[Traumatic flap dislocation after laser in situ keratomileusis].

PURPOSE: To report our experience in treating cases of flap dislocation caused by trauma after laser in situ keratomileusis (LASIK). PATIENTS AND METHODS: We did a retrospective review of the case records of 16,319 patients (31,655 eyes) who underwent LASIK in Minamiaoyama Eye Clinic. Ten eyes of 9 patients were treated for flap dislocation. Conditions of the trauma occurrence, main findings of the eyes, treatments and clinical results are described. RESULTS: Dislocation occurred during a period of 5 days to 4 years after LASIK. Accidents happened when working, when playing with children or pets, or when fighting. The main findings were folds or microstriae, diffuse lamellar keratitis (DLK), and epithelial ingrowth, including partial splitting of the flap (1 eye) and only a crack in the epithelium of the flap edge (1 eye). Seven flaps were lifted, irrigated and repositioned, and observed after fitting the patients with soft contact lenses. Three flaps were treated with eye drops of hyaluronic acid only, or with systemic steroids, topical steroids, and antibiotics. Uncorrected visual acuity recovered to more than 1.0 in 7 eyes, and best corrected visual acuity (BCVA) was more than 1.0 in all eyes. However, 3 eyes lost one line and 1 eye lost two lines of BCVA. CONCLUSION: Many cases of flap dislocation showed recovery of good visual acuity with adequate and prompt treatment. However, it is possible to leave irregular astigmatism untreated which has a bad effect on visual acuity, depending on the affected part and the seriousness of the injury. The connection between patient and clinic is important for proper and prompt treatment.

Autologous serum eye drops for dry eye after LASIK.

PURPOSE: To evaluate the efficacy of autologous serum eye drops for dry eye after LASIK in a prospective, randomized study. METHODS: Fifty-four eyes of 27 male patients who underwent LASIK were divided into two groups; patients who used autologous serum eye drops and those who used artificial tears postoperatively. Schirmer test with anesthesia, tear break-up time (BUT), and rose bengal and fluorescein staining for the ocular surface were prospectively compared between the groups. All values were also compared before and after surgery (at 1 week [except for Schirmer test], 1 month, 3 months, and 6 months) in each group. RESULTS: Tear BUT was greater in the autologous serum eye drops group than in the artificial tears group at 6 months postoperatively. Rose bengal score was lower in patients using autologous serum eye drops than in patients using artificial tears at 1 month and 3 months postoperatively. No significant difference was noted between patients using autologous serum eye drops and patients using artificial tears in the value of Schirmer test with anesthesia and fluorescein scores. In the autologous serum eye drops group, tear BUT was increased at 3 months after LASIK, rose bengal score was lower at 1 month and 3 months, and fluorescein score was lower at 1 month after LASIK compared to preoperative values, respectively. In the artificial tears group, all values (Schirmer test, tear BUT, rose bengal score, and fluorescein score) showed no differences between before and after LASIK. No differences were noted in the subjective scores for dryness between the autologous serum eye drops and artificial tears groups. CONCLUSIONS: The autologous serum eye drops group showed prolongation of the tear BUT and a reduction in rose bengal staining score.

Comparison of LASIK using the NIDEK EC-5000 optimized aspheric transition zone (OATz) and conventional ablation profile.

PURPOSE: To compare a new ablation algorithm termed the optimized aspheric transition zone (OATz) with the conventional laser ablation profile for correction of myopic astigmatism. METHODS: LASIK using OATz profile #6 or using conventional ablation profile was performed on 98 eyes of 53 patients (OATz #6 group) and 111 eyes of 66 patients (control #6 group), respectively. Further, LASIK using OATz profile #5 or using the conventional ablation profile was performed on 109 eyes of 58 patients (OATz #5 group) and 109 eyes of 75 patients (control #5 group), respectively. The effective optical zone, uncorrected visual acuity, manifest refraction, aberrations, contrast sensitivity, and patient satisfaction at 3 months postoperatively were compared between the OATz #6 and control #6 groups and between the OATz #5 and control #5 groups. RESULTS: The effective optical zones in the OATz #6 group (6.45 +/- 0.29 mm) or OATz #5 group (6.40 +/- 0.21 mm) were significantly larger than those in the control #6 group (6.33 +/- 0.27 mm) or control #5 group (6.26 +/- 0.25 mm) (P < .01), respectively. Uncorrected visual acuity and manifest refraction were similar in all groups. The changes in contrast sensitivity were significant and favored the OATz #6 (P < .01) and OATz #5 groups (P < .05). The patient satisfaction survey found no statistical difference at 3 months postoperatively. CONCLUSIONS: Patients treated with the OATz profiles had better visual quality as measured by contrast sensitivity and also had larger effective optical zones as compared with those treated by the conventional ablation profile.

