Refractive Surgery
The History of Refractive Surgery
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Forerunners to Modern Refractive Surgery
o Leonardo da Vinci- Early 16th C
 Italian scientist, philosopher, artist
 Contemplated the possible source of visual disturbances.
o Johannes Purkinje
o Hermann Snellen- 1869
 Dutch Ophthalmologist
 Proposed using incisions across the steep meridian of the cornea to
flatten it. Also hypothesized the concept of astigmatism.
o Hjamar Schiotz- 1885
 Norwegian Ophthalmologist
 First to make “Limbal Relaxing Incisions” in a patient who
underwent cataract surgery, altering the shape of the human eye.
Incisions made in the steep corneal meridian flattened it.
Early Non-Surgical “Techniques”
o Eye cup with a spring-powered mallet designed to flatten the cornea (early
ortho-K?)
o Firm rubber bands to flatten the cornea.
Lans- 1898
o Dutch Physician
o First to think of changing the shape and power of the cornea by making
incisions on the anterior corneal surface. This defined the principles of
“keratotomy” surgery to correct refractive errors.
Tsutoma Sato and the early 1930s
o Japanese Ophthalmologist.
o In 1939, he observed that the spontaneous breaks in Descemet’s
membrane in keratoconus patients produced a flattening of the cornea. He
also observed that the flattening of the cornea due to injury to Descemet’s
membrane was greater than that caused by injury to Bowman’s layer. This
lead Sato to conclude that surgery on the posterior cornea would be more
effective than surgery on the anterior cornea. He became the first to
perform surgeries on the cornea (refractive keratotomy) to help correct
myopia.
o In the early 1950s, Japanese patients would receive as many as 80
incisions on the anterior and posterior cornea to correct myopia and
astigmatism. The role of the corneal endothelium to maintain corneal
thickness and clarity was not fully understood in Sato’s time. Many
patients eventually suffered severe corneal edema requiring corneal
transplantation.
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Jose Barraquer- 1940s
o Columbian Ophthalmologist, One of the fathers of lamellar surgery.
o Barraquer performed a procedure called keratomileusis in which he
removed a section of the anterior cornea, similar to today’s flap, via an
instrument that he invented called a microkeratome. This was handcranked. He then froze it, reshaped it with a cryolathe, and then sutured it
back onto the patient for improved vision.
Luis Ruiz- 1987
o Columbian Ophthalmologist. Protégé of Barraquer that modified his
technique.
o He used an automated microkeratome without the freezing of the cornea.
This was called “Automated Lamellar Keratoplasty,” ALK, or the Ruiz
technique, and it was used to treat high amounts of astigmatism using
transverse corneal incisions.
Svyatoslav Fyodorov- 1972
o Russian Ophthalmologist
o Fyodorov studied these surgical techniques and laid ground rules on how a
surgery will be successful. He said that the correction of refractive error
would result from a certain depth and length of the incisions, as well as
their distance from the limbus. Fyodorov also varied the amount of uncut
clear zones between incisions. He determined that most of the “RK”
flattening effect was achieved in 16 or fewer incisions on only the anterior
cornea. This preserves the corneal endothelium, thereby avoiding the
problems that Sato’s patients suffered. This new technique triggered a
stampede of surgeons traveling to Moscow to learn about RK, making
Fyodor the modern day father of RK.
Dr. Leo Bores- 1980s.
o Dr. Bores, an ophthalmologist in Arizona, finally brought these surgical
procedures to the US.
o NIH sponsored the PERK study (Prospective Evaluation of RK) in 1980.
Drs John Taboada and Steve Trokel- 1981 and 1983
o American Ophthalmologists
o These doctors were amongst the first to propose the use of the excimer
laser for RK, ablating large areas of tissue.
Dr. Margeurite McDonald- 1987
o Louisiana Ophthalmologist
o First to perform PRK on a sighted human eye. This patient is reported to
still be 20/20 today.
Drs. Ionnis Pallikaris and Lucio Buratto- 1990 and 1991
o Greek and Italian Ophthalmologists
o First to combine Barraquer’s Keratomileusis technique with PRK.
o Pallikaris coined the term LASIK.
Types of Refractive Surgery
Definitions
 Keratoplasty- corneal graft or corneal plastic surgery
 Keratotomy- surgical incision of the cornea
 Keratectomy- surgical excision of the cornea
 Keratomileusis- surgical removal of a thin segment of the cornea
Radial Keratotomy (RK)
 This is an outdated procedure for low myopia in which a surgeon, using a
magnification system, makes a series of radial incisions (typically 4-8, up to 16)
in a symmetric pattern in the cornea, to reduce its curvature by weakening the
peripheral cornea. The depth is up to 90-95% of the corneal thickness at the edge
of the optic zone. The number of incision is related to the magnitude of refractive
error.
 This procedure has a longer healing period than LASIK, and is more painful postoperatively.
 Short-term Complications
o Corneal Edema
 Seen in 93% of patients, the normally mild edema usually spares
the optic zone. It occurs in cases in which the cornea has been kept
wet or has had excessive irritation of the incisions following
surgery. Generally the edema resolves without treatment within 2
weeks.
o Monocular Diplopia
 This is caused by the vertical folds in Descemet’s Membrane
within the optic zone. The folds and diplopia usually disappear by
4 months, thus the best management would be reassurance to the
patient.
o Cataract Formation
 This is not very common. It can result from direct lens injury
during the surgery.
o Haloes and Glare
 These are produced by the corneal scars and are especially noted at
night when the pupil dilates, exposing the ends of the incision,
making night driving difficult.
 This is generally self-limiting, beginning to diminish 3-4 months
post-op and gone for the most part after one year. It can be treated
with anti-reflective coatings, tinted lenses, and a miotic drop if
night driving is too problematic.
o Over, uncorrection, induced astigmatism
 Incisions that are too shallow, too few, too short, or made in the
wrong axis can result in induced astigmatism. These patients can
be managed by referring them back to the surgeon to correct the
deficiency. Timing is important for these corrective methods.
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Other management would be spectacles (wait min of 2 weeks),
HCL (wait 6 weeks), SCL (wait 8 weeks), and LASIK.
 For overcorrection, any hyperopia greater than 1D and lasting
more than 6-8 weeks is likely to remain, therefore it can be
classified as a long-term issue.
 The administration of 1% Pred forte qid has been shown to reduce
the overcorrection by as much as 1D. In addition, Pilocarpine has
also been shown to reduce overcorrection after RK.
Longterm Complications
o Hyperopic Shift
 According to the PERK study, the rate of hyperopic progression
during the first 2 years was 0.21D per year. From 2-10 years, it
declined to 0.06D/year. The shift is only prevalent in about 2% of
the operative population.
 The degree of hyperopic shift was directly proportional to the
degree of preoperative myopia. This continual hyperopic drift is
desirable in undercorrected patients but can cause problems for the
newly emmetropic patient. Because of this issue, some surgeons
plan on undercorrecting patients to provide a protective buffer
against the hyperopic shift.
o Diurnal Fluctuation
 A diurnal myopic shift of 0.5-1.0D was observed in 33% of
operated eyes. This may result from the diurnal change in corneal
hydration in unstable wounds. The newly flattened cornea is
weaker than the cornea once was. The condition is self-limited, but
it may not go away completely for many years. Attempts to fix
these patients with HCL had not shown to be successful. The SCL
fitting is not recommended before 8 weeks because of the danger
of neovascularization of the incisions.
RK Enhancements
o This type of surgery has become very conservatively performed, due to the
fear of overcorrecting the patient. Enhancements can be even more painful
than the original surgery. There is an increased morbidity and cost to both
the patient and doctor.
o Correcting Undercorrection
 Incisions can be made deeper.
 The optic zone can be reduced by making the incisions longer.
 More incisions can be added.
o Correcting Overcorrection
 The incisions can be sutured individually or via a purse-string
suture to avoid gaping.
 ALK is the treatment of choice with a significant overcorrection,
and is a valid option after 12 months post-op.
o AK
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Doctors need to be more aggressive with ATR than WTR
astigmatism. Topography should be utilized on a cornea that has
been stable for a minimum of 4 weeks.
o LASIK
 A year after RK, LASIK can be used to correct for
under/overcorrection. It can also reduce corneal haze.
Astigmatic Keratotomy (AK)
 This employs the same technique as RK. Incisions are used to “relax” the corneal
tissue and produce a rounder shape. It is frequently combined with the RK
procedure.
 Astigmatism is corrected with the combination of assymetical and tangential
incisions. There are infinite variations of this procedure which include differences
in depth, length, shape, and number of incisions.
 Because it is similar to RK, the complications are the same.
Photorefractive Keratectomy (PRK), aka Advanced Surface Applanation (ASA)
 Introduction
o Longest track record, safest laser procedure, longest healing period.
o Can be used as primary or clean-up.
o Used for low to moderate myopia (up to -7.00).
 History
o 1987- First PRK done on a sighted eye.
o 1995- First FDA approved procedure in the US
o 2005- Renewed interest in the PRK.
 Advantages
o Better visual quality after PRK is for those patients with higher
expectations for visual perfection. This is one reason why the military
almost exclusively uses PRK.
o Certain patients prefer to avoid a “flap.” Recent litigation against LASIK
is making patients more cautious. This procedure is also not involved in as
much litigation against the surgeons. PRK eliminates the complications
that could arise due to the flap. This is good if the patient is involved in
contact sports.
o Increased understanding of high risk corneas. This includes thin corneas
(<500 microns or <30 micron difference between central and peripheral
pachs), decentered central pachs possibly due to asymmetric astigmatism,
those with irregular topographies (>2D difference between inferior and
superior K readings, posterior floats >55D and/or >40 micron elevation,
“sagging” or decentered anterior and posterior floats), ABMD, FF
Keratoconus. PRK treating on the surface has less chance to destabilize an
abnormal cornea and eliminates any risk of microfolds. This causes much
less chance of creating post-laser ectasia.
o PRK can be used for enhancement over irregular flaps or as a laser
treatment over old RK.
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Patient Counseling
o Explain why PRK recommended.
o Disadvantages include increased discomfort and delayed vision recovery.
o Advantages include
 No flap complications
 More residual tissue
 Navy pilots have same procedure
 Same vision outcome as LASIK (or better)
Pre-Op Considerations
o All the same pre-surgery measurements
o Topo, orbs, cycloplegic rx, DFE, pupils, wavefront analysis.
PRK Pre-Op Meds
o Restasis and Artificial Tears
o Zymar qid day before.
o Ibuprofen 400-600mg qid day before?
o Vit C, E
o PO Doxycycline, EES ung if blepharitis/meibomitis
Procedure
o PRK uses an excimer (UV) laser to vaporize the surface of the cornea and
“sculpt” a new shape.
o First the epithelium needs to be removed.
 Alcohol
 Brush/ Manual Scrape
 Laser
 LASEK
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The epithelium is scored with a trephine and loosened with
a topical 18-25% dilute colvent (alcohol or methyl
cellulose) to soften the top layer of the cornea, then rolled
back, preserving it to some extent in one piece.
 The thought is that this will have less corneal scarring with
a cut closer to the surface, but currently there are no lasers
FDA approved for this procedure. This is an “off-label
procedure”
 There is a chance of the cornea “falling apart.”
Epi-LASIK
 This uses new epi-keratomes to create a 40-50 micron epiflap for better preservation of the epithelium. No alcohol is
used.
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o The surgeon then photoablates the cornea and folds the epithelium back on
the cornea.
o Mitomycin C
 This is an antibiotic/chemotherapeutic agent that inhibits DNA
synthesis.
 The incorporation of Mitomycin C intraoperatively has reduced the
incidence of scarring and haze following high risk PRK, including
post-incisional keratotomy, high myopia, post-LASIK
enhancements, and following Intacs with thin corneas.
 The surgeon places a sponge soaked in Mitomycin C on the cornea
for about 60-120 seconds after the laser is performed.
 The disadvantage is that it may delay re-epithelialization.
o A bandage CL is generally used post-surgery. This speeds recovery.
o Painful because it leaves nerves exposed.
o Heals in 7-10 days (F/up every other day)
Post-Op
o Create realistic expectations for recovery. The biggest challenge is
managing psychological aspects of decreased comfort and slower visual
recovery. Be prepared for more follow-up and hand-holding.
o Post-Op Follow-Up
 Day 1, Day 4-5 to remove the BCL, Week 2-3 if necessary
 Month 1 and 3
 Avoid refractions for one month post-op.
o Meds
 Antibiotic (Zymar) qid for one week.
 Steroids Pred Forte 1%
 Qid x 1 week, tid x 1 week, qd x 1 week
 Pain Management
 Recently there is increased pain management.
 Cold compresses or ice packs
 Acular LS q2h to qid 2-4 days
 Keep eyes closed/ Sleep
 Better fitting overnight BCLs
 PO Ibuprofen
 PO steroids
 Comfort drops (2ml diluted tetracaine) prn
 Hydrocodone (vicodin) q4-6h prn
 Neurontin (Gabapentin) 1200mg po x3-4 days
o Normal Epithelial Healing
 The epithelium will usually heal within the first 4-5 days. Do not
be alarmed if it takes a bit longer.
 Usually the BCL is removed at day 4-5. If in doubt, leave the BCL
in additional 1-2 days. Once the BCL is removed, reassess the
epithelium and then replace with a new BCL if necessary. Caution,
because this may increase pain and delay healing.
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o Vision Recovery
 Day 1
20/40-20/80
 Days 2-4
20/40-20/200
 Day 4-5
20/30-20/80
 VA rapidly improves 2-3 days after removal of BCL removal as
the epithelium thickens and smoothes out.
 Day 5-6
Driving vision (local)
 Day 7-10
Good vision
 Weeks 4-6
Excellent vision
Complications of PRK
o Complications are rare.
o Post-PRK Haze
 Late onset corneal haze and decreased visual acuity can occur from
one to several months after surgery. It usually resolves over time,
but severe cases may require corneal debridement and treatment
with MMC.
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Grade 1
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Grade 3
Infection
Pain
Delayed vision recovery
Elevated IOP (steroid responder)
Grade 2
o Corneal melt
o Hemosiderin Post-RK
Automated Lamellar Keratoplasty (ALK)
 Aka keratomileusis in situ, advanced corneal shaping, lamellar keratoplasty.
 For high amounts of myopia (11-15D), the surface layer of the cornea is separated
using a microkeratome. This flap is folded back and a thin disc of corneal tissue is
removed by a second pass of the microkeratome. The flap is then returned to its
original position. With increased prescriptions, RK would be performed after
ALK.
 Since planar slices are removed from an oblate cornea, it causes the cornea to be
irregularly shaped. There is less success with this procedure since it is very
imprecise.
Myopic Keratomileusis (MKM)
 A microkeratome is used to resect a thick corneal cap which is frozen, lathed and
then sutured back onto the cornea.
Epikeratophakia
 A superficial portion is removed from the eye and replaced with a donor disc.
LASIK
 LASIK is a combination of ASA and ALK. This procedure uses a microkeratome
to produce a flap of corneal tissue that is lifted so that an excimer laser can sculpt
the corneal shape underneath to achieve the desired topography. This can be used
for myopic and hyperopic prescriptions.
 Advantages
o Allows for same-day surgery on both eyes. The actual surgery takes only
minutes, about 10 seconds per diopter.
o No pain during the surgery and post-op pain is relatively low.
o Rapid visual return and return of normal sensation. This allows most
patients to return to work the day after. Refraction stabilization is
generally obtained within weeks. Off all medication in 4-7 days
o Avoids the risk of anterior stromal haze and pain associated with PRK.
o Preservation of Bowman’s, optimizing corneal stability.
o Reduced infection risk, making bilateral surgery safe.
o Less corneal impact than wearing SCL
 History
o 1996- US clinical trials begin
o 1999- FDA approves the LASIK procedure
 Good candidates
o Some doctors will perform LASIK on children under certain
circumstances when all other corrective methods have failed, i.e., those
with ADD, high anisometropia (congenital or trauma induced).
o Prescription
 Up to 11D of myopia
 Up to 6D of myopic astigmatism
 Up to 6D of spherical hyperopia
 Up to 2D of hyperopic astigmatism.
o Occupational benefits
 Law enforcement officers that have to perform under extreme
circumstances. Glasses can be knocked off or broken and contact
lens wearers have difficulty with tear gas.
 Firemen- Glasses cannot fit under fireman’s gear and contact
lenses are irritated by smoke and debris. Same with forest rangers.
 Lifeguards save lives in conditions containing sand and salt water.
Glasses are not feasible for water rescues and sand and salt are not
compatible with contact lenses.
 Athletes- Glasses slide and fog up from swear and contacts may
not stay in the eye during contact sports.
 Travelers- Contacts and glasses are a hassle to keep clean and
spares are hard to keep on hand
 Pilots- Glasses and contacts can cause safety hazards if dislodged
when flying. Airlines set their own policies with respect to LASIK.
Airline policies are evolving and more pilots are having it done.
o Recreation
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Water sports including scuba, water skiing, wakeboarding, tubing,
jet skiing, wave runners, river rafting, kayaking, etc.
 Water spray causes droplets on glasses and can wash
contacts out of eyes.
 Sports including football, water polo, swimming, volleyball,
gymnastics, etc.
 Outdoor recreation including camping, mountain biking, hiking,
etc.
 Cleanliness and sanitation are difficult in the outdoors.
Contraindications
o Uncontrolled DM
o Pregnancy
o Inability to wear CL
o Cataract formation
o Both eyes cannot be corrected better than 20/40
o Abnormally thin corneas
o High correction and astigmatism
o Dry eyes (TBUT <6sec)
o Large pupils.
Pre-Op
o Advice to patients
 Do not choose a surgeon on price alone.
 Beware of promises of 20/20 (30% do not achieve this)
 Does not cure presbyopia
 Cannot be reversed.
 Relatively new procedure- long term effects unknown
 Results may not be lasting.
Procedure Overview
o An anesthetic is used before a microkeratome (the knife) is used to slice
off a very thin layer of the cornea, leaving a hinge on one end. A computer
controlled excimer laser is used to remove a precise amount of the corneal
stroma. Then the flap is flipped back and allowed to heal.
o The only pressure felt is with the vacuum (90mmHg)
o Alignment rings made so the flap can go back into place.
Creating the Flap
o Flap creation is usually at the surgeon’s discretion and preference, and the
design of the flap is usually a superior or nasal hinge.
o Types
 Steel Microkeratomes
 The surgeon affixes the microkeratome to the eye using a
suction applicator, and then the foot-controlled, motordriven blade slides over the cornea and creates the thin flap.
 Waterjet Keratomes
 Laser Keratomes (Intralase)
 1053nm wavelength with brief laser pulses
 Epikeratomes/ EpiLASIK
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Creates a flap without a blade and delaminates the corneal
epithelium above Bowman’s Membrane without the use of
alcohol. A platic separator splits the two layers at their
natural junction, causing less trauma to the eye.
The Excimer Laser
o Designed in the late 1970s, this is a “cool” laser beam (low heat) of
unequaled precision. It is high energy, so that it can split the C-C bonds. A
mushroom cloud occurs when this happens.
o It can removes 39 millionths of an inch of tissue in 12 billionths of a
second, producing very sharp edges. 4 pulses/sec, 1/4u/pulse = 1u/sec
(12u/D)
Laser Systems
o Alcon Surgical- LadarVision 4000
o Nidek- EC 2000 and EC 5000
o LaserSight- LaserScan LSX
o Bausch & Lomb- Technolas 217c
o Visx VSS (Variable Speed Scanning)- Star Smoothscan S3 and S4
o Wavelight Laser Technologie AG- Allegretto Wave
o Asclepion- Meditec AG- MEL 70 G-Scan
o Schwind GmbD & KG- ESIRIS
Machines
o Alcon Ladarvision 4000
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A flying (scanning) spot with beam size of 0.8mm and optic zone
size of 6.5mm with a blend out to 9.0mm.
Requires dilated pupil
More precise.
Important devices
 Broad beam to narrow beam laser
 Tracking devices detect movements 100-4000x/sec,
allowing surgery to be performed on those with nystagmus.
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Parameters
o Bausch & Lomb 217A Zyoptics Excimer Laser
 Designed to couple with the most advanced corneal diagnostics.
 Optic zone size of 7.0mm with a blend out to 9.0mm.
 “Flying spot” software can create any size/shape of incision. This
allows for better peripheral vision due to decreased aberrations and
haloes.
 Pupil dilation is not required. Decreased neosenephrine means less
vasoconstriction and less edema, meaning less flap wrinkling.
 Tracking technology
 Sampling rate: 120Hz = 8.3msec
 The laser calculates the center of the pupil which becomes
the tracking reference that guides the scanning system.
 Unmatched VA in FDA studies to date
 99.7% 20/40 or better
 87.3% 20/20 or better
 30.3% 20/15 or better
 Parameters
o Visx Star S4 CustomVue Laser
 This is used for primary treatments only.
 Variable Spot Scanning (VSS), variable beam sizes (0.65-6.5),
variable repetition rate (VRR), active track 3-D active tracking and
active track automatic centering.
 Optic zone size of 6.0mm with a blend out to 8.0mm.
 Parameters
o Zeiss Meditec
 Flying spot with beam size of 0.7mm.
 Extremely fast laser at 250Hz.
 Video-based tracker.
 -10.00/ 4D cyl
o Allegretto Wavelight
 Excellent vision quality
 Good night vision
 No degradation of vision with astigmatism correction.
 Decreased enhancement rates
 <3% overall, <1% in myopes up to 7D
 Parameters
Wavefront
 History of “Wavefront Technology” or “Adaptive Optics”
o Julius Feileib, PhD- 1980-89
o Robert Fugate, PhD started the “Starfire Project” 1982-1991
o David Williams, PhD is a vision scientist from 1991-present
o Larry Thibos, PhD- 1992-present
o Ray Applegate, OD, PhD- 1995-present
 Introduction
o This applies the principles of adaptive optics, and offers us ways of
assessing lower and higher order aberrations of the eye. The optics of the
human visual system are far from perfect.
 Aberrations
o Aberrations are errors of the entire eye. Over 65 total aberrations have
been identified. There are two types. Lower order aberrations include
sphere and cylinder. Higher order aberrations include coma and spherical
aberrations.
o Causes
 Low order aberrations are due to the fovea.
 High order aberrations are due to changes in the corneal curvature.
The cornea is prolate. This is normally fixed by the pupil and its
diameter. Surgery creates an oblate cornea, meaning that it is
flatter. The visual axis must be kept in an aspheric orientation.
 The crystalline lens also directly affects lower and higher order
aberrations.
 This changes with age, unlike the cornea. It becomes more
spherical (oblate). In the earlier years, the lens makes the
CLC 0, because it corrects the cornea.
 Under 20 years of age, the spherical aberration of the
cornea is about -0.26. That of the lens is +0.26. Between
the ages of 20-30, the spherical aberration of the lens
changes to about +0.52, the +0.78 about 30-40 years of age.
>40 years, it can increase to about +1.04.
o Currently, glasses and contact lenses and conventional excimer laser
ablations can only treat lower order aberrations. The problem is that these
always induce higher order aberrations. The magnitude of induced
spherical aberrations is directly proportional to the pre-op magnitude of
myopia.
o Why do Conventional Ablations Induce HOAs?
 Laser ablation algorithms were developed by testing ablation
profiles on flat pieces of plastic, but the cornea is a dome. Central
spots are round and match the ablation of a piece of plastic.
Peripheral spots are oval with larger surface area and therefore
lower fluence. Peripheral spots are partially reflected and not
completely absorbed.
o Lower Order Aberrations (80-83%)
 Measured by
 Traditional refraction: Subjective and Objective
 Automated refraction
 Computerized refraction
 Keratometry
 Corneal topography
 Here the goal is “20/20.”
Types
Name
Description
st
1 Order
Tilt (Prism)
2nd Order Defocus (Sphere) and
Cylinder
o Higher Order Aberrations (17-20%)
 Measured by wavefront analysis
 Measures lower and higher order aberrations.
 This is generally objective with a subjective refinement
capability.
 It measures to 0.05u (0.005D)
o 3u = about 0.25D
 Here, the goal is 20/8
 This is dependent on pupil size.
 For every 2mm increase in pupil size, HOA increases
100%. Avg is about 3.5.
 Eliminating or decreasing HOAs is “probably” good. Increasing
HOAs is “usually” a problem. Changing a person’s HOAs is
“always” bad. This is because the brain “learns” vision.
 Types
Types
Name
Description
3rd Order
 Coma
 Overlapping with
tail following
 Trefoil
 Multiple Tails
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Primary Causes
o Corneal geometry
o Corneal remolding
o Biomechanical insult
o Induced by the keratectomy in the LASIK
procedure
 Effects
o Reduces mesopic and scotopic vision
4th Order
 Spherical
 Symmetrical
Aberration
degradation. This is
seen as a “starburst,”
decreased contrast,
and decreased night
vision
 Quadrefoil
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 Primary Causes
o Strongest influence on human optics
o Media changes
o Crystalline lens changes
o Diffraction of light
o Induced by corneal laser photoablation
 Effects
o Reduced mesopic aand scotopic vision
o Glare, halos, starbursts
o Reduced contrast sensitivity
5th Order
Distortions/ Irregular
Astigmatism
6th-11th
Increasing levels of
irregular astigmatism
RMS System (vs. Diopter) and “Marechal’s Criterion”
o RMS deviations (Root Mean Square) = √w(r,Ø)2
 This is the measurement of aberrations of an optical system (coma,
spherical aberrations, distortion, defraction, etc).
 The lower the RMS, the better the visual acuity.
 Lowest potential RMS for the eye is about 0.07u, which is
Marechal’s Criterion.
 An RMS of 0.07u can produce a visual acuity of 20/6, which is
thus the maximum potential visual acuity of the human eye. This is
“Super Vision.”
o But….
 There are neural and retinal considerations
 There are 4-7 million cones in the retina. The maximum
number of cones in the fovea is about 5 million. Visual
acuity resolution threshold for 5 million cones is only about
20/8. This becomes the “Super Vision.”
Traditional Refraction


