Refractive Long - Term Flap Striae Post - LASIK

A 30-year-old white male underwent LASIK by another surgeon in July 1998 with a VISX STAR laser (VISX, Inc., Santa Clara, CA) and a Moria LSK microkeratome (Moria, Antony, France) to correct moderate myopia: -5.50 D sphere OD, -6.00 D sphere OS, and a BCVA of 20/20 OU. His preoperative corneal thicknesses were 548 and 555 μm OD and OS, respectively. The initial LASIK surgery resulted in an overcorrection of both eyes and a central island in his left eye. In June 1999, the patient’s refraction measured +1.25 OD and +1.25 +0.50 X 80 OS, yielding 20/25 BCVA OU. He underwent a LASIK enhancement in his left eye that involved recutting the flap. Postoperatively, the patient complained of visual distortion and polyopia. He had a UCVA of 20/80 and a BCVA of 20/30. Upon slit lamp examination, striae were evident throughout the visual axis. One month after the enhancement procedure, the surgeon lifted and stretched the flap of the patient’s left eye. Three days later, he had to relift and restretch the flap to address recalcitrant striae. The surgeon also employed a hypotonic solution to induce flap swelling. These efforts were unsuccessful. After 4 months, the surgeon relifted and floated the flap of the patient’s left eye. This procedure was partially successful; it reduced the number of images the patient was seeing from five to two. A rigid gas permeable contact lens trial was attempted, but the patient became contact lens intolerant. He then tried soft contact lenses, but they did not alleviate the monocular diplopia. In August 2001, 3 years after his initial procedure, the patient presented to us with the chief complaint of polyopia in his left eye. HOW WOULD YOU PROCEED? 1. Would you relift and stretch the flap? 2. Perform epithelial debridement? 3. Recommend phototherapeutic keratectomy (PTK)? 4. Relift and suture the flap? 5. Perform either lamellar or penetrating keratoplasty?