Flap Dislocation Research Articles

Traumatic Flap Dislocation 4 Years After LASIK Due to Air Bag Injury

To report a patient who developed corneal flap dislocation following air bag injury 48 months after LASIK. Evaluation by slit-lamp microscopy and fluorescein angiography. A 29-year-old man was treated after air bag injury that occurred 48 months after LASIK. Examination revealed corneal flap dislocation, with severe folds and flap edema. Preoperative visual acuity was finger counting at 1 m. Visual acuity was 20/400 24 hours after repositioning the corneal flap. Retinal angiography revealed Berlin macular edema, which was injected with periocular steroids. Five days after injection, visual acuity remained 20/400, but improved to 20/40 1 month after injection. Significant trauma can dislocate a corneal flap many months after surgery.

239 Attitudes thérapeutiques et résultats dans les traumatismes du volet cornéen post LASIK

To report our experience treating flap complications secondary to trauma after LASIK. Retrospective analysis of 7 eyes treated for ocular trauma after LASIK including blunt trauma with partial flap dislocation (n=4), sharp trauma with complete dislocation of the flap (n=2) and total loss of the flap (n=1). The time of trauma ranged between 2 days and 3 years after LASIK. All the dislocated flaps were lifted, irrigated with a 50/50 BSS-distilled water solution and repositioned within 12 hours of the injury. One flap remained dislocated (infolded) for 36 hrs before relift and irrigation. A bandage contact lens was placed, and a regimen including topical antibiotics and corticosteroids was instituted in all cases. Best spectacle-corrected visual acuity, uncorrected visual acuity, refraction and topography were monitored after our intervention, along with the clinical course and complications. Postoperative follow-up ranged from 3 to 19 months. Nonprogressive epithelial ingrowth was noted in one patient, and nocardia infection and diffuse lamellar keratitis developed in another. One patient developed persistant macrostriae in the flap which necessitated a gel-smoothing treatment with PTK. At 3 months of the injury, all patients recovered pretrauma spectacle-corrected visual acuity. Traumatic flap dislocations can occur years after LASIK and can be complicated by epithelial ingrowth, diffuse lamellar keratitis, infections and macrostriae. Clinical outcome can be favorable if managed promptly and adequately. LASIK patients should be aware of flap vulnerability even years after their procedure and protective eyewear is recommended for sports and high risk activity.

Ultrabiomicroscopy (Ubm) in Flap Dislocation following Lasik: A Case Report

To describe postoperative laser-assisted in situ keratomileusis (LASIK) flap dislocation occurred after trauma Ultrabiomicroscopy (UBM) is used to obtain a high-resolution imaging of the cornea. The UBM results are presented and compared with histologic and confoscan findings The technique is useful and easy to perform, offering more opportunities to study the anatomical changes in LASK flap dislocation occurred after trauma.

Traumatic Corneal Flap Dislocation One to Six Years After LASIK in Nine Eyes With a Favorable Outcome

To report our experience treating eye trauma after LASIK refractive surgery. Nine eyes of eight patients (one woman and seven men) were treated for ocular trauma: blunt trauma (n=5), sharp instrument trauma (n=2,) and trauma from inflation of automobile air bags during a traffic accident (n=2). The time from LASIK varied between 3 months and 6 years. All patients were hospitalized as a result of severe decrease in visual acuity and pain. Seven of nine LASIK flaps had some degree of dislocation and were lifted, irrigated, and repositioned. Two flaps were edematous without dislocation. Intensive topical steroids and antibiotics were used in all patients up to 3 weeks after trauma. Three months after trauma, five eyes regained their pre-trauma visual acuity (between 20/20 and 20/40), and three eyes lost one line of best spectacle-corrected visual acuity. Trauma occurring several months or years after LASIK may cause flap injury. Adequate and prompt treatment usually is successful.