o Methods of Measurement
 Traditional subjective and objective refraction for:
 Plano
(Piston)
“0” Order Aberrations
 Prism
(Tilt)
1st Order Aberrations
 Sphere
(Defocus)
2nd Order Aberrations
 Cylinder
(Cylinder)
2nd Order Aberrations
 Automated objective refraction
 Computerized subjective and objective refraction
 Keratometry for corneal cylinder
 Corneal topography for corneal cylinder, asymmetry, warpage, etc.
Refractive Issues
o Zernike’s Polynomials (Coefficients)
 RMS values mathematically converted to 2 dimensional (color
maps) and 3 dimensional models describing the shape of a specific
aberration.
 All aberrations are measured in RMS units and a “point
spread function” which is an easier way to analyze vision.
o Red indicates a positive aberration. Blue is
negative.
o >0.4 RMS is clinically observable.
o A change of >0.2 RMS is clinically observable.
 Points Spread Function are also used, which is an easier
way to analyze vision.
o The appearance of a spot of light on a black
background, i.e., a star in the sky.
o Negative would be black spot (or image) on a white
background, i.e., a Snellen chart.
 Therefore this can be used to measure higher
order aberrations. It is referred to as the
“Poor man’s aberrometer.”
Wavefront Technology
o Laser photoablation relative to current refractive measurements
 Phoropters measure 0.25D levels.
 Keratometers and topographers measure corneal curvature and
elevations in 0.25D steps.
 In linear measure, one order of magnitude larger about 3 microns
equals 0.25D.
 But, excimer lasers can ablate tissue at as little a rate as 0.25
microns per pulse.

o
o
o
o
Thus, the level of potential accuracy for correcting refractive errors
with an excimer laser (0.25 microns) is 12x greater than our
current ability to measure refractive errors.
Wavefront Aberrometry
 Basic Principles
 Shack Hartmann (3 excimer platforms)- 250 points at once.
 Ray tracing aberrometry (Tracey)- 120, but one at a time.
 Tscherning Aberrometry (Subjective)
 Spatial Skiascopy (Marco 3D Wave)
 Holographic Imaging (Ophthonix)
 Fourier Analysis (Visx)
o This is the measurement of output vs. a piston.
 Dynamic Spatial Skiascopy- Scanning
 This can be corrected with lenslets, and is called Adaptive Optics
 Aberrometers
 Alcon Ladarvision (LadarWare)
 Nidek EC-5000 (OPD-10000)
 LaserSight LSX (AstraScan)
 Bausch and Lomb Technolas 217 (Zyoptix)
 Visx WaveScan (WavePrint)
 Tracey Visual Function Analyzer (VFA)
 Complete Ophthalmic Analysis System (COAS)
 Topcon Aberrometer (KR-9000PW)
 WaveLight Allegretto (WOSCA System)
Laser Photoablation Relative to Wavefront Analysis Measurements
 Whereas the level of potential accuracy for correcting refractive
errors with an excimer laser (0.25microns/pulse) is 12x greater
than our traditional methods of measuring refraction (3microns or
0.25D), wavefront analysis can measure refraction down to 0.05
microns (or 0.005D). Thus, wavefront measures 5x more
accurately than an excimer laser can correct (0.05 vs. 0.25
microns) and 50x more accurate than standard refractive
techniques can measure (0.005 vs. 0.25D).
Custom Ablation
 This decreased higher order aberrations, but physics and corneal
healing limit its effects to lower order aberrations only.
 Cells grow back at different times.
Diagnostic Applications of Aberrometry
 Evaluating all eyes not correctable to 20/20.
 Assessing static vs. dynamic visual differences.
 Comparing objective to subjective point spread functions.
 Differentiating corneal from lens aberrations.
 Pre and post posterior capsular opacification (PCO) effects
 Evaluating post-op IOL tilt, decentration, multifocal optics.
 Assessing cataract patients’ symptoms and “quality” of vision.





Assessing contact lens candidates for soft vs. hard lens wear.
Contact lens care including Ortho-K.
Pre and post-lens fit integrity, quality, and results.
Monitor progress and visual effects from varying ocular
pathologies and surgeries.
 Pathologies
o Cataracts
o Keratoconus
o Others
 Surgeries
o Lid and oculoplastic procedures
 Ptosis and chalazia induce vertical coma
o Others
 Post surgical or medical therapy monitoring of refraction
 Evaluating corneal aberrations secondary to certain lid and ocular
surface pathologies
 Lids
o Blepharo or dermatochalasis
o Chalazia and lid tumors
 Ocular surface
o ABMD
o Corneal dystrophies and degenerations
o Pterygium
o Tear-film dysfunction
o DES (K. sicca)
o Others
o Potential diagnostic and treatment implications in measuring lower and
higher order “instability.”
 Vision and refractive problems
 Contact lenses considerations
 Ocular surface disorders
 Quantifying dry eye syndromes
 Refractive surgery patients
Wavefront
o Conclusions
 Wavefront guided ablations minimize the magnitude of HOAs.
 In patients with significant pre-op HOAs, wavefront guided
ablations reduce the HOAs.
 Wavefront guided ablations are necessary to perform
enhancements on refractive surgery patients who are symptomatichalos, glare, ghosting of images, and poor quality of vision.
o Readouts


Aberrations are represented by a “root mean square” measure.
Myopia

Hyperopia

Mixed Astigmatism

Coma

Sperhical Aberration
o Orbscan
o Aberrations above the 6th order are inconsequential. These actually only
introduce “noise” from tear film debris and instability, vitreous floaters,
and corneal disruptions.
o RMS values can vary between blinks, mostly due to tear film dynamics.
o A patient whose RMS value is greater than 0.3microns has visually
significant higher order aberrations and would benefit from wavefront.
o Those that benefit most from wavefront are those with larger pupils, larger
prescriptions, astigmatism, and higher RMS values. Most patients with
large puils, whatever their refractive error, would probably benefit from
wavefront.
o In general, this is less likely to induce new aberrations than traditional
LASIK.
o Problems:
 Wound healing is unpredictable.
 Wavefront is dynamic and correction is static. Wavefront changes
daily, as well as with age.
o Types of Lasers
 Conventional
 Wavefront Guided (Custom)
 Treats both spherocylinder and HOAs
 Wavefront Optimized (Custom)
 Designed to treat spherocylinder errors without affecting
HOAs, especially spherical aberration.
 Topography Guided (Custom)
 Poor predictability. Need to know apex. Rings depend on
distance. laser inability to ablate desired shape.
 Used with asymmetric astigmatism, irregular corneas, and
previous corneal surgeries.
 Waiting for FDA approval.
o VISX CustomVue Aberrations in Normal Eyes
o
o
o
o
o
 SA- 0.13 +/- 0.07 microns
 Coma- 0.17 +/- 0.09microns
 Total HO RMS- 0.31 +/- 0.10 microns
Aberrations in normal eyes: Pre-Op Alcon CustomCornea
 SA- 0.15 +/- 0.07 microns
 Coma- 0.21 +/- 0.09 microns
 Other- 0.23 +/- 0.09 microns
 Total HO RMS- 0.37 +/- 0.10 microns
Aberrations in Normal Eyes: Post-Op Alcon CustomCornea
 SA- 0.25 +/- 0.10 microns
 Coma- 0.36 +/- 0.11 microns
 Other- 0.33 +/- 0.10 microns
 Total HO RMS- 0.58 +/- 0.12 microns
Summary of Aberration Change with CustomCornea LASIK
 SA- +0.11 microns (30% improved)
 Coma- +0.16 microns (25% improved)
 Other- +0.11 microns (30% improved)
 Total HO RMS- +0.21 microns (36% improved)
High Order RMS
 Standard LASIK increases HO RMS
 Predominantly SA
 Custom LASIK maintains or decreases HO RMS
 Facts
 Increased amounts associated with loss of BCVA
 Increased amounts associated with loss of contrast
sensitivity
 Reduced amounts associated with better quality of vision.
Wavefront Optimized
 Optimized profile is created by adding more laser spots to the
periphery.
 Compensates for
 Reflected spots
 Ovalization (cosine effect)
 Preserves pre-op asphericity = prolate shape of cornea.
 WaveLight Allegretto Wave Excimer Laser System utilizes a
wavefront optimized ablation in all of its conventional ablations.
 Advantages
o Faster
 200 Hz Pulse Rate = ~4.5 sec/D
o More predictable
 Faster treatment means less time for drying,
etc.
o Very precise
 0.95mm Gaussian-shaped beam diameter.
o Better optics

Wavefront optimized built-in to all
treatments.
o Safer
 Fast, pulse to pulse tracking (<6mSec)
 Wavefront optimized ablations are a good choice for most eyes.
 Most eyes do not have significant asymmetric higher order
aberrations.
 Of those that do, many have the aberrations in the lens.
 Lenticular aberrations should not be corrected on the cornea.
 Can lead to worsened aberrations and will degrade with
time.
 Induced spherical aberration is the major cause of night driving
complaints after LASIK.
 Lasers other than the Alegretto can only minimize induced
spherical aberrations with their wavefront guided ablations but not
with their conventional ablations.
 The Allegretto is the only laser to provide this advantage (minimal
to no induced spherical aberrations) in all conventional treatments
by utilizing wavefront optimized ablations.
 Treatments do not worsen night vision
 The FDA studies showed most patients had improved night
vision after LASIK with the Allegretto.
 Most patients do not need to have lengthy custom work-ups.
 <15% receive custom treatments internationally with the
Allegretto.
 Faster, more comfortable treatments with better optical results.
o “Guided” vs. “Optimized”
 Optimized is a conventional treatment
 Optimized prolate ablation pattern is based on a population
averaged wavefront.
 Optimized may only address spherical aberration.
 Optimized = one size fits all.
 Guided addresses all HOA in a particular patient
 Existing and induced
 Symmetrical and asymmetrical.
 Wavefront guided treatments are not needed in most cases with the
Allegretto. It is still needed in laser with non-Wavefront Optimized
ablation profiles.
 All procedures induce aberrations. Need is to minimize induced
aberrations or decrease as many of them as possible.
o Conclusions
 Customized ablations are most beneficial for patients with
asymmetrical topography and significant HOAs.
 Speed of ablation and amount of tissue removed per diopter of
correction are important factors to be considered.




