Review Article

Complications of laser-assisted in situ keratomileusis

Pranita Sahay, Rahul Kumar Bafna1, Jagadesh C Reddy2, Rasik B Vajpayee3, Namrata Sharma1

Laser-assisted in situ keratomileusis (LASIK) is one of the most commonly performed kerato‑refractive surgery Access this article online
globally. Since its introduction in 1990, there has been a constant evolution in its technology to improve the Website:
visual outcome. The safety, efficacy, and predictability of LASIK are well known, but complications with this www.ijo.in
procedure, although rare, are not unknown. Literature review suggests that intraoperative complications DOI:
include suction loss, free cap, flap tear, buttonhole flap, decentered ablation, central island, interface debris, 10.4103/ijo.IJO_1872_20
femtosecond laser‑related complications, and others. The postoperative complications include flap striae, PMID:
*****
flap dislocation, residual refractive error, diffuse lamellar keratitis, microbial keratitis, epithelial ingrowth,
refractive regression, corneal ectasia, and others. This review aims to provide a comprehensive knowledge Quick Response Code:
of risk factors, clinical features, and management protocol of all the reported complications of LASIK. This
knowledge will help in prevention as well as early identification and timely intervention with the appropriate
strategy for achieving optimal visual outcome even in the face of complications.

Key words: Diffuse lamellar keratitis, epithelial ingrowth, flap‑related complications, laser in‑situ
keratomileusis, laser vision correction, LASIK; refractive surgery, LASIK complications

The field of refractive surgery has witnessed a major revolution in onwards), using the terms: Laser In‑Situ Keratomileusis,
the past two decades with the introduction of phakic intraocular LASIK, Complications of LASIK, Flap related complications,
lens and small incision lenticule extraction. But laser-assisted decentered ablation, Complications of FS LASIK, Diffuse
in situ keratomileusis (LASIK) still remains the most commonly lamellar keratitis, Post‑LASIK Keratitis, Post‑LASIK ectasia,
performed refractive surgery world over. In the current era, a Pressure‑induced stromal keratitis, Post‑LASIK Epithelial
postoperative visual acuity (VA) of <20/20 following refractive ingrowth, Post‑LASIK Refractive regression and Visual
surgery has become unacceptable considering the high outcome in LASIK. A total of 6249 articles matched our search
demands of patients and the fact that most patients have a best strategy, of which 98 articles were selected by three experts (JR,
spectacle‑corrected visual acuity of (BSCVA) of 20/20 before RBV, and NS) and included in this review. Preference was given
surgery. The technological advances in LASIK, ever since its to meta‑analysis, randomized control trials, and systematic
introduction has increased its safety, efficacy, and predictability. review articles over case series and case reports.
However, one needs an in‑depth knowledge of its intraoperative
and postoperative complications. This will help surgeons take Intraoperative Complications
preventive measures to reduce its occurrence, early identification,
Subconjunctival hemorrhage
and appropriate management for achieving an optimal outcome.
A subconjunctival hemorrhage occurs in nearly one‑third
In this review, we aim to highlight the risk factors, of cases. [1] [Fig. 2a] Risk factors include decentered or
clinical presentation, management, and prevention of inappropriate size suction ring and large/decentered flap
various intraoperative and postoperative complications of in cases with corneal pannus.[2] Pressure application with
LASIK [Fig. 1]. meroceal sponge helps to control the bleed. In case blood
reaches the interface, it should be thoroughly irrigated before
Methods excimer laser delivery.[3]
A literature search was performed using PubMed, Medline, Spontaneous resolution occurs in 1–2 weeks.
Cochrane Library Database, EMBASE, and Scopus (1960
Prophylaxis
A gradual, controlled, and well‑centered application of suction
Department of Ophthalmology, Lady Hardinge Medical College, 1Dr. ring with an average size and well‑centered flap reduces its
Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of
Medical Sciences, New Delhi, 2Cataract and Refractive Surgery Services,
Cornea Institute, L V Prasad Eye Institute, L V Prasad Marg, Roan No‑2, This is an open access journal, and articles are distributed under the terms of
Banjara Hills, Hyderabad, Telangana, India, 3Vision Eye Institute, Royal the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
Australia
the identical terms.
Correspondence to: Dr. Namrata Sharma, Professor, Department of
Ophthalmology, Room‑ 482, 4th Floor, Dr. Rajendra Prasad Centre For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
for Ophthalmic Sciences, All India Institute of Medical Sciences,
New Delhi ‑ 110 029, India. E‑mail: namrata.sharma@gmail.com Cite this article as: Sahay P, Bafna RK, Reddy JC, Vajpayee RB,
Received: 07-Jun-2020 Revision: 19-Jul-2020 Sharma N. Complications of laser-assisted in situ keratomileusis. Indian J
Ophthalmol 2021;69:1658-69.
Accepted: 27-Oct-2020 Published: 18-Jun-2021

