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New technique for epithelial ingrowth after LASIK prevents regrowth; BCVA is maintained
This flap-suturing technique is used if conventional methods fail to prevent recurrence.
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VIENNA — Suturing a portion of the flap may prevent recurrence of fulminating epithelial ingrowth in laser in situ keratomileusis (LASIK) patients. This new method, developed by Johann Kruger, MD, FRCS, was presented here at the European Society of Cataract and Refractive Surgeons meeting. Dr. Kruger said he has used this procedure successfully in several patients, and so have other practitioners who have adopted the technique.
Reversing epithelial ingrowth
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Dr. Kruger has successfully performed his new treatment for epithelial ingrowth in 5 cases. Dr. Kruger’s procedure consists of debridement of both surfaces using a dry sponge spear, which should be discarded after every scrape. The area should be brushed or irrigated. YAG laser or phototherapeutic keratectomy (PTK) can also be used.
The epithelial ingrowth should be carefully removed, followed by suturing the end of the flap in the area of ingrowth. The suture is passed 1 mm from the edge of the flap, from the flap side, through the cornea, coming out through the peripheral part of the cornea. According to Dr. Kruger, passing the suture through the flap side first ensures that the anatomy of the flap will not be distorted.
The sutures are made generally 1 mm apart in the area of ingrowth. The suture should be tied tight, but not so tight that it causes astigmatism.
“This works fantastically,” Dr. Kruger said. “In every case, I have kept the sutures in between 2 and 6 weeks and the epithelial ingrowth has not re turned.”
Follow-up on these cases has been approximately 18 months, and they are still being followed. Dr. Kruger said he would present further data at the upcoming meeting of the American Society of Cataract and Refractive Surgeons.
When conventional methods fail
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General measures to prevent ingrowth include use of photorefractive keratectomy instead of LASIK; use of mitomycin; removal of loose epithelium from the edge of the flap, especially in revision cases; and use of a contact lens.
“What it boils down to is, if you get a patient with a fulminating epithelial ingrowth, sometimes when you remove it you just put the flap back or you put a contact lens on,” Dr. Kruger said. “It just comes back after a couple of weeks and invades the interface again.”
The problem some LASIK patients have, according to Dr. Kruger, is poor flap adhesion or loose epithelium at the edge of the flap. Conventional methods to correct epithelial in growth, he said, generally fail after 1 to 2 weeks. Other risk factors associated with epithelial ingrowth and its conventional correction include stromal melting, resultant loss of best corrected visual acuity (BCVA), topographic changes and irregular astigmatism. Revision of hyperopic ablation, such as manual lifting of the flap, can also cause epithelial ingrowth.
According to Dr. Kruger, the time to treat epithelial ingrowth is when 2 mm or more needs to be removed to prevent stromal melting. In cases of necrotic islands, treatment should be attempted immediately.
“Very importantly, none of these cases lost BCVA,” Dr. Kruger said. “If you get a case of epithelial ingrowth, and you remove it and it happens to come back, I would immediately resort to this method.”
Successful cases
The cases Dr. Kruger presented had all undergone general measures to correct the epithelial ingrowth, but after several weeks the ingrowth returned. In one case of a male patient with loose epithelium, the epithelial ingrowth was removed but recurred in spite of the edges being cleared and the use of a contact lens. The second attempt included use of mitomycin, but the ingrowth returned. The third time, the flap was sutured locally and resulted in no recurrence and no loss of BCVA.
Dr. Kruger’s second case consisted of a 46-year-old male with loose epithelium at the primary LASIK procedure. Epithelial ingrowth occurred at 3 months. The defect was removed and a contact lens was used. After several weeks, the ingrowth returned. Then the flap was sutured locally, which resulted in no recurrence and no loss of BCVA.
In a third case, a 52-year-old male with loose epithelium at primary LASIK procedure developed acute epithelial ingrowth at day 3. There was recurrence after initial removal, which was then followed by Dr. Kruger’s procedure of removal and suturing of the flap locally, which resulted in no recurrence and no loss of BCVA.
In all of Dr. Kruger’s cases, suturing has consistently prevented recurrent epithelial ingrowth in cases with flap adhesion abnormality while preserving BCVA.
For Your Information:
- Johann Kruger, MD, FRCS, can be reached at 130 Edward St., Bellville, South Africa 7530; +(27) 21-910-0300; fax: +(27) 21-910-0340. Dr. Kruger has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.