Accuracy of outcome is more important than induced HOAs as
long as the amount of induced HOAs is not significant.
The ideal laser is fast, accurate, and induces minimal to no HOAs
and reduces pre-existing HOAs.
Tissue removal
 Wavefront guided > wavefront optimized > conventional
Aberrometers
o Bausch & Lomb Orbscan- Zyoptics
 Anterior segment analysis system
 Must know this with all pre and post op.
 Only system that scans the anterior and posterior, as well as
pachymetry, recognizing the weakest points, predicting
keratoconus.
 Can estimate VA under low light conditions
 Zyoptics option
 Wavefront guided corneal reshaping
 Minimizes the risk for haloes and glare.
 If you experience a poor quality vision now with your
glasses or contacts.
 If you have had laser surgery before and wish to consider a
refinement.
o Zywave II Wavefront Aberrometer
 Hartmann Shack Technology
 A narrow laser beam is focused on the retina to generate a single,
focused point source.
 Outcoming light rays are bent by aberrations caused by all
refracting media (cornea, lens, vitreous)
 Light ray bending is detected by an array of lenses.
 Adaptive optics flattens the wave aberration
 Technology to eliminate higher order aberrations by
evening the cornea
 From NASA.
 Who is a candidate?
 This is a highly sophisticated decision made between an
experienced doctor and the patient. It is made on an
individual basis based on the probability that we will meet
the patients expectations for vision improvement and the
activities that the patient most wishes were uncomplicated
by eyewear.
o Ladar

Intralase/ IntraLASIK
o This is an improved flap procedure.
o Femtosecond Laser
 This laser contains extremely high power attained at relatively low
energy. Each pulse of focused laser light lasts about 10-15 seconds
(500-800 femtoseconds).
 Programmable Parameters
 Flap thickness, diameter, centration, hinge angle, side cut
angle.
 The laser creates a cleft of water and CO2 via an excimer laser.
o Structure of IntraLase Flap
 Smooth Stromal Bed
 Precise Flap Thickness
 Larger standard deviations generally reported for mean
LASIK flap thickness with mechnical microkeratomes.
o 10-15 microns for intralase (avg 12)
o 15-35 microns (avg 24)

Uniform Thickness
 UTZ pachymetry is the current method of measuring flap
thickness, but it measures the central point only and does
not measure uniformity.
 Visante OCT measures anterior segment with high
precision and resolution, so it can measure the flap
thickness and stromal bed.
 Biomechanically stable.
 Corneal Biomechanics
o The way that the cornea is set up is responsible for
its shape with certain loads. There is a structural
stability. The lamellar structure of the cornea means
that peripheral fibers contribute to strength, as well
as deeper fibers. Cutting larger flaps can cause
ectasia.
 Mechanical Microkeratome Flap
o A microkeratome cuts deep in the periphery with
poor diameter and centration control. This leads to
variability in central thickness across different flaps,
as well as significant variability regionally within a
flap. This confirms earlier studies using regional
subtraction pachymetry.
 IntraLase Flap
o An intralase cuts thin planar flaps with precise
depth, diameter, and centration control. Minimal
variability in central thickness across different flaps,
as well as minimal variability regionally within the
flap. This confirms earlier studies performed with
regional subtraction pachymetry and histology. The
angle of the cut also has less chance to epithelial
ingrowth.
o Clinical Experience
 300 lasers installed worldwide.
 500,000 LASIK flaps performed.
 In the US, 20% of LASIK flaps are done with this.
o Clinical Results
 Tran, Sarayba et al. JCRS Jan 2005
 Randomized, prospective
 Contralateral- blade vs. intralase
 9 patients, 18 eyes
 Flap cut only
 Measured flap-induced HOA
 Excimer treatment 10 weeks after flap
 Durrie, Kezirian, JCRS Jan 2005
 Randomized, prospective, contralateral eye
 Blade vs. intralase
 102 eyes
 Noted better visual outcome with intralase. Also less HOA.
 US Navy Study (Schallhorn, Tanzer)
 Comparison of visual outcomes with femtosecond and
mechanical keratomes for WFG LASIK.
 Return to flight status sooner.
 Best technology for flap creation.
 Methods included hansatome, Amadeus, intralase, and Visx
excimer laser in 300 patients
 Conclusions:
o WFG LASIK approach favors intralase
 Better clinical results
 Faster visual recovery
 Improved mesopic low contrast VA
o No significant difference in overall HOA based on
keratome use.
 Amadeus induces more spherical aberration
 Both Amadeus and hansatome induce more
horizontal coma compared to intralase.
 Lindstrom, Davis
 Blade vs. intralase
 More IL patients achieve 20/20
 Better flap thickness predictability
 Costs more but patients willing to pay.
 Biomechanics, Alio JL et al.
 Compare biomechanical response of ocornea after myopic
LASEK, IntraLase LASIK, and blade LASIK.
 Lower biomechanical response with intralase, followed by
LASEk, then blade LASIK.
 F Price ARVO 2006
 Reduced epi ingrowth in retreatment.
 Significantly less epi ingrowth with LASIK enhancements
if the original LASIK was done with intralase compared to
mechanical microkeratomes.
 Why?
o Bladed microkeratomes all have a tapered or
gradual entry into the cornea.
o All FLS cases had either a 65 or 70 degree side cut
from the lamellar dissection to the anterior surface
of the cornea.
o Summary
 Smooth bed
 Uniform flap, small hinge
 Thin, uniform
 Better VA
o
o
o
o
o
o
o
o
o
o
o
o
 Better HOA
 Better biomechanical effect
Creates an inflammation
A: no keratome
This creates the flap through photodisruption and hydrodissection of the
stromal tissue. Specifically, it creates thousands of 2-3 micron capitation
bubbles within the cornea. This technically destroys tissue and creates a
space in which the flap can be separated from the bed.
This demonstrated more predictable flap thickness, better astigmatic
neutrality, and decreased epithelial injury.
Can predictably create flap diameters, hinge location and flap thickness
while eliminating the risk for cap perforations.
Risks come from the energy and fluid from the IntraLase yield more
corneal edema, and patients typically require stronger steroid drops for a
longer period.
Flap creation with the IntraLase can take 1-2 minutes, depending on the
surgeon, vs. less than 30 seconds with the microkeratome. This can lead to
increased pain and discomfort.
Flap complications such as striae/microfolds, buttonhole flaps, epithelial
ingrowth and infection occur at approximately the same rate with either
procedure.
A newer keratome, the Hansatome Excellus with the Zero Compression
Head, creates ultra-thin flaps, but IntraLase does create a flap with a more
uniform thickness from edge to edge.
IntraLase can also be used to create the lamellar channels for Intacs and
for therapeutic anterior lamellar keratoplasty.
Inflammation?
 The FS laser produces greater corneal stromal inflammation than
the MM early postoperatively without any increase in apoptosis
and stronger flap adhesion late postoperatively. Therefore, it may
require stronger anti-inflammatory drugs to be administered.
 Early post-op inflammation
 Injury to corneal epithelium. Apoptotic keratocytes and
inflammatory cell infiltrations.
 PMNs are the first cells to migrate into the corneal tissues
in response to injury.
o Highly differentiated cells.
o Found in the limbus and wounded areas within the
first 2 days after corneal injuries.
 With cells on day 1, need to return the next
day.
o The density of the PMNs start to decline by the
third day.
 Treatment with steroids and irrigation?
Flap Adhesion Strength
 Forces required to detach the flaps at one month:
 Intralase FS group 126.7g of force.
 Mechanical microkeratome group 65g of force.
 Forces required to detach the flaps at 3 months
 Intralase FS group 191.3g of force.
 Mechanical microkeratome group 127.5g of force
 The grams of force needed was significantly higher in the FS
group than in the MM group at 3 months. (P<0.05)
o HOA Comparison in Fellow Eyes Following LI LASIK with Wavelight
Allegretto and CustomCornea LADAR 4000 Systems Conclusions
 Both laser platforms produced accurate refractive outcomes.
 Statistically significant difference found for spherical aberration
correction at 1M and 3M.
 No statistically significant differences in
 Low and high contrast acuity.
 Patient preference.
 Further study enrollment is underway.
o Complications
 Flap related complications- 8.3%
 Includes thin flap (buttonhole, striae), thick flap (ectasia),
incomplete flap, decentered flap, small/large flap.
 Interference by gas bubbles
 In the anterior chamber
o The gas bubbles can get into the anterior chamber
via the peripheral cornea and trabecular meshwork.
o If the bubble is large enough, it may prevent pupil
margin tracking by the laser and inhibit the patient’s
ability to focus.
o Bubbles absorbs into the aqueous humor in 2-3
hours and treatment may be completed.
 In the cornea
o The bubbles may get into the anterior stroma and
are not released upon the lifting of the flap.
o Depending on the location of the deep opaque
bubble layer, the pupil or iris landmarks may be
obscured, preventing either pupil localization for
tracking and/or iris landmarked-based iris
registration.
o These usually resolve in 30-45 minutes.
 Unliftable Flap
 Attempts to forcefully open the interface with patulas and
blades may lead to torn flaps or rough or irregular surfaces.
 Etiology is uncertain, but appears to occur bilaterally in
individual patients.
 There iften is some keratocyte activastion and associated
interface haze. This is corticosteroid sensitive and resolves
with treatment within 3-4 months with no effect on vision.




If this occurs, abort the procedure. Allow 1 months for
healing and reattempt with a blade keratome set to cut the
flap 50 microns deeper than the original femtosecond flap
interface.
Nondissected Islands
 Sometimes for various reasons, the laser will skip over a
spot, causing the undissected zone to be not seperable.
Forceful attempts to delaminate the corneal collagen fibers
in this area can result in a tear through to the surface,
leaving an isolated “island
of undissected tissue similar to the central islands that may
occur with blade microkeratome-created flaps.
 This can occur with thin flaps, through incision such as
after RK or PK and through scars such as after previous
microbial keratoplasty or CK.
 Allow it to heal for 6 weeks and then recut the flap with a
blade microkeratome at a level of at least 50 microns
deeper.
Transient Light Sensitivity
 Patients have reported severe photosensitivity 6-8 weeks
after LASIK. This has been called Track-Related
Iridiocyclitis and Scleritis (TRISC), Good Acuity Plus
Photosensitivity (GAPP), and Transient Light Sensitivity
(TLS). It is still unclear as to what causes the syndrome.
Treatment with a topical steroir for 1-4 weeks resolves the
symptoms.
 Patients with good vision develop photophobia in the
absence of any apparent finding on examination.
 Corticosteroid drops are prescribed and symptoms improve
within 1 week. Sunglasses should also be work for the
period.
 Etiology is unknown, but speculation is around keratocytes
activation to laser-induced iritis, scleritis, or neuritis. Seen
in about 1% of patients.
Keratitis
 Intrastromal inflammation may be localized around the
edge of the flap, which can occur 2-7 days after flap
creation.
 The area appears hazy or white. Photophobia.
 It is associated with cellular infiltration in the interface and
in the superficial cornea in a narrow band along the edge of
the flap.
 Results from microscopic corneal tissue damage caused by
the laser photo disruption, perhaps exaggerated by
exogenous inflammatory factors in the tear film.



Treatment includes frequent topical corticosteroid drops. In
rare cases, the inflammation is severe, and scarring may
develop in the area of the side cut and haze in the interface.
LASIK Surgical/Procedural Complications
o Decentered treatment zones, laser-related complications and irregular
astigmatism can result from such factors as patient;s excessive eye
movement during surgery, loss of eye tracking by the laser, incorrect
programming of the treatment computer or improper/inaccurate
measurements taken during the presurgical evaluatioin. These can lead to
a decreased visual outcome. If possible, retreating the eye is the best
management, but glasses or CL correction may be the only option.
o Thin Flaps
 If the microkeratome does not have enough suction, the improper
size microtome blade is used, or patients squeeze their eyes
excessively during the procedure.
 This is difficult to replace and position.
 Treatment is usually delayed until the flap has healed.
o Buttonhole Flaps
 Ring-shaped flaps with a central hole or thin area.
 Performed without adequate suction or the microkeratome is
improperly positioned. This produces a meniscus-shaped flap that
is thinner in the center.
 Replace the flap and allow it to heal before performing any
excimer treatment.
o Free cap/flap
 Flap lacks a hinge. Usually results from a loss of suction during the
keratome pass and causes shallow engagement of the keratome on
the corneal surface.
 Treatment can proceed if the treatment zone has sufficient ablation
area.
 Replace the flap and cover it with a BCL. Monitor it for the
development of irregular astigmatism or epithelial ingrowth.
o Full perforation
 This is rare.
 Suturing of the cornea is required and no further surgery was
usually performed.
o Dislodged Flap
 Can be an early or late complication.
 Early flap dislocation can result from poor flap placement
after surgery or patient induced by squeezing of the eyelids
or rubbing.
 The surgeon should immediately reposition the flap to decrease the
chance of DLK, striae, and epithelial ingrowth.
Post-Surgical Complications
o Dry eyes
 Affects majority of all LASIK patients, most common.

Temporary or longterm. Generally mild. Patients predisposed to
dryness before the surgery may have moderate to severe
symptoms.
 Symptoms
 Redness, excess watering, burning, excess mucous, sandy
gritty feeling, blurry vision
 Causes
 Severed corneal nerves, damaged goblet cells, deficient tear
oil layer, altered cornea elevation, incomplete lid
closure/blink.
 Results from the creation of a temporary neurotrophic
cornea from severing the corneal nerves during the creation
of the LASIK flap. This leads to decreased corneal
sensation and decreased feedback to the lacrimal gland and
reduced tear production.
 Treatment
 AT, gels, restasis, punctal plugs.
o Halos, glare, and starburst
 Halo effect is an optical effect that is noticed in dim light.
 Halos are concentric blur circles that surround a point source like a
car headlight when viewed at night and occur when the optical
treatment zone size is smaller than the mesopic pupil size.
 Glare is the distortion radiating from light sources at night.
 Wavefront guided retreatment is the best solution.
 These are usually self-limiting, beginning to diminish 3-4 months
and are gone for the most part within a year. Can be managed with
AR lenses, as well as tinted of photochromatic lenses. A mild
miotic may be prescribed to help with the patients night activities,
especially driving.
 Causes
 Dependent on amount of correction being done (larger
corrections have higher risk)
 Larger pupil size have higher risk.
 Prevalence
 1/50 (glare)
o Contrast sensitivity
 Ability to discern images of varying shades from the background is
diminished.
 Symptoms
 Decreased night or low light vision linked with glare,
haloes, or starbursts.
 These usually subside within 1-3 months.
o Reduced VA
 Improper programming of the excimer laser, incorrect positioning
of treatment zone or complications in the healing process such as
excess scarring or flap wrinkling.
o Sand of Sahara (aka Diffuse Lamellar Keratitis)
 Inflammatory reaction underneath cornea flap. This is a multifocal
and/or diffuse inflammation confined to the flap interface. It
generally starts in the periphery and appears 2-6 days after
surgery, but it may not be present until as late as 6 months after
surgery.
 Symptoms
 It may be asymptomatic or accompanied by mild to severe
blurring, redness, and discomfort. Photophobia and tearing
are also seen. NOT an infection.
 Causes
 Unknown. May result from either a build up of bacterial
endotoxin in the wet autoclabe reservoir, talc from gloves,
meibomian gland secretions, microkeratome oil, or blade
debris.
 Grading
 1
o Description
 1-10 days post-op
 Focal white to gray granular material under
the LASIK flap.
 Easily mistaken for SPK, but it is not on the
surface rather at the stromal interface.
 No anterior chamber reaction/ quiet eye.
 Normal VA
o Treatment
 Topical Pred 1% steroid qh
 FU 1-2 days with gradual taper.