© 2021 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

 Sahay, et al.: Complications of LASIK
July 2021 1659

Figure 1: Flowchart showing the various complications of LASIK

risk. Preoperative instillation of brimonidine or apraclonidine head position, improper application of suction ring, low suction
can be useful.[4] pressure, and sudden eye movement.[2,10] In m‑LASIK, suction
loss is indicated by machine alarm, following which further
Epithelial defect
forward movement of microkeratome is stopped. If the flap
A n e p i t h e l i a l d e f e c t i s o b s e r ve d i n 0 . 6 % – 1 4 % o f is larger than the intended optical zone (OZ), ablation can be
cases.[2,5,6] Risk factors include epithelial basement membrane performed; however, if the hinge is in the ablation zone, then the
dystrophy (EBMD), old age, frequent instillation of topical procedure is aborted, and re‑treatment is planned, preferably
anesthetic before surgery, active suction during microkeratome surface ablation after three months.[5] In FS‑LASIK, a peripheral
reverse pass, hyperopia, drying of the flap and iatrogenic trauma asymmetric tear meniscus around the patient interface is the
with instruments.[6] The shearing forces of the microkeratome first sign of suction loss following which laser delivery is
blade results in its high incidence after microkeratome stopped.[11] A second attempt for docking while maintaining
LASIK (m‑LASIK). An epithelial defect can cause stromal centration over the previous flap can be attempted.[11] In case
edema and reduced flap adherence, which increases the risk the suction loss occurs before the sidecut, the same parameters
for diffuse lamellar keratitis (DLK) and epithelial ingrowth.[7] are used; however, if it occurs during the sidecut, the second
Management includes frequent preservative‑free lubricants. side cut diameter should be 0.5 mm smaller.[11]
Topical steroid is stepped up for 2‑3 days to reduce the risk
Prophylaxis
of DLK. In case of large epithelial defect (>3 mm), a bandage
contact lens (BCL) is applied.[8] Careful screening for risk factors and preoperative counseling
to remain calm and maintain fixation is essential. Proper
Prophylaxis functioning microkeratome, draping of the eye to avoid lashes
Careful screening for EBMD, preoperative use of lubricants, in the surgical field, and adequate suction pressure reduces
avoiding excessive instillation of topical anesthetic before its risk.
surgery, and switching off suction during microkeratome
Flap‑related complications
reverse pass can reduce its risk.
i. Decentered Flap
Suction loss Misaligned suction ring can result in a decentered
Suction loss occurs in 0.06%‑4.4% cases.[5,9,10] It can cause flap.[12] In case a decentered flap is formed, performing a
incomplete flap formation. [Fig. 2b] Risk factors include narrow pupil‑centered ablation can result in an unexpected visual
palpebral aperture, deep‑set eye, flat cornea, improper eye or outcome.[12] Hence, the procedure should be aborted if the
1660 Indian Journal of Ophthalmology Volume 69 Issue 7

a b a b

Figure 2: (a) Slit-lamp photograph of the right eye of a patient on day Figure 3: Intraoperative image showing (a) a peripheral flap tear (black
one after femtosecond LASIK showing subconjunctival hemorrhage arrow); (b) a buttonhole flap (yellow arrow)
and interface bleed; (b) Intraoperative image showing a peripheral
asymmetric tear meniscus during femtosecond LASIK indicating suction cornea (>48 D), suction loss, large flap, second eye, m‑LASIK,
loss resulting in incomplete flap formation and vertical gas breakthrough (VGB) in FS‑LASIK are the
reported risk factors.[18,19] Management includes aborting
expected gap between the peripheral edge of ablation and the procedure and planning for re‑treatment, preferably
flap margin is <1 mm, and a repeat procedure is performed surface ablation after three months.[18,19] In case, LASIK
after three months.[12] is performed, the flap should be of a larger diameter and
Prophylaxis greater thickness.[5] Buttonhole flap can result in irregular
astigmatism and epithelial ingrowth.
If there is a misaligned suction ring, the suction should be
turned off, and the suction ring should be repositioned. In cases Prophylaxis
with repeated unsuccessful attempts, waiting for 5‑10 minutes Preoperative assessment of risk factors, intraoperative
helps by allowing the decentered gutter‑like impression to precautions to avoid suction loss and lubrication of the second
disappear. eye is helpful.[18]
ii. Incomplete/Partial Flap v. Free Cap
An incomplete flap occurs in 0.3% to 3.6% cases with a higher Free cap is observed in 0.01%‑1.8% cases.[14,20] Risk factors
incidence in m‑LASIK.[5,13] [Fig. 2b] The risk factors include include malfunctioning or old model microkeratome,
suction loss, malfunctioning microkeratome, mechanical block flat cornea (<42D), deep orbit, decentered suction ring,
with drape, eyelash, loose epithelium, or crystallized salt.[13,14] inadequate suction, and small hinge.[20] Also, avulsion at
Management is the same as for suction loss.[15] Lamellar hinge during manipulation can result in a free cap.
dissectors have been described to complete the flap in If the flap is found intact and the stromal bed is of adequate
case the hinge lies in the optical zone. However, this adds size (>6.5 mm), the free cap is placed in an anti‑desiccation
the risk of buttonhole and uneven stromal bed, causing chamber with the epithelial side down and kept moist.[20]
irregular astigmatism. Also, the OZ can be reduced to After laser ablation, the free cap is placed on the stromal
protect the flap, but the scotopic pupil size should be given bed, allowed to air dry for > 5 mins, and BCL placed over
due consideration. it to achieve good adherence. 10‑0 nylon sutures are used
Prophylaxis to secure flaps that are edematous or show a tendency
to dislocate.[14] A slit‑lamp examination after 2‑3 hours
Same measures as for suction loss
is recommended. Pre‑placed corneal markings help in
iii. Flap Tear avoiding rotational misalignment that can cause irregular
Flap tear, although rare, can occur during flap lift and is astigmatism.
more common in FS‑LASIK.[5,16] [Fig. 3a] Large diameter In case of intraoperative flap loss, the procedure should be
flap with corneal pannus, re‑treatment procedure, presence abandoned. The surface heals by epithelization and corneal
of a corneal scar, and faulty instrumentation can result in haze. The postoperative hyperopic shift in these cases is
this complication.[17] Flap tears at the hinge can result in a managed with contact lens (CL), PRK, or flap reconstruction
free cap. In case of small peripheral tear, the flap should be with a donor cornea.[20]
dissected away from the tear. However, if it involves the
Prophylaxis
visual axis, the procedure should be aborted and followed
by re‑treatment with surface ablation. Regular servicing of microkeratome, avoiding intraoperative
drying of the flap and preoperative corneal marking can be
Prophylaxis useful.
Reducing the flap diameter in presence of corneal pannus and
vi. Thin flap
a careful dissection of the flap, especially in FS‑LASIK, can
The LASIK flap is created by a lamellar cut below the
reduce the risk.
bowman’s layer; however, a cut at or above the bowman’s
iv. Buttonhole Flap layer results in a thin flap (<60 microns). The risk factors
The failure to achieve a lamellar cut results in a hole in the are similar to those for a free cap. In uniform thickness thin
flap. [Fig. 3b] It is observed in 0.03% to 2.6% of cases.[18] Steep flap with adequate stromal bed (>6.5 mm), the procedure
 Sahay, et al.: Complications of LASIK
July 2021 1661