Tear film lipid layer alterations in allergic conjunctivitis.

PURPOSE: To assess the alterations of the tear film lipid layer and tear functions in patients with seasonal allergic conjunctivitis (SAC) and to compare the results with healthy control subjects. METHODS: Seventy-eight eyes of 39 consecutive patients diagnosed as SAC (mean age 32.6 years; 11 male, 28 female) as well as 20 eyes of 10 healthy control subjects (mean age 32.5 years; 6 male, 4 female) underwent slit-lamp examinations, tear film breakup time measurements (BUT), corneal fluorescein stain scoring, Schirmer test, and tear film lipid layer interferometry. The 2 groups were then compared for the examined parameters. RAST and serum IgE level evaluations were also carried out in the patients to confirm the diagnosis of allergy. RESULTS: The mean BUT was 3.4 +/- 1.5 seconds in patients with SAC compared with the mean value of 12.4 +/- 2.4 seconds in the controls (P < 0.05). There were no significant differences in relation to Schirmer test values between the 2 groups; 78% of the patients with SAC had grade 3 or above dry eye change in tear film lipid layer interferometry, whereas none of the controls had an interferometry grade greater than 3 (grade 1-2 normal; grade 3-4 dry eye; grade 5 severe dry eye). Eyes with SAC had significantly higher tear film lipid layer thickness ranges compared with the control eyes (P < 0.05). CONCLUSION: SAC was associated with advanced tear instability and thickening of the tear film lipid layer. Evaluation of the tear film lipid layer thickness might be useful in the assessment of the extent of dry eye disease and the treatment outcomes in patients with allergy.

Quantitative evaluation of the early changes in ocular surface inflammation following MMC-aided papillary resection in severe allergic patients with corneal complications.

BACKGROUND: Atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC) are chronic inflammatory allergic diseases that are associated with some common conjunctival and corneal complications.1 The clinical corneal manifestations of both entities may include superficial punctate keratitis, macroerosions, corneal ulceration, plaque formation, corneal neovascularization, and lipid infiltration. PURPOSE: To quantitatively evaluate the early ocular surface inflammation before and after mitomycin C (MMC)-aided papillary resection in severe allergy patients with corneal complications. METHODS: Three eyes with VKC and 5 eyes with AKC were included in this study. All eyes had cobblestone-like papillae on the upper tarsal conjunctiva and corneal complications such as corneal ulcers, defect, or erosions that were refractory to conventional treatment of more than 2 weeks. Papillary resection with intraoperative 0.05% MMC application for 5 minutes on the palpebral conjunctiva was carried out in all eyes. Corneal and conjunctival findings were evaluated before and 1 week and 2 weeks after surgery. Brush cytology (BC) and evaluation of tear eosinophilic cationic protein (ECP) levels by radioimmunoassay techniques were performed as well pre- and postoperatively. RESULTS: Corneal and conjunctival complications resolved in all patients within 7 days after resection. Postoperative tear ECP levels decreased significantly with papillary resection (P< 0.05). Concomitant brush cytology showed a significant decrease in the number of eosinophils and neutrophils following papillary resection (P < 0.05). CONCLUSION: MMC-aided papillary resection provided a dramatic decrease in ocular surface inflammation as evidenced by decrease in the number of inflammatory cells as well as tear ECP levels with a rapid improvement of clinical corneal and conjunctival findings.

Collagen-immobilized poly(vinyl alcohol) as an artificial cornea scaffold that supports a stratified corneal epithelium.

