Reviewed by David R. Hardten, MD
Minnetonka, MN—Got adhesives? Adhesives for post-LASIK epithelial ingrowth, that is.
The use of fibrin adhesives can help surgeons manage this common complication of LASIK surgery, which occurs in 0.5% to 15% of cases, said David R. Hardten, MD.
“Epithelial ingrowth is usually observed in the first few weeks, it may be nonprogressive or progressive, and in the most advanced stage it may result in flap melt,” said Dr. Hardten, Minnesota Eye Consultants, Minnetonka, MN.
Common signs of epithelial ingrowth are isolated nests or sheets of cells, decreased visual acuity, induced astigmatism on refraction, and irregular astigmatism on topography.
Two common treatments for epithelial ingrowth are removal and neodymium:YAG laser treatment, Dr. Hardten said.
Removal usually consists of lifting and scraping epithelial cells, using a blunt spatula and Merocel sponge, and then using ethanol to supplement complete removal. Neodymium: YAG laser treatment is helpful when there are stable pockets of ingrowth where the elevation of the cornea causes changes in comfort or vision, he explained.
To help prevent the recurrence of epithelial ingrowth, surgeons can consider suturing the flap edges, although Dr. Hardten has found that this can induce striae, irregular astigmatism, and require suture removal. This also has a longer recovery. The use of a fibrin adhesive application is useful for recurrent cases but also has a longer recovery.
Another treatment alternative is hydrogel adhesive applications, Dr. Hardten said.
One fibrin adhesive (Tisseel Fibrin Glue, Baxter) is a mix of fibrinogen and thrombin, but it also has a bovine fibrinolysis inhibitor. The product takes 8 to 10 minutes to dry so a bandage scleral contact lens can be placed; it dissolves in 10 to 14 days.
In a study that Dr. Hardten led with fibrin glue used after LASIK to treat epithelial ingrowth, there was no recurrence in 80% of eyes over an average 26 months of follow-up.1
Thirty-nine eyes from 38 patients were included in the retrospective case series. Five eyes (12.8%) had mild epithelial ingrowth, but it did not require removal; at the 3-month follow up, three eyes (7.7%) had significant epithelial ingrowth requiring removal and fibrin application. At the final follow-up, which occurred at a little over 2 years, 84.6% of eyes had corrected distance visual acuity of 20/25 or better, and 74.4% had 20/40 or better uncorrected distance visual acuity. Ninety-two percent of eyes had unchanged or improved corrected visual acuity.
Two eyes in the study had flap amputation due to irregular astigmatism from pre-existing areas of flap melt that were still a problem; one eye had ectasia (also pre-existing) and subsequent Intacs placement (Addition Technology), and another eye had poor vision from glaucoma (also pre-existing), Dr. Hardten said.
“Any of the brands of fibrin adhesive may be a useful adjunct in epithelial ingrowth removal in complicated cases,” he said.
These fibrin adhesives may reduce the incidence of recurrent epi-ingrowth, and they are well tolerated with no associated complications. However, larger randomized studies would be helpful to determine safety and efficacy compared with primary removal or sutures, he said.
Dr. Hardten noted some researchers have described using hydrogel adhesives in cases that do not require as long of a time for retention of the adhesive.
1. Hardten DR, Fahmy MM, Vora GK, Berdahl JP, Kim T. Fibrin adhesive in conjunction with epithelial ingrowth removal after laser in situ keratomileusis: long-term results. J Cataract Refract Surg. 2015;41:1400-1405.
David R. Hardten, MD
This article was adapted from Dr. Hardten’s presentation during Cornea Day at the 2016 meeting of the American Society of Cataract and Refractive Surgery. Dr. Hardten has done research, consulting, or speaking for Abbott, Allergan, Calhoun Vision, CXL-USA, ESI, Humanoptics, Oculus, OSD, Quantel and TLCV. Some of the information may represent off-label uses of approved drug or devices.