can be continued. However, for irregular thin flap having should be performed carefully. It disappears after a flap lift;
an inadequate stromal bed, the procedure is aborted, and however, its persistence can cause difficulty in pupil tracking
re‑treatment is planned after three months with a deeper for excimer laser delivery. Waiting for a few minutes and
cut to obtain a thicker flap. allowing it to disappear is prudent. Increase in higher‑order
aberration (HOA), especially trefoil, has been observed with
Prophylaxis
occurrence of OBL.[1,2]
Screening patients for risk factors, proper blade assembly, and
adequate suction can reduce this complication. Prophylaxis
The use of a soft docking technique with a relatively large
vi. Corneal Perforation
diameter flap can reduce its risk.[26,27] Soft docking implicates
Corneal perforation is a rare and dreaded complication of
docking the patient interface just enough to leave a peripheral
LASIK. It can occur during flap creation, especially with
ring of tear meniscus that allows the dissipation of gas bubbles
old microkeratome model that required assembly of the
through the side cut.
thickness footplate), and excimer laser ablation due to either
miscalculation of the residual stromal bed thickness (RSBT) iii. Anterior Chamber Air Bubbles
or excessive ablation due to corneal dehydration.[14,21] The incidence of an air bubble in the anterior chamber (AC)
during LASIK is <1%.[29] [Fig. 4b] It occurs due to the
If corneal perforation occurs during flap creation, suction migration of cavitation bubbles through the episclera,
should be immediately stopped. Conservative management schlemm canal, and trabecular meshwork into the AC.[30]
by repositioning the flap and placing a BCL is done for small Large diameter flap and small corneal diameter are the
perforation; however, large perforation requires surgical repair reported risk factors.[2,11]
under sterile conditions. Poor visual outcome due to corneal
scar and recurrent epithelial ingrowth occur in these cases.[22] Bubbles in AC interfere with pupil tracking for excimer
laser ablation. Hence, its ideal to wait for it to disappear before
Prophylaxis proceeding. However, few surgeons prefer to disable automatic
Careful microkeratome assembly, preoperative calculation tracking and proceed with manual tracking to reduce operating
of RSBT and avoiding intraoperative dehydration of cornea. time.[2,11,29–31] No adverse effect is seen on the endothelial cell
Complications peculiar to femtosecond laser‑assisted LASIK with its occurrence.[31]
i. Vertical Gas Breakthrough Excimer laser ablation relation complication
Femtosecond laser (FSL) works on the principle of i. Central Island
photo‑disruption. It creates a plasma that spreads The central island represents a well‑circumscribed area of
horizontally in the cornea, path of least resistance, as unablated cornea with a relatively higher corneal power
cavitation bubbles. In the presence of corneal scar or revealed on corneal topography.[32] Power of >3D and size
break/abnormality in the bowman’s layer, the gas dissects of >1.5 mm is used for its definition, but few authors believe
vertically towards the stroma or epithelium following that any area of central steepening should be considered
the path of least resistance.[23,24] [Fig. 4a] This results in as a central island as it ultimately affects the VA.[14,32,33] Its
an incomplete dissection of the flap with a potential site incidence varies from 5.7% to 11%.[14,34] The risk factors
for buttonholing. Rarely, the gas can breach the corneal include broad beam laser delivery pattern, non‑uniform
epithelium resulting in an epithelial defect.[23] corneal hydration, or presence of debris on the stromal
VGB is noted in 0.03% to 0.13% cases.[23,25] If a VGB is surface resulting in non‑uniform excimer laser delivery.[14,32]
observed ahead of the advancing edge of the flap, the procedure Postoperatively, patients complain of glare, halo, ghost
should be aborted.[2] However, if a VGB is noted behind images, and monocular diplopia. On examination, VA
the advancing edge of the flap, the procedure can be safely and contrast sensitivity are reduced due to irregular
continued.[2] astigmatism.[35] Corneal topography helps in diagnosis
and shows an area of hot color surrounded by cool color
Prophylaxis in the OZ. As spontaneous regression occurs in 25‑80%
Careful preoperative slit‑lamp examination to look for corneal cases by six months, it is prudent to wait for refraction
scar or any obvious break in the bowman’s layer. and corneal topography to stabilize before planning
a re‑intervention.[35] Wavefront or topography‑guided
ii. Opaque Bubble Layer LASIK can be planned for re‑treatment; however, the
Opaque bubble layer (OBL) forms due to entrapment results are unpredictable, considering the corneal contour’s
of gas from cavitation bubbles within the corneal complexity. Rigid gas‑permeable (RGP) CL can be used for
stroma. [Fig. 4a] Variable incidence has been observed in the visual rehabilitation.[36]
literature (5%‑72.6%).[26,27] Thick cornea, small flap diameter,
hard docking technique, corneal hysteresis, use of low laser Prophylaxis
frequency or energy, and small spot or line separation are Use of a scanning slit or flying spot pattern of laser delivery,
the reported risk factors.[26,27] drying of the stromal surface, and checking for the presence
of debris prior to excimer laser delivery can reduce its risk.[32]
OBL has been classified into early and late.[28] Early OBL or
hard OBL, occurs at the time of laser delivery and appears to ii. Decentered Ablation
be dense. Late OBL or soft OBL, appears after laser delivery Corneal ablation centered over the pupil is essential for
has passed through an area and is relatively transparent. The optimal visual outcome and >0.3 mm deviation compromises
presence of OBL suggests flap adhesion; hence, flap lifting the visual outcome.[14] The causes for decentered ablation
1662 Indian Journal of Ophthalmology Volume 69 Issue 7

