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Interview answers for Ophthalmology Management magazine

By Andrew Holzman on February 10, 2010

  • 1-3) LASIK eye surgery today is safer than ever. Thanks to many improved protocols, including better and more predictable pre-operative exams, improved pre-op medications to better prepare the patient for surgery, and greatly improved technology which we use during the procedure, serious complications are largely avoidable. For this reason, many of us thankfully do not see severe sight-threatening complications occurring within our practices. Of course, all surgeons still worry about the risk of ectasia following refractive surgery, but even this complication is becoming rarer. This is due to improved elevation-based mapping systems such as the Pentacam, better enabling us to find the non-candidates, as well as thinner profile, small diameter, planar shaped flaps which we are able to create with the Intralase. This has led to corneas which are more structurally stable than in the past, when the bladed keratomes disrupted the anterior corneal lamellae with a deeper cut. • We should categorize complications into either sight threatening or non sight threatening. Sight threatening issues are complications such as ectasia, corneal scarring, infection and severe inflammation. Ectasia is becoming less of a risk for the reasons mentioned above as well as the re-emergence of PRK in many surgeon's armamentarium. Improved medication protocols and enhanced laser ablation algorithms have made PRK a much better procedure than in the past, giving us another good option for correction of refractive errors when the cornea appears slightly thinner than normal. 
 Corneal scarring has become very rare due to the fact that lamellar procedures such as LASIK can be performed with a Femtosecond laser, obviating the need for a bladed microkeratome. Buttonholes and short, scarred flaps are no longer part of our “worry list” . We can see a very rare case of vertical gas breakthrough during an Intralase flap, but these are almost always still liftable flaps, and if not, conversion to PRK without scarring is the norm. Corneal haze from a PRK procedure is still possible but also very rare due to the widespread use of Mitomycin C intraoperatively. In my practice we limit our PRK patients to 7 D of myopia or less, and 3 D of hyperopia or less. I recommend vitamin C for our patients both pre and post op, and we are also very vigilant in recommending UV protection sunglasses for the patients post op PRK. These are recommended for 6 months. We have noticed that patients with more darkly pigmented skin and patients from regions with high UV exposure appear to be at higher risk. For this reason, we use Mitomycin C on all PRK’s in patients such as these, on patients with occupational UV exposure, and on all ablations deeper than 50 microns. Infection thankfully is very rare in our practice. We use preoperative flouroquinolones prophylactically, and are careful in pre-treating lid and surface conditions which predispose the patient to Keratitis. We frequently employ lid hygiene along with Doxycycline po bid and/or Azasite bid for one week in order to help decrease blepharitis and meibomian gland disease. Eyelid prep with Betadine, gloved sterile technique, lid draping and attention to post op instructions are in my opinion all very important in preventing infection. Severe inflammation such as stage 3 or 4 Diffuse Lamellar Keratitis can be sight threatening and lead to reduced BCVA, but as with most other complications today, prevention is the key to avoiding them. Attentive detail to ensuring epithelial integrity decreases the risk of epithelial disturbance and therefore also reduces DLK risk. i just recently completed a study of several hundred eyes (to be presented at this year's Boston ASCRS) in which we found that treating patients with preoperative hyperosmotics prior to LASIK is associated with a statistically significant reduction in epithelial disturbance in patients greater than 35 years of age. Hyperosmotics pre op is the norm in my LASIK practice and we believe this helps to reduce inflammatory conditions post operatively. We also use both steroids and non-steroidal medications. I begin Xibrom BID one day preop and continue this for the first 3 days post op, and add Pred Forte Q2 for the first day post op, followed by QID for the rest of the week. These medications work synergistically by attacking on both arms of the prostaglandin cascade, thereby reducing inflammation better than using either one medication alone. Two complications that can be sight threatening but are now rarely seen in our practice are micro/macrostriae of the flap and disabling glare due to optical zone/pupillary disparities. Striae of the flap is usually preventable by maintaining careful attention to detail when replacing the flap into its bed, and by ensuring adequate lubrication in the immediate post op period. Due to the steep side angle architecture of the flap created by the Intralase, we are able to make a flap which fits into the bed similar to the manhole cover fitting into a manhole. This is a big improvement over other keratomes which create beveled side cuts, allowing easier slippage and are more prone to minor trauma. I prefer a superior hinged flap as I believe the natural blink is more smoothing when the hinge is superior, as opposed to the perpendicular vector forces applied to the nasal or temporal hinged flaps on strong blinking or squeezing of the lids. I also place a drop of Celluvisc post op and tell the patients to use a drop of it just prior to taking a 3 hour nap after the surgery. This prevents the lid from 'sticking' to the underlying flap during sleep. It is important to limit patients naps post op to 3 or 4 hours max, as more than that can lead to lid/flap adhesion from dehydration and lack of adequate lubrication. Post op glare used to be a much greater concern for our patients, but now is not on the "worry list" due to major advances in our laser technology. Greatly improved ablation patterns with both custom and wavefront optimized algorithms have decreased the risk of glare substantially. Well tapered transition zones, larger optical zones, highly optimized tracking systems, and improved centration techniques help as well. There have been many recent studies which refute the claim that larger pupil diameters are associated with increased glare risk. Most of these