The cornea is a transparent tissue of the eye, which is responsible for the refraction of incoming light. Both biological corneal equivalents and synthetic keratoprostheses have been developed to replace donor tissue as a means to restore vision. However, both designs have drawbacks in terms of stability and biocompatibility. Clinically available synthetic devices do not support an intact epithelium, which poses a risk of microbial infection or protrusion of the prosthesis. In the present study, type I collagen was immobilized onto poly(vinyl alcohol) (PVA-COL) as a possible artificial cornea scaffold that can sustain a functional corneal epithelium. Human and rabbit corneal epithelial cells were air-lift cultured with 3T3 feeder fibroblasts to form a stratified epithelial layer on PVA-COL. The epithelial sheet expressed keratin 3/12 differentiation markers, the tight junction protein occludin, and had characteristic microvilli structures on transmission electron microscopy. Functionally, the stratified epithelium contained normal glycogen levels, and an apical tight-junction network was observed to exclude the diffusion of horseradish peroxidase. Furthermore, the epithelium-PVA-COL composite was suturable in the rabbit cornea, suggesting the possibility of using PVA-COL as a biocompatible material for keratoprosthesis.

Tryptase increases proliferative activity of human conjunctival fibroblasts through protease-activated receptor-2.

PURPOSE: Tryptase that is released by mast cell degranulation has recently been thought to play a key role in wound healing in allergic bronchitis. Conjunctival fibroblasts secrete mediators and extracellular matrices that could exacerbate inflammation and papillary formation in allergic conjunctivitis. This study was conducted to investigate the effect of tryptase on the proliferation of conjunctival fibroblasts and studied whether this effect was mediated by protease-activated receptor (PAR)-2. METHODS: Conjunctival fibroblasts were cultured with or without tryptase (0.1 ng/mL to 1.0 microg/mL), and the proliferation rate was assessed after 48 hours. The effects of tryptase inhibitors (leupeptin, benzamidine) and a PAR-2 agonist (SLIGKV) were examined. The existence of PAR-2 mRNA and protein in conjunctival fibroblasts was examined by RT-PCR and Western blot analysis, respectively. The existence of PAR-2 in cultured conjunctival fibroblasts and conjunctival papillae from patients with vernal keratoconjunctivitis, as well as conjunctival tissue from normal subjects was examined by immunohistochemistry. RESULTS: Conjunctival fibroblast proliferation was upregulated by tryptase in a dose-dependent manner (P < 0.001). Leupeptin and benzamidine inhibited tryptase-induced fibroblast proliferation (P < 0.05), and SLIGKV mimicked tryptase's effect. PAR-2 mRNA and protein were detected in cultured conjunctival fibroblasts using RT-PCR and Western blot analysis. PAR-2 immunoreactivity in both the cultured conjunctival fibroblasts and in stromal cells in excised conjunctival tissues was observed. CONCLUSIONS: Tryptase increased conjunctival fibroblast proliferation and this response appeared to be mediated by PAR-2. Mast cells are the most likely source of tryptase in the conjunctiva and may play an important role in chronic exacerbations with conjunctival papillary formation in allergic conjunctivitis.

Ocular integrity after anterior ciliary sclerotomy and scleral ablation by the Er:YAG laser.

PURPOSE: To establish the risk of ocular rupture after proposed surgical reversal of presbyopia by anterior ciliary sclerotomy (ACS) or by the Er:YAG laser (HOYA Continuum, Tokyo, Japan). METHODS: A total of 45 pig eyes (15 control eyes) were examined. Fifteen eyes were placed into one of two study groups and another 15 eyes were used as controls. One group underwent scleral incisions with the use of a diamond knife, and the other group underwent Er:YAG laser scleral incisions. In both study groups, 8 radial incisions, 2 parallel cuts each at 4 quadrants, 2 mm apart, 4 mm long, and starting 2 mm away from the limbus, were made. A 3-kg steel weight was released from a measured height to the pig's eye, and ocular rupture energy (joules) was measured. RESULTS: The mean rupture energy was 26.0 J for control eyes, 15.7 J for the ACS eyes, and 12.2 J for the Er:YAG laser eyes. The ACS and the Er:YAG laser eyes ruptured at significantly lower energies (ACS, P < .001; Er:YAG, P < .001) than the control eyes. Comparison of the ACS group and the Er:YAG laser group showed no statistically significant difference (P = .052) in rupture energy. CONCLUSIONS: Scleral incisions by ACS and the Er:YAG laser significantly weakened ocular integrity compared with control eyes. Any patients undergoing ACS or Er:YAG laser scleral incision should be informed of the attendant potential risk after ocular trauma.

