Unilateral progressive epitheliopathy after LASIK

Abstract

A 36-year-old man was referred back to our clinic after an uneventful laser in situ keratomileusis (LASIK) surgery 6 months previously, with a chief complaint of declining vision in the left eye for the last several months. His pertinent ocular history prior to the LASIK surgery was significant for episodic left eye irritation and inflammation of the superior part of the left cornea secondary to contact lens-induced keratopathy, according to his optometrist.This was a femtosecond-assisted LASIK surgery using the WaveLight FS200 femtosecond laser (Alcon) with the Allegretto EX500 excimer laser (Alcon) for attempted correction of -4.50 diopter (D) of myopia in both eyes under an 8.8 mm flap with a thickness of 100 m. The uncorrected distance visual acuity (UDVA) was 20/15 in both eyes for the first 2 weeks; at the 1-month follow-up visit, a well-demarcated, wavelike plaque of coarse, thickened corneal epithelium along the superior aspect of the cornea was noted. The UDVA had declined to 20/30 in the left eye. The right eye remained clear with a UDVA of 20/15. The patient was treated for presumed interface inflammation with 1% topical prednisolone acetate for 3 weeks on a tapering regimen and it was noted that there was some improvement in the vision subjectively although the epithelial ridge involving the superior one third of the LASIK flap was present without any change.Over the course of the next 2 months, a progressive decline in vision was noted in the left eye. At no point did his right eye experience symptoms or visual decline. Four months postoperatively the UDVA had declined to 20/60 in the left eye. A linear epithelial ridge extending from limbus at 11 to 2 o'clock position was noted superiorly; staining showed the ridge involved the superior aspect of the flap. The patient was again given corticosteroid treatment, which would improve the symptom of irritation without any change in the visual acuity. Over the course of the next few months, a new wave of abnormal epithelium involving the inferior aspect of the limbus and the flap, encompassing the 2 o'clock position of the flap from the 4 to 6 o'clock positions, was also noted (Figure 1).Figure 1.Slitlamp images of the left eye. Blue arrows indicate the advancing edge of the irregular epithelial ridge.Conjunctival staining using lissamine green and fluorescein dye showed staining of the well-demarcated epithelial ridge superiorly and inferiorly involving the flap encroaching the visual axis. On examination, the patient's corrected distance visual acuity was now 20/80 in the left eye. Figures 2, 3, and 4 show the tomographic, topographic, and optical coherence tomography (OCT) results at the 6-month follow-up post-LASIK surgery.Figure 2.Placido topographic images of the right and left eyes 6 months post-LASIK surgery.Figure 3.Pentacam tomography of the left eye.Figure 4.Optical coherence tomography, pachymetry, and epithelium mapping images of the left eye.Preoperatively the patient denied any ocular history but on further questioning at the 6-month follow-up visit, he provided information about the use of systemic isotretinoin (Accutane) for juvenile acne for 1 year at age 17 and potential exposure to chemicals during military service although he denied any specific ocular exposure. He is a barbeque enthusiast and brews his own alcohol but denies any thermal or direct injury to either eye. His mother had recently told him that he might have had battery acid exposure when he was very young, before age 10, but never required medical attention.What is the most likely diagnosis? What medical or surgical interventions would you recommend for this patient? What is the prognosis for this patient?