a b
Figure 4: Intraoperative image showing (a) vertical gas breakthrough
appearing as a dark patch (black arrow) and opaque bubble layer
appearing as white stromal opacification (red arrow); (b) air bubbles
in anterior chamber obscuring the pupil

include poor fixation, sudden involuntary ocular or head

movement, and surgeon’s error. [14,33] An inadvertent
laser delivery to the stromal side of the flap can cause
irregular astigmatism. Postoperatively, patients complain
of poor vision, glare, halo, and monocular diplopia due to
induced corneal astigmatism. Corneal topography shows
asymmetric corneal contour with flattening on one side and Figure 5: Slit-lamp photograph showing a cotton fiber in the LASIK
steepening on the other. Management options include RGP interface
CL, miotics to reduce optical aberrations, and decentered
PRK or wavefront‑guided LASIK or topo‑guided LASIK for within the first postoperative week, as even minor trauma
re‑treatment.[37] due to lid squeezing, forceful blinking and rubbing of
Prophylaxis eyes can dislodge the flap in this phase.[5,41] Dry ocular
surface, m‑LASIK, nasal hinged flap, large‑diameter/
Use of pupil tracking system, dim lighting of the operating
thin flap, and hyperopic correction are the other risk
room during excimer laser delivery and preoperative
factors.[5,11,14,41]
counseling besides intraoperative verbal communication with
patient to maintain central fixation during the procedure is Patients present with sudden onset blurred or decreased
helpful. vision, which may be associated with pain. Management
includes flap lift, debridement of epithelium from stromal
Interface debris
bed (if present), irrigation of interface for debris removal, and
A variable incidence of interface debris has been reported (0.06% flap repositioning. The edges are dried meticulously to achieve
to 100%). [38,39] [Fig. 5] It is identified postoperatively on good adherence, followed by BCL application. In some cases,
slit‑lamp examination and should be carefully differentiated sutures may be required to realign the flap. Complete visual
from an inflammatory and infectious reaction. The debris recovery occurs in cases that present early.[41,42] Secondary
consists of talc from the glove, sponge fiber, metallic particle complications like DLK, epithelial ingrowth, and interface haze
from microkeratome, meibomian gland secretion, and are seen in a few cases.[29,42,43]
eyelash.[14] Most debris are biodegradable and does not induce
inflammation; hence can be observed. However, if it involves Prophylaxis
the central visual axis or is suspected of causing inflammation, Preoperative counseling to avoid ocular trauma (squeezing/
it is managed with flap lift and irrigation of interface.[39] Diffuse rubbing/contact sports) after surgery. Intraoperative superior
lamellar keratitis (DLK) and irregular astigmatism are its hinge flap, adequate drying of flap edges, and use of BCL.
reported complication.[40] Postoperative counseling to sleep after they return home, and
use of protective shield for a week.[11,14]
Prophylaxis
Careful draping of the eye to keep eyelashes and meibomian ii. Flap Striae
gland secretions away from the surgical site, use of powder‑free The incidence of flap striae varies from 0.03% to 3.5%.[11,42,44]
gloves, non‑fragmenting sponges, and fibrocellulose [Fig. 6] Most cases present within the first few days of
ring (Chayet ring) that isolates the ablation zone from the LASIK.[11,42,44] Flap striae are classified into micro‑striae
surrounding area is helpful. and macro‑striae. Irregularities within flap are referred
to as microstriae, while full‑thickness flap‑folds represent
Postoperative Complications macrostriae. Flap striae involving visual axis affects vision
by inducing irregular astigmatism and optical aberrations.
Early complications They are best appreciated on slit‑lamp examination in
i. Flap Dislocation retro‑illumination. Fine striae can be detected using
Flap dislocation is an ocular emergency. Its incidence fluorescein under cobalt blue filter as irregularities in the
varies from 0.012% to 2.5%.[5,11,14,41] Most cases present tear film.
 Sahay, et al.: Complications of LASIK
July 2021 1663

