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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 362-364

Spontaneous corneal stromal bed perforation in post-laser-assisted in situ keratomileusis ectasia: A case report


Department of Ophthalmology, College of Medicine, King Saud University, Saudi Arabia

Date of Submission04-Oct-2021
Date of Acceptance24-Nov-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Abdullah Alfawaz
Department of Ophthalmology, College of Medicine, King Saud University, P.O Box 245 Riyadh - 11411
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2565_21

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  Abstract 


A 30-year-old female presented to our emergency room for the first time with reduced vision in her right eye (OD) after gentle rubbing. Her ocular history revealed laser-assisted in situ keratomileusis in both eyes (OU) 10 years back. Five years later, she developed ectasia OU where only the right eye was cross-linked. Both procedures were performed at another center. Isolated corneal stromal bed perforation with severe surrounding stromal thinning was evident. Sole glue application either at the bed or the flap edge was not successful. The patient underwent Penetrating keratoplasty (PKP) with a good outcome.

Keywords: Corneal perforation, hydrops, laser-assisted in situ keratomileusis (LASIK), post LASIK ectasia, sutures and LASIK, traumatic bed perforation


How to cite this article:
Abusayf M, Alfawaz A. Spontaneous corneal stromal bed perforation in post-laser-assisted in situ keratomileusis ectasia: A case report. Indian J Ophthalmol Case Rep 2022;2:362-4

How to cite this URL:
Abusayf M, Alfawaz A. Spontaneous corneal stromal bed perforation in post-laser-assisted in situ keratomileusis ectasia: A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 18];2:362-4. Available from: https://www.ijoreports.in/text.asp?2022/2/2/362/342966



Meticulous preoperative screening is of critical importance before revealed laser-assisted in situ keratomileusis (LASIK) procedure to exclude cases at higher risk of ectasia. Post LASIK ectasia, though rare, remains a serious complication that can be encountered at any point of time after the procedure. Avoiding treating post LASIK ectasia as myopic regression is also crucial. Corneal cross-linking (CXL) is indicated if the patient progresses to prevent severe thinning and related complications such as perforation.[1] Corneal stromal bed perforation related to LASIK has been reported intraoperatively during the stage of excimer ablation.[2] In contrast, postoperative perforation is a rare long-term complication either related to hydrops in the presence of post-LASIK ectasia or secondary to trauma (full thickness or flap sparing).[3],[4],[5] We report a case of post LASIK ectasia presented with stromal bed perforation after minor eye rubbing.


  Case Report Top


A 30-year-old female presented for the first time to our emergency room with an acute decrease in vision OD after gentle eye rubbing. Ten years back, the patient had LASIK OU for high myopia that was complicated five years after by ectasia, where CXL OD was performed. Details of procedures are not available. The visual acuity was hand motion, and the globe was soft. Slit-lamp showed central corneal edema, LASIK flap was in place, interface fluid was evident, and very shallow anterior chamber (AC) with full-thickness bed macro perforation (>2 mm) [Figure 1]a and [Figure 1]b. Seidel's test showed a leak at the nasal gutter. Clinical exam of the other eye showed thin cornea [Figure 1]c. Cornea optical coherence tomography (OCT) is shown in [Figure 2]a and [Figure 2]b. Tomography at presentation [Figure 3]a and [Figure 3]b showed signs of ectasia OS. Cyanoacrylate glue was applied at the nasal gutter and a bandage contact lens. On the next day, the glue fell, and the AC was very shallow. A second attempt using fibrin glue placed under the flap to plug the perforation and at the nasal gutter was tried. However, AC reformation was not achieved. Eventually, an urgent penetrating keratoplasty was needed. We sent the patient's cornea for histopathology. Postoperatively, the globe integrity was restored. Three months after, the uncorrected VA OD improved to 20/60. On consecutive follow-up, the left eye showed progression; hence, CXL was performed.
Figure 1: Slit-lamp photos. (a) Diffuse illumination showing edema localized to the decentered LASIK area (arrowheads pointing to the leak area) OD. (b) Slit over the perforated corneal bed showing full-thickness bed perforation and a very shallow AC with iridocorneal touch, OD. (c) Thin cornea, OS

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Figure 2: Corneal OCT, OD. (a) Horizontal cut (9 to 3 clock hours) and (b) Vertical cut (11 to 5 clock hours) showing interface fluid, full-thickness bed perforation, severe corneal thinning surrounding the perforation and iridocorneal touch. Notice the presence of Bandage contact lens (BCL) (arrowheads)

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Figure 3: Tomography. (a) OD. (b) OS

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  Discussion Top


In the light of the current literature, corneal stromal bed perforation in relation to LASIK can be divided based on occurrence into intraoperative and postoperative. Intraoperative perforation is related to deep excimer laser ablation. This can be seen either in first time LASIK or enhancement.[2] While postoperative perforation is either associated with hydrops or related to trauma,[3],[4],[5] our case represents the first case of isolated stromal bed perforation secondary to eye rubbing.

