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Case study: Losing a flap during a LASIK procedure
In this month’s Corneal Health column, surgeons discuss the best ways to avoid infection after a flap becomes contaminated.
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Eric D. Donnenfeld, MD: This is a case I have talked about before, but I think it makes a good teaching point so I’m going to talk about it again. A 45-year-old woman came in for routine LASIK. I’m doing my LASIK, I hand off the keratome, and they blow out the keratome. And suddenly there is no flap.
 Eric D. Donnenfeld |
Now we’re looking for the flap, but we can’t find it. And all of you know how to find out if spaghetti is done. You throw it against the wall. If it sticks, it’s done. And that’s exactly what happened. The cornea ended up against the wall. We find it, but now it’s been sitting on the wall for about 5 minutes. What do you do next?
How would you manage this? My major concern is going to be infection with this having sat on the wall. What are you going to do with this flap to make certain the patient doesn’t get an infection?
 Terrence P. O'Brien |
Terrence P. O’Brien, MD: You want to remain calm, just as you did. And don’t throw away the flap. It’s a good thing you found it on the wall. If you have some corneal preservation media, it would be great to put the flap in that because that has some antibiotic supplementation in the corneal preservation media, and you could rehydrate the flap in that media and then replace it. In absence of that, you could put it in some balanced saline solution, and then I would add a preservative-free antibiotic into that solution and then replace the flap. So I would definitely replace the flap, but I would use antibiotic and maybe some antiseptic on the cornea as well.
Dr. Donnenfeld: OK. Any other opinions?
 Terry Kim |
Terry Kim, MD: These patients actually do fairly well with just re-epithelialization without flap replacement. There have been studies to show that in patients who have had amputated or missing flaps, visual acuity is quite reasonable after re-epithelization over the stromal bed, so that’s also an option.
In this scenario, I would evaluate the condition of the amputated flap to determine if I would replace it or discard it. Either way, I would recommend the use of a topical broad-spectrum fluoroquinolone such as moxifloxacin in addition to topical povidone iodine to prevent any potential infection.
William B. Trattler, MD: When a flap is lost, it is not uncommon for haze to develop in the remaining stroma, and the haze can adversely affect vision. With a thinner cornea, there is not as much room to laser ablate the haze and end up with a good visual result, so the goal should be to preserve the flap. I would therefore recommend working to save the flap, by soaking the dislocated flap in a fluoroquinolone that contained a preservative. This combination will help sterilize the flap because the flap could have been exposed to all sorts of pathogens. Of course, in situations where the flap cannot be salvaged and haze develops, [phototherapeutic keratectomy] to remove the haze would be the recommended treatment.
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Dr. Kim: I would certainly recommend the use of mitomycin-C 0.02% on the stromal bed for at least 1 minute to minimize the risk of haze formation if I chose to discard the flap.
Dr. Donnenfeld: We applied a topical fluoroquinolone. And we did apply Betadine. We soaked it, and we put the flap back on the eye. We put a contact lens in. The patient was 20/20 the next day. And this was the patient’s better eye the next day as compared with the previous eye. But I think the point here is that a topical antibiotic alone, certainly a nonpreserved antibiotic alone, would not be enough for this case. You are not going to kill fungus or other contaminants that might be on that wall. You need to apply something that’s going to kill these other entities. And I think Betadine or benzalkonium chloride or a combination of both is important. You need to have something here that is going to kill infectious organisms other than bacteria and something that’s going to kill quickly. The antiseptic Betadine and the preservative BAK are is the most important things we employed here.
For more information:
- Eric D. Donnenfeld, MD, can be reached at Ryan Medical Arts Building, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com.
- Terry Kim, MD, can be reached at Duke University Eye Center, Erwin Road P.O. Box 3802, Durham, NC 27710-3802; 919-681-3568; fax: 919-681-7661; e-mail: terry.kim@duke.edu.
- Terrence P. O’Brien, MD, can be reached at Bascom Palmer Eye Institute, 7101 Fairway Drive, Palm Beach Gardens, FL 33418; 561-515-1544; fax: 561-515-1588; e-mail: tobrien@med.miami.edu.
- William B. Trattler, MD, can be reached at 8940 N. Kendall Drive, #400, Miami, FL 33176; 305-598-2020; fax: 305-274-0426; e-mail: wtrattler@gmail.com.