To any Doctor!
I had lasik on 1/4/01. I immediatly developed SOS. I was treated with pred 4 drops and monitored for 4 days. My conditioned got worse. The Dr. lifted my flaps irrigated and cleaned the area. The SOS has been eliminated. Now my flaps have wrinkled and the Dr. is not sure my refraction was totally corrected. My vision is not improving and is 20/60 in one eye 20/100 in the other. I had astigmatism and vision was -7 in one eye and -5 in the other preop.
Question: What is the remedy for wrinkled flaps? lifting? How long do you wait to lift and is the chance of correcting less the longer you wait? How soon can you have the procedure done again to "touch-up" or correct the refraction and do you wait until then to correct the wrinkling? Any insight or help would be greatly appreciated.

The most important thing at this point is to eliminate the flap wrinkles, which may be the cause of your poor vision. Do not worry about whether your final refractive error will be such that you will not need glasses at this point - because you can always have an enhancement in 306 months.
The problem is that flap wrinkles can cause a significant loss of vision - such that your vision may be poor even with glasses or contacts. I am assuming that the 20/60 and 20/100 vision refer to your "best-corrected vision".
There are a few techniques to fix flap wrinkles - in my experience, I had only a 50% success rate at eliminating wrinkles with:

1. Hydration of the flap with sterile water or diluted BSS
2. Epithelium debridement (this maneuver also puts patients at risk for DLK, so I personally would not consider this an option
3. Straight lifting of the flap and vigorous stretching - the problem here is that the flap has memory, and there is a good chance that the wrinkles will not all be eliminated.

My preferred method is flap suturing. To understand how this works, imagine that your flap is like a wrinkled piece of plain paper. If you wanted to remove the wrinkles, stretching the paper for a few minutes would be inneffective. But if you could place a heavy book on the paper and leave it there for a few days, the paper will eventually flatten out. Flap sutures work by placing the flap on stretch for an extended period of time.
I therefore have personally switched to suturing of the flap for wrinkles that are over 48 hours old. Although some surgeons may think that this is overkill, I have found that suturing the flap has eliminated the wrinkles within 24 hours. Mark Speaker, who is in New York, reported similar excellent results with flap suturing. You should note that the procedure should take around 15 to 25 minutes, and doctors will generally place between 5-7 sutures. The sutures are left in place from a week to a few weeks depending on the amount of time since the LASIK procedure. Postoperatively, a bandage contact lens can be placed so that the procedure is generally very comfortable. I am happy to discuss this technique with any surgeon, although most will be familiar with this.
Again - every case of flap wrinkles is different, so it would be impossible for me to know for sure what the best and most effective technique is.

Best of luck

Bill Trattler, MD
Miami, FL

Dr. Trattler,
I felt it was not prudent to wait any longer so I moved my appt up to this Tues. The Dr. checked my vision - no improvement - then examined my eyes. No change in wrinkles. His recommendation was exactly the same as yours. Lift flaps, suture and contact. My Dr. was highly recommended and has an excellent reputation in Richmond, Va. Though I have had complications, I don't believe them to be a result of inexperience or negligence on the part of my Dr. He has performed over 2000 lasik procedures and has approx 10 that have developed inflammation. But, he has never had to suture flaps to correct wrinkles. He has been doing cornea surgery and transplants for 25 years. He said he is comfortable suturing flaps. Though I agree with his recommendations and am confident in his abilities, how concerned should I be that he has never had to suture flaps. Few complications in the past speaks well of his success, but what about now that I do have complications, I am scheduled for surgery next Tues. Your thoughts would be appreciated.
Thanks,
Byron

