We noticed you’re blocking ads

Thanks for visiting CRSTG | Europe Edition. Our advertisers are important supporters of this site, and content cannot be accessed if ad-blocking software is activated.

In order to avoid adverse performance issues with this site, please white list https://crstodayeurope.com in your ad blocker then refresh this page.

Need help? Click here for instructions.

Up Front | Jul 2008

Struck With an Action Figure: Patient Experienced Significant Eye Pain

Proper surgical care usually provides excellent visual outcomes after a traumatic LASIK flap injury.

Traumatic flap injuries have been reported after LASIK, but thankfully they are a rare occurrence.1-4 When these injuries transpire, the visual results of surgical repair are good—even when there is a delay in seeking care.5

CASE PRESENTATION
In May, a 32-year-old man visited a local ophthalmologist for a corneal abrasion. He reported being struck in the eye with his child's Aquaman action figure (Figure 1) and was in significant eye pain. The patient failed to report a history of previous refractive surgery, and he was prescribed topical antibiotics and advised to return the next day—but he never did. The same patient arrived in my office approximately 1 month after the injury.

On exam, his vision was 6/18 with no improvement on refraction. Slit-lamp exam revealed a clump of tissue inferiorly (Figure 2). Upon questioning, the patient revealed that he had had LASIK approximately 5 years ago in South America. The anterior topography image (Figure 3) showed severe asymmetry with an inferior bulge, and slit-lamp examination in retroillumination revealed the flap injury. In retrospect, the plastic edge of the action figure appeared to have sliced the flap and folded the edge of the torn flap underneath the remaining flap.

HOW WOULD YOU PROCEED?
In my opinion, there were three possible solutions to reposition the flap: (1) place sutures to secure the partially torn flap, (2) use fibrin glue to secure the partially torn flap, or (3) directly reposition the partially torn flap and place a bandage contact lens.

If this were your patient, how would you proceed?

HOW I PROCEEDED
The patient elected to undergo surgical repair. Under the microscope, I placed dilute alcohol on the cornea for 30 seconds via a round, 8-mm sponge. I carefully removed the epithelium from the bare stromal bed from over the bulge using a hockey-stick spatula.

With the epithelium removed, it was obvious that the torn piece of flap was tucked under the remaining flap edge. In that area, I lifted the flap and unfolded and repositioned the torn piece of flap. I removed and identified all epithelium on both sides of the torn flap, thus minimizing the risk of epithelial ingrowth. After allowing the flap to dry in place, it appeared that the partially torn flap would remain in position without placing flap sutures or using fibrin glue. I placed an Acuvue Oasys (Vistakon, Jacksonville, Florida) bandage contact lens, followed by drops of Zymar (gatifloxacin), Pred Forte (prednisolone acetate), and Acular LS (ketorolac tromethamine) (all manufactured by Allergan, Inc., Irvine, California). The patient was instructed to sit in the waiting room for 1 hour. Once I determined that the flap remained in the proper position, I placed a shield over the eye and prescribed the same three medications to be used four times daily.

FOLLOW-UP
The following morning, the bandage contact lens was still in place, and the repositioned flap remained in the proper position. On postop day 6, the patient's UCVA was 6/12, and the cornea had reepithelialized (Figure 4), so I removed the bandage contact lens. Refraction improved the vision to 6/7.5. Topography also dramatically improved (Figure 5). The patient was, of course, pleased with his early visual results; however, I advised him that there was still a risk of epithelial ingrowth. He will be expected to return several times over the next few months.

WHAT HAVE I LEARNED FROM THIS CASE?
This is the second traumatic LASIK flap injury I have cared for over the past 10 years in my practice. The first patient was struck in the central cornea with her 2-year-old's plastic fork. Thankfully, the puncture wound in that instance did not dislocate the flap, and she regained 6/6 UCVA despite a tiny central corneal scar.

Although these cases are anecdotal, a surgeon might consider reminding his patients with young children to be cautious of unpredictable actions that may occur when young children hold an object with sharp edges. In the significant majority of cases, appropriate surgical care can provide excellent visual outcomes following traumatic injuries to LASIK flaps.

William B. Trattler, MD, is a corneal specialist at the Center for Excellence in Eye Care, Miami, and a volunteer Assistant Professor of Ophthalmology at the Bascom Palmer Eye Institute. Dr. Trattler states that he is a consultant to and on the speaker's bureau for Allergan, Inc. He also receives research support from Allergan. may be reached at tel: +1 305 598 2020; e-mail: wtrattler@earthlink.net.

NEXT IN THIS ISSUE