Immediate diagnosis, treatment vital for cap stria problems following LASIK

Issue: November 1998

AKRON, Ohio - Treating corneal wrinkling, or cap striae, following laser in situ keratomileusis (LASIK) surgery requires immediate recognition and prompt attention, according to Edward C. Kondrot, MD, in private practice in Pittsburgh. Dr. Kondrot lectured on this complication at the second annual meeting of the Optometric Refractive Surgery Society here.

Cap striae occur in less than 0.2% of LASIK patients, but the visual effects are usually significant, Dr. Kondrot said.

Patients with thin caps and with high degrees of myopia are more susceptible to striae, where the deeper excavation can create a tenting effect on the cap and can lead to wrinkling. Inadequate drying time also can lead to striae. Subtle wrinkling will usually disappear over time, but severe wrinkling needs to be addressed immediately, he said.

Causes of striae

In the postoperative period, flap displacement can be caused by blunt trauma or by the patient rubbing the eye. Epithelial defects, irregular edges, epithelial ingrowth and cysts can cause late postoperative complications.

Recognition of the striae on the first day after surgery is very important for the comanaging optometrist. The cap and gutter should be examined for centration under retroillumination, Dr. Kondrot said. In most cases, striae will not be detected unless the optometrist uses retroillumination. The next step is to determine if the striae are visually significant. "The patient may be seeing 20/20, but if he or she has visual complaints, then it is visually significant," he said. "Don't base your judgment on Snellen vision."

If the striae are located in the periphery, they are likely of little consequence, but striae that are centrally located must be addressed.

Pressure patches

A method of treatment for striae developed by Dr. Kondrot uses a pressure patch to smooth corneal wrinkles.

The first case of striae Dr. Kondrot treated using this technique was a man who had undergone bilateral LASIK without complications. At home, following surgery, the man awoke at 2 a.m. with severe eye pain and marked loss of vision. When Dr. Kondrot met the patient in the emergency room, he found the man had a hanging flap that resembled a crinkled contact lens.

"I refloated the cap and tried to position it on the eye, but the cap was like an accordion and kept springing back," Dr. Kondrot said.

Repeated attempts to smooth the cap were unsuccessful. Deciding that suturing the cap at that time was impractical, Dr. Kondrot opted for a pressure patch. The cap was refloated back into position, antibiotic drops were instilled, the patient gently closed his eyelids and a very tight bandage was placed on the eye using several patches and tape.

"The following day, the pressure patch was removed, and I was shocked because there were no striae present. The cap was smooth, and he had excellent visual acuity," Dr. Kondrot said.

A possible modification of this technique would be to place a bandage contact lens on the flap before applying the pressure patch. In cases where the cornea is severely wrinkled, however, the cap is probably not very adherent, and there is a risk of disturbing it, Dr. Kondrot said.

Late corneal wrinkling

A second use of the procedure suggests the pressure patch technique may be beneficial in late corneal wrinkling. The patient had undergone uncomplicated LASIK, but his best-corrected visual acuity was reduced to 20/60 in one eye when he came to Dr. Kondrot several months after surgery.

"We decided to refloat the cap and use the pressure patching technique to see if we could accomplish anything. In my experience, refloating caps and smoothing them late is unsuccessful," Dr. Kondrot said.

After the patch was removed, the patient had only minimal stria, had a marked improvement in uncorrected vision and was asymptomatic, he said.

Although his experience with pressure patches is limited to these two cases, Dr. Kondrot said this technique is a beneficial addition to a practitioner's armamentarium in correcting this complication. He added that his first line of treatment in cases of cornea striae is still irrigation and refloating the cap back into position.

"We've all been told that pressure patching is an absolute contraindication in lamellar procedures. I don't feel it is an absolute contraindication, and it may be beneficial in the treatment of early and - possibly - late corneal wrinkling," Dr. Kondrot said.

For Your Information:

Edward C. Kondrot, MD, is in private practice in Pittsburgh and can be reached at 239 Fourth Ave., 2020 Investment Building, Pittsburgh, PA 15222; (412) 281-0447; fax; (412) 281-3660. Dr. Kondrot has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.