same studies concluded that it was the correction amount and not the pupil size which had correlation with post op glare. We definitely see more glare in these high correction patients in the early post op period, but after several weeks, the glare has largely subsided. Larger pupils do not seem to be a problem, and are certainly not as menacing as we once thought. Adequate pre operative counseling concerning any increased risk is essential as part of a thorough informed consent. Non sight threatening complications are more common, and by far the most commonly encountered is post operative dry eye. Even though we see it commonly, the severity of the dry eye and the frequency is far less than what we used to see when using bladed microkeratomes. By making thinner profile flaps with the Intralase we are able to avoid more of the corneal nerve plexus, leading to less dry eye. We also utilize pre-operative Restasis frequently and screen our patients carefully in order to diagnose who may be at most risk for dryness. Thankfully, the dry eye we see today is temporary and most always easily treated. We like to start Restasis a minimum of 2 or 3 wks preop, and then continue on with it for at least 3 months post op. Patients at greatest risk for dry eye are hyperopes, patients over 40 yrs of age, patients with wide palpebral fissures, heavy computer users and patients living or working in very dry environments. We pre-treat all of these patients with Restasis and also recommend Omega 3 fatty acids, flaxseed oil and avoidance of both wind and air vents blowing in the face. Environmental factors are very important in the correct diagnosis and treatment of dry eye syndrome. Work environment and computer habits are among the most important. Frequent lubrication is emphasized and I like to employ Celluvisc in the evening for dry eye patients. Punctal plugs still have their place and I prefer to use the Silicone variety preop in the more severe dry eye patients. It is important to treat the dry eye in advance and make the condition manageable. Epithelial ingrowth is almost never seen in primary cases done with the Intralase, and this is due largely to the side cut angle and the flap architecture. A secure fit into the bed with crisp edges and an angle of 65 degrees or more make ingrowth very unlikely. However, cellular ingrowth is more common in enhancement cases and although not usually sight threatening, sometimes may need to be removed. Preventing ingrowth during enhancements requires delicate handling of the epithelium, as any disruption can lead to both ingrowth and DLK. Many times, a decision is made not to lift the original flap and instead either perform PRK on top of the flap with Mitomycin or create a new sidecut with the Intralase. Both of these techniques are very effective and safe, and decrease the risk of lifting an older, microkeratome based flap. Over and under response to the laser energy continues to be seen on occasion. The current enhancement rate in my clinic is less than 1%, however some clinics report enhancement rates in the range of 5-10%. I believe that adherence to strict operating room protocols, maintaining the operating room environment with stable temperature and humidity, and calculating all the treatments on my own without relying on other personnel for that task have allowed me to keep enhancements to a minimum. A consistent technique and a staff that operates well together will help ensure that each and every procedure is done exactly the same, under the same conditions. These are very helpful in providing the best, most consistent results. 4) When a problem does present itself, the most important thing is honesty. It is always best to not only explain what is going on, but sometimes also illustrate the issue for the patient. I find it important to also include the spouse in these discussions, as patients sometimes are too distracted to hear what you are saying. Work hard to develop a relationship and a rapport with your patients. This shouldn't be hard, but can be difficult for many physicians. We want our patients to relax during the surgery as it makes our jobs easier-- a patient who trusts and believes in you is much more likely to relax during your surgery and be patient with a less than expected result should something rare occur. As to informed consent preop, I always make sure to answer all questions that the patient may have and then discuss any particular special risk that the patient presents with. Make sure to document this discussion well on the chart. I have always given my patients a "pop quiz" on the day of surgery. It is a 10 question True/False quiz that is quite easy if the patient has read the consent and has a good basic understanding of the procedure. Any questions that they may answer incorrectly are of course addressed and if they miss more than two questions, we have to reset. This has only happened a few times as most of our patients are very involved in their care and seem to be very educated about the process. Fortunately, complications are so rare today that the informed consent process has become less stressful for both the patient and the surgeon. By turning away high risk patients and non-candidates, by performing careful surgery with experienced hands and advanced technology, us LASIK surgeons have much less to worry about today! 5) Many patients get concerned about what they hear in the media, but I happen to practice in a highly educated market, where patients do their own research. Most of our patients know that Laser Vision Correction has gotten much better over the last decade and that the safety of the procedure has improved dramatically. I invite the FDA's inquiry into quality of life post LASIK. My belief is that they will find the overwhelming majority of LASIK patients are thrilled with the results and almost all will say that they would do the procedure again. Most of the unhappy patients that presented to the FDA were done with older technology. Dry eye was much worse when we didn't have the Intralase to create the flap. Striae and decentrations leading to glare are also very uncommon today due to advances in technology. We LASIK surgeons should encourage the media and FDA to look at our procedure again, as this time they will find a much better and safer procedure. Andrew E Holzman, MD FACS Medical Director TLC Laser Eye Centers- McLean, Va. andrew.holzman@tlcvision.com

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