Epithelial ingrowth following laser in situ keratomileusis (LASIK): prevalence, risk factors, management and visual outcomes

Abstract

The number of laser in situ keratomileusis (LASIK) procedures is continuing to rise. Since its first application for correcting simple refractive errors over 25 years ago, the role of LASIK has extended to treat other conditions, including postkeratoplasty astigmatism/ametropia, postcataract surgery refractive error and presbyopia, among others. The long-term effectiveness, predictability and safety have been well established by many large studies. However, due to the creation of a potential interface between the flap and the underlying stroma, interface complications such as infectious keratitis, diffuse lamellar keratitis and epithelial ingrowth may occur. Post-LASIK epithelial ingrowth (PLEI) is an uncommon complication that usually arises during the early postoperative period. The reported incidence of PLEI ranged from 0%–3.9% in primary treatment to 10%–20% in retreatment cases. It can cause a wide spectrum of clinical presentations, ranging from asymptomatic interface changes to severe visual impairment and flap melt requiring keratoplasty. PLEI can usually be treated with mechanical debridement of the affected interface; however, additional interventions, such as alcohol, mitomycin C, fibrin glue, ocular hydrogel sealant, neodymium:yttriumaluminum garnet laser and amniotic membrane graft, may be required for recurrent or refractory cases. The aims of this review are to determine the prevalence and risk factors of PLEI; to describe its pathogenesis and clinical features and to summarise the therapeutic armamentarium and the visual outcome of PLEI.

Epithelial ingrowth through venting incision into laser-assisted in situ keratomileusis flap interface after descemet stripping automated endothelial keratoplasty

“… 3 , 4 , 7 Despite being a well-known complication of LASIK (incidence up to 20%), the percent requiring surgical treatment is small after both primary treatment and enhancement (0.92% and 1.7% respectively). 5 , 7 For mild ingrowth, simple observation is recommended. Surgical management of epithelial ingrowth in LASIK typically involves a flap lift, but additional interventions, such as suturing or fibrin glue, may be required, depending upon recurrence.…”

“…Prevention has been recommended as the best way to manage this complication. 3 , 4 , 5 This includes utilizing careful surgical technique. Suggestions include debriding loose donor epithelium, removing epithelium around venting incisions and avoiding excessive intraocular manipulation.…”

“…After epithelial invasion, the cells may regress, remain stable, or progress and proliferate. 4 , 5 A patient with this postoperative complication may be asymptomatic, requiring only observation, or in rare cases, might need surgical treatment to manage its sequelae. 3 , 6 Complications resulting from epithelial ingrowth include growth of opacity into the visual axis, induction of irregular astigmatism, foreign body sensation and flap melt.…”

“…In LASIK, the ingrowth occurs when epithelial cells are introduced intraoperatively or invade postoperatively into the flap-stromal bed interface. 5 In contrast, epithelial ingrowth occurs post EK primarily at the donor graft-host interface and additionally can result in epithelial downgrowth retrocorneally. 3 , 4 Venting incisions have been implicated in a few cases of epithelial invasion post EK and it has been demonstrated in vitro that corneal epithelial cells may migrate deeper into the cornea through such incisions.…”

Management of recalcitrant epithelial ingrowth after laser in situ keratomileusis

“…The prevalence of epithelial ingrowth following primary LASIK is very low, estimated between 0% and 3.9%. [ 1 ] The condition is often treated by surgically lifting the corneal flap and scraping away the unwanted epithelial cells. Unfortunately, epithelial ingrowth can recur after intervention.…”