual acuity of the eye improved to 20/20 1 week after the injury (Figure 3), and the appearance has remained stable for 1 year.
