眼科醫療-雷射近視
之感受
鄭永豐
雷射近視手術的演變歷史
雷射近視手術









放射狀角膜切開手術(RK)
上角膜晶片(Epikeratophakia)
準分子雷射(Excimer)
雷射屈光角膜切削術(PRK)
雷射原位層狀角膜塑形術(LASIK)
雷射上皮細胞下角膜切除術(LASEK)
基質內雷射光角膜切除術(IPAR)
雷射熱角膜切除術(LTK)
角膜塑形術(OK)
「雷射原位層狀角膜重塑術」





現代近視手術的主流
Laser in situ keratomileusis，簡稱LASIK。
層狀角膜手術結合了準分子雷射
美國衛生署 (FDA) 經過6年多之臨床評估,終於
在 1995年開放了常規使用，我國也跟在1995年
有限度開放使用 (visx)。
IBM公司發明用以切割晶片的「準分子雷射」
於眼角膜上 (Trokel) 。
BASIC PRINCIPLES of
LASIK
LASIK PRINCIPLES
Goals

Use of Excimer Laser
 Use of microkeratome
LASIK Flap Thickness
LASIK PRINCIPLES
Why LASIK?

1st step in PRK is removal of surface
cells with brush, spatula, or laser
 1st step in LASIK is creation of thin flap
of cornea with microkeratome
 Remainder of procedure is the same
Flap
Laser sculpting
LASIK
“Perfect” Flap Characteristics

No epithelial damage
 Smooth bed
 Consistent diameter and thickness
 ?Predictable effects on topography and
refraction
– Influence of positioning, thickness, shape
LASIK PRINCIPLES
Excimer Laser
DIAPHRAGM
DISC
LASIK Principles
Laser Complications
Undercorrection-occurs when the laser has not
removed an adequate amount of tissue




Aftershave/perfume and/or any other scented
products
Tissue density and composition which can
modify the effect of the laser and the resulting
amount of tissue removed
Room Temperature and Humidity
Regression - In some instances, during the
healing process, portions of the treated tissue
returns to it's original state thus reversing the
results of the treatment
LASIK
Patient Preparation

Valium 5-10 mg 1 hr preop
 Ocuflox or ciloxan
 Tetracaine 1% X 3
 Prep eye with Betadine
– Blot to avoid Betadine
beneath flap

Drape eye
LASIK Procedure

Assemble microkeratome
(組合角膜板層刀)
LASIK Procedure

Check suction
 Check microkeratome
LASIK Procedure

Place speculum and assure good
exposure
– Cover lashes
– Avoid skin folds
LASIK Procedure

Mark cornea to facilitate flap
realignment
LASIK Procedure

Place suction ring
– Decenter slightly nasally (1mm) to give
good exposure to laser beam
LASIK Procedure

Avoid lid speculum and assure path for
microkeratome is clear
–
–
–
–

Speculum
Lashes
Drape
Conjunctiva
Chin up/chin down
LASIK Procedure

Assure complete suction
– Check with tonometer
– Avoid false meniscus

Warn patient that vision may darken
LASIK Procedure

Wet cornea with artificial tears, filtered
BSS, proparacaine
 Remove excess with dry sponge
LASIK Procedure

Advance microkeratome by tapping
pedal
LASIK Procedure

Stop suction
 Remove suction ring
 Place “flap protector”
LASIK Procedure

Flip flap back
– Spatula, McPherson forceps
– Place over moist cellulose sponge
LASIK Procedure

Apply laser
– Nomogram

Can remove foot from pedal and
resume as needed
– With LADARVision, do not place
instruments in field
LASIK Procedure

Replace flap
 Dry versus wet technique
LASIK Procedure

Gently float flap into position
LASIK Procedure

Stroke flap gently
LASIK Procedure

Dry gutter, assure symmetry
 Wait 3-5 minutes for flap to read here
 Endothelial pump dehydrates flap,
causing adherence
LASIK Procedure

Inspect for folds, sublamellar debris
LASIK
Postoperative Care

Place antibiotic, corticosteroid, NSAID
 Remove lid speculum with care
LASIK
Postoperative Care

Examine at slitlamp
– Check flap position and adherence
– Check for folds
– Check for debris
LASIK
Postoperative Care

