REFRACTIVE SURGERY COMPLEX CASE MANAGEMENT s HEADLINEPERSISTENT LASIK FLAP INTERFACE FLUID AFTER DSAEK PROCEDURE IOP measurement is key to this case.

BY MARK S. GOROVOY, MD; RICHARD S. HOFFMAN, MD; ROBERT K. MALONEY, MD; AND ALAN N. CARLSON, MD

A

Figure 1. Initial anterior segment OCT (AS-OCT) shows a small gap in the LASIK flap. B A

B

Figure 2. AS-OCT 10 days after the image shown in Figure 1 demonstrates increased Figure 3. After a rebubbling procedure with venting incisions, AS-OCT shows a persistent— fluid in the LASIK flap (A). Slit-lamp photograph taken at the same visit also shows a but smaller—cleft in the LASIK flap (A), and slit-lamp photography reveals a subtle gap in the gap in the LASIK flap (B). LASIK flap (B).

CASE PRESENTATION A 47-year-old black woman with a remote history of LASIK and steroid-responsive The patient’s extensive history included trabeculectomy in both and the advanced in both eyes was referred by the Duke Glaucoma Service to the implantation of a Baerveldt 350-mm2 implant (Johnson & Johnson Vision) in her Service because of corneal decompensation involving her right .1 right eye, with a subsequent exchange for a Baerveldt 250-mm2 implant owing

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4 Ultimately, these Ultimately, 2 —Case prepared by Morgan R. Godin, MD; —Case prepared by Morgan R. Godin, MD; Nicole Fuerst, MD; and Melissa B. Daluvoy, MD A week later, visual acuity in the patient’s right the patient’s right acuity in A week later, visual you proceed? would How In this case, if the IOP has been has IOP the if case, this In problemat patient’s this of Because diffuse lamellar keratitis and treated and keratitis lamellar diffuse only steroids, topical with aggressively nerve optic worsening experience to undiagnosed of because damage the in glaucoma steroid-induced fluid. interface of presence eye remained poor—count fingers at face—and the the at face—and poor—count fingers eye remained Slit-lamp photographs 19 mm Hg. IOP measured glaucoma this time (Figure 3). Topical at were taken lower further restarted in an attempt to therapy was weeks, the patient Over the subsequent the IOP. her own topical glaucoma drops on all discontinued have examinations ocular irritation. Her because of a poor visual acuity (cur been relatively stable, with mm Hg on the low 20s feet), an IOP in rently 200E at 4 cleft. a persistent fluid oral acetazolamide, and would recommend that she undergo she that recommend would My procedure. shunt tube repeat a interven this that be would hope IFS. the resolve to help would tion to allowed is IFS if Unfortunately, will patients many months, for persist flap the in haze permanent develop hydropic keratocyte from interface degeneration. measured centrally, over the area of area the over centrally, measured may IOP actual the fluid, interface to opposed as Hg mm 40 above be be may patient the and Hg, mm 19 well as glaucoma from vision losing cornea. decompensated the from as of presence the in reason, that For measurements IOP all fluid, interface in Tono-Pen a with taken be should result can IFS cornea. peripheral the dysfuncendothelial corneal from elevated from or graft) failed (a tion will reading pressure accurate an IOP; diagnosis. differential the with assist ther glaucoma topical with history ic I high, dangerously is IOP her if apy,

