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Main Issue July 2012

Under Pressure: Managing a Surgical Complication in a Firefighter Candidate

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A 23-year-old patient underwent bilateral ReLEx femtosecond lenticule extraction (flex) in late November 2011 to correct the following refractions: -6.25 -1.00 X 20° in the right eye and -5.75 -2.50 X 0° in the left. His motivation to seek refractive correction was professional, as he wanted to become a firefighter, and one of the requirements is that myopia should not exceed 3.00 D.

The patient’s preoperative exam and topography were normal (Figure 1A and 1B), and his pachymetry was 550 μm. After counseling, he elected ReLEx flex. During the procedure, three femtosecond planes were incised (Figure 1C). First, the posterior surface of the refractive lenticule was created, followed by the anterior surface of the refractive lenticule (ie, flap interface). Last, the flap sidecut was created to join the flap interface to the corneal surface. Then, the flap was lifted and the lenticule extracted. After extraction, the flap was repositioned. No complications occurred during the procedure. For a typical ReLEx flex procedure, the refractive lenticule is 6.5 mm in diameter, has a thickness of 11 μm per 1.00 D of myopia, and is 15 μm on its edge.

TEMPORAL EPITHELIAL DEFECT

One day after surgery, the patient’s UCVA was limited to 6/10 and 8/10 in his right and left eyes, respectively, and he complained that both eyes were painful. He had visible conjunctival hyperemia, and biomicroscopy showed a large temporal epithelial defect, 6 mm long and 3.2 mm wide, in his right eye (Figure 2A). There were also signs of interface infiltration or flap edema (Figures 2B and 2C). In the left eye, a small nasal epithelial defect was seen with a few nodules (Figure 3).

Bilateral cleaning of the interfaces with dexamethasone and gentamicin sulfate was completed. The patient was hospitalized for treatment with ticarcillin, gentamicin, and vancomycin (TGV) drops hourly and dexamethasone six times daily. Conjunctival and interface samples were obtained, and bacterial, mycologic, and virologic analyses were performed.

On postoperative day 3, the appearance of the corneas and the interfaces was stable, and interface cleaning was repeated.

On day 4, the epithelial defect was smaller, the left corneal epithelium was almost healed, and the patient was feeling less pain. The diagnosis leaned toward a severe diffuse lamellar keratitis (stage 3) rather than an infection, as the samples were negative except for the presence of few beta lactamase-negative Staphylococcus capitis. Treatment with TGV drops was stopped, and treatment with a fluoroquinolone antibiotic was continued, along with dexamethasone drops eight times a day and oral prednisone 20 mg for 4 days.

Over the next 2 days, the appearance of the interface and the flap improved quickly, and UCVA improved to 6/10 and 9/10 in the right and left eyes, respectively (Figure 4). The patient was discharged from the hospital on day 8 and remained on prednisolone, which was tapered between days 8 and 14. The patient also took dexamethasone drops six times a day.

FOLLOW-UP

The patient returned on day 14 for further follow-up. At this time, UCVA in the right eye was 6/10 and BCVA was 10/10 with correction of 1.00 -0.50 X 20°. In the left eye, UCVA was 6/10 and BCVA was 10/10. Additionally, the epithelium healed in both eyes, and the flaps and the interfaces were clear. Only a slight nebula remained underneath the epithelial defect in the right eye. Dexamethasone drops were stopped on day 15.

At 3 months, the patient returned for another follow-up and reported no additional side effects. The visual acuities were the same as on day 14, and the corneal biomicroscopy exam was stable (Figure 5). The patient passed the firefighter’s medical exam.

Cati Albou-Ganem, MD, is a founding member and surgeon at Clinique de la Vision, Paris. Dr. Albou-Ganem states that she is a paid consultant to Carl Zeiss Meditec and PhysIOL. She may be reached at e-mail: cati.ganem@ wanadoo.fr.

Julien Bullet, MD, is a clinical fellow at CHNO QuinzeVingts, Paris. Dr. Bullet states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: julien.bullet@polytechnique.org.

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