Place clear shield, no patch
 Use antibiotic/steroid QID X 1 week
LASIK
Postoperative Course

Rapid visual recovery
 Pain is minimal
LASIK
Postoperative Care

Postoperative visits
– 1 day
– 1-2 weeks
– 2-3 months
– 6 months
– 1 year
雷射近視手術病人品質安全指引
一、施術醫師品質管控
 二、雷射儀器每月定期維護保養及較正
 三、手術耗材品質管控：
如手術用刀片必須更新

眼科醫學會監控
 公告於醫學會網站：wwwophorgtw

高價雷射醫療器材之管控
健康商品化與醫病關係：
（Commodification of Health and the DoctorPatient Relationship: An Economic
Sociological Critique）(成大 許甘霖 助理教授)
 健康商品化趨勢下醫 病關係中醫師自主性的弱
化；
 ＜轉虛弱的病人為有力的消費者？健康商品化
與公民權初探＞（From Weak Patient to
Powerful Consumer? Preliminary Remarks on
Commodification of Health and citizenship），
「公民權/統治術工作 坊」（東海大學）
 主要探討健康商品化 趨勢下的病患權益的弱化。

併發症機率

輕症
眼症乾燥，敏感 …
< 5/100

重症
< 1~2/1000
(醫療爭議個案比白內障手術少)
Lasik Complications
Types of Complications

Intraoperative
 Postoperative
Intraoperative Complications

Partial Flap
(部份層狀角膜瓣)
– Motor Failure
– Obstacle
– Assembly
Intraoperative Complications

Irregular Flap / Bed
– Manual Keratomes
– Gears
– Blade Quality
– Dirty Rings / Head
Intraoperative Complications

Epithelial Abrasions
– Excessive Dye / Anesthetic
– Dehydrated Epithelium
– Blade Quality
– Dirty Head
Intraoperative Complications

Intraoperative Bleeding
– Flap Diameter Too Large
– Contact Lens Users
Intraoperative Complications

Suction Loss
– Pump Failure
– Defective Ring
– Ring / Eye Compatibility
– Rough Handling
Intraoperative Complications

Free Cap
(層狀角膜瓣斷落)
– Suction Loss
– Very Flat K’s
– Ring / Eye Compatibility
– De-centered Ring
Intraoperative Complications

Button Hole
Intraoperative Complications

Button Hole
Intraoperative Complications

Button Hole
Intraoperative Complications

Button Hole
Intraoperative Complications

Button Hole
Intraoperative Complications

Button Hole
Intraoperative Complications

Button Hole
Intraoperative Complications
Button
Hole
Postoperative Complications

Corneal Ectasia
– Misread Pachymetry
– Poor patient selection
(角膜擴張)
Postoperative Complications

Dislocated Flap
– Poor Adhesion
– Eye Rubbing
Postoperative Complications

Flap Striae
– Flap Displacement
– Eye Rubbing
– Overseen
Intraoperatively
Postoperative Complications
Whrinkled
and Dislocation
Postoperative Complications

Diffuse Lamellar Keratitis (DLK, SOS)
– Inflammatory Response
48hours
Grade 3
Postoperative Complications

Epithelial Ingrowth
– Flap Displacement
– Intraopertive Flap Mismanagement
Postoperative Complications

Stromal Melting
Grade 4 epithelial
ingrowth with edge melt
at the 8 o’clock position,
2 months after LASIK
Grade 4 epithelial ingrowth
with a severe edge melt at
the 4 o’clock position, 6
months after LASIK
Postoperative Complications

Stromal Haze (scar)
Postoperative Complications


Infection
Prevention








Use talc free gloves
Broad spectrum antibiotic coverage
Appropriate lid prep prior to surgery
Treat blepharitis prior to procedure
Eye make-up and swimming should be avoided 2 weeks
preoperatively
Proper cleaning and sterilization of instruments
Avoid excessive intraoperative irrigation which causes an
influx of debris in interface
Use sterile technique
Postoperative Complications

Avoid complications that encourage
infections
– Dislocated flap
– Lost flap
– Perforated flap
– Epithelial ingrowth
– Corneal melting
– Debris in the interface
Postoperative Complications

Interface Debris
綜合討論