Surgical management of epithelial ingrowth following traumatic lamellar laceration of the cornea: A case report

Andreas Katsimpris; Nafsika Voulgari; Anna Nina Dimitropoulou; Marios Katsimpras; George Kymionis

doi:10.4103/IJO.IJO_2676_22

CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 308-310

Surgical management of epithelial ingrowth following traumatic lamellar laceration of the cornea: A case report

Andreas Katsimpris, Nafsika Voulgari, Anna Nina Dimitropoulou, Marios Katsimpras, George Kymionis
First Ophthalmology Department, “G.Gennimatas” Hospital, National and Kapodistrian University of Athens, Athens, Greece

Date of Submission	12-Oct-2022
Date of Acceptance	03-Jan-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Andreas Katsimpris
First Ophthalmology Department, “G.Gennimatas” Hospital, National and Kapodistrian University of Athens, Leof. Mesogeion 154, Athens
Greece

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2676_22

Abstract

We report a case of epithelial ingrowth (EI) after traumatic corneal lamellar laceration in a 57-year-old woman with a history of corneal trauma on her left eye (LE) 1 month before. On examination, best-corrected visual acuity (BCVA) was counting fingers at 1 m. Slit-lamp biomicroscopy showed a partial thickness corneal laceration with an undisplaced flap with EI within the flap–stroma interface. Since the EI affected the visual axis, we performed mechanical debridement. BCVA of the LE improved to 0.6 at 1 year postoperatively without recurrence of EI and with good flap apposition. We conclude that timely surgical debridement of posttraumatic EI can result in a favorable visual outcome.

Keywords: Corneal laceration, epithelial ingrowth, trauma

How to cite this article:
Katsimpris A, Voulgari N, Dimitropoulou AN, Katsimpras M, Kymionis G. Surgical management of epithelial ingrowth following traumatic lamellar laceration of the cornea: A case report. Indian J Ophthalmol Case Rep 2023;3:308-10

How to cite this URL:
Katsimpris A, Voulgari N, Dimitropoulou AN, Katsimpras M, Kymionis G. Surgical management of epithelial ingrowth following traumatic lamellar laceration of the cornea: A case report. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:308-10. Available from: https://www.ijoreports.in/text.asp?2023/3/2/308/374968

Andreas Katsimpris, Nafsika Voulgari; Equal contribution

Epithelial ingrowth (EI) is a relatively rare complication that occurs following a breach in corneal integrity due to intraocular surgery or penetrating trauma. Corneal nonkeratinized stratified epithelium can migrate through breaks in corneal surface and proliferate over ocular structures, thus compromising vision.^[1]

Proliferation of corneal epithelial cells in the interface between the stromal bed and the corneal flap presents as an infrequent complication of laser in situ keratomileusis (LASIK) surgery, with a prevalence of 0%–3.9% following primary LASIK and increasing to 10%–20% after flap lift for retreatment.^[2] Contrarily, EI in the flap–stroma interface of traumatic corneal lamellar laceration has been described only once in the literature.^[3] Herein, we report a case of EI after corneal traumatic lamellar laceration and its surgical management.

Case Report

A 57-year-old woman presented to our department complaining of photophobia, blurred vision, and foreign body sensation in her left eye (LE). She had a history of trauma to her LE after falling on an aluminum window 1 month before, whereupon the diagnosis of corneal lamellar laceration was made. She was initially treated conservatively with antibiotic eye drops and referred to our department 2 weeks later since her symptoms did not resolve.

Upon presentation, best-corrected visual acuity (BCVA) was 1.0 in her right eye (RE) and counting fingers at 1 m in her LE with S + 1.50 C-6.00 × 140. Intraocular pressure in the LE was 15 mmHg. Slit-lamp biomicroscopy of her LE showed a partial thickness corneal laceration with an undisplaced flap with mild conjunctival congestion and a well-formed anterior chamber. Seidel's test was negative, while fluorescein pooling was observed at the edges of the flap. The traumatic flap was triangular in shape, with a hinge extending nasally from 8 o'clock to 12 o'clock at a distance of 1.5 mm from the limbus and two well-defined edges of 4.5 mm extending toward the center of the cornea [Figure 1]a. The lacerated flap crossed the visual axis. High-magnification slit-lamp examination revealed EI within almost the entire flap–stroma interface and fine, diffuse granular opacities [Figure 1]b without any flap striae or melting. Scheimpflug imaging (Pentacam HR; Oculus, Wetzlar, Germany) revealed high astigmatism in the area of the flap [Figure 2]a. Corneal tomography showed the exact depth of the corneal laceration [Figure 2]b. Funduscopic examination of the LE was within normal limits. Examination of the RE was otherwise normal. Although the lacerated flap was undisplaced, we decided to proceed with surgical debridement of the EI, as it affected the visual axis.

