Recutting, flap lifting both have pros and cons

ANAHEIM, Calif. — Surgeons retreating patients who have undergone previous LASIK must choose whether to cut a new flap or lift the existing one. Two surgeons speaking here discussed the pluses and minuses of each choice.

“It’s certainly a hot topic,” Stephen Slade, MD, FACS, told attendees here at the American Academy of Ophthalmology meeting. Of paramount importance in deciding which surgical technique to use is proper patient selection, Dr. Slade said. Timing is also important.

“You can lift the flap during the first few weeks,” he said. “It’s safer for the stroma, but not for the epithelium, though.”

One reason to prefer recutting is the potential of creating striae by lifting the original flap, Dr. Slade said. Recutting may also be the better choice if there has been a long interval between initial cut and secondary cut.

“Make sure you place the second cut outside of the first one, so you come down on fresh tissue,” Dr. Slade suggested. “And don’t throw away any little extra bits you might have.”

Cutting the flap with the IntraLase femtosecond laser, “you can set a precise depth for cutting and can do it at any time. The control and precision of this device will let us do recuts whenever we want,” he said.

John Doane, MD, FACS, wasted no words in expressing his opinion on the choice.

“Lifting is superior,” he said. The only advantage to recutting, he said, is that it is faster and possibly more precise. But the potential for creation of a double interface with stromal fragments is an unnecessary risk, he said.

A downside to flap lifting is a higher potential for epithelial ingrowth, and “pain is more frequent after lifting,” he said.

When lifting the flap, Dr. Doane said surgeons should irrigate the fornices. The lids and lashes should be prepped with povidone-iodine swabs.

“Do not forget that this is surgery,” he warned. Also, if an epithelial defect is created, surgeons must monitor patients for diffuse lamellar keratitis, Dr. Doane said.