Pupil decentration and iris tilting detected by Orbscan: anatomic variations among healthy subjects and influence on outcomes of laser refractive surgeries.

PURPOSE: To investigate the anatomic variations of entrance pupil decentration and tilting angle of the iris in healthy subjects and the influence of these factors on the outcome of laser in situ keratomileusis (LASIK). SETTING: Minamiaoyama Eye Clinic, Tokyo, Japan. METHODS: The degree of pupil decentration and tilting angle of the iris in 2280 eyes of 1144 myopic patients without abnormal findings by ophthalmologic examination were assessed using Orbscan. Of these, 901 eyes of 467 patients had LASIK. Multiple analysis of variance (ANOVA) was used to determine risk factors for reduction of postoperative best spectacle-corrected visual acuity (BSCVA) considering patient age, refractive power, tilting angle of the iris, pupil decentration, and corneal power. RESULTS: The mean pupil decentration in all eyes was 0.19 mm +/- 0.11 (SD) (range 0 to 0.9 mm); tilting angle of the iris was 4.06 +/- 1.41 degrees (range 0.19 to 12.69 degrees). By multiple ANOVA, refractive power, pupil decentration, and tilting angle of the iris were significant for the reduction of BSCVA. CONCLUSIONS: Some eyes with pupil decentration or tilting angle of the iris could not be detected under typical ophthalmologic examination but only with topographic examination. Attention should be paid to eyes with large pupil decentration and tilting angle of the iris because these may be risk factors for reduction of postoperative BSCVA during corneal refractive surgeries.

Experience with the Artisan phakic intraocular lens in Asian eyes.

PURPOSE: To investigate the efficacy and safety of implantation of an iris-claw phakic intraocular lens (PIOL), Artisan Myopia, in Asian eyes. SETTING: Minamiaoyama Eye Clinic, Tokyo, Japan. METHODS: Forty-four eyes of 32 Japanese patients and 1 Korean patient with high myopia had Artisan Myopia lens implantation to correct their refractive errors. Lens models, 5/8.5 or 6/8.5 (optic diameter/overall diameter), were chosen as standard lens model. A smaller lens model (5/7.5-Artisan Myopia Small) was implanted in eyes with corneal diameter less than 11.0 mm. Postoperative examinations were performed on 1 day, 1 week, 1 month, 3 months, 6 months, 1 year, and 2 years after surgery. Uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), manifest refraction, corneal endothelial cell counts, intraocular pressure, and complications were evaluated. RESULTS: Artisan Myopia Small lenses were implanted in 4 eyes (9.1%) and 8.5 mm diameter lenses were implanted in 40 eyes. Preoperative UCVA (logMAR) improved from 1.57 to 0.09 at 1 month after surgery and no regression was observed thereafter. Postoperative manifest refraction was -1.02 +/- 0.87 D (-3.25 to -0.00 D), and within 1.0 D in 20 eyes (55.6%), within 2.0 D in 32 eyes (88.9%) at 1 month after surgery, and stable during the follow-up period. The final BCVA decreased 2 lines in 2 eyes (4.5%) due to progression of age-related cataract. No serious complications such as angle closure or progressive endothelial cell loss were observed. CONCLUSION: Implantation of an Artisan iris-claw PIOL implantation may be a safe and effective procedure for Asian eyes.

Histopathological findings of epithelial ingrowth after laser in situ keratomileusis.

PURPOSE: To investigate the histopathological features of epithelial ingrowth after laser in situ keratomileusis (LASIK). METHODS: Five epithelial ingrowth specimens of 4 patients (2 to 17 months after initial LASIK) were examined. The lesions were surgically removed and examined using light and transmission electron microscopy. RESULTS: Early epithelial ingrowth was clinically observed as faint opacities with demarcation lines and epithelial pearls. Late epithelial ingrowth was observed as homogeneous whitish masses. Histopathologically, early epithelial ingrowth consisted of multilayered squamous epithelium resembling normal corneal epithelium, whereas late ingrowth was made up of clumps containing amorphous materials with scarce cellular elements. CONCLUSIONS: Our findings suggest that clinical appearance and histopathology of epithelial ingrowth from LASIK flap margins differ in early and late stages, which might reflect proliferative activity of the lesions.

Atopic ocular surface disease: implications on tear function and ocular surface mucins.

