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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 174-176

The resurgence of post-LASIK epithelial ingrowth


Little Flower Hospital and Research Centre, Angamaly, Kerala, India

Date of Submission13-Mar-2020
Date of Acceptance31-Mar-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. Neena Chris William
Odathamparambil House, 34/2232B, MRA27, Pottakuzhy Road, Mamangalam, Cochin - 682 025, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_30_20

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  Abstract 


We are reporting a case of a 32-year-old female who presented with a gradual painless progressive decrease in vision in the right eye for 2 months. She underwent laser in situ keratomileusis (LASIK) for myopia in both eyes 8 years back. The right eye showed rolled flap margin with epithelial ingrowth extending from margin to pupillary area. Mechanical debridement was done along with flap wash and mitomycin-C and bandage contact lens placement. Visual acuity showed improvement on follow-up. However, the recurrence was noted at 6-month follow-up. This case highlights the challenges in the management of epithelial ingrowth.

Keywords: Epithelial ingrowth, flap interface, LASIK, mitomycin-C


How to cite this article:
William NC, Nixon HK, Pudukadan D, Bhat L. The resurgence of post-LASIK epithelial ingrowth. Kerala J Ophthalmol 2020;32:174-6

How to cite this URL:
William NC, Nixon HK, Pudukadan D, Bhat L. The resurgence of post-LASIK epithelial ingrowth. Kerala J Ophthalmol [serial online] 2020 [cited 2020 Nov 24];32:174-6. Available from: http://www.kjophthal.com/text.asp?2020/32/2/174/293293




  Introduction Top


Epithelial growth is one of the rare complications seen in post-LASIK patients and is usually seen in the early postoperative period. The incidence of post-LASIK epithelial ingrowth (PLEI) ranges from 0% to 3.9% in primary treatment cases to 10%–20% in retreatment cases.[1] However, clinically significant PLEI requiring removal was noted in only 0.92%–3.2%.[2]

Epithelial ingrowth occurs due to the implantation of basal epithelial cells under the flap, which is mechanically dragged during keratectomy by the microkeratome blade. It has also been stated that poor adherence of flap to the underlying stroma can cause epithelial cell migration.[3] The risk factors for PLEI noted are LASIK flap dislocation, corneal epithelial injury, flap lift for retreatment, and flap lift with forceps. PLEI is more commonly seen after microkeratome LASIK compared to femtosecond LASIK.[1]

We are reporting a rare case of clinically significant epithelial ingrowth occurring 8 years post-LASIK and the challenges in its management.


  Case Report Top


A 32-year-old female patient presented to our hospital with a gradual painless progressive decrease in vision in the right eye over the past 2 months.

The patient gave a history of trivial trauma to the right eye with a tennis ball 2 months back. She underwent microkeratome-assisted LASIK for myopia in both eyes in the year 2011 at another hospital. There was no history of recurrent corneal erosion. On examination, the visual acuity was 6/36, improving to 6/18 with + 1.25 DS in the right eye and 6/9 not improving with pinhole in the left eye.

On slit-lamp examination in the right eye, the flap edge was rolled with the thickened whitish-gray appearance and peripheral confluent haze at the inferotemporal flap edge without flap melt. Epithelial ingrowth was noted beneath the flap. There were irregular islands of epithelial pearls seen in the interface (flap undersurface and stromal bed) extending from the temporal and nasal flap margins and migrating towards the central optical zone [Figure 1], [Figure 2], [Figure 3].
Figure 1: Epithelial pearls under LASIK flap

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Figure 2: Displaced flap margin with epithelial pearls seen at the interface

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Figure 3: Epithelial pearls migrating from flap periphery to the central optical zone

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In the left eye, the post-LASIK scar was seen with a well-centered flap and clear interface. The posterior segment of the two eyes did not reveal any abnormality.

The patient was counseled regarding the risk and benefit of surgical intervention and was scheduled for flap lift and debridement with mitomycin-C under topical anesthesia using aseptic precautions.

The peripheral flap hinge was identified and lifted meticulously along the original cleavage plane using a blunt spatula. Mechanical debridement of the epithelial pearls under the flap surface and stromal bed was done using blunt forceps. The epithelium was also resected around the flap bed. Balanced salt solution (BSS) was to irrigate the interface and flush out any debris. This was followed by placement of mitomycin-C (0.02%) soaked sponge for 30 s on the residual stromal bed. The interface and stromal bed were thoroughly irrigated with BSS. The flap was carefully repositioned, smoothened, and bandage contact lens (BCL) placed.