2
o Description
 Moderate density of interface material with
potential clumping or coalescence
 Slightly reduced BCVA
 Quiet eye
 Often present with temporary hyperopia
with astigmatism
o Treatment
 Topical PF 1% qh
 FU 24 hours
 If worse, may require lifting flap and
irrigating inflammatory cells from interface.

3
o Description
 Dense accumulation of interface materials
 Reduced BCVA typically 20/30 – 20/60.
Hyperopia with astigmatism
 Possible slight conjunctival injection but not
anterior chamber reaction
o Treatment
 Consider lifting flap and irrigation of
interface with saline and steroid
 Topical PF 1% qh
 Evaluate in 24 hours.

4


o Description
 Very dense interface material
 Reduced BCVA worse than 20/50-20/60
 Difficult to get refraction
 Conjunctival injection with rare anterior
chamber reaction
 May develop striae in the flap
o Treatment
 Lifting flap and irrigation with saline and
steroids ASAP
 Topical PF 1% q30-60min
 FU 24 hours
Resolving Sands with Striae
Prevalence
 1/500
 Treatment
 If untreated, it may extend into the central cornea and lead
to a progressive decrease in VA.
 Frequent/aggressive use of eye drops (corticosteroids). Q12h
 Flap lift and irrigation may be required for more severe
cases.
 Severe cases left untreated can cause corneal scarring and
ultimately lead to vision loss.
o Infection/ Infectious Keratitis. Sterile Infiltrates

o
o
o
o
This is rare. It is usually acquired intraoperatively and caused bu
G+ bacteria, atypical mycobacteria, fungus, or virus.
 It presents early with isolated infiltrates, corneal inflammation,
conjunctival injection, and in severe cases, with an anterior
chamber reaction.
 Treat any suspected infection immediately.
Double vision (Monocular Diplopia)
 Symptoms
 Secondary image tends to be more opaque
 Causes
 Due to irregular astigmatism (hills and valleys in the cornea
that bend in strange directions) resulting in multiple images
on the retina.
Overcorrection/undercorrection/ induced astigmatism
 Overcorrection occurs when the laser has removed too much
tissue.
 Undercorrection occurs when the laser has not removed an
adequate amount of tissue
 Symptoms
 Noticeable blur
 10% of patients need re-treatment (enhancements) to correct vision
after LASIK
 may need to continue to wear glasses to help correct the vision
problem.
 Over and under response is more commin in higher prescriptions.
 Refer back to surgeon for enhancement before 3 months so that the
flap can be easily reflected and manipulated.
Haze
Flap Striae


These are wrinkles or folds in the flap which usually occur
immediately after replacement of the flap or during the initial
healing of the flap.
Striae appear as vertical lines on a nasal hinge flap and horizontal
lines on a superior hinge flap.


Treatment involves removing the striae by smoothing the flap
which should be performed as soon as possible.
1



Description
o Seen early post-op first days.
o Very faint lines
o More common with high refractive errors
o Not associated with reduced acuity.
Treatment
o Generally not clinically significant and none
required.
2


Description
o Seen early as distinct lines, single, or in clusters.
o Mild reduced acuity and subjective reports of
“qualitative problems.”
o Retroillumination with dilated pupil is absolute best
technique to observe.
o Delayed viewing following fluorescein instillation
may help seeing grooves.
Retro


Treatment
o Flap needs to be lifted and repositioned within 1-3
days for optimal results.
o Striae that affect BCVA do not “go away” or
resolve on their own and much better results occur
with prompt treatment.
o Evaluate patient in 24 hours.
o Occasionally BCL are applied to enhance comfort
and stability.

Description
o Seen first few hours post-op or from trauma
o Marked striations
o May have discomfort due to flap displacement
o Gutter of the flap may have gap and increases risk
of infection and/or epithelial ingrowth.
o Reduced acuity from moderate to severe
Treatment
o Repositioning and alignment should be done
immediately.
o Epithelial compromise or other conditions may
warrant a BCL along with appropriate antibiotic
treatment.
o Evaluate patient in 24 hours.
o Rarely if striae do not respond to lifting and
stretching, appropriate suturing techniques have
shown to be beneficial.
3

o Epithelial Defect
o Fiber Debris Under the Flap
o Debris with inflammation under flap
o Epithelial Ingrowth




This occurs in up to 20% of LASIK cases. It is related either to
contiguous migration of cells from the edge of the flap or direct
inflammation of cells in the interface during the LASIK procedure.
It can progress to cause irregular astigmatism or to induce melting
of the overlying flap.
Although a definitive cause is still uncertain, it appears to be
associated with epithelial defects at the time of surgery, history of
recurrent corneal erosion, hyperopic correction, repeated LASIK
treatments, flap instability and/or ABMD.
Treat with topical steroids. More severe cases require lifting of the
flap and scraping the epithelial cells from the stroma.
1



2
Description
o Grey to white fine deposit typically at or near the
flap edge.
o Only 1-2 cell layers thick appearing as thin haze or
may be in small clusters (1-2mm)
o Noted early 1-10 days post-op
o No subjective complaint or acuity change
Treatment
o Observation in 5-10 days
o No treatment usually required
o Typically thin layers of epithelium die and if a fine
white line is noted along the leading edge of the
ingrowth, it is not likely to progress.



Description
o Dense opaque accumulation in small clusters of a
sheet which extends up to 2-3mm from the flap
edge.
o May approach pupillary axis if aggressive.
o VA affected if central location
o Flap edge may appear hazy
Treatment
o Non-urgent observe closely to prevent progression
to edge retraction or flap melt.
o If progresses flap is lifted and epithelial cells are
cleaned out of interface.
3


Description
o Thick opaque accumulation often geographic
presentation larger than 2mm
o If at the flap edge probably melt and/or retraction of
flap, possible discomfort
o Vision may be affected if encroaching visual axis
o Epithelial defect possible over site of ingrowth if
melt occurs.
Ingrowth with Flap Melt



Retroillumination

Treatment
o If in visual axis or flap melt occurs, should treat
ASAP
o Can result in permanent loss of BCVA if not
resolved in time.
o Loss of BCVA
o Corneal Ectasia
 This is one of the more difficult complications and potentially the
most visually devastating.
 A progressive anterior shift of the cornea associated with central
steepening and thinning, myopic shift, and visual symptoms.
Severe cases often require a PK. Other cases managed with RGPs
or intacts.
 Possible causes
 Residual corneal stroma, coreal modulus, corneal flap
thickness, IOP, apoptosis of corneal cells.
Regression
o This is reported more often with high-myopic and hyperopic LASIK. this
is caused by post-op epithelial and stromal hyperplasia resulting in corneal
steepening. These patients are referred back to the surgeon for LASIK
enhancement. Additional ablation requires very precise calculation of the
stromal bed thickness because often the underlying stromal bed is too thin
to permit additional ablation.
Enhancements
o 20/ Unhappy Patient Evaluation
 Careful manifest refraction with BCVA
 SLE
o
o
o
o
o
 R/O TF problems
 R/O epithelial ingrowth
 R/O flap microstriae
 RGP Test
 R/O Cataracts and macular problems
15% of all surgeries require some form of enhancement. 82% of those
only required one operation.
Surgical enhancements are usually required if less than optimal outcome
has occurred or if previous surgical treatment has regressed to cause a
symptomatic refractive error. Initial under correction and epithelial
hyperplasia are usually the common causes associated with enhancements.
Risks depends on the original rx
 Myopes around 6%
 With cyl over 3D about 10%
 Myopes >9D and hyperpes around 11-15%
Pre-op Examination
 History
 Uncorrected monocular VA
 BCMVA
 Careful manifest dry refraction
 PreVue Lenses- directly comes from the aberrometers
 Cycloplegic wet refraction
 Schirmer test
 Ant seg examination
 Pachymetry/ ultrasound
 Pupillometry (IR)
 Corneal topography
 Dilated post. seg examination
 Wavefront aberrometry
Pre-op considerations
 How soon should we enhance a patient?
 Rule of thumb: 1 month for every diopter of primary
ablation.
 Must have 2 consecutive similar refractions, corneal topographies,
and normal aberrometry (less than 0.50D change)
 Must have wet rx on all enhancement procedures
 Corneal thickness
 Must leave 250-275 microns in bed. If not, it could lead to
ectasia.
 Must leave 400 microns overall.
 Never go deeper than 50% original thickness.
 Beware of epithelial hyperplasia
o The cornea attempts to “fill-in” the corneal
depressions. Associated with abrupt change in
corneal curvature. Rule out by performing PIB
(Patch In Bed). Pre-op pach – ablation depth > postop pach.
 Beware of corneal ectasia
o Seen first in the posterior cornea.
 Average depth 18.3 microns/D
 Depth range: 14.9 – 22.9 microns/D (varies due to
wavefront)
 Deppest part of ablation not necessarily central
 Retreatment depths as much as 50microns/ D
 Glare is multifactorial
 Pupil size
 Flatness of keratometry
 Residual refractive error
 Anterior chamber depth
 Media opacities
 Smoothness of media (striae, ingrowth, opacities)
 High order aberrations
o What to Watch out for
 Keractasia

Bent Bow Tie

Pellucid
o Wavefront Maps
 High spherical aberrations may be closely associated with LASIK
postoperative night vision complaints of glare.

High amounts of trefoil are commonly found in patients
complaining of starbursts at night.

Asymmetric aberrations such as trefoil and quadrafoil may give
rise to patient symptoms of monocular diplopia and triplopia.
o For post-Custom LASIK patients, recommend Custom LASIK
enhancement, especially if there is a loss of BCVA or subjective visual
symptoms resolved with phoropter/trial frame correction. You might want
to wait for the next generation customized treatments. If there is
satisfactory vision, standard LASIK could be performed.
 Must be careful regarding over-corrections with patients with large
amounts of HOA (SA)
 Adjust treatment +0.25 for every 0.1 microns > 0.20 of
symmetrical HOA.
o Cap Mgmt
 Lift or recut?
 Generally lift flap. There are poorer results with recutting.
 Timing
o A recut has been safely performed as soon as 8
weeks post primary LASIK, but it is recommended
to wait 3-9 months.
o A lift has been safely performed 27 months after
primary LASIK but the recommendation has been
to consider a recut after 12 months.
 Recuts
o This used to be more common, because it was
thought to be faster with a decreased chance of
inducing epithelial ingrowth. Today the technique
and instrumentation of flap lifting have both
improved. Recutting has the advantage of not
involving flap manipulation, especially if the flap is
thin or perforated.
o Pachymetry
 Pacymetry – (250bed + old cap160) =
residula for ablation after lift
 E.g., 450 – 410 = 40 microns
 Pachymetry – (250bed + 200new cap) =
residual for ablation after recut (unless at
same depth)
o
o
o
o
 E.g., 450 – 450 = 0 microns
Interface fibrosis, or after 12 months pre-op
If minimal pach, recut at same depth after 12
months
Lasik, post RK….one cut per year
History of recurrent ingrowth
o Correcting Striae
 This can be corrected with a sequential lift and suture technique. It
eliminates the need to fixate the flap with forceps during suturing
and increased accuracy of suture placement.
o Great for the correction of residual myopia and/or astigmatism, following
RK
 PRK haze, following incisional surgery, has been associated with a
30% chance of loss of 3 lines of BCVA
 Haze prophylaxis
o Mitomycin C- 0.02mg/ml for 2 min
o Inhibits haze after primary high PRK
o Inhibits haze following PRK after RK
o Lower risk than use in glaucoma filtration surgery
(0.4% for 2 min)
 LASIK is the procedure of choice for residual or consecutive
refractive errors after incisional surgery (RK)- Ideal.
 Methods
o Previous incision RK, +/- AK
o Visually significant refractive error, with BCVA >2
lines over UCVA
o No epithelial inclusion cysts in incisions.
 Inclusions encourage ingrowth
o General Rules
 UCVA 20/40 or 20/unhappy
 Not zero risk
 Pachymetry is only one limiting factor
 Supplemental P/T Spec Rx?
 Resist small monovision adjustments
o Case Studies
 Decentered Ablation with Induced Vertical Coma
 53 yo female presents with complaints of glare,
multiplopia, and “smeared vision” in left eye. S/P LASIK
for -8D spherical myopia. -1.75 -1.25 x 090 20/25. Topo
shows superior decentered ablation.
 Patient undergoes wavefront-guided enhancement. 3 mo.
Post-op pt pleased with quality of vision. MR -0.50DS
20/20. wavefront refraction -0.66 -0.49 x101. Vertical
coma -0.48. OZ nearly centered on topo.
 Poor vision after PRK


-6.25 -1.00 x120 OD, -6.75 -1.00 x055 OS. PRK OU 1995
with ablation zone 4.5mm.
 Post-op complains of poor quality vision and glare- ou.
OD: -1.75 -1.50 x165 20/30 OS: -1.00 -1.25 x025 20/30.
Scotopic pupils 7mm, Pachymetry 49-/505
 Amadeus microkeratome 9.0mm diameter flap with 140
plate to achieve a 120 micron flap. Visx custom ablation
OU. Physician adjustment +0.35 OU
Poor vision after LASIK
 -6.25 -1.00 x120, -6.75 -1.00 x055. LASIK 2000.
 Post-op complains of poor quality vision and glare- OU.
Bilateral Striae, flap suturing OD, hyperthermia OS.
Residual striae OD (best seen with dilation, and retro on
DO). -0.50 -0.50 x114 20/30, -1.00 -1.25 x025 20/20.
Scotopic pupils 5.5mm, pachs 480


MO




Combined Visx S4 PTK with 6mm ablation zone without
blend zone of 50 depth. Scraping of peripheral epithelium
to 9mm. wavefront PRK with 7mm optical zone and 9mm
ablation zone. Ablation depth 28.5 (6/8 treatment ablation
depth 19). Topical mitomycin C 0.02% for 2 min.
38yo white male. CEO large bank. Ocular/systemic history
unremarkable. DW soft CL D/C x4 weeks. OD: -7.50 -1.25
x010 20/20, OS: -9.50 -0.50 x008 20/20-. Dry = Wet RX.
OD Dom. K: 44.25/45.50 x180- OU. Pupil (scotopic)
7.0mm OU. Pachs 554/551. Normal topos. Bilateral LASIK
03/24/99. Hansatome 160 plate/8.5 ring. Summit apex.
Uneventful (double card) surgery.
Post-op: UCVA 20/20, 20/70-. BCVA OD plano 20/20, OS
+3.25 -3.50 x105 20/30+. Biomicroscopy normal. Patient is
“miserable”, nausea, dizzy, vertigo. “I cannot ride in trains
or cars without closing eye.”
1st enhancement: Dry = Wet +3.25 -3.50 x105. Alcon
Autonomous LADARVision 4000. Recut with Moria LSK
150.
Post-Op: UCVA 20/70. BCVA +3.50 -3.50 x105 20/30. No
change in rx! Cannot correct with soft toric. RGP 20/20 but
cannot tolerate.