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2,3 RICHARD S. HOFFMAN, MD RICHARD S. HOFFMAN, MD Before assessing the next stepfor next the assessing Before The patient was unable to tolerate topical glau patient The value in eyes with IFS. with eyes in value having as misdiagnosed be can IFS this patient, it would be essential to essential be would it patient, this calculated. was IOP her how learn appla either with IOP Measuring Tono-Pen a or tonometry nation the over Technologies) (Reichert low artificially an yields cornea central to assess the patient’s DSAEK status DSAEK patient’s the assess to IOP the of Normalization accurately. cleft flap LASIK the eliminate should verification allow hope, would I and, after viable was graft DSAEK the that no Under cleared. had cornea the corneal further should circumstances IOP the before performed be surgery normalizes. fluid and collapsing the interface. Acetazolamide the interface. Acetazolamide fluid and collapsing during the pro was administered intravenously with oral cedure, and the patient was sent home acetazolamide 500 mg. 350-mm Baerveldt the Once quadrant. inferior the in weeks, 6 for controlled been had IOP to time ligature tube the allowing possible be then would it dissolve, small cleft of fluid was observed in the LASIK flap observed in the LASIK flap of fluid was small cleft 20/400, acuity measured 1). Visual (Figure interface a mm Hg, suggesting measured 32 the IOP and syndrome (IFS) fluid similar to interface mechanism after LASIK. worsened and the cleft of fluid coma medications, subsequent week (Figure 2). She was the over to The surgeon attempted taken back to the OR. fluid through venting incisions while the drain releasing procedure, rebubbling a air in adding 2018 - - - - - FEBRUARY

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COMPLEX CASE MANAGEMENT MARK S. GOROVOY, MD MARK S. GOROVOY, MD Assuming that the IOP is high, is IOP the that Assuming My recommendation is first to first is recommendation My IFS presents as elevated IOP with IOP elevated as presents IFS A third DSAEK procedure was performed. On post was performed. third DSAEK procedure A The patient underwent a triple procedure underwent a triple procedure patient The to be very high. It would be impera be would It high. very be to IOP elevated the address to tive evalu corneal further pursuing before procedures. or ations a place to be would preference my for a cyclodestructive procedure. cyclodestructive a for reading, IOP accurate an obtain Model the use would I so do to and (Reichert Pneumatonometer 30 IOP the expect would I Technologies). is an example of the former scenario, former the of example an is misdiagnosed likely most was she and primary from suffering as times three three of history Her failure. DSAEK unusu highly is procedures glaucoma shunts of exchange the especially al, explanation shunt’s the finally, and, fluid accumulation in the LASIK flap LASIK the in accumulation fluid IOP low falsely as well as interface failure endothelial Primary readings. edema corneal diffuse causes typically read IOP and fluid, interface without patient this Clearly, accurate. are ings operative day 1, the graft was fully attached, but a attached, but a fully operative day 1, the graft was keratoplasty (DSAEK). The postoperative course was The postoperative course was keratoplasty (DSAEK). graft second failure. A complicated by primary graft additional after shortly failed but it placed, was tube removal and of consisting laser endocyclophotocoagulation. eye measured 20/400, with a visual potential of a visual potential of with measured 20/400, eye corneal examination prior to on her based 20/40 decompensation. implantation, removal, IOL combining cataract endothelial stripping automated Descemet and to the formation of a large bleb. Upon presentation presentation Upon large bleb. a of to the formation right her the visual acuity in Service, to the Cornea CATARACT & REFRACTIVE SURGERY TODAY