PURPOSE: To describe tear function, mucin alterations, and ocular surface disorder in patients with atopic diseases. METHODS: Subjects underwent corneal sensitivity measurements, Schirmer test, tear film break-up time (BUT) assay, and fluorescein and rose Bengal staining of the ocular surface. Conjunctival impression cytology and brush cytology were also conducted. Impression cytology samples underwent PAS and immunohistochemical staining for MUC5AC. Brush cytology specimens underwent evaluation for inflammatory cell expression and RT-PCR for MUC5AC mRNA expression. Differences related to tear function and ocular surface examination parameters among patients with and without corneal ulceration and healthy control subjects were studied. RESULTS: Mean corneal sensitivity and BUT values were significantly lower in atopic patients with corneal ulcers compared with patients without ulcers and controls (P<0.001). Brush cytology specimens from patients with corneal ulcers revealed significantly higher expression of inflammatory cells compared with patients without ulcers and controls (P<0.001). Impression cytology samples from eyes with corneal ulcers showed significant squamous metaplasia and reduction of goblet cell density compared with eyes without ulcers and control subjects. Specimens from eyes with corneal ulcers showed PAS (+) mucin pick up and did not stain positive for MUC5AC. MUC5AC mRNA expression was significantly lower in eyes with corneal ulcers compared with in eyes without ulcers and control subjects. CONCLUSIONS: Ocular surface inflammation, tear film instability, and decreased conjunctival MUC5AC mRNA expression are important in the pathogenesis of noninfectious corneal shield ulcers in atopic ocular surface disease.

Ocular surface and MUC5AC alterations in atopic patients with corneal shield ulcers.

PURPOSE: To describe MUC5AC alterations and the ocular surface disorder in atopic patients with or without corneal ulcers. METHODS: Atopic patients' eyes were divided into two groups according to the presence and absence of corneal ulceration. The subjects underwent corneal sensitivity measurements, Schirmer test, tear film break-up time (BUT), fluorescein and Rose Bengal staining of the ocular surface and conjunctival impression cytology and brush cytology. Impression cytology samples underwent PAS and immunohistochemical staining for MUC5AC. Brush cytology specimens underwent evaluation for inflammatory cell expression and quantitative real-time PCR for MUC5AC mRNA expression. The differences related to the tear function and ocular surface examination parameters between patients with and without corneal ulceration and healthy control subjects were studied. In addition, the differences of the study parameters related to ocular surface epithelial health and inflammatory status between patient eyes with atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC) were investigated. RESULTS: The mean corneal sensitivity and BUT values were significantly lower in atopic patients with corneal ulcers, compared to patients without ulcers and controls (p < 0.001). Brush cytology specimens from patients with corneal ulcers revealed significantly higher expression of inflammatory cells compared to patients without ulcers and controls (p < 0.001). Impression cytology samples from eyes with corneal ulcers showed significant squamous metaplasia and reduction in goblet cell density compared to eyes without ulcers and eyes of control subjects. The mean squamous metaplasia grade was significantly higher in eyes with AKC compared to eyes with VKC (p < 0.02). The mean goblet cell density was significantly lower in eyes with AKC compared to eyes with VKC (p < 0.01). Specimens from eyes with corneal ulcers showed PAS positive mucin pickup and did not stain positive for MUC5AC. MUC5AC mRNA expression was significantly lower in eyes with corneal ulcers compared to eyes without ulcers and eyes of control subjects. MUC5AC mRNA expression was also significantly lower in eyes with AKC compared to eyes with VKC. CONCLUSIONS: Ocular surface inflammation, tear film instability, and decreased conjunctival MUC5AC mRNA expression were thought to be important in the pathogenesis of noninfectious corneal shield ulcers in atopic ocular surface disease.

Laser-assisted in situ keratomileusis for patients with dry eye.