Suture flap. UCVA 20/20 BCVA plano 20/20. Remove
sutures. Within 2 weeks Rx +3.50 -3.50 x105 20/30.
WaveScan Rx -1.99 1.66 x024. Repeatable on multiple
aberrometers. Repeatable wet or dry. PreVue lens 20/20
clear.
Healing
o In minutes to hours.
 Not fully complete until about 2 years.
o Fibrin
o Physical attraction
o Endothelium and negative pump
Cost
o On the average, the price of LASIK has been decreasing.
 The average price of LASIK was 1655 per eye in the 1st quarter in
2001.
 This decrease in price is because of an increase in consumer
interest and co-management of laser centers.
 Currently there is no universal standard regarding price of
refractive surgery.
 This is good when thinking about the amount spent on contacts or
glasses every year.
o What the fee covers
 A portion of the purchase price of the laser.
 Laser maintenance, excimer laser manufacturer fee
 Surgical devices, gowns, gloves, masks, and other sterile surgical
tools.
 Insurance
 Running the surgical center: staff salaries, advertisements, rent,
and other office equipment
 Surgeon’s fee
 Standard pre-op and post-op visits. Maybe touch-ups.
o Method of payment
 There are medical flex plans where you set aside pre-tax dollars
from your paycheck for medical expenses.
 You can earn a federal tax deducation if you itemize your medical
and dental expenses, because LASIK surgery is a medical expense.
 Because LASIK is in high demand, insurance companies are
beginning to offer benefits for the procedure. Some insurance
companies already offer to pay for a portion of the LASIK surgery
and care.
Laser Thermal Keratoplasty (LTK)
 A holmium laser is being evaluated for correction of small amounts of hyperopia.
The technique uses a laser to tighten the tissue fibers in the peripheral cornea in
an attempt to steepen its curvature.
 Uses the “Sand Principle”





o Produces heat generating spots that coalesce to steepen the cornea.
16 pulses of Holmium: Yag delivered simultaneously to 8 spots on a 6mm and 8
spots on a 7mm optical zone
1.4sec exposure times per ring.
Adaptation can take months, so not used as much.
Good for hyperopes.
Machinery
o Sunrise Hyperion LTK System- expensive
Conductive Keratoplasty (CK)
 Uses controlled release of radiofrequency thermal energy (instead of a laser) to
heat and shrink the corneal tissue. The energy is applied at points in a circular
pattern around the peripheral cornea. The heat creates shrinkage and all point pull
together via striae that form. This acts as a ring of tightening that steepens the
cornea. The result reduces the need for reading glasses.
 There is a temporary induction from -1.00 - -2.00D of myopia to improve near
vision in the non-dominant eye.
 The limited range is -1.00 - -2.25D or treatment with 16-24 spots.
 86% of patients in this range achieved both uncorrected distance vision of 20/20
or better and near vision of J3 or better.
 This was originally approved by the FDA in 2002 to treat +0.75 - +3.25D of
hyperopia, with up to -0.75D of cyl. In February 2004, it was approved for
presbyopia.
 This does not affect the DVA.
 The first FDA approved technology for presbyopia. It induces a
progressive/aspheric effect (a multifocal cornea effect). The distance vision
improves, and the near benefit remains. “Blended vision”
 The stainless steel handle is 450 microns (corneal needle is 400 microns), so need
a 510 micron cornea. It delivers 350 kHz radio frequency energy placed in a
series of circumferential spot applications to the mid-peripheral cornea. This
causes the corneal collagen to contract like a belt, resulting in the steepening of
the central cornea.
 The effect of CK is determined by the number of spot applications, the number of
rings of applications, and the diameter of the application rings.
 Marks at 6, 7, or 8mm.
 With +1.00, monovision is sufficient. Do bilateral with high hyperopes.
 Lower tech, but higher durability
 Non-laser, in-office, correction of spherical hyperopia. Surgeon-friendly.
 Deteriorated accommodative ET?
 Candidates
o At least 40 years old
o No eye disease
o Need “readers”
o Realistic goals
 Less dependent on glasses











Read a menu
See my watch
Mark my golf card
See the compuer
Features
o Treats
 Farsightedness
 Astigmatism
 Presbyopia, even after LASIK correction
o Induces permanent change
o Utilizes harmless “radio waves”
Procedure
o Topical anesthesia
o Takes about 10 min per eye
o The instrument resembles a slit lamp.
o AT and sometimes antibiotic and steroid drops are used one week post-op.
o Some FBS and fluctuation in vision will occur.
o Treatment usually lasts for 1-4 years. Patients can be retreated but
outcomes for retreatments are not yet published.
Logistics
o Are both eyes treated at once?
 If necessary, and as the patient requests
 For about 50%, one eye is sufficient
o When can I go back to normal activities?
 Next day
o Do I need to take time off of work?
 If driving or computers require
 1-2 days (weekend rest)
Benefits
o Designed specifically for farsightedness.
o FDA proven as an effective vision correction procedure
o Excellent safety profile
 CK does not require cutting or tissue removal.
Risks
o This is the safest refractive procedure. No infections because the heat spot
is self sterilizing.
o Fluctuations in vision (only temporary)
o Undercorrection (corrected with enhancement)
o Overcorrection (rare, may require temporary glasses)
o Glare (temporary first month)
o Sensitivity to light (temporary during first month_
Off-label
o Post-cataract
o Astigmatism touch-ups
Machinery
o Viewpoint CK System



 Portable
 Generates radiofrequency waves
Common questions
o Is it painful? No. Eyes might feel a little “scratchy”
o How is CK different than LASIK? None of the lasik risks
o Is it an office procedure? Yes
o Will I ever need glasses again?
 Demanding night driving
 Extended reading
 The older we are, the more we may need occasional correction.
Conclusions- CK may be used to treat blurred vision, without incisions or the
removal of corneal tissue.
Refracttech.com
Intacs (Intracorneal Rings)
 A small incision is made in the surface of the cornea. 2 microsized tunnels are
made in the peripheral cornea. Small curved plastic half-rings are inserted in these
tunnels. The result is a flattening effect to the center of the cornea. The size of the
intacts are calibrated to the amount of correction needed.
 Up to 6D internationally (3D in the US)
 Inserted in 2/3 the depth of the cornea.
 Bad if the pupil in low illuminations is >7mm, because that is the diameter of the
intacts.
 They are removable without any induced side effects.
 Can adjust the prescription with age since they are removable.
 For low to moderate myopes.
 Can be used alone or in combination
o Alone, if simple myopia <3D
o With PRK to follow in one month for residual refractive error
 When sphere is >3D or there is cyl >0.75D.
 Indications
o Any excimer where residual bed <250
 Or pach <500, low myopes
o Forme Fruste Keratoconus
o Frank keratoconus, contact intolerant
 In keratoconus CL failures to reduce irregular astigmatism, flatten
and center the cone to
 Improve BCVA
 Improve CL tolerance
 Avoid corneal transplantation.
o Plano presbyopia in a monovision contact
o Previously operated corneas with scars of old incisional keratotomy, lasik,
etc.
o “Flap fear”
 Pre-op eval
o
o
o
o
o

Simple low spherical myopia <3D
Pupils <6.5mm
Astigmatism <0.75%
Complete the usual lasik pre-op form
For keratoconus, if a CL OR is available, it helps select the size of the
inserts.
Post-op care
o Single, 1.2mm radial incision causes a slight FBS for several hours.
o Same post-op as lasik
 Meds qid x1wk
 Shield at sleep x1wk
 After keratoconus, can CL fit after 2 weeks. Daily wear for one
month.
Clear Lens Extraction (CLE)
 The internal lens of the eye is removed (as in a cataract extraction) and a lens
implant of a different power is implanted. Used for patients over 40 with
hyperopia. Could also be used for presbyopes.
 Risks may outweigh the benefits.
o Hemorrhage, RD, and endophthalmitis.
 Patients who may benefit the most from lens extraction are those older than 50
and who have already have some cataract with reduced accommodation. There is
a decreased risk for RD once the vitreous is forward.
 Additionally, some patients may need LASIK after implantation to correct
residual refractive error.
Phakic Intraocular Lens (PIOL)
 A lens implant, inside the AC for either myopia or hyperopia. This lens is in
effect an internal CL.
 Types
o 3rd Baikoff- A/C 4 point fixation- Chiron
o “Nu Vita MB20”
o Worst- Fechner- Iris Fixation- Ophthtech
o Artisan
o Iris Claw Phakic IOL
 Flexes
 Can move out of place
 Not good
 Endophthalmitis
o 5th Feydorov- P/C- Staar
 “Intraocular Contact Lens- ICL”
 between the iris and lens
 can touch the lens, causing cataracts
 can create papillary block, so perform a PI
 1-2 weeks prior to ICL implantation
 power settings low as possible.

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Placed at 10 and 2 o’clock
0.8-1.0mm in diameter
<90 degrees (3 clock hours) apart
Patency verified prior to ICL surgery
1 iridotomy clear after ICL pleacement
for myopia or hyperopia
advantages
 Corneal thickness irrelevant
 Wide range of refractive errors correctable
 No regression
 Excellent predictability
 Preservation of accommodation
 Small incision- foldable IOL
 Insertion pearls
 Minimal viscoelastic
 Keep cartridge head just inside wound
 Inject ICL slow and steady
 Pulsate after 70% injection to unfold
 Dipple on right leading haptic.
 Complications
 IOP >21mmHg (controlled)- 5/46
 Glare- 1/46
 Pigmentray dispersion- 1/46
 Pigmentary Glaucoma- 0
 Pupillary block- 0
 Decentration- 0
 Size adjustments- 0
 Cataracts
o Mild ASC changes 6/46 eyes
o Probably surgery related
o All occur in first 2 weeks
 No changes in BCVA
 No ICL removal
 Mean endothelial cell loss 6.1%
 Touch the lens, get a cataract
 Intraocular toxicity, endophthalmitis
 Explant prior to vitreoretinal surgery
 Decentration
 Exchange for power adjustment through areas of previous trauma
 Papillary block/pigmentary glaucoma.
Verisyse (AMO)
o The FDA approved the first phakic IOL in Sept 2004, the Verisyse.
 This is a delicate surgery, and it requires a great deal of precision
and dexterity by the surgeon.
 Successfully used in Europe for over 15 years.
o It is a PMMA implant that clips onto the mid-peripheral iris (iris fixated).
 It is manufactured from Perspex CQ-UV PMMA. n = 1.49. The
lens has an overall diameter of 8.5mm and is vaulted anteriorly to
ensure optical clearance from the anterior lens capsule. The overall
height of the lens will not exceed 0.95mm at its highest power.
There is both a 5 and 6mm optic zone.
 5 mm optic: -5D – 20D, correcting -4.5 to -22D
 6mm optic: -5 - -15D
o Considerations
 At least 21 years old
 -5.00 - -20.00D (0.5D increments) with -2.50D of astigmatism.
 Stable refraction, in whom satisfactory vision is not achieved with
CL or spectacles.
 Pupil size of 6.0mm of smaller.
 Patients anterior chamber depth and endothelial cell count will
determine whether they are good candidates.
 A loss of endothelial cells in patients who have undergone
the procedure of 1.8% per year. At this rate, a patient will
lose 50% of the endothelial cells after 25 years. If too many
endothelial cells are lost, the patient will require a corneal
transplant.
o The “Right” Patient
 Dissatisfied with quality of vision and functional/ cosmetic
limitations with spectacles.
 Unable to wear CL
 Progressive corneal problems, inconvenience, and cost.
 Outside the range of laser refractive surgery, Intacs, CK
 Risks of refractive lens exchange not acceptable.
o The “Wrong” Patient
 Age- early cataract
 Inappropriate expectations
 Expect “perfect” vision
 Demand immediate results
 Side effects and complications
 Unstable personality/ psychological issues
 Occupational risks (pugilist)
 The ‘discount’ shopper
 Astigmatism and enhancements may be an additional fee.
 Hx of RD, or family history of RD, especially high myopes.
 Abnormal pupils, irises, shallow AC (<3.2mm)
 IOP >21
 Endothelial cell counts less than 2000 cells/mm2
Age
Min. Edothelial Cell Density (cells/mm2)
21-25
3550
26-30
3175
31-35
2825
36-40
2500
41-45
2225
>45
2000
 Chronic or recurrent uveitis/iritis, rubeosis irides
 ARMD, retinopathy
o Patient Education
 Set appropriate expectations
 Risks
 Infection, corneal decomposition, iritis, lens dislocation, cataract,
edema.
 High myopia risks- RD
 Side effects/ cosmesis
 Halos, glare at night.
 Lens reflection
 Physiological changes of aging
 Presbyopia
 Cataract
 Glaucoma
o Pre-op
 Examination

Pupil Size
o Scotopic pupil size greater than lens optic diameter
may cause glare and halos.
o Elicit history of meds or other factors that may be
influencing pupil size.
o Set appropriate post-surgical expectations.
 Refraction
 Keratometry
 Anterior Depth- Biometry
 Instructions
 Normal instructions
o Procedure
 Pre-op Meds
 20mg Valium
 Pilocarpine 4%
 Alphagan-P reduced SCH intraoperatively.
 Medrol Dose Pack reduces inflammation
 In Surgical Suite
 Eye is prepped with providence-iodine solution
 Topical 2% Lidocaine gel is generously instilled.
 Paracentesis incisions are performed.
 An iridectomy is performed
 Viscoelastic is injected (Healon or CoEase)
 The insertion incision is made, typically a 6.2mm stepped
limbal incision. If the patient has significant astigmatism,
the incision is made on the steep axis.
 The verisyse lens is prepared.
 The lens is inserted. Sufficient miosis and chamber depth is
ensured.
 The implant is rotated to appropriate position.
 Enclavation of haptics through paracentesis incisions.
 The chamber is reformed and checked for leakage, pupil
centration is verified, and adequate enclavation is verified.
 Reposition or reenclavation if necessary.
 Incision is secured.
 Viscoelastic is removed.
o Post-Op
 Medication
Day
Medication
Dosage
# of times
Day of Surgery Diamox
1 capsule
At bedtime
Week 1
Vigamox
1 drop
Qid
Nevenac
Econopred
Week 2
Vigamox
1 drop
Bid
Nevenac
Bid
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Econopred
Tid
Week 3
Vigamox
1 drop
Qd
Nevenac
Qd
Econopred
Bid
Week 4
Econopred
1 drop
Qd
After Surgery to 1 Day Post-op
 Post-op management is similar to cataract surgery. Larger
incision may be prone to leakage for the first 24-48 hours,
so check for positive Seidel sign.
 Appearance
o The verisyse lens will be attached (clipped) to the
peripheral iris at 2 locations. The orientation of the
lens will be based on the entry incision, so the lens
will not always be horizontal. The meridian of the
entry incision is in the axis of astigmatism as this
will help reduce astigmatism when the corneal
edema resolves and sutures naturally relax. There
will be localized peripheral corneal edema in the
location of the entry incision and the paracentesis,
which resolves over 1-2 weeks typically. There may
be SCH as well. There will be some degree of cells
and flare in the AC which resolves over a 2-4 week
period. Sometimes the pupil may appear slightly
oval which will normalize after a few weeks (there
is no adverse visual effects, just a slit lamp finding).
 Testing
o Uncorrected VA, IOP, fluorescein staining to verify
Seidel negative, SLE. There may be some retained
viscoelastic which can cause a temporary elevated
IOP.
o An IOP between 21 and 29 does not require
intervention, while IOP of 30 or more does require a
glaucoma drop for 1 week as retained viscoelastic is
naturally cleared.
o Patient should be cautioned against bumping,
rubbing, or touching the eye for 1 week.
o An eye shield should be applied and should be used
for sleeping for at least 1 week.
o Pain medications can be prescribed as necessary in
addition to post-op medication.
o Patients unfamiliar with LASIK should be
instructed on the intraocular lens recovery process,
which may include more discomfort, longer healing
time, and slower visual recovery.
1 week post-op
 Appearance


o Corneal edema will be resolving along with cells
and flare in the AC.
o Patients should notice significant improvement in
UCVA. Check for quiet eye, deep AC. Well
centered lens should be apparent.
o UCVA (D/N), MR, BSCVA, IOP, SLE, Check
Meds
4-6 week post-op
 Appearance
o Quiet eye with deep AC and well centered lens.
BCVA should be as good or better than pre-op
refraction.
o If UCVA is poor, determine the cause
(inflammation, astigmatism, retinal/macular
problems).
o If the problem is lens centration or power, consider
lens repositioning or replacement.
o If poor vision is related to existing or induced
astigmatism reassure the patient and consider
enhancement surgery at the 3 month visit.
o UCVA (D/N), MR, BSCVA (D/N), IOP, SLE,
Corneal topo
3 mo post-op
 Appearance
o Vision will stabilize between 1-3 months. Corneal
edema and AC cells will be resolved by the 1 month
visit in almost all patients. Sutures may become
loose at various times and may cause FBS.
Fluorescein testing will reveal the elevated suture
with fluorescein pooling around the suture. This is
an indication for suture removal which can be
performed at the slit lamp. If there are no symptoms
and sutures are flat, suture can remain in place.
 Testing
o MR may be performed at any time. If patient is
having difficulty with vision during healing period,
glasses may be prescribed. In some cases, it is
expected that glasses or CL will be needed post-op.
IOP should be checked at each visit along with slit
lamp evaluation. In some cases, LASIK after 6 mo
may be an option for residual refractive error is that
is desired by the patient.
o In addition to seeing you for a 3 month visit, patient
should also be seen at the surgery center for
endothelial cell count.
o Check for secure well-centered lens.
o VA should be good or better than pre-op BCVA. If
not, consider an enhancement if refraction has
stabilized.
o UCVA (D/N), MR, BSCVA (D/N), IOP, SLE,
Corneal topo, endothelial cell count

o
o
o
o
o
1 year
 Punctal plugs (silicone or collagen) should be used liberally
which can aid in comfort and lubrication after surgery.
 Follow patient carefully until vision has stabilized and they
are satisfied with VA.
 UCVA (D/N), MR, BSCVA (D/N), IOP, SLE, DFE
Considerations
 If a patient has eye trauma at any time, the eye should be evaluated
for lens disinsertion. If the lens is ever found to not be attached to
the iris, it will need to be surgically reattached as soon as possible
to avoid trauma to the endothelium from an unstable lens.
 After the 12 month visit, patients should be evaluated annually.
Enhancements
 Remove sutures and evaluate vision and patient satisfaction. Allow
refraction and topography to stabilize. If patient is happy, do
nothing and continue to follow up. If patient is not functional or
patent is not happy, consider the following based on lifestyle,
occupation, and level of refractive error.
 3-6 months post-op
 Residual myopia
o Corneal laser refractive surgery
 Residual hyperopia
o Corneal laser refractive surgery
 Existing or induced astigmatism
o LRI or corneal laser refractive surgery.
Advantages
 Contrast sensitivity is preserved and often improved.
 Rate of retinal detachment was not increased
 Preservation of the crystalline lens allowed for continued
accommodation.
Patient Screening
 Thorough clinical work-up. See visian.
Complications
 Study 1
 1.36% had the IOL exchanged due to adequate surgical
fixation, improper optic size vs. pupil size or power
calculation error.
 1.51% had the IOL removed due to inflammation, patient
enxiety, optic zone that was too small, postoperative trauma
or surgical trauma.
 0.60% had to have the IOL reattached.

