s COMPLEX CASE MANAGEMENT AFTER LASIK CORNEAL FLAP REMOVAL What is the next step for a patient who has become intolerant and desires better visual acuity?

BY MARK KONTOS, MD; MITCHELL A. JACKSON, MD; AND KARL G. STONECIPHER, MD

CASE PRESENTATION A 53-year-old woman who desires improved visual acuity is referred to you. The patient received hyperopic LASIK 3 years ago. Her operative records are unobtainable, however, so her preoperative parameters are unknown. She subsequently developed severe epithelial ingrowth and flap necrosis in her right . The patient underwent multiple surgical interventions by several physicians, including the primary surgeon. Ultimately, the corneal flap was removed, followed by amniotic membrane placement. The eye has re-epithelialized. The patient’s UCVA measures 20/200 OD, and a manifest refraction of -12.25 +0.75 X 090º yields a BCVA of 20/60. With a scleral contact lens in place, Figure 1. The OPD-Scan III (Nidek) shows severe central corneal steepening. the patient’s BCVA improves to 20/40, with glare testing of 20/70. The slit-lamp examination is significant for mild corneal haze and 1+ to 2+ nuclear sclerosis. A B C A central pachymetry reading is 402 µm (Figures 1 and 2). Meibomian gland dysfunction (MGD) has reduced the patient’s contact lens wear to 1 to 2 hours per day. She has received maximum pharmaceutical and systemic

intervention, and she has s undergone two treatments WATCH IT NOW D E with the LipiFlow Thermal Pulsation System (Johnson & Johnson Vision) without improvement. How would you proceed? Figure 2. Corneal topography prior to flap removal (A), after flap removal (B), and 8 months after flap removal (C). The difference map comparing Figure 1A with Figure 1B shows severe steepening of the (D), whereas the difference map —Case prepared by comparing Figure 1B with Figure 1C does not (E). Karl G. Stonecipher, MD BIT.LY/STONECIPHER2318

cornea and (2) the difficult IOL power corneal steepening is either the result calculation. It would be nice to know of the primary LASIK procedure or of the patient’s preoperative degree of abnormal healing. hyperopia. Is the eye stable from a First, I would address the abnormal refractive and topographic standpoint? shape and potential instability of the MARK KONTOS, MD It would also be helpful to know the cornea. I would recommend CXL status of the contralateral eye. Usually, to stop any potential progressive This is a very challenging case for flap amputation does not induce steepening of the cornea, followed two reasons: (1) the possibly unstable much refractive change, so the severe by careful topography-guided PRK

