The Routine LASIK Procedure

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  • I acknowledge a financial interest in the Artemis technology - VHF digital ultrasound scanning developed by my colleagues and I at Cornell and licensed to Ultralink LLC.
  • Slide 9
  • Find better image (if possible)
  • Find photo of patient with wire speculum with neat tape
  • Better marking picture
  • 3 examples of too much above, too much below and perfectly centered
  • Ring application: finger pushing away lid
  • Find better picture
  • MEL80 specifics
  • Slide 30
  • MEL80 specifics Activate the tracker on your laser and make sure the center of your ablation is where you want it to be Put in generic tracker image
  • Need better pictures
  • Better pictures Better to have video clips
  • Flap lift image to ablation image
  • MEL80 specifics
  • Better pictures Video clip of irrigating and wiping
  • The Routine LASIK Procedure

    1. 1. The Routine LASIK Procedure Dan Z Reinstein MD MA(Cantab) FRCSC 1,2,3,4 1. London Vision Clinic, London, UK 2. St. Thomas’ Hospital - Kings College, London, UK 3. Weill Medical College of Cornell University, New York 4. Centre Hospitalier National d’Ophtalmologie, (Pr. Laroche), Paris, France
    2. 2. A Step-by-Step Primer to Starting LASIK in 2009 This course is sponsored by the International Society of Refractive Surgery of the American Academy of Ophthalmology (ISRS/AAO) Visit the ISRS/AAO at the Membership Booth in the Academy’s Resource Center (Booth #2939)
    3. 3. Financial Disclosure The author acknowledges a financial interest in Artemis™ VHF digital ultrasound ( ArcScan Inc , Morrison, Colorado) The author is a consultant for Carl Zeiss Meditec (Jena, Germany)
    4. 4. <ul><li>Only 17% of global procedures in 2009 used a femtosecond laser </li></ul><ul><li>This presentation will describe the microkeratome procedure </li></ul><ul><li>Femtosecond lasers have been discussed earlier </li></ul>Femtosecond or Mechanical Microkeratome? Data courtesy: Dave Harmon, MarketScope, Manchester, MO
    5. 5. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    6. 6. Standard Operating Procedure: LASIK 82 Steps
    7. 7. LASIK Surgeon ≡ 747 Captain <ul><li>“ A superior pilot is one who uses superior preparation and judgment to avoid situations that require the use of superior skill” </li></ul>
    8. 8. Video of routine LASIK procedure 0:00 2:28 1:00 2:00
    9. 9. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    10. 10. Room Conditions <ul><li>Ensure standard room atmospheric conditions are achieved. </li></ul><ul><li>Recommended 18–24°C, and less than 50 % relative humidity </li></ul><ul><li>N.B. Ensure that there is no fan or air-conditioner blowing toward the patient’s head/treatment area. </li></ul>
    11. 11. Calibration <ul><li>Factors influencing energy stability: </li></ul><ul><ul><li>Perfume / deodorant / hair spray </li></ul></ul><ul><ul><li>Alcohol wipe down </li></ul></ul><ul><ul><li>Recent painting or building works </li></ul></ul>
    12. 12. Patient Identification <ul><li>Confirm that the correct patient is lying under the laser </li></ul><ul><li>(name and date of birth) </li></ul><ul><li>Cross-check the refraction entered into the laser software with respect to the medical record </li></ul><ul><li>Verify residual stromal thickness of at least 250 µm </li></ul>
    13. 13. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    14. 14. Patient Positioning: Centration of Patient <ul><li>Head centration – forehead to chin (not nose!) </li></ul><ul><li>Body straight and centered on laser bed, legs uncrossed </li></ul><ul><li>Patient position should be attained with no muscular effort (do not ask patient to raise or lower their chin into a position requiring continuous muscular effort) </li></ul>
    15. 15. Ocular Alignment <ul><li>Adjust the patient bed in the x, y and z axes to centre the eye under the laser </li></ul><ul><li>Each laser has slightly different laser alignment beams – refer to the specific instructions </li></ul><ul><li>Keep the z-axis positioning beams on during the entire procedure </li></ul><ul><li>Use this position to ensure that the cornea is vertical below the laser (x-y position) and at the right focal plane (z-axis) aperture </li></ul>
    16. 16. Psychological management <ul><li>The “virtual strait-jacket” </li></ul><ul><li>Verbal anaesthesia </li></ul><ul><ul><li>Talk to the patient continuously, delineating each step as you proceed – this keeps the patient from becoming startled </li></ul></ul><ul><ul><li>Don’t describe what you’re doing, describe what they’re about to feel </li></ul></ul><ul><li>Control the patient </li></ul><ul><ul><li>Curb any questions, curb any discussion </li></ul></ul><ul><ul><li>Force their attention to the fixation target at all times </li></ul></ul><ul><li>Use authority if needed </li></ul>