Postoperatively, the patient was on moxifloxacin (0.5%) drops, fluorometholone (0.1%) drops 4 times/day, and lubricants. The patient was on regular follow-up, and medications were tapered. BCL was removed after 2 weeks, and topical lubricants were continued.

At 3-month follow-up, the LASIK flap was well centered. No signs of epithelial regrowth were noted. The patient's vision in the right eye had improved to 6/9(p).

At 6-month follow-up, few pockets of epithelial cells were seen at the inferior peripheral flap interface, suggestive of recurrence. Since vision was maintained at 6/9(p), no intervention was done. However, the patient needs to be closely observed and followed up to monitor the progression of epithelial ingrowth.


  Discussion Top


Epithelial ingrowth is an uncommon complication in post-LASIK patients and has a wide spectrum of clinical presentations, ranging from asymptomatic interface changes to severe impairment of vision and flap melt requiring keratoplasty. Studies have shown that following LASIK, corneal wound healing occurs at the periphery of the LASIK flap-stromal junction. This explains the late onset of LASIK flap dislocation, even after a decade.[4] Therefore, the occurrence of late onset of epithelial ingrowth in post-LASIK surgery should raise the suspicion of occult traumatic dislocation of the LASIK flap. In our patient, most likely, the irregularity of the LASIK flap edge following trauma initiated the epithelial ingrowth.

Based on the location, clinical features and severity of PLEI can be categorized into four grades using the Probst/Machat classification [Table 1].[5]
Table 1: Probst/Machat classification of post laser in situ keratomileusis epithelial ingrowth[5]

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Majmudar et al.[6] reported that mitomycin-C was successfully used to treat subepithelial fibrosis after previous corneal refractive surgery. Studies have shown for severe and recurrent cases, along with the standard surgical management, the use of adjunctive therapies such as 20% ethanol, mitomycin-C, phototherapeutic keratectomy, suturing of flap, fibrin glue, and Nd: YAG laser prevents the recurrence.

Our patient showed Grade 4 epithelial ingrowth and hence was managed with surgical intervention, as mentioned above. Although at 3-month follow-up, there was no signs of recurrence, at 6-month follow-up, the epithelial pearls had recurred. The use of BCL is a probable cause of recurrence.

Our case report provides a better understanding of epithelial ingrowth and awareness regarding its complications and management. All cases of PLEI require long-term follow-up to know the aggressive or refractory nature of epithelial ingrowth to facilitate complete resolution.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ting DS, Srinivasan S, Danjoux JP. Epithelial ingrowth following laser in situ keratomileusis (LASIK): Prevalence, risk factors, management and visual outcomes. BMJ Open Ophthalmol 2018;3:e000133.  Back to cited text no. 1
    
2.
Rojas MC, Lumba JD, Manche EE. Treatment of epithelial ingrowth after laser in situ keratomileusis with mechanical debridement and flap suturing. Arch Ophthalmol 2004;122:997-1001.  Back to cited text no. 2
    
3.
Naoumidi I, Papadaki T, Zacharopoulos I, Siganos C, Pallikaris I. Epithelial ingrowth after laser in situ keratomileusis: A histopathologic study in human corneas. Arch Ophthalmol 2003;121:950-5.  Back to cited text no. 3
    
4.
Maycock NJ, Marshall J. Genomics of corneal wound healing: A review of the literature. Acta Ophthalmol 2014;92:e170-84.  Back to cited text no. 4
    
5.
Krachmer JH, Mannis MJ, Holland EJ, Neff KD, Probst LE. LASIK complications. In: Krachmer JH, Mannis MJ, Holland EJ, editors. Cornea: Surgery of the Cornea and Conjunctiva. 3rd ed. St. Louis, MO: Mosby; 2011. p. 1861-82.  Back to cited text no. 5
    
6.
Majmudar PA, Forstot SL, Dennis RF, Nirankari VS, Damiano RE, Brenart R, et al. Topical mitomycin-C for subepithelial fibrosis after refractive corneal surgery. Ophthalmology 2000;107:89-94.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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