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to reduce the irregular contour and The pachymetry reading of 402 µm and numerous interventions had central steepening. More than one PRK might make a postoperative LASIK failed to resolve her problems. To my treatment might be necessary. enhancement problematic. My first mind, this case exemplifies the nega- Once the cornea had stabilized step would therefore be to remove tive effects of undertreated MGD on and the irregular had the nuclear sclerotic cataract, which LASIK outcomes. The corneal steepen- decreased, I would observe the patient would provide a refractive solution to ing induced by the hyperopic LASIK for at least 6 months while continu- the patient’s ametropia and should procedure exacerbated her preexisting ing aggressive treatment of the ocular improve her visual acuity. The chal- evaporative dry eye disease. The cor- surface. After corneal stabilization, lenge lies in selecting the IOL. neal melting and epithelial ingrowth the patient could undergo surgery In patients who have undergone were directly related to peripheral for the 2+ nuclear sclerotic cataract. hyperopic LASIK, I typically favor the marginal keratitis postoperatively. An irregular cornea and higher-order zero-aberration MX-60 IOL (Bausch Flap removal after LASIK is a aberrations make her a poor candidate + Lomb). I would target -0.75 to straightforward procedure. I observed for a multifocal lens. Typically, a nona- -1.00 D of myopia. In addition to the patient for more than 9 months spheric monofocal or accommodating corneal topography, I would use all until the cornea stabilized. She was IOL maximizes quality of vision after available online calculators and intra- able to wear a scleral contact lens with hyperopic LASIK. Given this patient’s operative aberrometry to assist my success, but the cataract progressed. complicated refractive status, intraop- choice of IOL power. Although I would Her visual acuity declined, and her erative aberrometry could be helpful plan to perform cataract extraction in contact lens wear time decreased in determining the most appropriate my standard manner, I would carefully despite aggressive intervention for IOL power, but obtaining accurate mark the cornea preoperatively in case MGD, including intense pulsed light readings with the ORA System (Alcon) an intraoperative refractive surprise therapy, low-level light therapy, and might prove difficult in this case. required me to change my choice LipiFlow treatment. Preoperatively, I would counsel the of IOL. Corneal astigmatism cur- The patient and I decided to proceed patient about her potential need for rently measures 1.27 D, but that could with cataract surgery. Preoperative glasses or contact lenses after surgery. change after the lens is removed. I testing was extensive to assist with IOL I would also inform her that she might would be prepared in case intraopera- selection. I assessed corneal curvature require an IOL exchange and/or fur- tive aberrometry proved challenging. using the Holladay software on the ther corneal refractive surgery. Prior to surgery, I would thoroughly Pentacam (Oculus Optikgeräte) and discuss possible postoperative out- studied corneal maps obtained with comes with the patient. If I encounter a the OPD-Scan III. I used the Lenstar refractive surprise, for instance, I would LS900 (Haag-Streit), IOLMaster (Carl be inclined to consider a laser enhance- Zeiss Meditec), and ultrasound mea- ment with CXL. I would also inform surements to obtain weighted aver- the patient that reducing her refractive ages of the IOL power calculations. error closer to emmetropia will give her I supplemented those readings with MITCHELL A. JACKSON, MD more options as far as contact lenses. results obtained from the ASCRS online software for hyperopia, the Barrett for- I have amputated two flaps after mula, and the Haigis formula for post- LASIK to manage severe epithelial operative hyperopic LASIK. ingrowth that was unresponsive to (Continued on page 34) standard management. Removing the flap did not induce a severe refractive s WATCH IT NOW change in either case, so I presume the alteration here is related instead to the WHAT I DID: hyperopic treatment. Details on the KARL G. STONECIPHER, MD patient’s treatment prior to the origi- nal LASIK surgery would be helpful. Many patients are referred to me Key to management in this case for refractive surgery complications, is achieving corneal stability. CXL is but this case represents one of the an option, but I am not sure how greatest challenges I have faced after much stability it would provide to LASIK. Many excellent surgeons had the eye of a 53-year-old woman.1 already seen and treated the patient, BIT.LY/STONECIPHER318

MARCH 2018 | CATARACT & REFRACTIVE SURGERY TODAY 31 s REFRACTIVE SURGERY COMPLEX CASE MANAGEMENT SECTION EDITOR KARL G. STONECIPHER, MD “THIS CASE EXEMPLIFIES THE NEGATIVE n Clinical Associate Professor of , University of North Carolina, Chapel Hill EFFECTS OF UNDERTREATED MEIBOMIAN GLAND n Director of Refractive Surgery, TLC, Greensboro, North Carolina n CRST Executive Advisor DYSFUNCTION ON LASIK OUTCOMES.” n [email protected] —KARL G. STONECIPHER, MD- n Financial disclosure: None MITCHELL A. JACKSON, MD (Continued from page 31) lens when she wants to see her best n Founder and CEO, Jacksoneye, Lake Villa, Illinois After presoftening the lens and because she finds that it improves the n Member, CRST Editorial Board performing the with a quality of her vision. The patient has n [email protected]; @djmjspin femtosecond laser, I used a blade to since undergone cataract surgery on n Financial disclosure: Consultant (Bausch + Lomb) manually create an on-axis incision. her left eye. She manages her evapora- Intraoperatively, I used the ORA tive dry eye disease with cyclosporine MARK KONTOS, MD System statically and dynamically. ophthalmic emulsion 0.05% (Restasis; n Senior Partner, Empire Eye Physicians, Spokane, Cataract surgery was uneventful. Allergan) and lid hygiene (Avenova; Washington Postoperatively, the patient has NovaBay Pharmaceuticals) twice n CRST Executive Advisor a UCVA of 20/25, and her manifest per day. n n [email protected] n Financial disclosure: Consultant (Allergan, Carl Zeiss refraction is essentially plano. 1. Koller T, Mrochen M, Seiler T. Complication and failure rates after corneal Nevertheless, she wears a contact crosslinking. J Cataract Refract Surg. 2009;35(8):1358-1362. Meditec, Johnson & Johnson Vision, Shire, Sun Pharma)

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