Mitomycin-C assisted photorefractive keratectomy in the treatment of buttonholed laser in situ keratomileusis flaps associated with epithelial ingrowth Suphi Taneri, MD, Jo ¨rg M. Koch, MD, Samir A. Melki, MD, PhD, Dimitri T. Azar, MD The prophylactic intraoperative use of mitomycin-C (MMC) to prevent haze and scarring after ex- cimer laser surface ablation (phototherapeutic/photorefractive keratectomy [PTK/PRK]) in an eye with a previous laser in situ keratomileusis (LASIK) flap buttonhole with epithelial ingrowth is de- scribed. A well-centered buttonhole measuring 2.0 mm in diameter was cut within a thin LASIK flap in an amblyopic eye. Over the next 8 weeks, corneal haze and progressive epithelial ingrowth formed centrally. An early transepithelial PTK/PRK approach was chosen to manage the button- hole together with the epithelial ingrowth and to treat ametropia before the onset of scarring. The approach included epithelial removal with PTK, application of MMC 0.02% for 1 minute, irri- gation, a short waiting period to allow for diffusion, PRK correction of ÿ4.0 diopters without nomogram adjustment, and bandage contact lens. A regimen of prednisolone acetate 1% and ofloxacin 0.03% 5 times a day for 1 week (steroid tapered) was prescribed. Epithelial ingrowth was removed successfully. Minimal haze formation was visible 2 weeks after the retreatment but did not reduce best spectacle-corrected visual acuity (BSCVA) and resolved within the next few weeks. After 6 weeks, uncorrected visual acuity was equal to BSCVA preoperatively (20/50). There was no evidence of recurrent epithelial ingrowth or central scarring after 24 months. Transepithelial PTK/PRK was effective in managing central epithelial ingrowth in a buttonholed LASIK flap. Prophylactic intraoperative use of MMC may reduce haze formation and corneal scarring in early treatments and may also prevent recurrent epithelial ingrowth. This approach may offer faster visual recovery and no risk for a repeated buttonhole creation compared with the widespread recutting a new flap after a couple of months. The optimal appli- cation time and concentration of MMC need to be established. J Cataract Refract Surg 2005; 31:2026–2030 Q 2005 ASCRS and ESCRS Intraoperative flap complications are among the risks of la- ser in situ keratomileusis (LASIK) most feared by both pa- tients and surgeons. A doughnut-shaped or buttonholed flap has been reported in 0.3% to 2.6% of cases. 1–3 Al- though most flap complications such as free caps and short flaps usually do not cause long-term loss of vision, button- holed flaps are the flap complication most likely resulting in significant loss of visual acuity. 1,2 The conventional man- agement is to carefully reapproximate the flap with the stromal bed and defer laser ablation for several months. A new flap is then created and the refractive error treated. Several disadvantages of this strategy led to the search for superior techniques. We report a case of a LASIK flap but- tonhole leading to central epithelial ingrowth and discuss its management with transepithelial phototherapeutic/ photorefractive keratectomy (PTK/PRK) assisted by the in- traoperative use of mitomycin-C (MMC) to prevent haze and scar formation and recurrent epithelial ingrowth. CASE REPORT Contact lens intolerance developed in a 22-year-old healthy woman with no significant medical history and a stable refraction. The patient elected to have LASIK in the amblyopic left eye for the treatment of myopia and anisometropia. The best corrected visual acuity (BCVA) was 20/20 in the right eye and 20/50 in the left eye. The manifest refraction was plano in the right eye and ÿ4.0 sphere in the left eye. The cycloplegic refraction was plano ÿ 0.37  96 in the right eye and ÿ4.0 ÿ 0.62  63 in the left eye. Orbscan IIz analysis (Version 3.14, Bausch & Lomb) showed normal topogra- phy in both eyes. Keratometry was 46.3/46.0 in the right eye and Q 2005 ASCRS and ESCRS Published by Elsevier Inc. 0886-3350/05/$-see front matter doi:10.1016/j.jcrs.2005.06.035 2026 J CATARACT REFRACT SURG - VOL 31, OCTOBER 2005