Eyelid Disease

Abstract

LASIK is the most commonly performed refractive surgical procedure in the United States. However, it is not without risks. Complications include completely separated corneal flaps, incomplete corneal flaps, flap striae, epithelial ingrowth, and diffuse lamellar keratitis (DLK). We present our experience with a group of post-LASIK patients with complications severe enough to require surgical intervention and report their visual outcomes.Out of 4051 LASIK procedures and 676 routine enhancements performed at the Duke Laser Vision Center from January 1998 to August 2001, 31 eyes of 30 patients required 43 surgical interventions for complications (8 eyes had already undergone routine enhancement before the complications). The mean age of the 30 patients was 46.3 years. The mean preoperative spherical refractive error was −3.95 diopters (D), and the mean preoperative cylindrical refractive error was −1.37 D. The mean corneal pachymetry was 547.5 μm.Complications included 11 eyes (0.27%) with epithelial ingrowth, 6 (0.15%) with striae, 6 (0.15%) with DLK, 5 (0.12%) with striae and epithelial ingrowth, and 2 with mild DLK and epithelial ingrowth (1 of these also developed striae). One eye sustained corneal perforation; the patient declined surgical intervention and was not included in outcome analysis as she did not meet inclusion criteria. Of the 8 eyes that underwent routine LASIK enhancement before developing complications requiring surgical intervention, all developed epithelial ingrowth, 2 also developed striae, and 1 developed striae and DLK. However, no demographic or preoperative refractive variables were associated with the development of complications.Interventions for the above-mentioned complications involved 10 eyes requiring flap lift and irrigation (4 for striae and 6 for DLK), 15 eyes requiring debridement with or without flap lift and irrigation (10 for epithelial ingrowth, 3 for epithelial ingrowth plus striae, and 2 for epithelial ingrowth plus DLK), and 5 eyes requiring suturing of the flap (2 for striae alone, 2 for striae with epithelial ingrowth, and 1 after debridement for epithelial ingrowth).Analysis of visual outcomes revealed that there were no significant differences between preoperative and postoperative best-corrected visual acuities (BCVAs) in any patients or any of the subgroups, with only 4 eyes (0.09%) losing correctable vision. Three of these lost a single line of acuity (2 due to epithelial ingrowth, 1 due to striae), and 1 lost 4 lines of acuity (due to striae requiring flap suturing).However, patients did lose an average of 1 line of acuity from preoperative BCVA to postoperative uncorrected visual acuity (UCVA). Of the 17 patients whose postoperative UCVA was worse than their preoperative BCVA, 5 had epithelial ingrowth, 4 had striae (2 requiring suturing), 3 had DLK, 3 had striae and epithelial ingrowth (1 requiring suturing), and 2 had DLK and epithelial ingrowth.Mean postoperative spherical correction was −0.06 D, and mean postoperative cylindrical correction was −0.5 D. Postoperative refractive error was not correlated with demographic or operative variables or with complications.Although LASIK remains a popular procedure, there has been increasing scrutiny concernng its complications—most notably, epithelial ingrowth (commonly after enhancement), DLK, and flap striae. In our study, the development of epithelial ingrowth resulted in an average postoperative UCVA of 20/25; DLK resulted in visual acuity of 20/26, whereas flap striae averaged 20/27. The intervention most associated with poor postoperative UCVA was suturing, with an average acuity of 20/32. Our study’s results are comparable to those of other reports in the literature on complications of LASIK requiring surgical intervention.1Chitkara D.K. Rosen E. Gore C. et al.Tracker-assisted laser in situ keratomileusis for myopia using the autonomous scanning and tracking laser 12-month results.Ophthalmology. 2002; 109: 965-972Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 2Johnson J.D. Harissi-Dagher M. Pineda R. et al.Diffuse lamellar keratitis.J Cataract Refract Surg. 2001; 27: 1560-1566Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 3Shah M.N. Misra M. Wihelmus K.R. Koch D.D. Diffuse lamellar keratitis associated with epithelial defects after laser in situ keratomileusis.J Cataract Refract Surg. 2000; 26: 1312-1318Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar, 4Wang M.Y. Maloney R.K. Epithelial ingrowth after laser in situ keratomileusis.Am J Ophthalmol. 2000; 129: 746-751Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar, 5Lin R.T. Maloney R.K. Flap complications associated with lamellar refractive surgery.Am J Ophthalmol. 