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
0.45% required retinal repair.
0.15% experienced surgical trauma that required retinal
repair.
Study 2
 Adverse events
o IOL Replacement 0.7%
o Repositioning of the lens 0.3%
o Removal and cataract implant- 0.3%
o Secondary glaucoma- 0.7%
 Average Cell loss declines over time and levels off to <1%
per year. This is related to the individual surgical
technique.
o Budo et al
n = 518
7.0% at 3 years
o Landesz et al n = 67
10.9% at 3 years
o Phase III
n = 536
3.1% at 2 years
 Complications
o Iris atrophy 0.2%
o Iris pigment precipitates 0.8%
o Non pigment precipitates 1.6%
o Lens not centered 1.6%
o Mild corneal edema 0.4%
o Glare/halos- rings 18.5%
o Macular degeneration 0.4%
o Incipient cataract formation 3.0%
o Diplopia 0.2%
o Increased IOP requiring treatment 0.2%
Iris Defect
Elevated IOP
 This happens in a few cases. After treatment, it generally
reverts to normal values. In 2 cases, Urrets-Zavalia
syndrome developed, which can be caused by incomplete
removal of visco-elastic.
 Other causes include
o Use of a visco-elastic with an extremely high
viscosity.
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o No iridectomy or iridotomy
o Secondary glaucoma
Flat AC and Non-Sealed Wound Closure
 Inadequate closure of the tunnel can lead to an incomplete
seal. Without immediate and adequate treatment, corneal
edema can arise.
Decentered Lens- 1.5%
 The lens is not optimally centered. This does not have any
effect on endothelial cell loss.


Dislocated Enclavation
 Trauma or insufficient iris tissue in haptic.
Cataract (unlikely)
Iris Atrophy

Endophthalmitis

Visian ICL
o Implanted collamer lens
o Preferred refractive alternative
 Moderate to high myopia
 Thin corneas
 Flat corneas
 Large pupils
 Fear of failed outcome (permanent procedure)
 Dry eye patients
 Patients who want the best vision
o Off label Use
 Keratoconus
 History of previous ocular surgery
 Patients under age 21 older than 45
 Collagen sensitivity (none reported)
o Safer refractive Alternative
 Inserted through a small self sealing incision
 No suture required
 No induced astigmatism.
 Much faster recovery
 No contact with moving intraocular structures
 Avoids potential damage to iris
 Affords safer removal in future
 Invisible to the patient and observers
 Less incidence dysphotopsia due to edge glare.
 Collamer material is more biocompatible.
 Thin, flexible, stored in solution
 Location in the posterior chamber.
 Resting position far from corneal endothelium
o Advantages
 Maintains normal cornea curvature. No oblate corneal flattening.
 No tissue removal
 No regression
 No induced nighttime distortions (HOAs)


o
o
o
o
No exacerbation of dry eye cymptoms
Results are immediate. Faster than LASIK, because there is no
corneal edema.
 Inserted through a tiny clear cornea microincision that requires no
stitches.
 Lens material is proven safe and nonreactive in the eye.
 High level of predictability
 Uncorrected VA better than 20/20 and/or better than with glasses
or CLs occurs in more than half of patients.
 Optical diameter of the ICL is quite large which means effective
optical zone at the corneal plane is typically larger that with laser
vision correction.
 The ICL will not scar inside the eye, therefore it is easily
removable/ reversible.
 Better optical quality of vision since it is closer to the nodal point
of the eye.
 Dry eye and halos are not an issue like as in LASIK.
Contraindications
 Glaucoma, including pseudoexfoliation and PDS
 Cataracts
 Retinal disease
 Keratoconus and related corneal conditions
 Anatomic narrow angle or shallow AC
 Previous ocular surgery or serious ocular traumas
 Poor systemic health
 Pregnant or nursing.
Material/ Specifications
 Collamer 0.3% porcine collagen + HEMA copolymer
 Current design (V4) is 5th generation
 Foldable and injected through a 3.0mm incision
 Footplates rest in ciliary sulcus
 Four overall lengths ICM 12.1 – 13.7mm
 ICM central thickness 50 microns
 Refractive index 1.453 at 35º C
 UV filter
FDA Study
Safety and Efficacy Data
 Acute IOP Rise in 20/526 (3.8%)
 Majority of cases reported during first 1-2 days post-op. no reports
after 21 days post-op.
 17 eyes- additional YAG iridotomy or enlargement of existing
iridotomy.
 3 eyes- AC irrigation for removal of retained viscoelastic.
 Surgical iridotomy largely avoids this issue.
 Clinically significant Anterior- Subcapsular Opacities in 2/526
(0.4%)

2 cases progressed to clinically significant opacity required
cataract extraction.
 1 case inadvertent use of preserved miotic agent (topical
Carbachol) in intraocular irrigating solution. BSCVA 20/20
pre-op and post-cataract extraction.
 1 case opacity observed 6 months post-op. cataract surgery
performed at 16 months. BSCVA 20/40 pre-op and postcataract extraction.
o Evolution of the ICL


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
STAAR Surgical Company
5th generation lens over more than 10 years worldwide.
Over 75,000 implants performed
Procedure based on cataract surgery platform
Wide treatment range
 -3.00 to -15.00 sphere (up to 2.5D cyl)
 Up to -20.00 for the reduction of myopia.
 Can do larger, off label. Toric coming soon.
 4 sizes available to best fit individual eyes.
 Stored in a sterile solution, just like soft CLs.
o Protocols
 Screening process
 Myopic range: -5.00 to -15.00D
 Less than or equal to 2.5D refracted cylinder
 Normal anatomy: slit lamp exam, gonioscopy, IOP,
retinoscopy
 Best Candidates
 21-50yo
 Stable refraction (<0.5D change for 1 year preceding
implantation)
 -3.00 - -17.00D
 Up to 2.50D of refractive astigmatism. Can correct even
more cyl with LVC enhancement.
 Thin corneas by orbscan/pach. Even with keratoconus.
 Proposed result of LASIK or PRK would leave the cornea
“too flat.”
 Preoperative Visit


1-2 weeks prior to surgery
Required measurements
o VA
o Accurate refraction (manifest and cyclo)
 Back vertex distance assumed 12.0mm.
o Keratometry with axis
o SLE dilated and undilated.
o IOP
o ACD
 Using Pentacam- direct optical
measurement.
 Need 3.0mm
Pachs
Gonio
Central 1.5mm K
Horizontal W-W
Endothelial cell count
Laser peripheral iridotomies
 Provide outlet for aqueous flow around the
ICL to prevent pupillary block.
 Facilitates removal of viscoelastic at
surgery.
 1-2 weeks prior to procedure to decrease
inflammation, etc.
 This procedure can hurt!
o PF qid x1 week
o Rx for Vigamox/Zymar starting 1 day prior
o Consents signed.
 Interim Essentials
 Refractive stability visits in your office
o Dry refraction
o Cycloplegic refraction
o Manual keratometry
o Back vertex distance (12mm = default)
o Surgical Procedure
o
o
o
o
o
o
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Done in a surgical center under “twilight”
A driver is required and should anticipate total time at the center of
1½ hours.
Valium 10mg-20mg 30 min prior to surgery.
IV heplock or Vered for additional relaxation/sedation.
Pupil is widely dilated.
Conscious S/R
Nurse monitor
LRIs for cyl
The ICL lens is inserted through a 3mm incision that seals up by
itself.
A viscous gel is used during the procedure to protect internal
structures of the eye.
15 min
Virtually painless
Immediate results
Surgery for fellow eye ideally 2 weeks after initial eye. Bilateral
procedures now being performed.
Loading the Visian ICL
 Insert cartridge into injector. Lock into place.
Clear corneal incision
 Temporal, clear corneal incision orients best to iris place.
o Post-Op Care
 2-4 hours post-surgery
 Ensure IOP not elevated. Over 25mmHg must be
addressed.
 IOP elevation
o Retained viscoelastic- burp and check.
o Non-patent iridotomy- back to the laser.
 SLE
o ICL centration
o Inflammation
o Vault-generally less at this time than will be seen in
longer-term follow-up care (less than 1/2x corneal
thickness not uncommon)

 VA
Post-Op Day 1, 7 and Beyond
 VA
 Refraction (Day 7 and beyond)
 SLE
o ICL Centration, Inflammation, Vault 0.5-2x corneal
thickness.
 IOP
 Evaluation of crystalline lens

Assessing the Vault
o Thin optic section with biomicroscope
 Angle between ocular and light source
should be 30-45º
 Use bright illumination
o Alternate focus from corneal thickness (ct) to vault
space for comparison.
o Under 0.5ct observe for capsular haze.
o Over 2.0ct observe fro narrowing angle.
 Medications
 Vigamox/Zymar qid
 Nevenac/Acular LS qid until finished
 PF qid for 1 month with quick taper.
 Copsopt for 3 days
 ATs
 Biomicroscopy examination and IOP check
 1 day, 1 week, 1 month.
 Along with Vas, Ks, MR
 ICL Vault
o SL beam from lens to crystalline lens.
o K = 100%
o 50% and up is good.
 Enhancing laser vision correction procedure can be done 1 month
after surgery if needed.
o Patient Satisfaction
 Only procedure that consistently produces UCVA significantly
better than BCVA pre-op. Patients routinely comment on this. This
is since the nodal point is within the eye, which is the best optical
location. Corneal surgery, contacts, and glasses are relatively far
from the nodal point.
 When you bring up to patients, surprising how many patients are
comfortable with concept of ICL compared to LASIK. There is
less fear. It is viewed as “no maintenance contacts.”
Procedures and Protocol


Meeting patients expectations
o Clearly understand the patient’s goals and limitations
o Define the reasonable outcomes and limitations of a procedure
o Success = matching goals with reasonable outcomes.
Who is a candidate?
o Age 18 and older (prefer >30)
o Stable refractive status, 0.50D or more change over 12 months and we’re
in a holding pattern. l
o Myopes are more stable and therefore have a better outcome.
 Up to -14.00DS with 6D cyl.
o
o
o
o
o
o
o

+6D and up to 6D cyl
Has realistic expectations. Never, “Never want to wear glasses.”
Desires good “functional vision
CL intolerant
Wants less dependency on glasses/CL
Not an engineer
Good ocular health: no visually significant lens opacity and healthy
macula.
o Corneal Thickness
 >470 microns (depending on refractive error)
 Preserve minimally 150 microns in stromal bed.
 Average 15 microns per D with 6.5 OZ blended to 9mm.
 As OZ increases, the amount of tissue removed increases
exponentially.
o Keratometric Ranges
 Myopes
 35.00D flattest K reading
 Uses 75% of power to determine change in K.
 Hyperopes
 49.00D steepest K
 Uses 100% of power to determine change in K.
 i.e., 45D with +4 → 49D
Bad Candidates
o Contraindications
 Active autoimmune disease- Graves, Lupus, RA, MS
 CA (immunosupressed)
 Uncontrolled HTN, vascular disease.
 Uncontrolled DM
 Type 1- one eye at a time, due to poor healing
 Type II- OK as long as no DR
 Keloid former
 Pregnancy or lactating mothers- cornea swells during lactation so
will cause under-correction, pre and post-op meds will be passed to
the fetus. (Preg abs)
 Wait 3 months post lactation
 Rosacea
 Pacemaker
 Active HSV Keratitis, HZO (abs)
 Caution in patients with a history of this. Should be no
activity in 2 years. Treat with oral antivirals and viroptic
pre and post-op. No PRK.
 HIV
 Active ocular disease- iritis, conjunctivitis, corneal problems
(ulcers, scarring, erosions) abs
 Glaucoma with VF defect or NFL defect (abs)

