This first video shows a small gap or gutter from the 5-7 o’clock position. Utilizing the base of a wet merocel it is easily closed. While perhaps not responsible for a line of best corrected vision, it may impact on visual quality/contrast sensitivity, etc. When this technique is not utilized, the gutter will quickly fill in with epithelium. This may not create an appearance of striae but may be responsible for the edematous (peau de orange) appearance sometimes seen in the early post-op period.

This gap is a bit more pronounced and associated with fine horizontal macrostriae. Though most surgeons would probably address this picture clinically, it would most likely occur in the laser suite. As you can see, this issue is easily resolved by using this technique.

In this example, a large gutter with associated vertical macrostriae is again observed. The sopping wet merocel is easily able to resolve this appearance.

When the folds become too significant, it is usually best to gently refloat the flap with a short stream of BSS or a 27G canula, then employ the smoothing technique.

This patient’s flap edge (6-8 o’clock) had flipped under within an hour of leaving the laser center. As such, no epithelium had grown onto the stromal bed. By utilizing the 27G canula tip with a small amount of BSS followed by the merocel smoothing technique, I was able to save this patient a trip back to the laser suite.

This clip shows SL treatment of patients who dislodged their flap on the evening following their procedure and were not seen until the following day. Unlike the flap presented on the same day patient discussed earlier, this demonstrates how quickly epithelium will migrate to cover the exposed stromal bed. This tissue will always reflect back off the bed very easily. The leap of faith is that the macrostriae are gone. Flap will approximate to a tight gap in the bed if interface hydration is limited. Although the striae seem to persist, retro illumination confirms they are gone and only in the epithelium in memory: They should be gone the following day.

Irrigation can also be used in the immediate post-op period to rinse small amounts of heme from under the flap.

Isolated fibers and particles are typically easy to remove from under the flap with forceps. Here, an extraxial fiber is removed without disturbing the position of the flap using an angled Kelman-McPherson forcep.

This is true even for particles that are axial in position. Interface fibers that escape detection during the flap check performed immediately following the procedure can still be easily removed at the one day post-op exam. Patients can help you to perform this maneuver by looking in a location opposite to the point of interface entry.

Experience has shown that the membrane-like sheet of EI swells readily with BSS (hydrodeliniation), and is easily coaxed out of the interface (hydro- extrusion). This maneuver is accomplished with a 27G canula on a half full 3cc syringe of BSS. This patient’s right eye shows 4-5 clock hours of variable 0.5-2.0mm EI at a 2 week post-op visit.

In this video, 5-6 o’clock hours of EI were noted at 5 days post-op. This video illustrates an excellent example of the hydrodeliniation and hyrdoextrusion technique. The redundant epithelium is carefully stripped from the flap edge and then smoothed with a wet merocel.

Here, a well-defined four o’clock hour sheet of 1.5-2.5mm monolayer EI is seen three weeks post lift enhancement. Removal is accomplished with hydrodelineation and angled non-toothed forceps are used to strip out the sheet of cells.

This video illustrates the removal of 3 o’clock hours of 1mm ingrowth on a patient who had LASIK over RK. Primary rational for SL removal of EI is two-fold. Visualization for attempted removal in the OR isn’t nearly as good and 2) carries risk of incision splay along previously unaffected incisions with potential for subsequent new EI.

When EI is more adherent to the underside of the flap, an attempt can be made to strip it from the flap underside with a Kelman-McPherson or other non- toothed forceps by utilizing a “one jaw in – one jaw out” manipulation. With practice, an in situ “tacoing” of the effected area of the flap can be achieved at the slit lamp to allow for more vigorous removal of EI from the flap underside.

This segment shows an excellent example of post-op 1 removal of fine vertical macrostriae and an oblique level of meibomian debris. This appearance was most likely present shortly following the patients procedure upon discharge. Copious lubrication is encouraged to prevent this occurrence.

As we are all familiar with following corneal abrasions or PRK, uncontacted corneal epithelium will rapidly migrate to cover any exposed stromal bed. This is also seen in patients who dislodged their flaps on the evening after LASIK and are not seen until the next day. Fortunately, the advancing epithelial edge will always reflect back very easily using the inverted tips of a Kelman or dry merocel. The flap can then be floated back down on a stream of BSS and painted back in place with a saturated merocel or Johnston Applanator.

This segment shows an excellent example of the typical consistency of early EI. At the conclusion of the video a portion of the EI is left draped over the flap, employing the logic that EI cannot grow under the flap if it is over the flap. The mechanical action of the lid will soon blink off the redundant epithelium.

One main advantage in utilizing these techniques to remove EI, is that any recurrence is confined to the initial distribution of treatment. When EI is treated by lifting the flap in the refractive surgery suite, recurrence can potentially affect areas previously not involved.

With cooperative patients, even large areas of EI can be removed. Although subtle in appearance, the EI here is extensive and axial in nature. Shifting manifest refraction was this patient’s presenting symptom.

This patient presented with a large but somewhat occult monolayer EI membrane 15d s/p lift enh of a 7 yr old ACS flap. EI seems to be fairly common following lifts on patients whose primaries were created with ACS, Hansatome Moria, and other shallow approach microkeratomes and less so with a Femtosecond laser.