Stability of the laser in situ keratomileusis corneal flap in rabbit eyes

To quantify the force required to dislodge a laser in situ keratomileusis (LASIK) corneal flap in rabbits and correlate that force with sources of injury to LASIK corneal flaps in humans. Animal Vivarium and Department of Ophthalmology, Naval Medical Center, San Diego, California, USA. Corneal flaps were cut in 56 eyes of 30 rabbits. A -8.00 diopter excimer ablation was also performed in 32 of the eyes. Injury testing, using a burst of CO2 from a modified paintball gun, was conducted from 1 to 9 days postoperatively. Impact force was compared to that generated by mechanical trauma (fingers and a small tree branch) striking a force gauge. Of 43 eyes tested for injury, flaps could not be dislocated in 11 eyes (26%). There was no significant difference between eyes treated with flap only and those that also had ablation. When flaps were dislodged, the required force generally resulted in extensive intraocular injury. There was no significant difference between the force required for flap dislocation on postoperative days 1 and 9. In rabbits, LASIK corneal flaps were very resistant to high-speed wind trauma as early as 24 hours postoperatively. Flap stability was robust prior to the formation of collagen scar tissue, probably due to epithelial bridging at the edge of the flap and an osmotic gradient across the flap-stromal bed interface. Although this study used a rabbit model, it seems likely that both these flap adhesion mechanisms would also provide stability to the LASIK flap in humans.

Late Traumatic Flap Dislocations After LASIK

To report the management and outcome of late onset traumatic dislocation of LASIK flaps. This retrospective, interventional case series presents three patients with late onset LASIK flap dislocation following mechanical trauma 1 to 7 years postoperatively. In all cases, the flap was surgically repositioned. Epithelial ingrowth was removed and diffuse lamellar keratitis was treated with an intensive steroid regimen. All patients returned to their preoperative best spectacle-corrected visual acuity. Aggressive steroid treatment during the perioperative period and meticulous handling of the epithelium are important in preventing further recurrence. Laser in situ keratomileusis flaps may experience mechanical dislocation as late as 7 years postoperatively. Diffuse lamellar keratitis and epithelial ingrowth are associated with flap dislodgment.

Treatment of Traumatic LASIK Flap Dislocation and Epithelial Ingrowth With Fibrin Glue

To describe a case of a traumatic late dislocation of a laser-assisted in situ keratomileusis (LASIK) flap complicated by epithelial ingrowth. Interventional case report. A 50-year-old woman presented 21 months after uncomplicated LASIK with painful vision loss in the right eye after minor trauma. A dislocation of the LASIK flap was noted at examination and was repositioned. One week later, epithelial ingrowth was detected in the flap interface. The ingrowth was treated with flap lifting, debridement, and sealing of the flap with fibrin glue. Visual acuity returned to baseline, and there was no recurrence after 20 months of follow-up. Traumatic dislocations of LASIK flaps may occur many months after uncomplicated surgery and may be associated with epithelial ingrowth after successful repositioning. The additional use of fibrin glue in conjunction with thorough debridement may be helpful in preventing the recurrence of epithelial ingrowth.

Post-LASIK Corneal Flap Displacement Following Penetrating Keratoplasty for Bullous Keratopathy

To report 3 patients who experienced late flap dislocation after laser in situ keratomileusis (LASIK) in eyes that had undergone prior penetrating keratoplasty (PKP) for bullous keratopathy. Retrospective chart review of 2 referral corneal and refractive surgery practices, case reports, and literature review. Three patients (mean age 58.3 years, 2 male, 1 female), all status post-corneal transplant for bullous keratopathy, had residual myopic astigmatism and underwent LASIK for correction of their significant anisometropia. Flap dislocation occurred at a mean of 7 days (range 3 to 14 days) following the LASIK procedure. All patients had peripheral corneal edema in their recipient bed. All 3 patients required an additional surgical procedure for visual rehabilitation. Flap displacement may occur following LASIK in patients who have undergone PKP for bullous keratopathy. The endothelial pump function, which is vital to maintaining flap adherence, may be compromised in these patients. We suggest that patients with a history of PKP and endothelial compromise who undergo LASIK wear protective shields for a longer than normal period and be followed closely to reduce the risk of flap slippage.

