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Lasik Buttonhole Flap

Complication of Lasik and Bladeless Lasik when the corneal flap is incomplete.

Image of Lasik flap with interface broken through; buttonhole flap.  
Arrows show a Lasik buttonhole flap in front of patient's pupil and made visible with special illumination.  

A buttonhole flap is a relatively rare but known complication of Lasik or Bladeless Lasik caused when the microkeratome passes through the top of the cornea while creating a flap of corneal tissue.

Lasik Flap

The first step of Lasik is the creation of a thin flap of corneal tissue. A microkeratome is affixed to the eye with suction and a blade or laser energy passes underneath to create the Lasik flap. If the microkeratome blade or laser energy cuts too thin, the flap is incomplete with a "hole" in the center that often resembles a buttonhole.

Loss of Suction

Buttonhole flaps are most often caused by loss of suction of the ring that holds the microkeratome to the eye. The usual response is to stop the surgery, replace the flap, protect the flap with a bandage contact lens for a few days, then if all heals well about three months later do the surgery again. The vast majority of people who have buttonhole flaps have no long-term problems and are able to have Lasik, PRK, or LASEK after the flap has sufficiently healed. While healing the doctor will monitor the flap to watch for epithelial ingrowth or other concerns.

Additional Factors

A flat cornea and eyes with small orbits tend to be more prone to buttonhole flaps, however buttonhole flaps are possible with any Lasik or Bladeless Lasik - even if the probability is low. If the probability of a buttonhole flap is elevated, the doctor may recommend PRK, LASEK, or Epi-Lasik as an alternative.

Mechanical v Laser Flap

Conventional Lasik with a mechanical microkeratome may be more likely to create a buttonhole flap than Bladeless Lasik with a laser microkeratome. The more planar shape of the Lasik flap created with a femtosecond laser may be more appropriate, as determined by a surgeon.

Looking For Best Lasik Surgeon?

If you are ready to choose a doctor to be evaluated for conventional or custom wavefront Lasik, Bladeless Lasik, PRK, or any refractive surgery procedure, we recommend you consider a doctor who has been evaluated and certified by the USAEyes nonprofit organization. Locate a USAEyes Evaluated & Certified Lasik Doctor.

Personalized Answers

If this article did not fully answer your questions, use our free Ask Lasik Expert patient forum.

Recent Lasik Buttonhole Flap Medical Journal Articles...

Related Articles

One-step transepithelial photorefractive keratectomy with mitomycin C as an early treatment for LASIK flap buttonhole formation.

J Refract Surg. 2015 Jan;31(1):48-52

Authors: Abdulaal MR, Wehbe HA, Awwad ST

PURPOSE: To assess the efficacy and safety of early one-step transepithelial photorefractive keratectomy (PRK) with mitomycin C as treatment for buttonhole formation during LASIK.
METHODS: Eight patients who developed a buttonhole during LASIK with mechanical or femtosecond flap creation underwent one-step transepithelial PRK a few days after the formation of the buttonhole. The re-treatment procedure was performed after complete epithelial healing and smooth epithelial fluorescein profile were ensured. Postoperative manifest refraction, uncorrected and corrected distance visual acuity, and haze formation were assessed during 6 months of follow-up.
RESULTS: Mean duration of the re-treatment procedure after buttonhole formation was 5 days (range: 4 to 7 days). Mean manifest refractive spherical equivalent and cylinder refraction were -0.05 ± 0.18 and -0.18 ± 0.22 diopters, respectively, at 6 months postoperatively. Uncorrected distance visual acuity was 20/20 in all patients after 3 months of follow-up. No haze formation was detected.
CONCLUSIONS: Early one-step transepithelial PRK with mitomycin C seems to be a safe and effective treatment for LASIK buttonhole complication.

PMID: 25380555 [PubMed - indexed for MEDLINE]


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