Risk factors include high refractive error, flap contracture, Prophylaxis

drying of the flap, misalignment during repositioning, and Pupil tracking and iris pattern registration (wavefront‑guided
excessive manipulation of the flap during surgery.[5,11,14] Striae LASIK) for torsion compensation reduces the risk of
formation in high refractive error results from the “tenting” postoperative residual and induced astigmatism. [53,54]
effect due to contour mismatch of the flap and stromal bed after Preoperative manual limbal marking of cardinal meridians
ablation.[45] Management varies from gentle stroking of the flap and intraoperative cyclotorsion adjustment can also be done.[53]
with a wet sponge on slit‑lamp perpendicular to striae (flap
sliding technique) to flap lift and repositioning.[46,47] Fixed folds iv. Dry Eye
resulting from epithelial hyperplasia in crevices occur in cases Dry eye disease (DED) is observed in >90% cases in the
presenting late. Management includes debridement of corneal immediate postoperative period; however, symptoms are
epithelium from flap and exposed stromal bed along with flap mostly transient.[55] The causes include pre‑existing DED,
lift, repositioning, and stroking with a sponge. Suturing of the peri‑limbal goblet cell damage during suction, sub‑basal
flap is required if folds persist.[14] The visual outcome is good nerve plexus and stromal nerve damage during flap creation,
in cases presenting early. and postoperative inflammation.[14] Superior hinged flap is at
greater risk as the long ciliary nerves enter at 3 and 9 O’ clock
Prophylaxis position; however, variable results have been observed.[56,57]
Intraoperative careful handling of the flap, keeping it moist, Improvement in corneal sensation and DED by 3‑6 months
and prior marking of surgical landmarks at its edge to achieve occur in most cases, but corneal re‑innervation is delayed by
proper alignment during its repositioning is useful. After 2‑5 years.[58] Management includes lubricant drops for 3‑6
surgery, slit‑lamp examination for flap position and uniformity months, topical cyclosporine, and slow tapering of topical
of peripheral gutter is useful.[8] steroids.[59] Temporary punctal plugs are considered in cases
with severe DED.
iii. Residual Refractive Error
Overcorrection & Under‑correction Prophylaxis
Residual refractive error following LASIK has been reported Careful screening of patients for DED before surgery.
in 5%‑51% cases.[33,48] Inaccurate assessment of refraction or
corneal contour change due to CL use, data entry errors in the v. Central Toxic Keratopathy
LASIK machine, and lack of machine calibration can result Central toxic keratopathy (CTK) is a rare complication
in this complication. Environmental factors like operating observed in 0.2%‑0.77% of cases.[60] [Fig. 7a and b] The
room temperature, humidity, and atmospheric pressure have pathogenesis of CTK is controversial; however, meibomian
also been hypothesized to affect the tissue ablation depth. gland secretion, marking ink, and talc from glove are
High humidity is presumed to cause stromal hydration and the reported inciting factors. Patients present with pain,
inadequate tissue ablation resulting in under‑correction; redness, photophobia, glare, and halo between day 2
however, this association is much debated.[49,50] to day 6.[61] Clinical examination reveals central corneal
opacification, hyperopic shift (3‑6D), and corneal thinning,
Management includes LASIK enhancement with flap which progresses over one week followed by a stable
re‑lift, or PRK.[48,51] The visual outcome is comparable in both; phase for 2‑3 months and recovery phase of 3‑18 months
however, epithelial ingrowth can occur in LASIK flap re‑lift.[48,51] wherein hyperopia decreases (1‑3D) and corneal thickness
Prophylaxis increases. [60] Non‑inflammatory stromal keratocyte
Soft CL should be discontinued >2 weeks and RGP CL >4 weeks apoptosis and enzymatic lysis of the stroma resulting in
before refractive workup. Cycloplegic refraction should be
performed in all cases.
Residual and Induced Astigmatism
In addition to the risk factors for over and under‑correction,
cyclotorsion from erect to supine position and poor centration
of eye during laser ablation can cause postoperative a b
astigmatism. [52,53] Management involves post‑LASIK
enhancement.

