Refractive Surgery Complications

Refractive Surgery Complications
SYMPTOMS Symptoms vary depending on complication: Flap buttonhole / free cap - blurry vision, glare, haloes | Overcorrection / undercorrection - blurry vision | Dry eye - dry, pain, discomfort | Diffuse lamellar keratitis (DLK) - blurry vision, pain, photophobia | Epithelial ingrowth - blurry vision. Usually asymptomatic | Ectasia - blurry vision
SIGNS Signs vary depending on complication: Flap buttonhole / free cap - irregular flap, free floating flap | Overcorrection / undercorrection - keratometry/topography may reveal refractive error and irregular corneal shape | Dry eye - corneal punctate keratopathy, sometimes no NaFl stain is present (“pain without stain”) | Diffuse lamellar keratitis (DLK) - infiltrates underneath the corneal flap, usually occurs within a couple days of surgery | Epithelial ingrowth - epithelial cells in between the stroma/flap interface, possible scarring. Rare chance of flap melt | Ectasia - keratometry/topography reveals irregular, asymmetric, ectatic corneal shape and refractive error
WORK-UP Thorough history. Slit lamp examination
Flap buttonhole/free cap requires proper flap placement and a bandage contact lens
Overcorrection/undercorrection may be addressed with glasses and/or contact lenses
Dry eye can be treated with a variety of options (preservative-free artificial tears, hot compresses, omega-3s, etc.)
DLK is treated aggressively with topical steroids (Pred Forte 1% q1-3h) and sometimes topical antibiotics to guard against infection | Rarely is a flap lift and rinse indicated
For epithelial ingrowth, the flap can be lifted and epithelial cells can be scraped if vision is affected and/or there is risk of flap melt
Ectasia can be managed with rigid gas permeable (RGP) or scleral contact lenses | Corneal cross-linking can be considered
FOLLOW-UP Frequent follow-up for most complications other than over- or undercorrection
ETIOLOGY Refractive surgery
PRK complications are often similar to LASIK complications with the exception of flap-related problems | Flap buttonhole usually occurs in steeper corneas, whereas free caps tend to occur in flatter corneas | Lifelong dry eye after LASIK may occur | DLK is commonly referred to as “sands of the Sahara”