A 60-year-old man developed contact lens intolerance OD and desired laser vision correction to reduce his anisometropia.
His past ocular history was notable for epiretinal membrane removal with subsequent cataract surgery OS. His visual acuity was 20/15 OU with a refraction of -4.00+2.75x15 OD and -0.75+0.50x145 OS.
He underwent uncomplicated LASIK surgery OD. Six months later his uncorrected vision OD was 20/25-1 and his best-corrected acuity was 20/15 with a manifest refraction of plano+1.00x25. He elected to have a LASIK enhancement. Once again, the procedure was uncomplicated and at the 1-month postop visit, his vision was 20/20 with a plano refraction. Slit lamp appearance of the cornea is shown below:
OD
What finding is present?
There is a small area of epithelial ingrowth at the temporal flap edge.
How is this condition treated?
Treatment of epithelial ingrowth depends upon location, size and associated symptoms. Small peripheral areas of epithelial ingrowth that do not affect vision should be observed because they usually regress spontaneously. Careful examination of the peripheral flap edge adjacent to the area of ingrowth is necessary to look for fluorescein staining, which indicates an active communication with the surface epithelium and likelihood that the ingrowth will progress. Larger, more central ingrowth often requires treatment because it may affect vision. Treatment to eradicate the epithelial cells can be performed with laser or by lifting the flap and debriding both interface surfaces (stromal bed and flap undersurface). A suture or ocular sealant can be placed across the flap edge at the original area of ingrowth to prevent a recurrence. Studies have demonstrated that use of a bandage contact lens after LASIK enhancements (with flap lift) increases the risk of epithelial ingrowth.
Additional information:
The area of epithelial ingrowth measured 2 mm x 2 mm and there was no fluorescein staining at the adjacent flap edge. The epithelial cells regressed completely over the next 12 months. The patient’s uncorrected vision remained 20/20 and 15 months later the corneal exam was unchanged. However, he returned 3 months later complaining of seasonal allergies and itchy eyes. On exam there was noted to be a recurrence of the epithelial ingrowth in the same location. There was no staining at the flap edge and the patient denied any eye trauma, although he may have been rubbing his eyes inadvertently in response to his allergy symptoms.
How would you treat the recurrence?
Once again, because of the similar size and peripheral location of the epithelial ingrowth, conservative management (i.e., observation) is recommended.
Follow up:
The recurrent epithelial ingrowth has remained unchanged for the last 5 years. It has not regressed nor has it progressed. The patient’s uncorrected vision is still 20/20 and he has no symptoms.
Discussion:
Recurrent epithelial ingrowth is rare and typically occurs when initial treatment with debridement or laser removal is inadequate or ineffective. This case of spontaneous recurrence was most likely the result of disruption of the LASIK flap edge from microtrauma (eye rubbing). Epithelial ingrowth should be monitored for growth and treated only when progressive or symptomatic.