Management of Severe Epithelial Ingrowth Following KLEx Using Crocodile-Forceps Extraction: Surgical Technique and Literature Review.

Background: Epithelial ingrowth is an uncommon but potentially vision-threatening complication after keratorefractive lenticule extraction (KLEx). Although this complication is well described after flap-based refractive surgery, its occurrence after flapless lenticule extraction remains rare and is mainly reported in isolated cases. This narrative review summarizes the available literature on epithelial ingrowth after KLEx, with particular attention to proposed mechanisms, clinical presentation, imaging findings, and surgical management. An illustrative case of severe epithelial ingrowth managed with crocodile-forceps extraction is also presented. Methods: A literature search was performed to identify published reports describing epithelial ingrowth after SMILE/KLEx. Relevant articles were reviewed and compared with regard to onset, suspected mechanism, clinical severity, treatment strategy, anatomical outcome, visual recovery, and recurrence. Results: The affected eye developed extensive epithelial ingrowth associated with a postoperative tunnel laceration and marked visual deterioration during the first postoperative week. Surgical clearance through the original incision was performed using crocodile forceps followed by copious interface irrigation. Approximately one hour after treatment, AS-OCT demonstrated complete clearance of the hyperreflective interface material, corneal topography showed marked regularization, and wavefront aberrometry demonstrated a reduction in overall OPD RMS from 1.21 to 0.58 µm and higher-order RMS from 1.03 to 0.37 µm at a 4 mm pupil. Visual acuity subsequently improved over the following postoperative days, with no recurrence during 6-month follow-up. Conclusions: Severe epithelial ingrowth after KLEx may require prompt surgical intervention when rapid progression and visual deterioration occur. In this case, crocodile-forceps-assisted interface clearance through the original incision was feasible and was associated with rapid anatomical and optical recovery without cap-to-flap conversion or chemical adjuvants. Further cases are required to determine the reproducibility, safety, and long-term outcomes of this approach.