Comparación de dos técnicas de implantación de lentes intracorneales en ojos de conejo

To compare two different surgical techniques of intracorneal lens implantation. To determine the incidence of corneal and lens complications in two groups of rabbits subjected to such surgery. The first group (7 rabbits) initially had a keratectomy performed with the microkeratome following which the corneal flap was sutured to the stromal layer. In the second group (7 rabbits), a pocket-shaped stromal dissection was performed manually. Both groups of rabbits had a secondary lens implantation in the corneal inlay. The follow up period was of 2 months duration. The incidence of corneal edema in the first month was higher in group 1 (71.4%) than in group 2 (14.3%) (p = 0.0155); during the second month, the incidence was 42.9% in group 1 and 28.6% in group 2 (p= 0.2927). Flap dislocation and retraction of the flap was seen in 4 of the 7 rabbits in group 1, whereas no complication of this type was observed in the manual pocket group (group 2). The incidence of lens subluxation was 28.6% in group 1 and 0% in group 2. Finally, there was a 71.4% (5/7) loss of the intracorneal lens in the rabbits treated with the microkeratome (group 1) while only 1 of 7 rabbits (14.3%) lost the lens in group 2 (P = 0.0155). Eyes in which the corneal pocket shape was made by manual stromal dissection had a higher stability of the lens and less post-operative corneal complications.

Traumatic flap dislocation 4 years after laser in situ keratomileusis

We present a case of late traumatic flap dislocation 47 months after laser in situ keratomileusis (LASIK). This is the latest reported case of traumatic LASIK flap dislocation to date. The patient was examined 5 days after being struck in the face and found to have a flap dislocation. The flap was repositioned surgically, and postoperatively the patient had 20/20 visual acuity and no visual complaints.

Novel tissue adhesives to secure laser in situ keratomileusis flaps

To evaluate 2 novel biodendrimer tissue adhesives in sealing and securing laser in situ keratomileusis (LASIK) flaps. Duke University Eye Center, Durham, North Carolina, USA. Laser in situ keratomileusis flaps were created in 10 human eye-bank eyes using the Hansatome microkeratome system (Bausch & Lomb). These eyes were divided into 2 groups. Flaps in the first group (n=4) were secured with a laser-activated biodendrimer adhesive along the flap edge. In the second group (n=6), the flaps were secured with a self-gelling dendritic adhesive. Dry Merocel sponges (Medtronic Solan) were used to test the strength of flap adherence in both groups. Further testing was performed in the second group. The hinges of these flaps were cut with a scalpel blade and fluorescein dye was injected under the flap to observe potential dye leakage along the flap edge. Laser in situ keratomileusis flaps sealed with both adhesives were secure with no flap dislocation. There was no leakage of fluorescein dye observed in the second group. Both adhesives were easy to apply, clear when dry, and had a soft rubbery consistency. Two novel biodendrimer adhesives successfully sealed and secured LASIK flaps. These adhesives may prove to be an effective alternative for treating LASIK flap complications such as epithelial ingrowth or flap dislocation.

Management of Prolonged LASIK Flap Dislocation in Combination With Retina Surgery

Management of Prolonged LASIK Flap Dislocation in Combination With Retina Surgery