    17. 17. Local Anaesthetic <ul><li>Instill local anesthetic drop into the eye about to be treated, explaining that it may sting for a moment </li></ul><ul><li>Tape the other eye shut </li></ul><ul><li>Dry the lashes of tears produced by the instillation of the anesthetic </li></ul><ul><li>(otherwise drapes or tape will not stick properly to the lid margin and eyelashes) </li></ul>
    18. 18. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    19. 19. Microkeratome Checks <ul><li>Vacuum checks </li></ul><ul><li>Running checks </li></ul><ul><li>Blade checks </li></ul>- 3.4 ”Hg - 3.8 ”Hg - 3.7 ”Hg
    20. 20. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    21. 21. Draping <ul><li>Drape or tape the lashes </li></ul><ul><li>Check if there are any lashes or tape in the surgical field </li></ul><ul><li>Avoid abrading the cornea with drape or tape </li></ul>
    22. 22. Speculum Insertion <ul><li>Use of a speculum with solid blades may obviate the need for taping of the lashes while reducing the chances of expressing meibomian contents into the field </li></ul><ul><li>Insert the lid speculum – open it gradually </li></ul><ul><li>Ensure adequate exposure – Ideally with equal exposure of sclera surrounding the limbus above and below </li></ul>
    23. 23. Surface Marking <ul><li>Mark the surface of the cornea with ink asymmetrically including the central 6 mm zone </li></ul><ul><li>In flatter corneas, mark in preparation for small hinges or free caps </li></ul><ul><li>In steeper corneas, mark in preparation for button holes </li></ul><ul><li>Indent the surface with the marker to break epithelial surface integrity to ensure that you can re-stain these in the event of a free cap in which the marks have washed off </li></ul>
    24. 24. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    25. 25. Suction Ring Application <ul><li>In preparation for applying the suction ring, if unequal scleral exposure exists, ask patient to alter head position to ensure perfect and equal scleral exposure all around the limbus </li></ul><ul><li>(e.g. Lift chin up or down or turn head toward the nose to move eye temporally within the palpebral fissure) </li></ul>
    26. 26. Suction Ring Application <ul><li>Push aside any lid skin overhang onto the speculum with one hand and approximate the ring onto the eye with the other, ensuring that any lid overhang lies above the ring track </li></ul><ul><li>“ This is the part where it’s going to get a little uncomfortable” </li></ul><ul><li>One hand will be holding the post, the other hand will be depressing the upper and lower blades of the speculum using the thumb and ring finger in order to proptose the globe while your index finger applies a counter force through the pivot post downward </li></ul>
    27. 27. Suction Ring Application <ul><li>Centration is key : center the ring in relation to the visual axis, rather than the pupil or the limbus if possible – this is especially important in patients with large angle-kappa </li></ul><ul><li>Create conjunctival/scleral indentation by pressing the ring down for 5 seconds before activating the vacuum </li></ul>
    28. 28. Suction Ring Application <ul><li>Start suction </li></ul><ul><li>Tell the patient “as the pressure increases in the eye, the lights will go dim” </li></ul><ul><li>Keep downward force on the speculum which also ensures tightening of the conjunctiva to produce adequate suction of the sclera into the ring. </li></ul><ul><li>Verify that suction level is satisfactory – on the console of microkeratome </li></ul><ul><li>Ask the patient “Are the lights dim?” </li></ul>
    29. 29. Tonometry <ul><li>Ensure that the cornea is not too wet before applying the Barraquer tonometer to test pressure </li></ul><ul><li>You may additionally use the tip of your finger on the cornea to verify adequate firmness of the globe if in any doubt </li></ul>
    30. 30. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    31. 31. Microkeratome Lubrication <ul><li>“ You’re going to feel a little fluid now” </li></ul><ul><li>Flood the cornea with more anaesthetic </li></ul><ul><li>( Not Balanced Salt Solution as this can lead to salt deposits on the microkeratome head) </li></ul><ul><li>Wet the keratome track and/or post with a lubricant to ease the engagement of the microkeratome head on the ring </li></ul>
    32. 32. Microkeratome Engagement <ul><li>Buzz the microkeratome head before engaging it </li></ul><ul><ul><li>Acclimatizes the patient to the sound of the microkeratome </li></ul></ul><ul><ul><li>Ensure free running mechanism </li></ul></ul><ul><li>Engage the head of the microkeratome on the ring </li></ul><ul><li>Check that the microkeratome head trajectory is clear </li></ul><ul><li>You may choose to tilt the post of the ring slightly away from the proximal lid at the beginning of the pass to avoid ‘catching’ anything during the forward passage </li></ul>
