Bilateral Retina Detachment After Laser In Situ Keratomileusis- Case Report Saba Al-Rashaed, MD, Emad Abboud, MD, Hassan Dhibi, MD King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia

Abstract Purpose. We report a case of bilateral retinal detachment after laser in situ keratomileusis Case. A 37-year-old male with refractive error of -8.00– 1.00x 85 degrees in right eye and-8.00 –0.25 x 95 degrees in left eye underwent LASIK. The uncorrected visual acuity improved postoperatively and the patient was satisfied. Six months later, he complained of a sudden loss of vision in the left eye secondary to rhegmatogenous retinal detachment with large horse-shoe tear which was managed by vitrectomy, per fluorocarbon/air exchange, 15% C3F8 injection and scleral buckle. The retina was attached post operatively. Five months later he presented with sudden visual loss in the right eye secondary to giant retinal tear retinal detachment; he underwent the same procedure as in left eye. The retina was flat postoperatively for 4 months then he developed a recurrent retinal detachment in the same eye (right eye) with new break and accelerated cataract; he underwent vitrectomy, air-fluid exchange, 15% C3F8 OD OD OS injection and phacoemulsification with posterior chamber intraocular lens implantation. Figure 1. Flat retina after surgery in both eyes. Notice the flat giant retinal tear in right eye. The retina reattached with follow up period of 20 months. Conclusion. Bilateral rhegmatogenous retinal detachment after LASIK for myopia can be a serious complication. Patients should be informed about the possibility of this complication. Background Laser in situ keratomileusis (LASIK) is a refractive surgical procedure for the correction of myopia. It combines lifting a corneal flap with a microkeratome and refractive photocoagulation on the stroma bed by means of a 193-nm argon fluoride eximer laser1. This procedure has become one of the most popular options for correction of low2,3 to high myopia4,5 Complications including undercorrection, overcorrection, flap displacement, epithelial ingrowth, flap melting, keratitis, corneal scleral perforation, irregular astigmatism, and retinal break. Retinal detachment, retinal hemorrhage, 6-22 choroidal neovascular membrane and macular holes have also been reported. OD OS We report one case of bilateral retinal detachment after LASIK and to the best of our Figure 2. Pseudophakia in both eyes with post subcapsular opacification in right eye. knowledge this is the first case to be reported in KKESH. Previous reports of post LASIK retinal detachments and possible related mechanisms were also reviewed.

Case Report A 37 years old man presents to the King Khaled Eye Specialist Hospital for LASIK The basic LASIK procedure is based on creating a lamellar corneal flap in which must be made to allow intrastromal ablation by 1 surgery to correct his refractive error. Visual acuity without correction was 5/200 and excimer laser and in order to obtain a consistent and optimal thickness; the cornea is stabilized by a suction ring behind the limbus that sucks the anterior segment into a vacuum device firming the cornea. The following sequences of events might hypothetically occur 8/200 in right eye and the left eye respectively; he pin holed to 20/40 in both eyes. 22 Fundus examination showed myopic flat retina without abnormalities. He underwent during the LASIK . The suction ring induces an increase in intraocular pressure and after that it is suddenly release, the anterior segment is rapidly drawn in a vacuum chamber with its shape changed rapidly, and all structures posterior to the suction ring are also LASIK procedure in both eyes for a refractive error of -8.00S– 1.00C x 85 degrees in compressed and decompressed in sequences. This type of trauma (closed-suction injury) is similar to what happens in closed eye right eye and -8.00S –0.25C x 95 degrees in left eye The procedure was uncomplicated. injury23,24. Mechanisms for development of peripheral breaks and detachments, could be anterior-posterior compression and expansion. The uncorrected visual acuity improved postoperatively to 20/40 in both eyes and the The eye elongates along the anterior-posterior axis and the diameter of the globe may increase. At the same time, because the eye is a patient was satisfied. Six months later, he complained of a sudden loss of vision in the closed system, the eye is constricted in the equatorial plan. As the anterior segment drawn into a vacuum, the lens may be displaced left eye secondary to a macula on rhegmatogenous retinal detachment with a large forward along the anterior hyaloid. This might accelerate vitreous detachment or cause traction at the vitreous base. When the suction horse shoe tear located on the nasal side. The patient was managed by pars plana suddenly is released, decompression leads to a dynamic overshot with equatorial expansion and shorting in the anterior-posterior vitrectomy, perfluorocarbon/air exchange, 15% C3F8 inflation and scleral buckle. At dimension. These events may cause acute vitreoretinal