c d e
Figure 7: (a) Slit-lamp photograph showing central circumscribed
scarring with striae suggestive of central toxic keratopathy; (b) ASOCT
showing an inverse dome-shaped homogenous hyperreflectivity;
Slit-lamp photograph showing (c) inflammatory cells extending from
a b periphery suggestive of diffuse lamellar keratitis (DLK) stage 1;
Figure 6: Slit-lamp photograph showing (a) flap striae in the visual (d) central involvement of inflammatory cells with "sands of Sahara
axis one week following LASIK; (b) resolution of flap striae after flap appearance" suggestive of DLK; (e) both peripheral and central
lift and ironing out the striae involvement of inflammatory cells suggestive of DLK stage 2
1664 Indian Journal of Ophthalmology Volume 69 Issue 7

corneal thinning is the presumed cause for hyperopic the interface. Elevated IOP secondary to steroid response is
shift.[62] DLK and microbial keratitis are the differential the presumed cause for fluid accumulation. Dynamic contour
diagnosis. tonometry and tonopen (reading from the peripheral cornea)
are superior to Goldmann applanation tonometry in these cases
Spontaneous regression occurs in most cases.[60] CTK is
for IOP measurement. Management includes anti‑glaucoma
a non‑inflammatory condition, and hence steroids are not
medication and cessation of steroids to avoid glaucomatous
indicated. On the contrary, it may hamper the healing process.
optic neuropathy.[68,69]
Prophylaxis viii. Interface Haze
Use of powder‑free gloves and proper draping to cover lid Interface haze is rarely seen following LASIK. DLK,
margins should be done. ultra‑thin flap (<90 µm), and young age are the reported
vi. Diffuse Lamellar Keratitis risk factors.[70] Most cases respond well to topical steroids
DLK is a non‑infectious inflammatory condition that in the early phase with good visual recovery.[70]
involves the LASIK interface in 0.13% to 18.9% of cases.[63,64] ix. Higher‑Order Aberrations
[Fig. 7c‑e] Risk factors include glove talc, marking pen, old Optical aberrations are observed in 2.3%‑43.5% of cases.[71,72]
microkeratome blade, small suction ring, high energy FSL, Symptoms include glare, halo, difficulty in night vision,
large‑diameter flap, chemical toxin and bacterial endotoxin and blurred vision despite good VA. Most cases adapt to
on instruments, and meibomian gland secretions.[33,40,65,66] these symptoms in a few months, but it may be visually
DLK presents within 24‑48 hours of surgery with peripheral incapacitating for few. The risk factors include large
granular cells in the interface, which progresses to involve mesopic pupil diameter (>6 mm), small OZ, decentered
both the center and periphery (sands of Sahara). Linebarger ablation, central island, flap striae, postoperative residual
et al. described stages of DLK to facilitate timely and refractive error, and DED.[14,73,74] Light rays passing from
appropriate intervention.[66] [Table 1] the peripheral untreated cornea results in blur circles and
affects vision quality. The optical aberrations are measured
Stage 1 and 2 are managed with intensive topical steroid.[66]
using the wavefront or ray tracing aberrometers.
Follow‑up at 24‑48 hrs helps in early identification of cases
progressing to Stage 3. Early flap lift and irrigation of interface Decreasing the pupil size with topical miotics or brimonidine,
with intensive topical steroids in stage 3 reduces the risk of use of tinted CL with an artificial pupil and, topography/
progression to stage 4. There is no benefit of any intervention wavefront‑guided enlargement of OZ are the treatment
in stage 4.[40,66] Microbial keratitis and CTK are the differential options.[14,75] The use of tear supplements or punctal plugs
diagnosis. benefits patients with DED.
Prophylaxis Prophylaxis
Preoperative screening and management of OSD and Screen for mesopic pupil diameter >6 mm and avoid LASIK in
intraoperative use of powder‑free gloves, drapes to cover lid these cases.[73] A large OZ can be targeted if surgery is planned.
margin, avoiding tear film debris from reaching the interface, Also, a wavefront‑guided LASIK shows better results in cases
and irrigating the interface after flap repositioning is useful. with high preoperative HOA.[76]
Topical steroids should be judiciously used postoperatively.[40]
The used instruments should be cleaned and sterilization x. Reduced Contrast Sensitivity
immediately after the procedure. Contrast sensitivity (CS) better assesses functional VA,
especially in patients complaining of poor vision quality
vii. Pressure‑Induced Stromal Keratitis despite 20/20 VA. Literature shows variable effect of LASIK
Pressure‑induced stroma keratitis (PISK) is also known as on CS.[77] However, majority suggests an initial decrease
pressure induced interface keratitis, interface fluid syndrome, in CS for 1‑2 months, followed by complete recovery by
and pressure induced stromal keratopathy.[67] It is often 3‑6 months.[3,78] The CS is more affected in cases with high
misdiagnosed as DLK, but unlike DLK, it presents >1 week refractive error, m‑LASIK, and high postoperative HOA.[77,78]
after surgery with high IOP, shows a poor response to Wavefront‑guided LASIK results in better CS.[76]
steroids, good response to anti‑glaucoma drugs, and
xi. Microbial Keratitis
absence of inflammatory cells in the interface.[68]
Microbial keratitis is a rare sight‑threatening complication
Patients present with poor vision and pain.[69] Interface haze observed in 0.005%‑0.034% cases with decreased incidence
is noted in mild cases, while severe cases have fluid clefts in over the years.[79–81] [Fig. 8] Based on onset, it is classified as