Cornea ectasia (Relative: Form fruste keratoconus; Absolute:
Clinical Keratoconus, pellucid)
 Exposure keratopathy- lagophthalmos, prior blepharoplasty,
thyroid orbitopathy
 Steep corneas
 Thin corneas- creates keratoconus
 Dry eyes
 Meibomitis
 Lenticular astigmatism
 ARMD
 Large pupils- increased aberrations
 RD
 RP or other retinal diseases
 Previous eye surgeries
 Amblyopia
 Monocular patients (abs)
 Ocular allergies
 Neo, pannus
 Cataracts
 Corneal distortion due to CL wear
 ABMD
 Endothelial dystrophies <1500mm2 (Fuchs)
 Progressive myopes.
 Small orbits (rel)
 Patients that are pregnant, want to become pregnant, or currently
breast feeding.
 Autoimmune disease (Do PRK, one eye at a time)
o Medications
 Allergies to medications
 Hormone replacement supplement
 *Prempro steepens corneal curvature
 Blood thinners
 Coumadin (hemorrhages)
 Antihistamines
 Claritin, Zyrtec (alter lacrimation, blurred vision, hemorrhages)
 Antidepressants
 Zoloft, Paxil (abnormal lacrimation, blurred vision, abnormal
accommodation, conjunctivitis)
 Anti-acne
 *Accutane (abnormal lacrimation
 Anti-HTN
 Norvasc, Zestril, Atenolol (abnormal vision, dry eyes)
 Lipid lowering agents
 Lipitor (amblyopia, dry eyes, refraction disorder, hemorrhages,
glaucoma)
 Antiinflammatories
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Celebrex, Prednisone (blurred vision, conjunctivitis, glaucoma)
Hypnotics
*Ambien (Abnormal vision, scleritis, corneal ulceration, abnormal
lacrimation)
 Anti-seizures
 Neurontin (dry eye, conjunctivitis)
 Migraine treatment
 *Imitrex (long term ocular side effects)
 Antiarrhythmic agents
 *Cordarone (corneal degenerations, corneal microcysts, macular
degeneration, dry eyes, optic neuritis)
Which Procedure?
Pre-op Expectations
o Good functional vision
 98% see 20/40 or better uncorrected
 75% see 20/20 or better uncorrected
 15% may need an enhancement
 the greater the correction, the more likely
 0.2% complication rate
o Manage these. Why?
 To avoid unhappy patients
 To avoid enhancements
 Increase word of mouth referrals.
o Create realistic expectations
 Surgical outcomes have tolerances.
 Vision continues to change and stabilize for 6-12 months after
surgery.
 Vision (refractive error) continues to change throughout life.
 Glasses or contact lenses may be needed after surgery to augment
vision.
 The decision to enhance must be conservative.
Presenting Refractive Surgery
 You need to list it as a treatment option.
 You must include a lifestyle assessment.
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Every candidate must have a current PCE
What not to say
o “Burn the cornea with a laser”
o “Slice the cornea with a blade”
o “Patient is over-corrected”
o “Patient is under-corrected”
Risks
 Infection- 1/5000
 Night glare- 2-5%
o Eliminated with wavefront
 Symptomatic aberrations- 1/500
 Regression- 5-15%
 Need touchup
 Overcorrection- 5%
 Blindness- 1/1 million
Pre-Op
 Patient medical history for any contraindications
o Autoimmune disease, rheumatoid/collagen vascular diseases, cancer,
uncontrolled hypertension, uncontrolled diabetes, keloid former,
pregnancy, glaucoma, keratoconus, retinal disease, prior disease,
infectious diseases such as HIV and hepatitis, pacemakers. Psychological
problems.
 Past ocular history
o Previous eye surgeries, corneal ulcers, erosions, keratoconus, or other
dystrophies, ocular herpes, glaucoma, cataracts, iritis, dry eyes,
amblyopia, diplopia, retinal tears or detachments, or DR.
 CL History
o What type of CL?
o If contemplating MV with LASIK, has your patient been a successful
wearer of monovision CLs?
o If no prior experience with monovision, we strongly recommend a CL trial
or a “test drive” before committing to a surgical last procedure.
o Contacts removed until stable refraction. CL wearers must be weaned off
their lenses
 SCL wearers need 2-4 weeks of no wear with stable refractions.
Min: 1 week
 RGP wearers need 4-20 weeks off RGPs with stable refractions.
 5 weeks off for every decade of wear.
 Medications
o Amiodarone, accutane, imitrex, and any anti-depressants or neurontin.
 Allergies
o To any meds, especially antibiotics. If hayfever, are they using any
antihistamines?
 Note that these are repeated days-weeks apart.
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Ortho K can take 8 months
Complete all pre-op forms.
UCVA, BCVA, Spectacle Rx
Comprehensive eye exam with manifest and cycloplegic
o Perhaps serial refractions, including one cycloplegic. This is especially
important in contact lens wearers and in patients who have tear film
issues, accommodative issues, or any other ocular conditions that may
cause refraction to fluctuate.
Repeatable topography, keratometry, and SRx measurements (usually 3
measurements) over a 2-4 week span are a safe bet. Verify that the Rx is in range
for the procedure.
Peripheral retinal exam with BIO. Any holes, tears, or questionable lattice should
be referred to a retinal specialist for an opinion before laser vision correction
procedures.
If monovision is an option for the patient, you have to mock that up prior to
surgery to make sure the adaptation is possible.
o Dominant eye must be determined.
o Over-glasses may be necessary to balance special tasks
Not a cure. It is a modification to increase function. 90% of activities can be done.
Lasts about 5 years until a new Srx is needed.
Residual Rx: What would you like to target? And for which eyes?
Pachymetry
o Need 150 microns for the flap
o 250-300 microns must be left for the corneal bed
o This leaves us with 100 microns to “vaporize”
o About 12-14 microns of cornea is removed for each diopter of refractive
change.
o Beware of pachs <500.
Topography
o Tells you the anterior corneal surface is too flat, steep, irregular, or
abnormal. Poor outcomes can result from abnormalities, which include
keratoconus, forme fruste keratoconus, pellucid marginal degeneration,
displaced apex syndrome, and CL-induced corneal warpage.
Slit Lamp Evaluation
o Note any abnormalities in the conjunctiva, lids, and tear film.
 Normal lid fissures, brow prominence, lid relaxation, deep set
eyes.
 Any unusual vessels in the conjunctiva?
o Corneal evaluation
 Epithelial or stromal scarring, endothelial defects, corneal thinning,
ABMD, or vascularization. Pannus ABMD
o Lens- cataracts (nuclear sclerosis can lead to lenticular myopia or other
cataract changes).
Posterior ocular tissue health assessment
o Disk anatomy, ARMD, vascular changes, or peripheral retinal thinning or
holes. Comment on sunglasses post-DFE/
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IOP
Tear evaluation
o Schirmer’s test, TBUT, and fluorescein corneal staining.
Pupil Size in Darkness- predicts the risk of post-op nighttime glare and haloes.
o Document anisocoria.
Wavefront Aberrometry
Show the patient the informed consent video and have them answer the “quiz”
and sign the informed consent form.
o A thorough review of the actual surgical procedure, the possible benefits,
risks and complications, the recovery process, and patients’ expectations
and responsibilities.
Discuss the fees and that it includes all aspects of care once they arrive at the
center through their 1-year follow-up period in your office and any needed
enhancement procedure.
Prescription for Vigamox 1gt OU qid beginning 1 day prior to surgery and 5-7
days post-op.
Patient can also increase the omega-3 intake (minimum 4000 units/day)
Recommend AT 1gt OU qid 5-7 days pre-op (Bion Tears or Thera Tears
preferred.)
Also: restasis, punctal plugs, lid hygiene, EES ung, doxycycline
Give the patient pre-op, post-op, and pre-surgical packet
Schedule the surgery date and 1-day post-op before the patient leaves.
Comments Section
o Comment on realistic expectations
 Reduce dependence on corrective lenses
 Understands they will need reading glasses (eventually)
o Recommendations
 Intralase vs. hansatome
 Custom vs. wavefront vs. traditionally
 VISX vs. Allegretto
Surgery Procedure
 Excimer laser is calibrated and programmed for the specific refractive treatment
and tested.
 Instillation of anesthesia and antibiotics. Position patient on the table. Clean the
eyelashes and fornices. Drape the eye and insert a lid speculum.
 Center the patient’s eye in the operating field and make alignment markings.
 Create the flap and lifts it. Swab the underneath stroma. Excimer laser ablates the
stroma. Swab and rehydrate. Reposition the flap, irrigating it to remove debris.
Check the alignment. Smooth the flap with a microsurgical sponge.
 Instill lubricant, antibiotics, and anti-inflammatory drops. Remove the eyelid
speculum.
 Check the flap.
Fees
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Usually enhancements are covered for 1 year. After that, a fee is charged.
Post-Op
 To ensure proper healing as well as monitor outcome progression, patients are
seen (a minimum of)
o 1 day, 3 days (PRK), 1 week, 1 month, 3 months, 6 months, 1 year.
o Then yearly after that.
 Be enthusiastic and encouraging!
 Uncorrected Vas
o Distance and near
o OU acuity first. Start with the large letters and work your way down.
Reassure the patient that they are doing great.
 Refraction
 Topography
 Slit lamp
o Normal: SCH, dryness, micro or pseudostriae, meibomian secretions and
small FBs, epi ingrowth.
 Fluoroscein
 TBUT and tear prism.
 Flap edge evaluation
 Refer the patient back immediately for significant straie, dislocated cap, or severe
pain. Minimal interface debris is not of concern. Consult with surgeon on DLK
for increased steroid dosing.
 IOP
 Meds/Instructions
 Refer the patient back to the surgeon immediately for significant striae, dislocated
cap, or severe pain. Consult with the surgeon on DLK for increased steroid
dosing. Minimal interface debris is not of concern.
 Schedule the next appointment. Fax post-op forms to the surgeon.
 If in doubt, don’t hesitate to call and speak to surgeon.
Post-Op Concerns
 Flap Complications
o Folds in the Flap
 This is the most common.
o Dislocation of the Flap
o Button-Hole Cut
 Microkeratome slips and tissue is ripped out of the flap.
 This means that LASIK cannot be performed. Probably continue
with ASA after healing.
o Scars from Flap Cuts
o Flap was handled and not smoothed.
o Flap Dislocation/ Wrinkling
 Due to problems with repositioning of the flap at end of procedure
o Post-op displacement
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o Deposits in the Interface
 Causes
 Nonorganic materials
 Metal from microkeratome/blade or instruments
 Particles from the sponge
 Talc from the gloves
 Lint from drapes/gauze
 Dust
 Organic Materials
 Endothelial Cells
 Tear Film Debris
 These can be left in the cornea. No harm will be done.
 Treatment
o Interface debris rarely interferes with functional
recovery, however, if optic quality of the cornea is
compromised, then the debris must be removed
(flap lifted, debris removed, flap replaced)
Epithelial Complications
o May occur pre-op
 Due to
 Excessive anesthetic
 Abrasions
o May occur during surgery
 Due to
 Dry cornea
 Blade, forceps, or spatula problems
 Movement of the eye as the speculum is removed
 Improper sponge use.
o Early
 Sands of Sahara (Diffuse Interlamellar Keratitis)
 Etiologies
o Varied and not entirely understood
o Seems to be linked to contaminants in the lamellar
interface introduced at the time of the surgery.
o An autoimmune response
 Occurs from day 1
 Stromal meltdown by day 5.
 Signs and Symptoms
o Typically noted 2-5 days post-op
 Patient notices progressive decrease in VA
 Slit lamp examination reveals diffuse white
granular cell infiltrates across the interface.
o The next stage shows a granular haze centrally (in
the center of the flap). It is a thick white.
 Refractive status is slightly hyperopic.
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o Late
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 Otherwise asymptomatic
o The next stage results in a dense central infiltrate
(dense, white clumped cells)]
 Decreased Vas
 Flap may have straie
 Hyeropic astigmatism is measured.
o The end result (if not diagnosed and treated) is
stromal melting, permanent scarring, and vision
loss.
 Management/Treatment
o Immediate and aggressive treatment must occur
before the final stage.
o Stage 1 and 2
 Steroid drops every hour and ointment at
night.
 24 hour monitoring
 Must resolve with this.
o Stage 3
 Lifting the flap and careful irrigation to
remove the inflammatory reaction and
steroid treatment over time.
Ingrowth
 Etiology
o Poor flap edge adhesion or alignment
Buttonhole flap
Free cap
Epithelial cells left under flap
 Results in
o Reduced VA
o Irregular astigmatism
o Discomfort
o Risk of stromal melting
o Debris
Sands
Ingrowth
Over-response (Leaving +)
Under-response (Leaving -)
Other staining, Flap Distortion
Discomfort
IOP
** It is extremely important that you carefully follow these instructions and any
additional ones that Dr. Dodge has recommended prior to surgery.
Pre-Op
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It is extremely important to follow Dr. Dodge’s instructions regarding when to
stop wearing your contact lenses. This is critical to the success of your procedure.
o Soft lenses a minimum of 72 hours prior to the procedure.
o Soft toric lenses one week prior to the procedure.
o RGP (hard lenses) a minimum of 2 weeks prior to the procedure.
Let Dr. Dodge know if you are pregnant, nursing, or if you form keloid scars.
Let Dr. Dodge know if you are on Accutane or Cordarone.
Starting 3 days prior to your procedure, begin eyelid scrubs every evening. (Do
not do this after surgery.) Place one drop of baby shampoo on a wet, warm
washcloth. With your eyes closed, gently massage your eyelashes with the
washcloth for about one minute, and then follow with a thorough rinse of the lids
with water before opening your eyes. Make sure that this is done the night before
surgery so that the eyelids are free of make-up. Wash your face with soap and
water in the morning.
You will be given a prescription for an antibiotic eye drop, either Zymar or
Vigamox that can be filled at the pharmacy of your choice. Start using the drop
four times daily in the operative eye one day prior to your procedure. By the time
you arrive at the surgery center, you should have used the drop four times (i.e., if
your procedure is scheduled for 5pm on Thursday, you should start using the
drops on Wednesday at dinnertime, again at bedtime, and then at breakfast and
lunch on Thursday).
Do not wear any eye or face make-up, cologne, lotion, or powder on the day of
your procedure. You will be asked to remove large earrings necklaces, or chains.
The area around your eyelids will be cleansed just prior to the procedure.
Wear warm, comfortable clothing the day of your procedure. The temperature is
kept very cool in the laser suite. You might want to bring a sweatshirt or sweater.
Please arrive at the surgery center on time. You will need to arrange for
transportation on the day of your procedure and for your one-day post-op
appointment. You will not be allowed to drive yourself home.
Please bring your prescribed eyedrops with you on the day of surgery.
Financial Arrangements
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Please have all financial matters completed prior to surgery.
Payment for surgery will be requested when you check in for surgery. We accept
cash, cashier’s checks, personal checks, Visa, Mastercard, Discover, and
American Express.
Financing is available.
o Generally the application must be filled out and submitted 48-72 hours
prior to the surgery date.
o Once you have received an approval, please contact our office confirming
that you are financing and received an approval. This way we may ensure
that we have all the necessary forms in order prior to your treatment. If
possible, please contact us within 48 hours.
o We will need to make a photocopy of your driver license to submit to
CareCredit. Please bring it with you the day of surgery. If you have a co-
borrower or if someone is financing the surgery other than yourself, they
must be present the day of surgery to sign the form. If this is not possible,
they may make arrangements with our office to come in prior to sign the
forms. We must also obtain a copy of their driver license to submit to
CareCredit.
Change in Planned Schedule/ Questions
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If you have any questions concerning your pre-operative or post-operative
instructions, please do not hesitate to call Dr. Dodge. In the event that you need to
reschedule, please notify us immediately.
A $250 cancellation fee will be charged if you fail to advise us of your
cancellation.
LASIK Patient Information
Your surgery will be performed on ___________________. Check in time is ______.
Pre-surgical Instructions
 There are no restrictions on eating or drinking before your procedure. Please do
not consume any alcoholic beverages on the day of surgery. Also refrain from
consuming beverages containing excessive amounts of caffeine. If you are
normally a coffee drinker, feel free to consume your usual amount.
 Continue to take your usual medications unless otherwise instructed.
 Follow your Dr. Dodge’s recommendations regarding the removal of your contact
lenses prior to your procedure date.
 If you would like family or friends to watch your procedure, they may do so from
the observation area.
 The total time spent in the laser facility will be about 1½ - 2 hours.
What to Expect on the Day of your Procedure
 You will be asked to read and sign a consent form, listen to an audiotape, and
watch a video. Should you have any questions or concerns, you will have the
opportunity to discuss them with the surgeon prior to your procedure.
 You will be offered a mild sedative to help you relax. Please let the staff and
surgeon know if you have allergies to any medications.
 You will not be asked to change your clothing, however you may be asked to
remove large earrings.
 A scrub will be performed to cleanse your lids and eye area. Please do not wear
any make-up to the surgery center.
 Several eye drops will be used to prepare your eye for the procedure. It is very
rare to react adversely to any of these drops, but please tell us if you have ever
had a reaction to any eye medications in the past.
 Your cooperation during the procedure is essential. If you are excessively sedated,
it will be more difficult for you to focus on the target light. You must be alert and
respond to instructions.
When you enter the laser suite:
 An assistant will help you into a chair that will be slowly reclined until you are
flat on your back.
 Anaesthetic drops will be administered and the eye not being treated will be
covered with a shield.
 After you are positioned under the laser, you will notice a blinking red light in the
center of a white ring. This is the light you will need to fixate on throughout the
procedure. The surgeon will keep your eye entered if you move slightly, but try to
remain as still as possible.
 An instrument will be placed around the eyelids that will prevent you from
blinking.
 The surgeon will make temporary marks on the surface of the eye that are used
when repositioning the flap.
 Next, a ring will be placed on the eye to stabilize it. You will hear the sound of
the vacuum as the ring is secured and your vision will temporarily fade away. Do
not be alarmed. The surgeon has complete control of your eye and your vision
will return in just a few moments.
 You will hear the sound of the microkeratome as the surgeon creates the corneal
flap. After just a few seconds, the microkeratome will be removed and the suction
on the eye reduced.
 The surgeon will gently fold back the corneal flap. You will hear the sound of the
laser as it prepares to treat the eye and you will be instructed to stare at the
blinking red light or in the center of the white ring.
 The laser will make a clicking of snapping sound as it painlessly reshapes the
cornea. The excimer laser can be stopped and started precisely within a fraction of
a second. If your eye moves, the laser will be stopped. Fixation will then be
reestablished and the procedure completed.
 You may become aware of an unpleasant odor during your treatment. This is the
smell of a vapor created by the laser. A vacuum tube will be placed near your eye
to minimize the scent.
 After the laser treatment is complete, the ring will be removed from your eye and
the surgeon will carefully reposition the flap.
 After the corneal flap has settled into position, the surgeon will remove the
instrument retaining your eyelids and post-op drops will be administered.
 You will be helped out of the chair and the surgeon will recheck your eyes before
you leave the center.
 When you check out at the front desk, your post-op instructions will be briefly
reviewed and you will be asked to put on eye protection for your trip home.
Common Symptoms you may Experience
 About 30-90 minutes following your procedure, you may experience some
discomfort (burning, stinging, and tearing) as the anaesthetic drops begin to wear
off. The symptoms may be severe. Please take the medication provided or an
over-the-counter pain reliever to reduce discomfort.
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Other temporary symptoms may include: light sensitivity, watery eyes, runny
nose, gritty, foreign body sensation, eye irritation, and eye redness. Frequent use
of lubricating drops will help with these minor irritations.
Cool compresses may be applied to the eyelids to relieve swelling or sensitivity.
Avoid getting water in the eye(s).
Vision will usually appear particularly blurry for 4-6 hours, and then begin to
improve.
For the first few months you may notice visual fluctuations, particularly when
driving and using the computer. Glare and halos around lights at night and in low
light conditions are normal and will gradually subside over 3-12 months.
Your eyes may feel dry for months. Use artifical tears to alleviate this.
You may notice red spots in the whites of your eyes. These will disappear with
time.
Upon Arrival Home:
 Take it easy for 4 hours. The medications will make you tired.
 You may resume your normal diet.
 Keep your eyes closed for at least 3-4 hours except to eat or use the restroom.
Activties Allowed:
 No swimming, hot tubs, or whirlpools for 7 days.
 Showers and baths are fine, but keep your eyes closed to avoid getting water or
shampoo in them. Wait to take a shower until after you have been seen for your
first post-op visit. When you take a shower, you may wash your hair and face.
Keep your eyes closed while the water is on your face. When drying your eyelids,
gently dab them without applying any pressure on the eyes.
 Do not sleep with your pets in your bed for the first 24 hours after the surgery.
Laundered bed linens should be placed on your bed.
 Avoid a dusty/dirty environment for one week. It is preferable that you do not
smoke since it will irritate your eyes.
 Keep the operative eye(s) closed as much as possible for the first 6-12 hours
following your procedure. This will speed healing of the ocular surface and
restore your vision faster.
 Watching television and reading is permitted.
 Do not drive until you have been authorized to do so by Dr. Dodge.
 It is best to wait for at least 1-3 days before returning to work to allow your ocular
surface tissue to completely heal.
 You may return to your normal exercise routine after 3 days and once you feel
comfortable. However, do not return to high-impact sports, such as boxing, until
authorized by Dr. Dodge. Although that it is always recommended that you wear
protective eyewear for racquetball and contact sports, you must wear eye
protection for these types of activities for 6 months.
 Wear ultraviolet sunglasses when outdoors.
 If in doubt about activities you can or cannot do, please call our staff/
Your Recovery:
 Your vision will be somewhat blurry for 6-12 hours following your procedure.
 If you choose to have only one eye treated at a time, you may feel a little offbalance after your first eye is treated. Your depth perception may be a little off as
well. Be careful performing tasks such as pouring hot coffee, hammering a nail, or
driving.
 It is important to remember that your distance vision will clear first and your
reading vision last, unless you are over the age of 40. In patients over 40, reading
glasses are usually needed to read small print unless correction for monovision
was done.
 Night glare is also more apparent during the first couple weeks of your recovery.
Star-bursting and halos around lights usually occur in patients with more severe
degrees of myopia and large pupils. Night glare usually resolves or returns to the
pre-procedural level once both eyes have healed.
 Infection is a possibility, although the risk is minimal if post-operative
medications are taken and instructions followed. Symptoms of infection may
include increased pain, redness, blurred vision, and discharge. Do not hesitate to
contact Dr. Dodge if you feel your eye is not healing correctly.
Follow-up Care After your Laser Procedure
 First Week
o Dr. Dodge will give you a schedule for your follow-up appointments. The
purpose of these initial follow-ups is to ensure normal healing of your
corneal surface and to detect any evidence of infection.
 First Three Months
o Less frequent follow-up appointments will be scheduled to ensure proper
healing, to measure visual progress, and to check eye pressure.
Eyecare and Medications
 Do nto rub the eyes for at least 6 months following your surgery.
 If your eyes itch, notify Dr. Dodge during the post-operative period visit and a
medication will be prescribed.
 Wear the eye shields provided at bedtime (or when lying down) for 1 week. If you
sleep on your stomach you will need to wear the goggles for 4 weeks. The shields
should rest against the bones of the brow and cheek and not the eyelids.
 Do not wear eye make-up for 3 days. When resuming the weasring of eye
cosmetics (mascara, eyeliner) please purchase new products and discard the old
cosmetics used prior to surgery.
 Whem removing eye make-up in the first 6 months after surgery, do so without
placing pressure on the eye. If you need further instruction, please ask a member
of the staff.
 You will receive a post-op bag the day of surgery that will include the following
items: Sunglasses, shields, tear samples, and steroid drops.
 Artificial tears: instill one drop in the treated eye(s) 4 or more times a day or as
needed.
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Prescription eye drops: begin using 1 drop of Zymar and one drop of PF 3 times a
day for 4 days in the treated eye(s), or as instructed by Dr. Dodge.
A prescription for Zymar will be given to you prior to surgery. Please have the
prescription filled at your pharmacy prior to surgery. Please bring the bottle of eye
drops with you to the office the day of your surgery.
Medications Needed After Your Procedure
 Zymar/ Vigamox
o Dose: One drop, four times a day
o Purpose: Infection prevention. Allergic reactions rarely develop.
Symptoms include increased redness, itchiness, and swelling.
 Lotemax
o Dose: One drop, four times a day
o Purpose: Initially to reduce redness, swelling, and light sensitivity.
Promotes normal healing.
When Putting in Eye Drops
 Do not use anything in the treated eye(s) except the above medications, unless
otherwise directed.
 Wash your hands before putting in the drops.
 Shake all bottles before each use.
 Pull down your lower lid and place the drop in the pocket of the eyelid, holding
the bottle top away from the eye.
 Wait 1-2 minutes between each drop. The order that the drops are put in does not
matter.
 You may experience a medicinal taste in the back of your throat after putting in
drops. This is normal.
 To avoid contamination of the eye drops, do not touch the tip of the bottle to the
eye.
 Use drops at breakfast, lunch, dinner, and bedtime. Wait at least one minute
between drops.
 Do not stop or change the frequency of any medication unless specifically
instructed to do so by Dr. Dodge. Failure top follow directions may influence the
outcome of your surgery. Misuse may result in damage to the cornea or a change
in your refractive condition.
PRK/LASEK Post-Op Regimen
 Post-op 1, 3-5, 10 day, then every 3-4 weeks to monitor healing/ IOP
 BSCTL until epithelium closed (usually day 3-5). If falls out day 1-3, the doctor,
not the patient should replace it.
 Zymar 4x/day until epithelium heals
 PF 4x/day until epithelium heals, then 2x day for 3 months. Increase if regression/
haze, decrease if overcorrected.
 Acular LS 4x/day for 48 hours, then stop because of epithelial toxicity.
 Copius preservative-free tears





