FLAP COMPLICATIONS

1. Intraoperative Complications (microkeratome-related flap

complications)
1.1 Flap Buttonhole
with either

Etiology: Abnormal lamellar cut during LASIK flap creation

microkeratome or a femtosecond laser.

Characteristic: Appear as a circular area of irregularity

representing the
area of buttonhole. If the flap is
lifted, the stromal bed
should have a
corresponding area of elevation that appears
smooth
representing the uncut area of cornea where
epithelium may still be present. A corresponding divot
should be seen on the undersurface of the flap.
In femtosecond assisted flap creation, appear as
an area of
clearing among the advancing raster
pattern or a bubble of
air within the treatment conecorneal surface interface. The
surgeon should
stop the flap creation, if possible, prior to
the creation of the corneal flap side cuts.
Incidence has been noted to be higher in the left (second)
eye treated with
microkeratome-assisted flaps.
Management: Do not perform laser ablation, recut the flap
and ablate a
minimum of 3 months later

1.2 Free Cap

Usually in LASIK, a hinged corneal flap is created that allows
eximer laser to
be applied on the exposed stromal bed. If the
hinge of the corneal flap
detaches, the flap becomes a
free flap/cap. The occurrence of this
complication is
most commonly associated with flat corneas, which
predisposes to small flap diameter. Free cap is preventable and
treatable.
Rarely does the complication lead to severe or
permanent decrease in
visual acuity.

The incidence of free cap during LASIK is generally low,

ranging from
0.004% to 1.31% depending on the study
Management: Perform laser ablation, orient the cap properly
and replace it
on the bed, allow air-drying for 3-5
minutes.

1.3 Incomplete, short, or irregular flaps

Occur because inadequate suction or microkeratome
malfunction.
Management: Do not manipulate the flap, do not perform
laser ablation,
place a bandage contact lens,
and recut the flap and ablate
at least 3 months later.

1.4 Vertical gas breakthrough

Etiology: Unknown, but a thin flap or a focal break in the
Bowman's layer
may consider. Occurs during FS
laser-assissted flap creation,
resulting in escape of
gas bubbles from the dissection plane
into the
subepithelial space.
Management: Lift the flap cautiously and perform laser
ablation.

1.5 Anterior chamber gas bubbles

Occurs during FS laser-assissted flap creation, resulting in
escape of gas
bubbles from the dissection plane into the
trabecular meshwork then to
the anterior chamber. They can
interfere with pupillary tracking, but usually
are self-limiting
and resolve over a short period of time.

2. Postoperative Complications

2.1 Flap fold or Striae

Flap folds may be classified into macro and microstriae.
2.1.1 Macrostriae
occur because

Macrostriae are full thickness, rolling stromal folds,

of flap malposition or slippage.

Management: Perform immediate refloating and

repositioning.
After 24 hours, need
refloating, de-epithelialization,
hydration,
stroking, and suturing.

2.1.2 Microstriae
Microstriae are fine folds in Bowmans layer, occur
because of
mismatch of flap to new bed and often
visually insignificant.
if visually
suturing.

Management: Observation with aggressive lubrication,

significant perform refloating, stroking, and

2.2 Flap dislocation

Etiology: Excessive lid squeezing, eye rubbing, excessive dry
eye,
presence of epithelial abrasion, poor
intraoperative
repositioning, excessive
irrigation of flap, and trauma.
Prevention: Check adhesion of flap at the end of procedure,
remind the
patient not to squeeze or rub
the eyes and wear the shield
for the first 24
hours and every night for the first week.
Management: Reposition the flap, suture the flap in the
event of persistent
fold, and use lubricants.