OBJECTIVE: To evaluate the efficacy and safety of laser-assisted in situ keratomileusis (LASIK) in patients with preoperative dry eye. METHODS: We divided the 543 eyes that underwent LASIK into the following 3 groups: eyes with definite dry eye (DE group), with probable dry eye (PDE group), and without dry eye (NDE group). We evaluated visual outcome, dry-eye status, and complications. OUTCOME MEASURES: We compared uncorrected and best-corrected visual acuity, manifest refraction, symptoms, tear function, ocular surface abnormality, complications, corneal sensitivity, endothelial cell count, and patient satisfaction among the groups. RESULTS: We found no significant differences among the groups in uncorrected and best-corrected visual acuity, manifest refraction, and patient satisfaction. A dry-eye symptom, dryness, was more severe in the DE than the NDE group after LASIK. The mean results of the Schirmer test with anesthesia and tear breakup times were significantly lower and the fluorescein score was higher in the DE than the NDE groups after LASIK. We found no differences in the incidence of complications among the groups. Corneal sensitivity was recovered within 6 months after LASIK in the DE and PDE groups and within 3 months in the NDE group. CONCLUSIONS: The efficacy and safety of LASIK were not affected by preexisting dry eye. However, preexisting dry eye is a risk factor for severe postoperative dry eye with lower tear function, more vital staining of the ocular surface, and more severe symptoms.

Epithelial ingrowth after laser in situ keratomileusis: clinical features and possible mechanisms.

PURPOSE: To analyze the incidence, clinical course, and possible mechanisms of epithelial ingrowth after laser in situ keratomileusis (LASIK). DESIGN: Interventional case series. METHODS: Retrospective evaluation of 4,867 eyes of 2,502 patients who had LASIK. The type of microkeratome (LSK-One or MK-2000), corneal flap thickness, and clinical course were analyzed. We also compared the cutting characteristics of both microkeratomes in pig cadaver eyes by scanning electron microscopy. RESULTS: The frequency of epithelial ingrowth was significantly greater in the MK-2000 (34 of 1,680 eyes; 2.0%) than the LSK-One group (30 of 3,187 eyes; 0.94%; P =.001). In 24 eyes (37.5%), blood, cell infiltration, ointment under the corneal flaps, or epithelial defect were detected at the area of epithelial ingrowth postoperatively. The incidence of epithelial ingrowth was correlated with the incidence of epithelial defect during surgery (P <.001) and with incidence of diffuse lamellar keratitis after surgery (P =.003). Flap thickness was thinner in eyes with epithelial ingrowth (126.0 +/- 29.1 microm) compared with flap thickness in eyes without epithelial ingrowth (133.8 +/- 27.3 microm; P <.001). Scanning electron microscopy showed clear differences in the appearance of flap edges created by the two types of microkeratomes. Epithelial ingrowth disappeared or remained unchanged in 54 eyes (90%) and progressed in six cases (10%). CONCLUSIONS: Poor adhesion caused by excessive hydration due to epithelial defect as well as by foreign bodies between the flap stromal bed and thickness and morphologic characters of the corneal flap, depending on the type of microkeratomes, are related factors for development of epithelial ingrowth.

Diffuse lamellar keratitis and flap margin epithelial healing after laser in situ keratomileusis.

PURPOSE: To evaluate whether wound healing of the corneal epithelium at the flap margin influences development of diffuse lamellar keratitis (DLK) after laser in situ keratomileusis (LASIK). METHODS: We examined prospectively 1928 eyes of 994 patients after LASIK. Condition of wound healing at the flap margin 1 day after LASIK was graded as gutter score from 0 to 3, according to the extent of fluorescein staining. Existence of DLK, gutter score, and the location of DLK and gutter were evaluated. RESULTS: Sixty-eight eyes (3.5%) developed DLK. The average gutter score was significantly higher in patients with DLK compared to those without DLK (P<.001). The location of DLK was identical to the location of gutter in 44 eyes (77.2%). CONCLUSION: Disruption of integrity of the epithelial barrier function at the flap margin was associcated with diffuse lamellar keratitis after laser in situ keratomileusis.

Ocular surface treatment before laser in situ keratomileusis in patients with severe dry eye.