Please feel free to have your doctor call my office on Monday, and I will be happy to share my "pearls" regarding flap suturing. The procedure is very straigtforward, but it is helpful to talk with someone who has sutured flaps. He may already be talking with doctors who he knows who are experienced in this area, but if not, please feel free to pass on my number

ext 1085

Best of luck

Bill Trattler, MD
Miami, FL

Thanks for the offer. I will pass along your number.
Byron

I had the flap on one eye sutured on 2/6/01. The results have been great thus far. I still have the sutures and contact in after 6 days. My vision in the one eye is now 20/30 - 20/20. I am scheduled to have the second eye done on 2/19. The vision in this is 20/60. I am hoping for results similar to the other eye. How long should sutures remain in considering the wrinkles have been there for 6 weeks?
Byron

I am so happy to hear that you have had such a positive response with flap sutures so far. I personally have been so impressed with how effective they are.
I can not guess how long your doctor will want to leave the sutures in. I would think the two week level is best from my experience, because they do leave same mild opacification in the peripheral cornea. For one patient with significant wrinkles I did leave the sutures in for 4 weeks, but I two weeks probably would have been fine.

Congratulations again, and best of luck

Bill Trattler, MD
Miami, FL

I had wrinkles in the flaps the day after an enhancement. The doctor re-lifted the flaps the next day and used a machine I believe he called an "adenator" (not sure of spelling) to smooth the flaps. The process made a huge difference for the better.

The ease if eliminating flap wrinkles is related to the lenth of time that they have been present. This is why flap wrinkles need to be addressed immediately.
So when flap wrinkles are seen on day 1 and fixed, the procedure can be very simple - just repostion the flap with some stretching. There are some instruments that are used (such as the one LT mentioned) that hel smooh the flap.
But if flap wrinkles are left in place for weeks to months, then simple flap lifts will often be unsuccessful. This is because the wrinkles become almost "locked in". So smoothing of the flap will often be unsuccessful, and more invasive methods are required to remove the wrinkles, such as flap suturing.

I hope this helps

Bill Trattler, MD
Miami, FL

Dr. Trattler,

I had my second (right) eye sutured a week ago Monday and the sutures removed from my left eye. I am scheduled to have the sutures removed from my right eye on Friday March 2. Inflammation and wrinkles appear to be gone. It does appear now that I have 20/40 vision in my left eye. The refraction was not totally corrected. I understand this is normally "touched-up." Given the 8 weeks of inflammation, flap relifts and sutures, should I even consider going through a flap lift again? I would assume because I have had problems, I have an increased chance of having problems again. Any thoughts?

Isn't 306 months a long time to wait for an enhancement?

I had initial Lasik on 1/4/01. It is now 60 days later - and i need to decide if enhancement is necessary.

It sounds like you have had alot of work done on your eyes. Most experts would recommend that you wait a minimum of 3 months after your last procedure to see how the eye has responded. The eye does require time to heal. Once things heal, you can decide whether you want to risk an enhancement. It may be best to give lots of time and see where things end up - perhaps with time things will improve enough on their own so that an enhancement will not be necessary.

Best of luck

Bill Trattler, MD
Miami, FL

That too seems to be what my Dr. thinks. I still have sutures and a contact in my right eye (20/30). I am scheduled on Thursday to have them removed. That will be 17 days with sutures in that eye. I had them in for 13 days in my left eye (20/40). Thanks for your advice.
Byron

Dr. Trattler,
I had an eye appointment last week. My vision with all sutures removed is 20/30 to 20/40. Vision in both eyes is -1 with some astigmatism still in one eye. I also have a wrinkle in one eye while the other is wrinkle free. The plan is to wait eight weeks - 3 months from the last procedure, and then take measurements again. My doctor then plans to lift the flaps and "touch-up" both eyes. He plans to put sutures in the eye with a wrinkle and leave it for 3 days. My question is - Am I crazy to go through the procedure again with all of the problems I have had. Should I be happy with my 20/40 vision and get a new set of contacts? I would appreciate your thoughts.
Thanks,
Byron

It is too early to know whether an enhancement would be helful for you. It depends on what your refraction is and how much better the refraction makes you. I just can not answer this question without being able to see and examine you.
But I understand your concern. The key is patience.

Best of luck

Bill Trattler, MD
Miami, FL