Etiology: Abnormal lamellar cut during LASIK flap creation
microkeratome or a femtosecond laser.
Characteristic: Appear as a circular area of irregularity
representing the area of buttonhole. If the flap is lifted, the stromal bed should have a corresponding area of elevation that appears smooth representing the uncut area of cornea where epithelium may still be present. A corresponding divot should be seen on the undersurface of the flap. In femtosecond assisted flap creation, appear as an area of clearing among the advancing raster pattern or a bubble of air within the treatment conecorneal surface interface. The surgeon should stop the flap creation, if possible, prior to the creation of the corneal flap side cuts. Incidence has been noted to be higher in the left (second) eye treated with microkeratome-assisted flaps. Management: Do not perform laser ablation, recut the flap and ablate a minimum of 3 months later
1.2 Free Cap
Usually in LASIK, a hinged corneal flap is created that allows eximer laser to be applied on the exposed stromal bed. If the hinge of the corneal flap detaches, the flap becomes a free flap/cap. The occurrence of this complication is most commonly associated with flat corneas, which predisposes to small flap diameter. Free cap is preventable and treatable. Rarely does the complication lead to severe or permanent decrease in visual acuity.
The incidence of free cap during LASIK is generally low,
ranging from 0.004% to 1.31% depending on the study Management: Perform laser ablation, orient the cap properly and replace it on the bed, allow air-drying for 3-5 minutes.
1.3 Incomplete, short, or irregular flaps
Occur because inadequate suction or microkeratome malfunction. Management: Do not manipulate the flap, do not perform laser ablation, place a bandage contact lens, and recut the flap and ablate at least 3 months later.
1.4 Vertical gas breakthrough
Etiology: Unknown, but a thin flap or a focal break in the Bowman's layer may consider. Occurs during FS laser-assissted flap creation, resulting in escape of gas bubbles from the dissection plane into the subepithelial space. Management: Lift the flap cautiously and perform laser ablation.
1.5 Anterior chamber gas bubbles
Occurs during FS laser-assissted flap creation, resulting in escape of gas bubbles from the dissection plane into the trabecular meshwork then to the anterior chamber. They can interfere with pupillary tracking, but usually are self-limiting and resolve over a short period of time.
2. Postoperative Complications
2.1 Flap fold or Striae
Flap folds may be classified into macro and microstriae. 2.1.1 Macrostriae occur because
Macrostriae are full thickness, rolling stromal folds,
of flap malposition or slippage.
Management: Perform immediate refloating and
repositioning. After 24 hours, need refloating, de-epithelialization, hydration, stroking, and suturing.
2.1.2 Microstriae Microstriae are fine folds in Bowmans layer, occur because of mismatch of flap to new bed and often visually insignificant. if visually suturing.
Management: Observation with aggressive lubrication,
significant perform refloating, stroking, and
2.2 Flap dislocation
Etiology: Excessive lid squeezing, eye rubbing, excessive dry eye, presence of epithelial abrasion, poor intraoperative repositioning, excessive irrigation of flap, and trauma. Prevention: Check adhesion of flap at the end of procedure, remind the patient not to squeeze or rub the eyes and wear the shield for the first 24 hours and every night for the first week. Management: Reposition the flap, suture the flap in the event of persistent fold, and use lubricants.