PURPOSE: To evaluate the efficacy and safety of laser in situ keratomileusis (LASIK) in patients with severe dry eye associated with Sjögren's syndrome. METHODS: Three patients (six eyes) with Sjögren's syndrome who underwent bilateral LASIK were retrospectively evaluated for visual outcome, intraoperative and postoperative complications, dry eye status (subjective symptoms and objective findings, Schirmer test, vital staining of the ocular surface), and outcome satisfaction by subjective questionnaire. All patients had negative reflex tearing and were treated with topical autologous serum and/or punctal occlusion prior to LASIK to improve the ocular surface. This treatment was continued postoperatively. RESULTS: Mean attempted correction of six eyes was -8.46 +/- 1.55 D (range -7.00 to -10.63 D). One year after LASIK, mean uncorrected visual acuity was 1.07 (range 0.7 to 1.5), mean best spectacle-corrected visual acuity was 1.29 (range 1.2 to 1.5), and mean refraction was -0.19 +/- 0.51 D (range -1.00 to +0.50 D). Tear production, rose bengal and fluorescein staining, and dry eye symptoms were not exacerbated after LASIK. No complications, such as intraoperative epithelial defect, diffuse lamellar keratitis, epithelial ingrowth, or recurrent erosion occurred. All three patients were satisfied with the outcome of their surgery. CONCLUSION: LASIK can be safely and effectively managed in patients with severe dry eye with reduced reflex tearing by preoperative and postoperative treatments consisting of a combination of artificial tears, topical autologous serum, and punctal occlusion. Careful assessment of preoperative and postoperative ocular surface status is mandatory in such patients.

Risk factors for development of diffuse lamellar keratitis after laser in situ keratomileusis.

PURPOSE: To investigate the risk factors and mechanisms of diffuse lamellar keratitis (DLK) after laser in situ keratomileusis (LASIK). METHODS: In 5708 eyes of 2927 patients who underwent LASIK, the patient's background, clinical findings, and surgical data were retrospectively evaluated and compared with patients who had DLK and those who did not (non-DLK group). RESULTS: DLK occurred in 46 of 5708 eyes (0.81%). DLK occurred more frequently in eyes operated with the MK-2000 microkeratome (1.1%) than with the LSK-One microkeratome (0.6%; P = .039). Corneal endothelial cell density (2686.8 +/- 235.3/mm2) was significantly lower in eyes that developed DLK than in eyes without DLK (2783.8 +/- 275.5/mm2; P = .017). The width of palpebral fissure in a normal state and the maximum opening position were significantly larger in the DLK group (10.3 +/- 1.9 mm and 18.1 +/- 7.2 mm, respectively) than the non-DLK group (8.3 +/- 1.6 mm with P < .001; 11.5 +/- 2.0 mm with P = .012). CONCLUSIONS: The type of microkeratome, lower corneal endothelial cell density, and larger palpebral fissure were potential risk factors for DLK after LASIK. These factors may be associated with delayed wound healing of the corneal flap margin, resulting in poor sealing of the flap, which may induce the influx of inflammatory cells.

Risk factors for insufficient fixation of microkeratome during laser in situ keratomileusis.

PURPOSE: To investigate the potential risk factors leading to insufficient fixation of a microkeratome during laser in situ keratomileusis (LASIK), especially in Asian eyes. METHODS: We performed a retrospective analysis of 1809 eyes of 972 patients that underwent LASIK. Profiles of patients (age, sex, past medical history, width of palpebral fissure, corneal power, and postoperative clinical course) whose operations were discontinued due to insufficient fixation were compared to all LASIK patients. RESULTS: Insufficient fixation was observed in 18 eyes of 16 patients. Those patients were significantly younger (26.1 +/- 5.5 yr) compared to all patients (32.3 +/- 8.6 yr). Mean keratometric power was 42.40 +/- 1.37 D in patients with insufficient fixation and 43.60 +/- 1.40 D in all patients (P < .001). Maximum width of palpebral fissure with eyes wide open was 0.96 +/- 0.20 mm in patients with insufficient fixation, and 1.10 +/- 0.19 mm in all patients (P = .0015). These patients subsequently underwent LASIK utilizing combinations of cooling, frequent corticosteroid instillation for several hours, and lateral canthotomy. CONCLUSION: Narrow palpebral fissures commonly found in Asian populations might be a risk factor for insufficient fixation of a microkeratome in LASIK, especially in young patients with flat corneas.

Severe late-onset recurrent epithelial erosion with diffuse lamellar keratitis after laser in situ keratomileusis.

A 39-year-old woman had laser in situ keratomileusis that was complicated by intraoperative epithelial erosion in both eyes. Seven months after surgery, the patient returned, complaining of pain and blurred vision in the left eye. Slitlamp examination revealed corneal epithelial erosion with severe diffuse lamellar keratitis (DLK). Reepithelialization was complete in several days. However, severe inflammation remained until systemic steroids were administered. Recurrent erosions can lead to a serious inflammatory reaction such as DLK because of the presence of the flap-stroma interface.