Refractive surgery in the United States Army, 2000–2003

To examine the history, current status, outcomes, and future direction of the Army Warfighter Refractive Eye Surgery Program (WRESP), which was established to reduce the limitations posed by corrective eyewear in combat arms soldiers. Retrospective study. Sixteen thousand one hundred eleven Army service members who underwent refractive surgery between May 2000 and September 2003. Results were collected from monthly WRESP reports and from questionnaires administered to refractive surgery patients returning from deployments to southwest Asia. Soldiers rated the impact of refractive surgery on their ability to perform select operational tasks as well as their overall readiness. Visual acuity (VA) and patient satisfaction. Between May 2000 and September 30, 2003, 32 068 eyes of 16 111 soldiers were treated. Postoperative uncorrected VA was better than or equal to 20/20 in 85.6%, 20/25 in 92.4%, and 20/40 in 98.2% of eyes with at least 3 months' follow-up, and 93.7% of 175 surveyed patients rated their overall readiness better or much better after surgery. This program has provided excellent outcomes and enhanced the overall readiness of over 16 000 Army service members. Reports of night vision difficulties, LASIK flap dislocation, and dry eye are infrequent, and do not seem to have a significant negative impact on military operations or individual readiness. This article contains additional online-only material available at http://www.ophsource.com/periodicals/ophtha.

LASIK Flap Dislocation by Blunt Trauma Seven Weeks After Surgery

LASIK Flap Dislocation by Blunt Trauma Seven Weeks After Surgery

Late traumatic dislocation of laser in situ keratomileusis flaps

We present 2 patients with late traumatic laser in situ keratomileusis flap dislocation 8 months and 17 months after surgery. One patient had a sharp trauma that caused a partial laceration and the second patient had a blunt trauma that caused a dislocation of the flap. The corneas were examined with slitlamp microscopy, computed corneal topography, and confocal microscopy. One flap was repositioned surgically; the other was treated conservatively with an eye patch. The final visual outcomes were good and illustrate the benefit of immediate attention and flap repositioning.

Late laser in situ keratomileusis flap dislocation caused by a thrown football

A 38-year-old man sustained a dislocated flap after being struck in the left eye with a football more than 30 months after uneventful laser in situ keratomileusis (LASIK). Consequent epithelial ingrowth and microstriae required surgical treatment. The postoperative course was uneventful with recovery of 20/20 Snellen uncorrected visual acuity. This case illustrates the need for LASIK patients to wear protective eyewear when participating in contact sports.

Subtarsal Flap Dislocation After Superior Hinge Laser in situ Keratomileusis in a Patient With Borderline Mental Illness

To report a case of complete subtarsal flap dislocation after uncomplicated superior hinge laser in situ keratomileusis (LASIK). Flap dislodgement resulted from eye rubbing in a patient with a past medical history of mental illness and epilepsy. The dislocated cap, which was also folded in half, was refloated, profusely irrigated, and ironed to eliminate flap wrinkles. Particular care was taken to avoid flap misalignment. Despite the above mentioned intervention, a prominent epithelial mark corresponding to the line of previous folding persisted for 3 additional days. Eventually, a perfectly aligned lenticule without wrinkles and an otherwise normal postoperative course occurred. Although superior hinge LASIK may reduce the likelihood of flap displacement, mechanical forces can generate complete flap dislocation. When a flap has been folded in half, an epithelial mark corresponding to the line of folding may persist. Patients with psychiatric disorders may be at higher risk of postoperative flap-related complications.

Laser In Situ Keratomileusis Flap Stability During Simulated Aircraft Ejection in a Rabbit Model

To determine the stability of the laser in situ keratomileusis (LASIK) flap in a rabbit model when subjected to vertical acceleration at nine times the force of gravity (+9 Gz) in an aircraft cockpit ejection simulator. Thirty-six eyes from 25 New Zealand white rabbits underwent LASIK flap creation without laser photoablation. One month after surgery, the rabbits were sedated and harnessed in a cockpit ejection seat simulator used to train United States Air Force pilots. They then underwent a controlled rapid-sequence ejection at +9 Gz. Subsequently, the rabbits were euthanized and the corneas harvested for microscopic examination. Refractive measurements and corneal examination were made before LASIK flap creation and prior to and after the +9 Gz ejections. Determination of LASIK flap dislocation was based on clinical observation of flap slippage or a significant shift in pre-ejection to postejection cylinder axis. The average preoperative refraction of the rabbit eye was +1.83 D + 3.25 D x 086 degrees. The average change from pre-ejection to postejection was 0.04 D sphere, 0.02 D cylinder, 6.8 axis degrees, and 0.04 D spherical equivalent. The pre-ejection to postejection measurements were not statistically significantly different by a paired test. Laser in situ keratomileusis flap dislocation or ejection-induced corneal folds or striae were not clinically observed. Histologic examination revealed well-healed LASIK flaps but no reactive keratocytes at the central stromal-stromal interface. Healed LASIK flaps as created in this rabbit model without laser ablation are stable when subjected to a rapid vertical ejection at nine times the force of gravity.

