SALK IN REFRACTIVE SURGERY INDUCED CORNEAL OPACITY- A VIABLE OPTION Anita Ganger, Radhika Tandon, Murgesan Vanathi Cornea & Ocular Surface Services, Dr R P Centre for Ophthalmic Sciences ALL INDIA INSTITUTE OF MEDICAL SCIENCES, New Delhi , INDIA THE AUTHORS HAVE NO FINANCIAL INTERESTS TO DISCLOSE

SALK IN REFRACTIVE SURGERY INDUCED CORNEAL OPACITY- A VIABLE OPTION BACKGROUND Post LASIK (Laser in situ keratomileusis) traumatic flap displacement is a known possible complication. [1] [1] In 1%-2% of cases approximately it happens in first 24 h after surgery. [2] [2] Whereas, late flap dislocations, occurring more than 1 week after the procedure, have been reported. 1.Lin RT, Maloney RK. Flap complications associated with lamellar refractive surgery. Am J Ophthalmol. 1999;127:129–36. 2.Gimbel HV, Penno EE, van Westenbrugge JA, Ferensowicz M, Furlong MT. Incidence and management of intraoperative and early postoperative complications in 1000 consecutive laserin situ keratomileusis cases. Ophthalmology. 1998;105:1839–47.

CASE REPORT History and Clinical Picture 32 year-old female underwent LASIK 2.5 years back. Presented with gradual painless diminution of vision OD since 5 months after blunt trauma to the right eye in a road traffic accident. LASIK has been done for refractive error of DS both eyes. Unaided visual acuity (VA) of 6/6 in both eyes was documented post LASIK. Patient presented to us with VA of 1/60 and 6/6 in OD and OS respectively.

SLIT LAMP EXAMINATION OD OS Descmet folds with scarring (due to flap dehiscence at the time of accident) Small macular scar over para foveal region post macular edema A faint flap margin (an evidence of previously performed LASIK) The anterior segment was within normal limits and there was absence of any treatable lesion in the fundus Flap dislocation with macrostriae. Preoperative clinical picture of OD

MANAGEMENT As the folds were long standing with scarring, Flap repositioning with interface wash was not an option. Superficial Anterior Lamellar Keratoplasty (SALK) OD done. On ASOCT noted depth of scarring was 154 µm, so dissection till 160 µm has been done. Interface has been cleared with thorough washing to avoid any epithelial ingrowth in future. Donor tissue has been cut by using automated lamellar microkeratome by using microkeratome head of 200 µm. Donor tissue trephined with 8 mm trephine, donor anterior lamella than put on the host dissected area with the help of fibrin glue At the end of surgery bandage contact lens was placed.

Post Operative Care Topical eye drops Moxifloxacin hydrochloride 0.5% TID Prednisolone acetate 1% eyedrops TID Carboxymethylcellulose 0.5% eye drops QID have been prescribed to the patient in OD After 4 days post op bandage contact lens has been removed. Vision of 6/36 was noted in 1 st week post op. Vision of 6/18 was noted in 4 th week post op. No further improvement in vision due to presence of macular scar over para foveal region pre operatively. Post Operative Day 1 after SALK Post Operative Day 14 after SALK

Superficial anterior lamellar keratoplasty is a viable and effective alternative for anterior stromal scars post refractive surgery. Whereas if patient present early prompt treatment with flap lifting, debridement of epithelial ingrowth if any, reposition and sealing of the flap with fibrin glue is the main stay of management with good outcomes. Dr Anita Ganger MD, FAICO Senior Resident Cornea & Ocular Surface Services CONCLUSION SALK IN REFRACTIVE SURGERY INDUCED CORNEAL OPACITY- A VIABLE OPTION