EyeWorld Asia-Pacific June 2011 Issue

25 EW REFRACTIVE June 2011 Stressing over striae by Maxine Lipner Senior EyeWorld Contributing Editor How one practitioner handled the longest case W hen it comes to flap striae, just because a certain length of time has passed does not mean that patients are out of the woods, according to Roxana Ursea, MD, assistant professor of ophthalmology, and director, cornea and refractive surgery division, University of Arizona, Tucson, Ariz., USA. In the November 2010 issue of the Journal of Refractive Surgery , Dr. Ursea reported on a case of traumatic flap striae, which occurred a record 6 years after LASIK. The case involved a 28-year- old patient who was referred to Dr. Ursea by a colleague. “The patient had trauma and poor vision and was referred to me for evaluation,” Dr. Ursea said. “Seven years prior to his presentation, he had LASIK for myopia and astigmatism— in fact, he was initially seen as a post-trauma patient with microhyphema.” At that point the flap striae were not yet detected. While the patient was put on anti-inflammatory drops and his hyphema cleared up, his vision did not improve much. It was then that the patient was referred for a second opinion to Dr. Ursea, who is a corneal specialist. At that point, Dr. Ursea detected the striae and proceeded to treat these. “Initially I tried a conservative approach with a lot of lubrication,” Dr. Ursea said. “There was no improvement, and after talking to the patient he agreed to have the flap lifted and irrigated and then repositioned.” Dr. Ursea found that she had remarkably little trouble accomplishing this. The patient’s vision then returned to 20/20 (6/6). “Looking back at the literature, it was the longest interval of time after the initial refractive surgery procedure that there was an occurrence of flap striae,” Dr. Ursea said. Smoothing techniques This was one of many different approaches that could have been taken. “There are a lot of approaches that were described before,” Dr. Ursea said. “Some involve using artificial tears, some involve lifting the flap and irrigating with a hyposaline solution.” In some cases a hypothermic spatula is tried. “A spatula is warmed up to try to smooth the striae in the flap,” Dr. Ursea said. Likewise, others use a Caro iron to warm up and smooth the tissue. Yet another tact is repeated stretching followed by smoothing. Dr. Ursea bases her chosen technique on whether or not vision is affected. “I tend to lift the flap and find that it’s better to lift it sooner rather than later if the vision is affected,” she said. “This is better visualized by the red reflex so that when I do a retinoscopy I can actually see the striae—I know that the vision is affected.” Another modality Dr. Ursea sometimes uses is sodium