traction at the vitreous base and the posterior pole. Another potential source of the same procedure, the dilated fundus examination of the right eye with scleral damage to the vitreous and retina is from the pulsed energy applied to the cornea. depression showed flat retina with only paving stones degeneration without breaks or On the other hand retinal breaks and detachments could be the natural history of myopic eyes and an expected occurrence regardless of lattice degeneration. The retina remained attached post operatively. Five months later (1 LASIK procedure25. Axial myopia, vitreous modification and peripheral fundus abnormalities in myopic eyes are major factors that 26 27 year post LASIK) he presented with sudden visual loss in his right eye secondary to predispose to RRD . There is a relationship between the severity of myopia and the frequency of RRD. Ogawa &Tanaka analyzed giant retinal tear macula partially off retinal detachment; the location of the break was 1116 RD cases and found that myopia was present in 82.16% in eyes with myopia higher than -15 D; the frequency of RD was 68.6% superotemporal. He had stage 1 proliferative vitreoretinopathy. He underwent the same times higher than in eyes in the hyperopic range. procedure as in the left eye. The retina was flat postoperatively for 4 months then he In our case RRD developed 6 months in one eye after LASIK although dilated fundus examination was done for the patients before the developed a recurrent retinal detachment in the same eye (right eye) with a new small LASIK and did not showed any predisposing lesion. Because of the short interval and absence of predisposing lesion it is probable that inferior break and accelerated cataract, he underwent pars-plana vitrectomy, air-fluid the LASIK has a direct impact on peripheral retina to cause RRD. It was not certain the development of giant retinal tear retinal detachment in the other eye 12 months after LASIK whether it was related to the effect of LASIK. It is more likely related to the late exchange, 15% C3F8 inflation and phacoemulsification with posterior chamber development of posterior vitreous detachment. Arevalo et al15 reported 33 cases of RRD after LASIK; 10 of 33 (30.3%) occurred less intraocular lens implantation. Retina attached with follow up period of 20 months. In than 6 months after LASIK and 20 of 33 (60.6%) occurred I2 months or more after LASIK. The early occurrence of RRD after LASIK the left eye he developed a visually significant cataract for which he underwent suggests a cause-effect relationship. In cases where RRD developed 12 months or more after LASIK a posterior vitreous detachment phacoemulsification with posterior chamber intraocular lens implantation. The may have developed later. In conclusion, although no cause-effect relationship between LASIK and retinal detachment can be proven, follow-up period was 20 months. The visual acuity at the last follow up was 20/70 in this case suggests that LASIK may be associated with retinal detachment. We believe that this fact should be mentioned to the patients in the right eye and 20/30 in the left eye. The retina was flat in both eyes and there was the pre LASIK counseling. The short time between LASIK and RD needs further study to assess the impact of suction ring on the visually significant posterior capsular opacification in the right eye. peripheral retina in myopic eye. Since most of traumatic retinal breaks occurred at time of injury13, it will be reasonable to evaluate the fundus with scleral depression not only before LASIK but one month after the procedure to exclude the direct effect of the procedure on the retinal periphery. Discussion

Laser in situ keratomileusis (LASIK) has become the procedure of choice in the field of References refractive surgery; post operative rhegmatogenous retinal detachment has also begun to 1. Pallikaris IC, Papatzanaki ME, Stathi E. Laser in-situ keratomileusis. Lasers Surg Med. 1990;10:463-468 occur. Little has been reported in the literature regarding retinal detachment after 2. Carr JD, Stulting RD, Sano Y, Thompson KP, Wiley W, Waring GO III. Prospective comparison of single-zone and multizone laser in-situ keratomileusis for the correction of low myopia. Ophthalmology 1998;105:1504-1511 9 3. Salah T, Waring GO III, el Maghraby A, Moadel K, Grimm SB. Excimer laser in-situ keratomileusis under a corneal flap for myopia of 2 to 20 diopters. Am J Ophthalmol 1996;121:143-155 LASIK. Ozdamar et al has reported a case of bilateral retinal detachment associated 4. Pallikaris IG, Siganos DS. Excimer laser in-situ keratomileusis and photorefractive keratectomy for correction of high myopia. J Refract Surg 1994;10:498-510 with giant retinal tear at 2 months after LASIK in a patient with high myopia. 