NEWS & OPINION 40 EWAP DECEMBER 2022 by Anthony Mai, MD, Mike Murri, MD, and Jeff Pettey, MD, MBA Contact information Mai: anthony.mai@hsc.utah.edu Murri: mike.murri@hsc.utah.edu Pettey: jeff.pettey@hsc.utah.edu Review of ‘Effect of time since primary laser-assisted in situ keratomileusis on flap relift success and epithelial ingrowth risk’ L aser-assisted in situ keratomileusis (LASIK) has become the refractive procedure of choice over the past few decades. LASIK enhancements are commonly performed for residual refractive errors, regression, or surgically induced astigmatism.1 Enhancement is done by direct surface ablation, cutting a new flap, or relifting the old flap. Direct surface ablation has increased risk for pain, infection, longer recovery time, and corneal haze.2,3,4,5 Recutting may cause a free cap, button hole, or displaced slivers of stromal tissue.7,8,9 Compared to recutting, relifting may yield fewer complications and better long-term stability of refractive error and visual acuity.7,10 Although flap relifting years after LASIK has been questioned, recent studies show success more than 15 years after the initial procedure.6,11 Nevertheless, relifting can be technically challenging and complicated by epithelial ingrowth (EI).12,13 Prior studies have suggested pre-enhancement time interval, microkeratome use, loose epithelium, and advanced age to be possible post-relifting EI risk factors.14,15,16,17,18 With this current study, Chang et al. seek not only to confirm the viability of flap relifting years after LASIK but also to assess the relationship between relifting success and EI with pre- enhancement time interval, age during relift, sex, and primary LASIK flap creation method. Methods The authors retrospectively reviewed all LASIK relifting enhancement cases performed by one surgeon at the Hong Kong Sanatorium & Hospital between 1997 and 2019. They included data only on the first relift procedure if a patient had multiple. They excluded patients with second flap-related procedures within 75 days of the first relift, less than 75 days of follow-up in the absence of epithelial ingrowth, macular disease, insufficient stromal bed, evidence or suspicion of keratectasia, hypertension, history or risk of retinal vessel occlusion, glaucoma, and other procedures like corneal crosslinking. Their primary outcomes were relifting success, EI development, intraoperative complications, and postoperative corrected distance visual acuity (CDVA). They defined clinically significant EI as distance visual acuity (corrected or uncorrected) loss, foreign body sensation, keratolysis, epithelial irregularity, or flap revision desired by either the surgeon or the patient. The study performed statistical analysis with R, especially using binary logistic regression to evaluate the association between relifting success and EI with pre-enhancement time interval, age during relift, sex, and primary LASIK flap creation method. These associations were presented as odds ratios. The authors described the relifting procedure used in the study. In summary, the previous flap edge was visualized under a slit lamp, anesthetized by 0.5% proparacaine, and initially lifted by a 25-gauge needle bent 2 mm from the tip that extended 1.5 mm inward. The needle created a 2–3 mm long flap lift that was pressed back on the stromal bed. The Seibel II IntraLase flap lifter and retreatment spatula short end extended the incision along the old flap’s circumference, after which the long end lifted the flap. The stromal bed was then treated by an excimer laser and scrubbed by a Merocel sponge. A feeding tube connected to suction removed residual fluid under the flap, and a bandage contact lens was placed. Results The authors included 73 eyes from 68 patients. The mean follow-up periods were 4.3±4.7 years. The mean time interval between LASIK and relift was This article originally appeared in the September 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
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