title: Secondary microkeratome-induced flap interference with the pathway of the primary flap.
abstract: OBJECTIVE
  To report a flap-related complication that occurs when a secondary microkeratome pass interferes with the pathway of a complicated first microkeratome pass.
  
  
  METHODS
  Small, retrospective, noncomparative, interventional case series.
  
  
  METHODS
  Three patients.
  
  
  METHODS
  In three cases, each patient experienced a different flap-related complication with the original surgery, followed by interference of a secondary flap with the primary. The first patient experienced a free cap, followed by an interference of the secondary flap at the nasal portion of the free cap. The second patient experienced a buttonhole, followed by secondary flap interference in the superior quadrant adjacent to the buttonhole. The third patient experienced a decentered flap originally, followed by secondary flap interference temporally.
  
  
  METHODS
  Visual result after secondary microkeratome-induced flap-related complications.
  
  
  RESULTS
  All three patients had poor best spectacle-corrected visual acuity on the first postoperative day, with subsequent visual recovery. All three patients had induced flattening on keratometry along the axis where stromal tissue was removed. In addition, two patients required multiple enhancements to achieve desired visual outcomes.
  
  
  CONCLUSIONS
  Complications related to the primary microkeratome pass add further risk for complications to arise during a second microkeratome pass. A secondary microkeratome pass should be attempted only if the original flap cannot be identified, if it is the result of primary flap complication, or if the desired treatment zone is notably larger than the diameter of the original flap. Intraoperative pachymetry of the residual stromal bed should be performed routinely. It is important to examine the stromal bed closely for loose or displaced slivers of tissue and to remove them before excimer treatment.
authors.affiliation: Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
authors.forename: Navin H
authors.initials: NH
authors.lastname: Tekwani
authors.forename: Maria Regina
authors.initials: MR
authors.lastname: Chalita
authors.forename: Ronald R
authors.initials: RR
authors.lastname: Krueger
mesh_terms: D000328:Adult; D003319:Corneal Stroma / Q000601:surgery*; D019781:Corneal Topography; D005260:Female; D006801:Humans; D007431:Intraoperative Complications; D020731:Keratomileusis, Laser In Situ / Q000009:adverse effects* / Q000295:instrumentation; D008297:Male; D008875:Middle Aged; D009216:Myopia / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000009:adverse effects*; D014786:Vision Disorders / Q000209:etiology*; D014792:Visual Acuity