Figure 1: (a) Slit-lamp photography of the left eye showing the hinge (black line) and the edges (dashed white line) of the lacerated corneal flap. (b) On high magnification, epithelial ingrowth and diffuse granular opacities (black arrows) can be seen

Click here to view

Figure 2: (a) Preoperative corneal topography and (b) Scheimpflug imaging at 132° of the left cornea, revealing high astigmatism and the level of the flap–stroma interface. (c) Postoperative corneal topography and (d) Scheimpflug imaging of the left cornea showing good flap apposition 1 year after surgery

Click here to view

Informed consent was obtained from the patient. Under topical anesthesia in the operating room, we performed flap lift using an iris repositor, followed by thorough mechanical debridement of EI in both the stromal bed and the underside of the flap with a cellulose sponge spear. The normal corneal epithelium surrounding the edges of the flap was removed with a 69 Beaver mini-blade, thus letting the flap adhere to the stromal bed before epithelization occurred. The flap–stoma interface was irrigated with sterile water, and the flap was carefully repositioned and realigned without sutures or fibrin glue. Finally, the surface epithelium of the flap was removed and a 15.55-mm hydrophobic bandage contact lens was placed to protect the flap from dislocation. Consideration was given to avoid any intraoperative trauma to the flap [Video 1][Additional file 1].

The procedure was uncomplicated. Postoperative treatment of the LE included topical antibiotic for 2 weeks. On day 1 postoperatively, the flap was well apposed and aligned, without any folds. Five days postoperatively, re-epithelialization of corneal surface was completed and the bandage contact lens was removed. Examination at week 3 after surgery revealed a small amount of debris in the interface, without recurrence of EI, flap dislocation, or signs of infection [Figure 3]. BCVA improved to 0.6 1 year postoperatively with S + 2.50 C-1.50 × 156 without recurrence of EI, topographic astigmatism of 4 D, and good flap apposition [Figure 2]c and [Figure 2]d.

Figure 3: Slit-lamp photography of the left eye at postoperative week 2 showing debris at the flap–stroma interface

Click here to view

Discussion

In this report, we describe a case of EI following a traumatic corneal lamellar laceration with an undisplaced flap. Traumatic corneal lamellar lacerations are an uncommon type of closed-globe injuries and may be differentiated according to the flap status. In the case of an undisplaced flap, a conservative approach may be adopted. However, a rare complication is the occurrence of EI within the flap–stroma interface, since a potential space for epithelial migration is created. The injury mechanism simulates the mechanical effect of microkeratome on flap creation in LASIK surgery, and the complications are similar to the ones of post-LASIK EI. EI may be asymptomatic or may cause a decrease in visual acuity due to progression into the visual axis, induced astigmatism, or flap melting.

Progressive and sight-threatening post-LASIK EI can be managed with surgical debridement with or without flap suturing or fibrin glue administration.^[4] Since in our case EI affected the visual acuity, we decided to proceed with mechanical debridement and flap repositioning. We did not use any sutures or fibrin glue as flap adherence was considered sufficient intraoperatively.

No EI was observed at the 1-year follow-up. Nevertheless, the recurrence rate of surgically treated posttraumatic EI is not known. We could approximate it to post-LASIK EI recurrence rate, which can reach 36%.^[2] The high recurrence rate should be included in the preoperative patient counseling and requires regular follow-up visits, especially during the first months postoperatively.

To our knowledge, only one case report describes EI following corneal lamellar laceration. Bansal et al.^[3] describe a corneal trauma by an iron wire complicated with EI, with similar clinical presentation and surgical management. Both cases are remarkable for the undisplaced triangular lacerated flap and underline the importance of prompt management to avoid occurrence of EI and subsequent vision impairment.

Conclusion

In conclusion, this report demonstrates that with timely mechanical debridement of posttraumatic EI, a favorable visual outcome can be obtained. More cases are needed with longer follow-up in order to assess the recurrence rate of EI.

Declaration of patient consent

Authors certify that they have obtained all appropriate patients consent form. In the form patient's parents (as patient is minor) have given their consent for patient's images and other clinical information to be reported in the journal. They understand that patient's name and initials will not be published and due effort will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Henry CR, Canto AP, Galor A, Vaddavalli PK, Culbertson WW, Yoo SH. Epithelial ingrowth after LASIK: Clinical characteristics, risk factors, and visual outcomes in patients requiring flap lift. J Refract Surg 2012;28:488-92.
2.	Ting DSJ, Srinivasan S, Danjoux JP: Epithelial ingrowth following laser in situ keratomileusis (LASIK): Prevalence, risk factors, management and visual outcomes. BMJ Open Ophthalmol 2018;3:e000133.
3.	Bansal R, Jain AK, Sukhija J. Epithelial ingrowth within the interface following traumatic corneal lamellar laceration. Ophthalmic Surg Lasers Imaging 2008;39:217-220.
4.	Güell JL, Verdaguer P, Mateu-Figueras G, Elies D, Gris O, Manero F, et al. Epithelial ingrowth after LASIK: Visual and refractive results after cleaning the interface and suturing the lenticule. Cornea 2014;33:1046-50.