Traumatic laser in situ keratomileusis flap dehiscence 17 years after surgery

Dear Editor, Laser in situ keratomileusis (LASIK) is one of the most widely performed refractive surgery techniques used to treat myopia, myopic astigmatism, and hypermetropia because of its safety and predictability.[1] In LASIK, a corneal flap is created, followed by excimer laser ablation to reshape the corneal stroma, thereby correcting the refractive error.[1] Flap creation in LASIK introduces additional intraoperative and postoperative risks compared to superficial ablation techniques such as photorefractive keratectomy.[2] One of the most significant complications is flap dislocation, which is not limited to a specific time frame and can occur weeks to even years after surgery.[3] It is most commonly associated with mechanical injury, either self-induced by the patient or caused by an external source.[3] A 37-year-old female presented in November 2024 with decreased vision, redness, and tearing in her left eye following trauma caused by her baby’s hand 5 h earlier. She had undergone an uneventful bilateral LASIK procedure with a nasal hinge for myopia correction 17 years prior. Her systemic history was unremarkable. On examination, her uncorrected visual acuity was 6/6 in the right eye and 6/18 in the left eye. The intraocular pressure in the both eyes was 14 mmHg, measured with a noncontact tonometer. Slit-lamp evaluation of the right eye showed a well-positioned LASIK flap with a normal anterior segment, whereas the left eye revealed +1 lid edema and +2 conjunctival hyperemia. Corneal examination in the left eye demonstrated inferior-nasal flap dehiscence with the flap inverted from the 6 o’clock to the 8 o’clock position, along with corneal edema around the flap margin and epithelial ingrowth [Figure 1]. No other clinical signs of trauma were noted. Optical coherence tomography was performed. A bandage contact lens (BCL) was applied. She was prescribed moxifloxacin 0.5% eye drops QID, loteprednol etabonate 0.5% eye drops QID, lubricant eye drops 0.5% QID, fluconazole 0.3% eye drops QID, and cyclopentolate 1% eye drops HS.Figure 1: Preoperative slit-lamp photographs of the left eye; (a) Optical section showing flap dehiscence with the flap inverted from the 6 o’clock to the 8 o’clock position, (b) Diffuse illumination view, and (c) Anterior segement optical coherence tomography of the left eye with over appication of bandage contact lensInformed consent was obtained from the patient with explained postsurgical complications include epithelial ingrowth, diffuse lamellar keratitis, and infection. The next morning, she underwent LASIK flap lifting with epithelial scraping and undersurface debris removal. The flap was then repositioned and ironed using balanced salt solution under topical anesthesia in the left eye. BCL was placed and removed after 1 week. Topical steroids, antibiotics, and lubricants were prescribed. At 1 month, her final uncorrected visual acuity was 6/6, with a well-attached flap [Figure 2].Figure 2: Postopertaive slit-lamp photographs of left eye using (a) Optical section, (b) Parallelepiped, and (c) Anterior segement optical coherence tomography demonstrate a well-attached flap one month after flap repositioningLASIK creates a corneal flap that remains a structural weak point because healing in the central interface is minimal to maintain corneal clarity.[2] As a result, the flap can dislocate not only in the early postoperative period, but even many years later, especially after trauma. However, late complications are uncommon. Reported causes include sports injuries, blunt impact, and animal-related accidents.[3] Long-term eye protection is advised for all post-LASIK patients. Late traumatic flap displacement can occur many years after LASIK; however, prompt recognition and emergency management with flap lifting, cleaning, and careful repositioning are essential to prevent the complications such as striae, epithelial ingrowth, infection, or vision distortion. Data availability statement Data will be made available on reasonable request to the corresponding authors. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.