Case reports and small case series: late dislocation of a LASIK flap caused by a fingernail.

Report of a Case. A 28-year-old white woman came to our casualty service following uncomplicated, bilateral LASIK performed elsewhere. Preoperative refraction was −2.25 diopters (D)OD and −3.75 DOS. Postoperatively she achieved an unaided visual acuity of 20/20 OU. Ten months after surgery, her fingernail brushed the left eye while she was removing a sweater, resulting in painful displacement of the corneal cap. The cap was repositioned using topical (0.5% tetracaine hydrochloride) and sub-Tenon (2% lignocaine hydrochloride) anesthesia. Operative manipulation suggested that the cap had everted, the lower edge of its nasal hinge had torn, it had twisted about the residual hinge, and one of its edges had folded over (Figure 1A). The stromal bed and cap were debrided. Three 10-0 interrupted nylon sutures were used to secure the cap and the patient was discharged receiving preservativefree topical antibiotics and tear supplements. Five days later, debris was noted in the interface between the cap and the corneal stroma, suggesting the presence of epithelial ingrowth. With the patient under general anesthesia, the nylon sutures were removed and the corneal cap was everted, revealing a sheet of gelatinous material (Figure 1B) that was wiped with a sterile surgical sponge and sent for histologic assessment (Figure 2). The undersurface of the cap and the stromal bed were cleaned with 100% alcohol to destroy residual epithelium. The cap was allowed to dry and then was hydrated before repositioning. The surface of the cap was stroked with a cyclodialysis spatula to remove excess fluid in the interface. A soft bandage lens was applied after debriding the epithelium on the surface of the cap. Forty-three days postoperatively, irregular astigmatism had reduced unaided visual acuity to 20/ 200. Retroillumination photography confirmed the recrudescence of epithelial ingrowth under the nasal part of the cap (Figure 3) with the presence of microcysts compatible with those seen histologically. One hundred three days after the second operation, an attempt was made to debride the epithelial ingrowth again. On this occasion it was impossible to easily define a cleavage plane for the cap. A small central area of corneal stroma was removed followed by scraping of the residual cap area.