5. Gűell JL, Muller A. Laser in-situ keratomileusis (LASIK) for myopia from -7 to -18 diopters. J Refract Surg 1996;12:222-228 6. Palikaris IG, Paptzanaki ME, Siganos DS: A corneal flap technieque for laser in-situ keratomileusis. Arch Opthalmol 1991, 109:1699-1702 10 Ruiz-Moreno et al reported four retinal detachments (an incidence of 0.25%) in 7. Stulting RD, Carr JD, Thompson KP, et al: Complications of laser in-situ keratomileusis for the correction of myopia. Ophthalmology 1999, 106:13-20 8. Luna JD, Reviglio VE, Juarez CP: Bilateral macular hemorrhage after laser in-situ keratomileusis. Graefes Arch Clin Exp Ophthalmol 1999, 237:611-613 myopic eyes after LASIK and a mean best corrective visual acuity of 20/45 after retinal 9. Ozdamar A, Aras C, Sener B, et al: Bilateral retinal detachment associated with giant retinal tear after laser-assisted in-situ keratomileusis. Retina 1998, 18:176-177 11 surgery. Aras et al described 10 cases of retinal detachments an (incidence of 0.22%) 10. Ruiz-Moreno JM, Peraz Santoja JJ, Alio JL: Retinal detachment in myopic eyes after laser in-situ keratomileusis. Am J Ophthalmol 1999, 128:588-594 12 11. Aras C, Ozdamar A, Karacorlu M, et al: Retinal detachment following laser in-situ keratomileusis. Ophthalmic Surg Lasers 2000, 31:121-125 2 to 9 months after LASIK in patients with myopia between -6 to -17 D. Farah et al 12. Farah ME, Hofling-Lima AL, Nascimento E: Early rhegmatogenous retinal detachment following laser in-situ keratomileusis for high myopia. J Refract Surg, 16:739-743 reported four cases that had early rhegmatogenous retinal detachment within 3 months 13. Arevalo JF, Ramirez E, Suarez E, et al: Incidence of Vitreo-retinal pathologic conditions 24 months after laser-assisted in-situ keratomileusis (LASIK). Ophthalmology 2000, 107:258-262 7 14. Arevalo JF, Ramirez E, Suarez E, et al: Retinal detachments after laser-assisted in-situ keratomileusis (LASIK) for the correction of myopia. Retina 2000, 20:338-341 of LASIK in high myopia. Stulting reported the appearance of one case of retina 15. Arevalo JF, Ramirez E, Suarez E, et al: Retinal detachment in myopic eyes after laser in-situ keratomileusis. J Refract Surg 2002. detachment in 1,062 eyes (0.09%). Arevalo et al13 have reported 2-years follow up of 16. Ruiz-Moreno JM, Alio JL: Incidence of retinal disease following refractive surgery in 9,239 eyes. J Refract Surg 2003, 19:534-547 17. Luna JD, Reviglio VE, Juarez CP: Bilateral macular hemorrhage after laser in-situ keratomileusis. Graefes Arch Clin Exp Ophthalmol 1999, 237:611-613 29,916 eyes after LASIK for the correction of ametropias (myopia and hyperopes). The 18. Ruiz-Moreno JM, Montero J, Alio JL: Lacquer crack information after LASIK. Ophthalmology 2003, 110:1669-1671 incidence at 24 months of vitreoretinal disease in this study was 0.06% including 14 19. Maturi RK, Kitchens JW, Spitzberg DH, et al: Choroidal neovascularization after LASIK. J Refract Surg 2003, 19:463-464 20. Ruiz-Monreno JM, Artola A, Peraz-Santonja JJ, Macular hole in a myopic eye after laser in-situ keratomileusis. J Refract Surg 2002, 18:746-749 rhegmatogenous retinal detachment (RRD). The incidence of RRD after LASIK in 21. Arevalo JF, Mendoza AJ, Velez-Vasquez W, et al: Macular hole after laser in-situ keratomileusis. J Refrat Surg 2004, 20:85 their previous studies ranges between 0.04% and 0.05%13,14. Arevalo et al15 reported on 22. Arevalo JF, Ramirez E, Suarez E, et al: Rhegmatogenous retinal detachment in myopic eyes after laser in-situ keratomileusis. Frequency, characteristics and mechanism. J Cataract Refract Surg 2001, 27:674-680 23. Weidenthal DT, Schepens CL: Peripheral fundus changes associated with ocular contusion. Am J Ophthalmol 1966, 62:465 the characteristic and surgical outcomes of RRD in myopic eyes after LASIK surgery to 24. Benson WE: The effects of blunt trauma o the posterior segment of the eye. Trans Pa Acad Ophthalmol Otolaryngol 1984, 37:26 repair RRD in 33 eyes (mean follow-up period of 14 months after vitroeretinal surgery). 25. Curtin BJ. The Myopias; Basic Science and Clinical Management. Hagerstown, MD, Harper & Row, 1985; 334 26. Wilkinson CP, Rice TA. Michels Retinal Detachment, 2nd ed. St Louis, MO, CV Mosby, 1997;77 A total of 38,823 eyes underwent surgical correction of myopia (mean -6.00D), 33 eyes 27. Ogawa A, Tanaka M. The relationship between refractive errors and retinal detachment – analysis of 1,166 retinal detachment cases. Jpn J Ophthalmol 1988; 32:310-315 (27 patients; frequency 0.08%) developed RRD after LASIK; detachments occurred between 12 days and 60 months (mean 16.3 months) after LASIK. Final best corrected visual acuity (BCVA) of 20/40 or better was obtained in 38.7% of the 31 eyes. Poor BCVA of 20/200 or worse occurred in 22.6% of eyes,45.8% lost two or more lines of King Khaled BCVA after vitroeretinal surgery. The reasons of poor BCVA included the development Eye Specialist of proliferative vitreoretinopathy. Recently Ruiz-Moreno et al16 reported that the incidence of RRD after LASIK was 0.36% the RRD occurred at a mean 24.6 (range 2 Hospital to 61) months after LASIK procedure and all in highly myopic eyes (-8.50—20D). P.O. Box 7191, Riyadh 11462 Kingdom Saudi Arabia There are little hard data to explain the cause-effect relation between LASIK and the (+966-1) 482-1234 x 3777 (O) development of retina breaks and detachments. (+966-1) 482-9311 (F)