Punctal occlusion may be necessary
Advil/ Tylenol for mild pain
Vicodin/Lortab for moderate/ severe pain
No swimming/dusty environments for 1 week
Enhancement, if necessary, month 4-6.
Patient Instructions After Laser Vision Correction
Immediately After the Laser Treatment:
1. It is very important for you to go home and relax for the day. Try to sleep as much
as possible for the first 24 hours after your procedure. If sleep is not possible,
please try to keep your eyes closed. Sleep will tremendously speed your recovery.
2. You may eat or drink normally, but do not drink more than one or two glasses of
any alcoholic beverage.
3. Take Tylenol, aspirin, or similar medications (unless allergic) for discomfort if
needed.
4. Keep glasses, goggles, or clear plastic shields securely taped over your treated
eye(s) until seen in the office tomorrow (except to instill drops). Tape shields or
goggles when asleep.
5. Apply the following eyedrops as gently as possible during waking hours:
a. Zymar or Vigamox (antibiotic), 1 drop 4 times a day
b. Pred Forte (steroid), 1 drop 4 times a day (shake the bottle well)
c. Artificial Tears every 2 hours
d. Acular-PF, 1 drop every 4 hours, as necessary for pain
6. Do not rub your eyes. You may gently pat the eyelids with a clean facial tissue
(with the eyes closed).
7. It is normal to experience any of the following:
a. Feeling as if something is in your eye causing mild to moderate irritation
and discomfort
b. Eye watering
c. Blurry vision
d. Sensitivity to light.
8. Do not shower, take a bath, or wash your face during the first 12-18 hours after
treatment (to avoid getting any soap or water in your eye(s)).
Your one day follow-up appointment is on ____________________________ .
Please bring your eye drops and your instruction sheets to your next visit.
You can contact Dr. Dodge at any time on the office number: 818-783-8750.
Instructions for the First Week After Laser Treatment
1. Apply the following eye drops during waking hours:
a. Zymar or Vigamox (antibiotic), 1 drop 4 times a day for 5-7 days
2.
3.
4.
5.
6.
7.
8.
9.
b. Pred Forte (steroid), 1 drop 4 times a day for 5-7 days (shake the bottle)
c. Artificial Tears every 2 hours
d. Acular-PF, 1 drop every 4 hours, as necessary for pain
The clear plastic protective shield(s) or goggles must be used for one week at any
time you sleep. Tape them in place when you nap during the day and at bedtime
for 1 week.
Do not rub your eye(s) for one week. You may gently blot or wipe your eyelids
with a clean tissue while the eyes are closed.
Do not wear eye make-up for 5 days.
If possible, avoid areas with a high concentration of smoke or fumes for one
week.
No water sports for 1 week.
You may resume your regular exercise routine the day after the procedure,
however, as a precaution, use a sweatband for the first week. You may do light
weights. Do not power lift for the first week.
After one week, there are usually no restrictions, but always check with Dr.
Dodge.
We strongly recommend that you always wear protective goggles when
participating in any sport or activity which might result in an injury to your eye.
Your one week follow-up appointment is on ____________________________
Please bring your eye drops and your instruction sheets to your next visit.
If you require an enhancement for maximal vision, we would typically schedule the
procedure 3-4 months after your initial surgery.
Nanotechnology

Considerations of the various tissues and structures
Tissue/ Structure
Considerations
Tear Film
Quality of vision after blink
Cornea
Clarity, curvature, symmetry
Lens
Clarity, curvature, changes
Media
Clarity, Index of refraction
Eyeball Potential
“Marechal’s Criterion”
Fovea
Optic Nerve
Visual Cortex
Perceptual Effects

Measurements
o One micron is 0.001 Millimeters (One thousandth of a millimeter).
 The smallest corneal epithelial cell is 5 microns in diameter
 Epithelium is 40-80 microns and the Stroma is 450-500.
o A nanometer is one thousandth of a micron, or about 3-4 atoms wide.


This is the size range wherein physics, chemistry, electrical
engineering, materials science, and biology converge. Simply
stated, nanotechnology is molecular manufacturing. It builds things
(anything) one atom or one molecule at a time, by robotics.
Crystalline Lens
o Current (and developing) refractive laser technologies (at 0.25microns
accuracy) are fully capable of correcting higher order aberrations in the
human eye and achieving higher order vision correction, but it is the
quantum physics and biology of the surface of the human cornea plus
other ocular, optical, and surgical limiting factors that make it impossible
to achieve higher order correction through corneal refractive surgery.
o So, if we cannot achieve higher order aberration correction due to the
quantum physics and the biological limits of soft tissue (cornea), what
about synthetic materials, i.e. intacs, inlays, onlays (CL)?
o What about the crystalline lens?
 While the cornea remains relatively stable and prolate throughout
life (unless, of course, we do something funny to it with corneal
refractive surgery).
 The lens is constantly changing in size and shape from retained
epithelial cells throughout life and becoming more spherical
(oblate) resulting in increasing spherical aberrations.
 Beyond 20 years of age, the lens isn’t a real “friend” to the visual
system. It adds spherical aberrations, which compromises
qualitative vision. Beyond 40ish, prebyopia begins, and then the
eventual formation of cataracts.
o The modern cataract extraction procedure (Lensectomy)
 Standard small incision, clear cornea, sutureless,
phacoemulsification, ECCE
 Done bilaterally, about one week apart.
 Ambulatory surgery with recovery time less than 24 hours.
 Complication <2% (<0.5% in most refractive practices)
 Safest surgical procedure in all of health care.
 Best if >40 years of age.
 If aspheric, decreases the HOA.
o Special considerations in Refractive Lens Exchange vs. Cataract Surgery
 Biometry with IOL Master (Zeiss) essential
 Resultant astigmatism goal is 0
 Consider only “high volume” cataract surgeons for refractive lens
exchange.
 HICFA considers >400 cases per year high volume
 <400 a year means 5-10 cataract surgeries a week.
 The surgeon must be fast and good!
o Synonyms for Refractive Lensectomy
 Refractive lens exchange (RLE)
 Clear lensectomy
 Clear lens exchange
 Presbyopic Lens Exchange (PRELEX)
 Lens-based refractive surgery
o Phakic IOLs
 Variable materials
 Plastic
 Silicone
 Collagen (Collamer) by Starr in Phase 3 trials
 Variable designs
 Anterior Chamber
o Acrysof, Alcon
o GBR, IOL Tech
o Kelman Duet, Tekia
o Memory Lens, Ciba
o NewLife, IOL Tech
o NuVita, B&L
o ThinOptX
o Vision Membrane
o 6H2, Oil
 Iris Supported
o Artisan/Verisyse, Ophtec and AMO
 Posterior Chamber
o PRL, Ciba
o ICL, Staar
o Beyond phakic IOLs, some interesting new developments in IOL
technology are leading to the new concept of Refractive Lens Exchange.
This is the removal of the crystalline lens in a clear of cataractous state
and its replacement with a specialized intraocular lens to create an optimal
refractive condition.
 Some examples of new developments in IOL technology to
support the concept of refractive lens exchange.
 Perhaps, the most controversial new technologies involve
presbyopia.
 Prebyopic Reduction Procedures
o Anterior ciliary sclerotomy
o Infrared scleral ablation (OptiVision by SurgiLight)
o Scleral expansion bands (SEB or Presby)
o “Blended vision” with CK
o Accommodating IOLs (12)
 ACOR IOLs (“Piggybacked”
multifocal/monofocal IOLs)
 AT 45 CrystLens (Bihinged moveable optics
by C&C)
 DualOptics IOL (“Piggyback” system in
animal studies)
 HumanOptics Akkommodative ICU
(injected hydrophilic)


Light Adjustable IOL (animal studies on
molecular lens)
 Medennium SmartLens (thermodynamic
hydrophilic)
 QuestVision FlexiOptic (haptic contoured to
capsule bag)
 Sarafarazi Elliptical Accommodating IOL
(B&L)
 Tecnis ZM001 IOL (Aspheric multifocal by
Pfizer)
 Visiogen Synchrony IOL (dual
anterior/posterior optics)
 Vivarte Baikoff IOL (Ciba)
o Pseudo-accommodating IOLs (15)
 Array Multifocal Silicone IOL (AMO)
 +6 - +3-D (in 0.50D steps)
 Array 2 Silicone IOL (AMO)
 ReStor IOL (Alcon)
 Plano - +36D
 Resume Multifocal Acrylic IOL (AMO)
 -10 - +30D
 Tecnis MF (Pfizer, acquired by AMO)
Comparing Refractive Corneal Surgery vs. Refractive Lens Exchange
o Corneal Surgery
 Strengths
 It works
 Safe and effective
 Not intraocular surgery
 Simultaneous surgery
 Potential of custom ablation
 Universally accepted
 The “WOW” factor
 “Potential” for HOA correction
 Weaknesses
 Surgery on a healthy cornea
 Microkeratome risks
 Reduction in prolate shape
 Central corneal “insult”
 Risk of ectasia
 Limited correction change
 Induces higher order aberrations
 Remodeling and epithelial limits
 Royalties
 Capital investment
 Disruption of surgery schedule


 Cant treat presbyopia
o Lens Surgery
 Strengths
 No flap
 Co central corneal insult
 Maintains prolate cornea
 Better results in higher powers
 Eliminates lens aberrations
 Correction at the nodal point
 HOA correction possible
 Stable (permanent) correction
 Routine surgery scheduling
 No royalties
 No capital investment
 Can treat presbyopia
 Weaknesses
 Intraocular surgery (with risks)
 Not done simultaneously
 Trade-offs (aberrations, etc)
 Risk of PCO
 Risk of CME
 Issues with corneal astigmatism
 Limited IOL technologies
 Need to take patient to OR
 ASC or hospital costs
 “Non-traditional” surgery (CLE)
 Limited “WOW” factor
o Even refractive lens exchange really does not entirely address the
limitations of HOA correction created by the cornea. If we cannot achieve
higher order correction on the cornea or with refractive lens exchange,
what about using synthetic materials?
Wavefront programmed, constructed, and controlled “intelligent” spectacles and
contact lenses
o Photosensitizing methods
o Electrochemical methods
o Nanotechnology
Nanotechnology
o Nanotechnology proposes the construction of novel molecular devices
possessing extraordinary properties. Anything can be “nanoconstructed.”
 Examples include synthetic materials, textiles, electronics,
pharmaceuticals, nerve tissue, animal tissue, micro (nano)
computers, virus (vectors), blood cells, stem cells, genes, anything
you can imagine.
 It is not just refractive surgeries alone that are going to “sculpt” the
future of refractive care. It is non-surgical refractive sciences that
we are talking about. These are sciences that optometry can and
must understand and deliver.
Why Comanage?
 Youre the right doctor for the job.
 Evidence to your patients that you are a progressive doctor/practice.
 Clinical interest
 High immediate profit from professional services containing no material costs or
third party
o Co-management vs. CL Profits
 LASIK co-management fee = $1,000
 2 week disposable profilts
 8 boxes/year at $15/box = $120/year +$40 for eval = $160.
 $1,000 = 6.25 years.
o After surgery, patients over time continue to need examinations, contact
lenses, prescription eyewear, plano sunglasses, and further surgery.
 Referrals
 Control
 Why not?
o Lack of knowledge
o Fear of failure
o Fear of success
Pearls in LASIK CO-Management
 Stay ahead of the curve.
 Select only good solid candidates for the surgery
 Foster realistic expectations
 Demonstrate outcomes using contact lenses
o Monovision
o Distance OU outcome in presbyopic patients.
 Ex 1: 62yo with -4.00 OU. Never worn CL. Adamantly against
MV. “Knows” she will need reading glasses after surgery.
 Ex 2: 55 yo office worker who anticipates 10 more years on the
job. 90% computer and near work. Wears SV glasses ~10%. Goal
is to have full distance for golf/bowling. Srx: -1.25/-2.00
o Previously untreated refractive amblyopes
 Ex 1: 21yo refractive amblyope. Srx -1.50 (20/20)/ -6.25 -2.75
x050 (20/80)
o Unstable binocularity
o Enhancements
 Ex1: 60yo MV LASIK 8 years ago. Reversed MV 3 years ago.
Wants to be retreated again for MV.
 Document everything
 Make yourself available/ accessible
 Discourage enhancement whenever possible.
Top 10 Mistakes in Co-Management
 Refraction
 Failure to assure refractive stability
 Failure to adequately manage dry eyes
 Failure to diagnose and aggressively treat chronic lid disease
o Blepharitis, Meibomian Gland Dysfunction
 Failure in creating a surgical game plan
o Full distance
o MV
o “Modified MV”
o Bilateral “soft” distance
o Staggered surgery
 Failure to anticipate the “downside” of surgery
 Failure to schedule interim visits when needed
 Failure to refer back when needed
 Failure to communicate
 Failure to be accessible/available
How to Build a LASIK Practice
 Speak regularly to all candidates about their potential and your role in comanagement
 Speak to all non-candidates about why
 Mailings (recall), office literature (pamphlets), signage (posters), etc.
 Attend surgeries
 Have a LASIK coordinator
 Help with financing
 Case presentations
Why its in their best interest?
 You know their eyes the best.
 You will be their advocate
 Lifetime commitement
 You will help choose the best laser.
 You will help choose the best surgeon
Consultation
 Develop a LASIK Instinct
o Patient profile
 Reasons, expectations
 Wishes, dreams, and desires
 Realistic? Acheivable?
o Honesty
 Establish a relationship and rapport
 Emphasize a team effort between your office and the surgeon for a “total visual
experience.”