Table 1: Diffuse lamellar keratitis‑ Staging and management (Lenberger et al.)[66]

Stage Clinical feature Visual acuity Management
1 Peripheral white granular cells in the interface Not affected Aggressive topical steroids
2 Both central and peripheral white granular cells “sands May be Aggressive topical steroids
of Sahara” affected
3 Aggregation of dense white clumped cells involving the Decreased by Aggressive topical steroids +
visual axis with clearing of the periphery 1‑2 lines Flap lift with irrigation of interface
4 Severe lamellar keratitis with stromal melting, fluid Severely ‑
collection in central lamellae, overlying epithelial bullae. affected
 Sahay, et al.: Complications of LASIK
July 2021 1665

early (<2 weeks) and late (2 weeks‑3 months).[80] Bacteria, xii.Transient light sensitivity syndrome
predominantly Staphylococcus, is noted in early infections Transient light sensitivity syndrome (TLSS) is a complication
while atypical mycobacteria, Nocardia, and fungus in late peculiar to FS‑LASIK seen in 1.1%‑1.3% cases.[82] Patients
infections.[80,81] The risk factors include DED, blepharitis, present with good VA and photosensitivity without any
immunocompromised state, contamination of surgical signs of inflammation at 4‑6 weeks.[82,83] The use of FSL
instruments or surroundings, intraoperative epithelial causes more inflammation, and this is hypothesized
defect, use of CL, re‑treatment, and trauma.[81] Patients as the cause of TLSS.[82,83] Topical steroids are used for
present with blurred vision, photophobia, redness, management. Also, topical cyclosporine has shown good
and pain. Clinical examination reveals focal infiltrate results.[82]
confined to the interface that later spreads to the flap and
underlying stroma. Differential diagnosis includes DLK and Prophylaxis
CTK. [Table 2] Reducing laser parameters (by 20‑30%) and increasing
postoperative steroid treatment has shown to reduce the
Management includes flap lift, scraping of bed, and occurrence of TLSS.[82,83]
irrigation of bed with antibiotics (vancomycin for early‑onset
and amikacin for late‑onset). Other than routine stain and Late complications
culture media, Ziehl‑Neelsen stain and Lowenstein‑Jensen i. Regression
media should be used to identify Mycobacteria and Nocardia. Refractive regression, defined as >0.25D shift in refractive
Topical fourth generation fluoroquinolone and vancomycin error, is observed in nearly 30% hyperopes and 5.5%–27.7%
5% are prescribed for early‑onset infections while amikacin myopes.[84] Risk factors include high refractive error, low
2% and vancomycin 5% or topical clarithromycin and 4th RSBT, old age, chronic DED, m‑LASIK, and small OZ.[84,85]
generation fluoroquinolone for late‑onset. [80,81] Besides, Compensatory epithelial hyperplasia, decreased flap
oral Doxycycline (100 mg BD) is used to reduce stromal thickness, an anterior shift of cornea, stromal remodeling,
collagenolysis. Steroids are discontinued.[80,81] Treatment should and lenticular nuclear sclerosis are hypothesized to result
be reviewed following the availability of culture and sensitivity in refractive regression.[84,85]
reports. In severe keratitis, flap amputation is needed for both
diagnostic and therapeutic purposes. Management includes IOP lowering agents like timolol
that reduces anterior shift of cornea.[86] However, the effect
Prophylaxis is temporary and reverts on cessation of treatment. Surgical
Preoperative screening and treatment of OSD. Use of sterile treatment options include LASIK enhancement, PRK, and
gown, mask, cap, and gloves by surgeon and assistant. Proper laser‑assisted sub‑epithelial keratomileusis (LASEK).[84] Careful
sterilization of instruments, betadine preparation of lid, and eye RSBT calculation is essential in these cases to avoid corneal
and use of separate instruments for both eyes reduce its risk.[80] ectasia.