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patients will require full-thickness optic atrophy because of this unrecog- to ascertain whether or not a patient to resolve nized elevated IOP. Figure 3 appears to has ever undergone LASIK. both the stromal haze and any endo- show diffuse microcystic edema, which I would also point out that vit- thelial failure.5 suggests that the true IOP is signifi- reoretinal surgeons who have a low cantly higher than indicated. threshold for debriding the corneal Draining the fluid in this case did epithelium to improve intraopera- not resolve the fluid pocket because it tive visualization are more likely to did not alter the fundamental physi- encounter healing problems owing to ology. This patient needs to have her the LASIK flap. Surface healing may IOP reduced to the lowest possible be slower due to flap innervation and level. An IOP measurement on the relative neurotrophism, and fluid may peripheral cornea will reveal whether collect in the interface because of ROBERT K. MALONEY, MD the pressure in the eye is elevated. If only moderately elevated IOP, which, so, a replacement tube with aggres- as the panel noted, can then be chal- The key features of this case are a sive lowering of the IOP, even at the lenging to measure accurately. n compromised endothelium from a expense of a large bleb, is indicated. 1. Hamilton DR, Manche EE, Rich LF, Maloney RK. Steroid-induced glaucoma DSAEK procedure, fluid collected in With a true IOP of 15 mm Hg or less after laser in situ associated with interface fluid. Ophthalmology. the original LASIK flap interface, an and a somewhat functional DSAEK 2002;109(4):659-665. 2. Dawson DG, Schmack I, Holley GP, Waring GO 3rd, Grossniklaus HE, Edel- IOP apparently in the high normal graft, the interface fluid pocket hauser HF. Interface fluid syndrome in bank after LASIK: range, and a hazy cornea. IFS develops should resolve on its own. causes and pathogenesis. Ophthalmology. 2007;114(10):1848-1859. 3. Randleman JB, Shah RD. LASIK interface complications: etiology, manage- when aqueous crosses the endothe- ment, and outcomes. J Refract Surg. 2012;28(8):575-586. lium and collects in the potential 4. Galal A, Artola A, Belda J, et al. Interface corneal edema secondary to steroid-induced elevation of simulating diffuse lamellar space that is the LASIK flap interface. keratitis. J Refract Surg. 2006;22(5):441-447. Aqueous can cross the endothelium 5. Hoffman RS, Fine IH, Packer M. Persistent interface fluid syndrome. either because elevated IOP drives it J Cataract Refract Surg. 2008;34(8):1405-1408. across or because endothelial com- promise prevents adequate drying SECTION EDITOR ALAN N. CARLSON, MD of the stroma through the normal n Professor of Ophthalmology and Vice Chair, endothelial pump function. This case ALAN N. CARLSON, MD Departmental Development, Duke Eye Center, appears to have features of both Durham, North Carolina mechanisms: the endothelial cell The frequency with which I am n [email protected]; alancarlsonmd.com density is reduced after DSAEK, and seeing late-onset problems with n Financial disclosure: None acknowledged the patient has a history of steroid- LASIK flap interfaces is increasing. induced glaucoma and is presum- Several key features of this case are MARK S. GOROVOY, MD ably still taking steroids because of notable. Most noteworthy is that the n Private practice, Gorovoy MD Eye Specialists, the DSAEK. LASIK flap interface, despite time and Fort Myers, Florida When my colleagues and I origi- healing, apparently remains suscep- n [email protected] nally described IFS,1 we emphasized tible to fluid collection if the IOP is n Financial disclosure: None acknowledged the difficulty of accurately measuring elevated, particularly when there is IOP in patients with this condition. In endothelial compromise. Also worth RICHARD S. HOFFMAN, MD eyes with a fluid pocket, applanation mentioning is that inflammation can n Clinical Associate Professor, Department of tonometry measures the pressure in occur in the interface with trauma or Ophthalmology, Casey Eye Institute, Oregon Health the pocket rather than in the eye itself. surgery, in this case causing late-onset and Science University, Eugene, Oregon Accurately measuring IOP requires the diffuse lamellar keratitis. n Private practice, Drs. Fine, Hoffman & Sims, use of a Tono-Pen on the peripheral I see more of these cases today Eugene, Oregon cornea, outside the area of the fluid than in the past, I believe, because n [email protected] pocket. We reported on eyes that had aging LASIK patients develop prob- n Financial disclosure: None acknowledged IOPs of less than 10 mm Hg when lems requiring surgery—cataracts, measured centrally by applanation glaucoma, and an increased risk ROBERT K. MALONEY, MD tonometry but 35 mm Hg or higher of developing retinal detachment n Director, Maloney Vision Institute, Los Angeles when measured on the peripheral cor- associated with axial myopia. It thus n Member, CRST Editorial Advisory Board nea. Three of the six eyes in our origi- becomes more relevant for cataract, n [email protected] nal report had severe glaucomatous glaucoma, and vitreoretinal surgeons n Financial disclosure: None acknowledged

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