1999; 127: 129-136Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar, 6Tole D.M. McCarty D.J. Couper T. Taylor H.R. Melbourne Excimer Laser GroupComparison of laser in situ keratomileusis and photorefractive keratectomy for the correction of myopia of -6.00 diopters or less.J Refract Surg. 2001; 27: 46-54Google Scholar It is heartening to note that, even in this select group of patients with moderately severe complications of LASIK, there was no significant loss in lines of best-corrected vision, and that postoperative UCVA closely approached preoperative best-corrected vision, which should reassure patients and surgeons alike.The limitations of this study are as follows. The outcomes were evaluated by nonmasked observers in lighting conditions minimizing optical aberration. Further, follow-up was limited. Also, as this was a retrospective case series, subjective patient satisfaction was not assessed.In summary, patients who sustain LASIK complications requiring surgical intervention have an excellent chance of retaining best-corrected vision and a good chance of having postoperative uncorrected vision approaching preoperative best-corrected vision. LASIK is the most commonly performed refractive surgical procedure in the United States. However, it is not without risks. Complications include completely separated corneal flaps, incomplete corneal flaps, flap striae, epithelial ingrowth, and diffuse lamellar keratitis (DLK). We present our experience with a group of post-LASIK patients with complications severe enough to require surgical intervention and report their visual outcomes. Out of 4051 LASIK procedures and 676 routine enhancements performed at the Duke Laser Vision Center from January 1998 to August 2001, 31 eyes of 30 patients required 43 surgical interventions for complications (8 eyes had already undergone routine enhancement before the complications). The mean age of the 30 patients was 46.3 years. The mean preoperative spherical refractive error was −3.95 diopters (D), and the mean preoperative cylindrical refractive error was −1.37 D. The mean corneal pachymetry was 547.5 μm. Complications included 11 eyes (0.27%) with epithelial ingrowth, 6 (0.15%) with striae, 6 (0.15%) with DLK, 5 (0.12%) with striae and epithelial ingrowth, and 2 with mild DLK and epithelial ingrowth (1 of these also developed striae). One eye sustained corneal perforation; the patient declined surgical intervention and was not included in outcome analysis as she did not meet inclusion criteria. Of the 8 eyes that underwent routine LASIK enhancement before developing complications requiring surgical intervention, all developed epithelial ingrowth, 2 also developed striae, and 1 developed striae and DLK. However, no demographic or preoperative refractive variables were associated with the development of complications. Interventions for the above-mentioned complications involved 10 eyes requiring flap lift and irrigation (4 for striae and 6 for DLK), 15 eyes requiring debridement with or without flap lift and irrigation (10 for epithelial ingrowth, 3 for epithelial ingrowth plus striae, and 2 for epithelial ingrowth plus DLK), and 5 eyes requiring suturing of the flap (2 for striae alone, 2 for striae with epithelial ingrowth, and 1 after debridement for epithelial ingrowth). Analysis of visual outcomes revealed that there were no significant differences between preoperative and postoperative best-corrected visual acuities (BCVAs) in any patients or any of the subgroups, with only 4 eyes (0.09%) losing correctable vision. Three of these lost a single line of acuity (2 due to epithelial ingrowth, 1 due to striae), and 1 lost 4 lines of acuity (due to striae requiring flap suturing). However, patients did lose an average of 1 line of acuity from preoperative BCVA to postoperative uncorrected visual acuity (UCVA). Of the 17 patients whose postoperative UCVA was worse than their preoperative BCVA, 5 had epithelial ingrowth, 4 had striae (2 requiring suturing), 3 had DLK, 3 had striae and epithelial ingrowth (1 requiring suturing), and 2 had DLK and epithelial ingrowth. Mean postoperative spherical correction was −0.06 D, and mean postoperative cylindrical correction was −0.5 D. Postoperative refractive error was not correlated with demographic or operative variables or with complications. Although LASIK remains a popular procedure, there has been increasing scrutiny concernng its complications—most notably, epithelial ingrowth (commonly after enhancement), DLK, and flap striae. In our study, the development of epithelial ingrowth resulted in an average postoperative UCVA of 20/25; DLK resulted in visual acuity of 20/26, whereas flap striae averaged 20/27. The intervention most associated with poor postoperative UCVA was suturing, with an average acuity of 20/32. Our study’s results are comparable to those of other reports in the literature on complications of LASIK requiring surgical intervention.1Chitkara D.K. Rosen E. Gore C. et al.Tracker-assisted laser in situ keratomileusis for myopia using the autonomous scanning and tracking laser 12-month results.Ophthalmology. 