Table 2: Differentiating Features Between Post‑LASIK Microbial Keratitis and Diffuse Lamellar Keratitis
Post‑LASIK Microbial Keratitis Diffuse Lamellar Keratitis
Etiology S. epidermidis, S. aureus, S. pneumonia, Sterile inflammation
atypical mycobacteria, Fungi, Nocardia
Onset >2‑3 days after surgery <24 hours after surgery
Symptoms Moderate‑severe pain & photophobia Mild pain and photophobia
Lid edema Moderate‑severe Mild
Conjunctival congestion Moderate‑severe Mild
Location of infiltrate Interface (later involves the flap & stroma) Confined to the interface, begins in the flap periphery
Appearance Focal area of infiltration surrounded by Interface inflammation initially involving the periphery and later
diffuse inflammation both center and periphery “Sands of Sahara” appearance
Anterior chamber reaction Present Absent

Table 3: Grading and Management of Epithelial Ingrowth (Probst and Machat grading)[88]
Grade Signs Location Progression Treatment
1 1‑2 cell thick fine growth with a white demarcated line along Within 2 mm of the No Not required
progressing edge; Difficult to identify on slit‑lamp examination flap edge
2 Thick growth showing discrete cells in the epithelial nest with no Within 2 mm of the Yes Required within
demarcation line; Flap edge may be rolled or grey in appearance flap edge 2‑3 weeks
3 Several cells thick opaque ingrowth with no demarcation line; >2 mm from flap Yes Urgently
The flap may be rolled with whitish‑grey appearance; Peripheral edge required
confluent haze at the flap edge
4 Aggressive growth with epithelial cells advancing towards the Threatening/ Yes Urgently
visual axis; Flap melt may be present involving visual axis required
1666 Indian Journal of Ophthalmology Volume 69 Issue 7

Prophylaxis
Corneal collagen cross‑linking (CXL) performed with LASIK
has shown to reduce the risk of regression.[87] However, these
results need further validation.
ii. Epithelial Ingrowth
Epithelial ingrowth occurs in 0%‑3.9% of cases undergoing
primary treatment and 10%‑20% in re‑treatment
cases. [88] [Fig. 9] Majority present within four weeks;
a b however, a delayed presentation (upto ten years) is
Figure 8: Slit-lamp photograph showing (a) central corneal infiltrate not unusual. [88] Pathogenesis involves implantation
in the interface three weeks following LASIK suggestive of microbial of epithelial cells in interface during surgery or later
keratitis; (b) signs of resolution of keratitis with residual corneal scarring migration from flap edge. Risk factors include EBMD or
after flap amputation and three months of anti-fungal therapy given recurrent erosion syndrome (RES), hyperopia, greater
based on the microbiological report that showed filamentous fungi ablation depth, m‑LASIK, small OZ, re‑treatment, flap fold/
dislocation.[88] Intraoperative faulty instrument handling,
fluid from periphery reaching interface and epithelial
defect adds to the risk. Probst and Machat suggested
a grading system for epithelial ingrowth to guide its
management.[88] [Table 3] Presence of epithelial pearls and
fibrotic demarcation line in the interface and flap melting
a b
are signs of epithelial ingrowth.[88,89] Patients present with
foreign body sensation and glare in early stages, and
diminution of vision in later stages.
Management includes observation for grade 1 and flap
c
lift with mechanical debridement of epithelial ingrowth
d
form interface and flap undersurface in grade 2‑4.[88,89] Also,
Figure 9: Slit-lamp photograph of (a) the right eye two years after mitomycin‑C 0.02% application on the interface, fibrin glue
LASIK showing white opacity extending up to 2 mm inside from the
application at flap edge, BCL placement, and flap suturing
flap edge suggestive of grade 2 epithelial ingrowth; (b) ASOCT image
prevents its recurrence, which occurs in one‑third cases.[88,90]
of the same eye showing increased flap thickness with interface
hyperreflectivity; (c) the left eye with white opacity extending beyond Recently, low energy (0.6 mJ) Nd‑YAG laser has been used for
2 mm of the flap edge suggestive of grade 3 epithelial ingrowth; management in few cases.[88,91]
(d) ASOCT image of the same eye showing increased flap thickness Prophylaxis
with interface hyperreflectivity
Careful surgical approach avoiding intraoperative implantation
of epithelial cells in the interface and achieving perfect flap
apposition without any folds (especially near flap edge)
reduces its risk.
iii. Corneal Ectasia
Post‑LASIK corneal ectasia is a serious complication
seen in 0.033%‑0.6% cases. [14,92] [Fig. 10] The use of
advanced topography devices and screening criteria
like Randleman ectasia risk scoring system and percent
tissue altered has reduced its incidence. [92,93] The risk
factors include young age, high myopia, thin cornea,
low RSBT, abnormal corneal topography, forme‑fruste
keratoconus, pregnancy, ocular allergy, and eye
rubbing. [94] The onset varies from 1 week to several
years. Patients present with diminution of vision and
refraction shows progressive myopia with astigmatism.
The topographic difference map on serial follow‑up is
instrumental in its diagnosis.
CXL is performed in cases with progressive ectasia.[95]
Visual rehabilitation is achieved with spectacles, RGP CL, or
intra‑corneal ring segments. Advanced cases require anterior
lamellar keratoplasty.

Figure 10: Slit-lamp photograph showing LASIK flap, steep corneal Prophylaxis
contour with central corneal thinning suggestive of post-LASIK corneal Stringent screening criteria for corneal topography reduces
ectasia its risk.[92,93]
 Sahay, et al.: Complications of LASIK
July 2021 1667

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