Accidental self-removal of a flap—a rare complication of laser in situ keratomileusis surgery

PURPOSE: To report a rare complication in which the patient accidentally removed the laser in situ keratomileusis corneal flap. METHODS: Interventional case report. A 35-year-old woman underwent uncomplicated laser in situ keratomileusis surgery. Ten days after surgery, she inserted a soft contact lens into the right eye to improve her vision. She tried to remove the contact lens, but had pain and bleeding. She was referred 10 days later with a diagnosis of loss of flap. RESULTS: On examination, she had a best-corrected visual acuity of 20/70 in the right eye. The right eye examination revealed no corneal flap, mild corneal edema, and significant haze. A central epithelial defect was found. CONCLUSION: Accidental corneal flap removal can rarely follow laser in situ keratomileusis surgery. This complication provides insight into the weak adhesion of the flap onto the stromal bed after laser in situ keratomileusis surgery and, hence, the inherent risk of traumatic flap dislocation or amputation, which needs to be explained to the patient.

The adverse effect of perioperative brimonidine tartrate 0.2% on flap adherence and enhancement rates in laser in situ keratomileusis patients.

To investigate the effect of perioperative brimonidine tartrate 0.2% on postoperative flap adherence and enhancement rates in patients undergoing laser in situ keratomileusis (LASIK). Noncomparative interventional case series. Records of 279 eyes of 144 consecutive patients who underwent LASIK between June 17, 1999, and March 1, 2000, were retrospectively reviewed. From September 28, 1999, to November 4, 1999, 39 eyes of 20 consecutive patients had a single drop of brimonidine tartrate 0.2% instilled into their operative eye(s) before LASIK. This group was interposed in time between two nonbrimonidine groups, one before the use of brimonidine, "prior nonbrimonidine group" (107 eyes of 56 patients), and one after the use of brimonidine, "post nonbrimonidine group" (133 eyes of 68 patients). All 279 eyes in the study were examined after surgery to identify flap folds and dislocations. Enhancement rates and visual outcomes for the brimonidine and nonbrimonidine groups were also documented. Comparison of the incidence of abnormal flap appearance and enhancement rates between the brimonidine and the nonbrimonidine groups. In the brimonidine treated group, 6 of 39 eyes (15.4%) had an abnormal flap appearance after LASIK, although no flap folds or dislocations were noted in the nonbrimonidine groups. The difference in incidence of abnormal flap appearance between the brimonidine group and the prior and post nonbrimonidine groups was statistically significant (P = 0.0008 and P = 0.0003, respectively). When the prior and post nonbrimonidine groups were combined and compared with the brimonidine group, the difference in flap adherence was highly statistically significant (P = 0.00001). The enhancement rate was significantly higher in the brimonidine group at 36% compared with 14% in the prior nonbrimonidine group (P = 0.01) and 9% in the post nonbrimonidine group (P = 0.0004). The mean 3-month postoperative spherical equivalent was significantly greater at -0.88 diopters (D) in the brimonidine group compared with -0.24 D (P = 0.0008) and -0.15 D (P = 0.0001) in the prior nonbrimonidine and post nonbrimonidine groups, respectively. In this study, when perioperative topical brimonidine was used in LASIK patients, an increase in the incidence of abnormal flap adherence and an increase in enhancement rates was observed.