Risk factors for post-LASIK ectasia include high myopia, residual bed thickness less than 250 mm, forme fruste keratoconus (FFKC), and multiple enhancements. It is worth mentioning that in our case, the only pointing evidence suggesting FFKC rather than post LASIK ectasia is the histopathological features [Figure 4].[6]
Figure 4: Histopathology slide of the corneal flap showing irregular acanthotic regenerating epithelium (black arrow), interrupted Bowman's layer (red arrow), and wavy deformity of the anterior collagenous stroma (arrowheads) (Hematoxylin-eosin, ×400)

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Postoperative perforation presents with a sudden decrease in vision and interface fluid collection. Interface fluid collection can also be seen in multiple clinical scenarios, including corneal decompensation and high IOP secondary to steroids.[3],[4],[5] Low intraocular pressure is seen in case of leak presence. The leak site is usually from the LASIK gutter if the flap was not involved such as in trauma cases.[3],[4],[5] Edematous LASIK flap and descemetocele formation can be seen.[7] Direct visualization of the corneal bed perforation on slit lamp will show thinning of the surrounding stroma secondary to ectasia in addition to shallowing of the anterior chamber. Herniation of the lens cortex to the anterior chamber was encountered in one of the reported cases through the perforated bed.[8] A careful exam of the other eye is vital to detect signs of ectasia. Tomography is a valuable tool to highlight ectasia. OCT is helpful to visualize the interface space, anterior segment structure and follow the initial management in such cases.

Postoperative spontaneous bed perforation secondary to hydrops tends to resist medical treatment and necessitate major surgical intervention. Reported cases were managed with early keratoplasty after failed conservative treatment.[9],[10] While one case was treated with LASIK flap excision, Amniotic membrane (AMT) placement with fibrin glue underneath, replacing the flap with 180° autorotation followed by 8 cardinal sutures.[7] The onset is from 9 to 11 years.[7],[9],[10] Acute hydrops post LASIK without perforation management is discussed thoroughly by Hirayama et al.[5]

Trauma-related bed perforation can be seen as full thickness or flap sparing. Special attention to the posterior part of the corneal wound, in primary repair, is necessary in full thickness perforation cases to prevent communication between the interface and the anterior chamber leading to fluid interface collection postoperatively.[3] Isolated penetrating traumatic bed perforation with anterior chamber foreign body (FB) was reported. After removal, OCT showed evidence of self-sealed tract that involved the bed only. Later the patient developed epithelial ingrowth suggesting the FB travelling tract from the edge to under the flap to the posterior cornea.[4]

Sole glue application is reported for the first time in our case. However, the patient showed no response to different types of glue and eventually PKP was necessary to save the globe.


  Conclusion Top


Careful preoperative assessment is crucial in patients going for LASIK. Eye rubbing should be discouraged, especially in a patient with post LASIK ectasia. Bed perforation in such patients might not respond to a minor intervention like glue, and keratoplasty might be necessary.

Declaration of patient consent

This report does not contain any personal information that could lead to the identification of the patient. Written informed consent for the research was obtained from the patients prior to participation.

Acknowledgements

The authors would like to thank Dr. Hind Alkattan, a pathologist, for providing the micrographs for the case.

The case was presented in the World Ophthalmology Congress 2020 Virtual as part of the oral presentation program.

Financial support and sponsorship

The authors would like to thank the deanship of scientific research in King Saud University (KSU) for funding and supporting this research through the initiative of DRS scholarship support.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chung SH, Chan YI, Eun SL, Soo YC, Kwon YA, Eung KK. Clinical manifestation and pathologic finding of unilateral acute hydrops after bilateral laser in situ keratomileusis. J Cataract Refract Surg 2005;31:1244-8.  Back to cited text no. 1
    
2.
Joo CK, Kim TG. Corneal perforation during laser in situ keratomileusis. J. Cataract Refract Surg 1999;25:1165-7.  Back to cited text no. 2
    
3.
Bushley DM, Holzinger KA, Winkle RK, Le LH, Olkowski JD. Lamellar interface fluid accumulation following traumatic corneal perforation and laser in situ keratomileusis. J Cataract Refract Surg 2005;31:1249-51.  Back to cited text no. 3
    
4.
Maki S, Hou JH. Case report: Penetrating corneal injury under an intact laser-assisted in situ keratomileusis flap. Optom Vis Sci 2018;95:1083-6.  Back to cited text no. 4
    
5.
Hirayama M, Fukui M, Yamaguchi T, Shimazaki J. Management of acute corneal hydrops after laser in situ keratomileusis. J Cataract Refract Surg 2020;46:784-8.  Back to cited text no. 5
    
6.
Argento C, Cosentino MJ, Tytiun A, Rapetti G, Zarate J. Corneal ectasia after laser in situ keratomileusis. J Cataract Refract Surg 2001;27:1440-8.  Back to cited text no. 6
    
7.
Fass ON, John T. Technique manages post-LASIK corneal perforation. Ocular Surgery News U.S. Edition. Healio.com. https://www.healio.com/news/ophthalmology/20120331/technique-manages-post-lasik-corneal-perforation. [Last accessed on 2009 Sep 10].  Back to cited text no. 7
    
8.
Nakamura K, Bissen-Miyajima H, Arai H, Toda I, Hori Y, Shimmura S, et al. Iatrogenic cataract after laser-assisted in situ keratomileusis. Am J Ophthalmol 1999;128:507-9.  Back to cited text no. 8
    
9.
Chen CL, Tai MC, Chen JT, Chen CH, Chang CJ, Lu DW. Acute corneal hydrops with perforation after LASIK-associated keratectasia. Clin Exp Ophthalmol 2007;35:62-5.  Back to cited text no. 9
    
10.
Gupta C, Tanaka TS, Elner VM, Soong HK. Acute hydrops with corneal perforation in post-LASIK ectasia. Cornea 2015;34:99-100.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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