2002; 109: 965-972Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 2Johnson J.D. Harissi-Dagher M. Pineda R. et al.Diffuse lamellar keratitis.J Cataract Refract Surg. 2001; 27: 1560-1566Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 3Shah M.N. Misra M. Wihelmus K.R. Koch D.D. Diffuse lamellar keratitis associated with epithelial defects after laser in situ keratomileusis.J Cataract Refract Surg. 2000; 26: 1312-1318Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar, 4Wang M.Y. Maloney R.K. Epithelial ingrowth after laser in situ keratomileusis.Am J Ophthalmol. 2000; 129: 746-751Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar, 5Lin R.T. Maloney R.K. Flap complications associated with lamellar refractive surgery.Am J Ophthalmol. 1999; 127: 129-136Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar, 6Tole D.M. McCarty D.J. Couper T. Taylor H.R. Melbourne Excimer Laser GroupComparison of laser in situ keratomileusis and photorefractive keratectomy for the correction of myopia of -6.00 diopters or less.J Refract Surg. 2001; 27: 46-54Google Scholar It is heartening to note that, even in this select group of patients with moderately severe complications of LASIK, there was no significant loss in lines of best-corrected vision, and that postoperative UCVA closely approached preoperative best-corrected vision, which should reassure patients and surgeons alike. The limitations of this study are as follows. The outcomes were evaluated by nonmasked observers in lighting conditions minimizing optical aberration. Further, follow-up was limited. Also, as this was a retrospective case series, subjective patient satisfaction was not assessed. In summary, patients who sustain LASIK complications requiring surgical intervention have an excellent chance of retaining best-corrected vision and a good chance of having postoperative uncorrected vision approaching preoperative best-corrected vision. Local Anesthetic in Vitreoretinal Surgery: Author ReplyOphthalmologyVol. 112Issue 11PreviewWe thank Drs Chhabra et al for their interest in our article. We also enjoyed reading about their use of peribulbar anesthesia for vitreoretinal surgery. The experience at their institution is consistent with previously published reports on the efficacy of peribulbar anesthesia in ophthalmic surgery.1–4 In a prospective, randomized, double-blind study comparing peribulbar and retrobulbar anesthesia for vitreoretinal surgical procedures, Demediuk et al found that both methods provided equal levels of akinesia and analgesia. Full-Text PDF Bilateral Cataract and Corectopia after Laser Eyelid EpilationOphthalmologyVol. 113Issue 6PreviewThe title “Bilateral Cataract and Corectopia after Laser Eyelid Epilation” (2005;112:1634–5) is confusing in that it refers to “eyelid,” whereas the abstract and article refer to “eyebrow.” The Editorial Office and the authors apologize for any confusion. The laser procedure was directed to the eyebrows and not to the eyelids. The correct title should be “Bilateral Cataract and Corectopia after Laser Eyebrow Epilation.” In a related matter, the Letter to the Editor on page 2052 of the November 2005 issue that relates to the above-mentioned article and LASIK surgery in general is entitled “Eyelid Disease.” This is in error and misleading; it should be entitled “LASIK Complications Requiring Surgery.” Full-Text PDF Cataract Surgery and Fuchs’ Corneal DystrophyOphthalmologyVol. 112Issue 11PreviewWe read with interest Seitzman et al’s article in the March 2005 issue.1 The authors studied the indication for an initial triple procedure (combined penetrating keratoplasty [PK], cataract extraction, and intraocular lens placement) in patients with Fuchs’ corneal dystrophy undergoing cataract surgery. According to the American Academy of Ophthalmology guidelines reported in the Preferred Practice Pattern and Basic and Clinical Science Series, a preoperative corneal thickness of >600 μm was taken as the cutoff point for recommendation for an initial triple procedure, as such patients are thought to be at high risk of postoperative corneal decompensation. Full-Text PDF