    33. 33. Microkeratome Engagement <ul><li>Make sure there is no tension or pulling on the motor cord and suction tubing </li></ul><ul><li>Warn the patient not to move or squeeze as the buzzing sound starts. “You’re going to feel some buzzing now, don’t move, hold nice and steady, here comes the buzzing” </li></ul><ul><li>Tell the patient that there is only 8 seconds to go and when there are 4 seconds to go </li></ul>
    34. 34. Microkeratome Pass <ul><li>Watch the pass with particular attention to the patient’s lids and speculum </li></ul><ul><li>Look at the “end position” of the microkeratome head </li></ul><ul><li>Have a particular land-mark on the ring memorized if this is not already present to verify a full pass has taken place </li></ul>
    35. 35. Microkeratome Disengagement <ul><li>Press the backward foot-pedal to reverse </li></ul><ul><li>Deactivate the suction </li></ul><ul><li>Wait a brief moment while pressing down on the eye before removing the ring to allow suction to decline </li></ul><ul><ul><li>Avoids generating a sudden “sucking sound” that can startle the patient </li></ul></ul>
    36. 36. Microkeratome Completion <ul><li>Remove the keratome head and ring together for simplicity </li></ul><ul><li>Try to avoid </li></ul><ul><ul><li>causing a displacement of the flap on the stromal bed </li></ul></ul><ul><ul><li>allowing fluid into the interface </li></ul></ul><ul><li>You may want to slightly loosen speculum at this point (if very tight) </li></ul><ul><li>Remind the patient to look at the green flashing light – this will reassure you to know that their vision has recovered from the black-out caused by the suction ring </li></ul>
    37. 37. Patient Repositioning <ul><li>Reposition head to the “natural” effortless position, so the patient is comfortable and relaxed again </li></ul><ul><li>Realign the patient bed using the laser alignment beams – t his ensures that the cornea is vertically below and therefore perpendicular to the laser beam </li></ul><ul><li>Reassure them that “the hardest part is now done and the rest is easy” </li></ul>
    38. 38. Eye-tracker Activation <ul><li>Activate the laser’s eye tracking system </li></ul><ul><li>Ensure that the eye is central within the tracking box indicated on the laser screen </li></ul><ul><li>Increase the magnification to 1.6x so that you can clearly visualize the light reflexes from the cornea in order to lock the eye tracker into the optimal position </li></ul><ul><li>Remember: the tracker is eye movements, not bad positioning </li></ul>
    39. 39. Aiming Beam <ul><li>Verify both on the infrared monitor as well as on the patient that the laser aiming beam has been automatically placed in the center of the pupil if it is a wavefront guided treatment </li></ul><ul><li>Adjust if necessary </li></ul><ul><li>For sphero-cylindrical cases (not wavefront guided) you should manually adjust the position of the laser aiming-beam to be superimposed over the 1st Purkinje reflex of the cornea while the patient is looking at the green flashing fixation light </li></ul>
    40. 40. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    41. 41. Sponge Placement <ul><li>Place a sterile moist sponge at the hinge, overlying the conjunctiva to act as a sterile platform for the flap during the ablation </li></ul>
    42. 42. Flap Lift <ul><li>Lift the flap without pulling, stretching or bending, preferably in one movement like opening a door </li></ul><ul><li>Lay down the flap on the moist sterile sponge surface </li></ul>
    43. 43. Time to Ablation <ul><li>Ensure consistent time interval from flap lift to start of ablation </li></ul><ul><li>Prevent excessive drying of the bed </li></ul><ul><li>Provide consistent conditions for every eye to improve nomogram accuracy </li></ul>
    44. 44. Drying of Corneal Bed <ul><li>Perform a “drying sweep” of the stromal bed and hinge (use sponges that do not release particles) </li></ul><ul><li>e.g. Versatool </li></ul><ul><li>This should be standardized and performed on every single eye in the same way to ensure homogeneous hydration and lack of excess hydration of the stromal surface before ablation </li></ul>
    45. 45. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    46. 46. Aiming Beam <ul><li>Switch on the red laser aiming-beam telling the patient to “continue looking into the center of the big red cloud” </li></ul><ul><li>Warn the patient of the “buzzing” of the laser about to start </li></ul>
    47. 47. Flap Hinge Protection <ul><li>You may need to protect the back of flap or hinge from ablation with a dry spear-tip sponge </li></ul><ul><li>Take care not to block ablation of the stromal bed </li></ul>
    48. 48. Laser Activation <ul><li>During ablation you may need to apply one or all of the following: </li></ul><ul><ul><li>Hold the patient’s head with one hand </li></ul></ul><ul><ul><li>Protect the hinge/flap with a sponge in the other hand </li></ul></ul><ul><ul><li>Keep encouraging the patient to look directly at the fixation light “Keep looking in the middle of big red cloud” </li></ul></ul>
    49. 49. Laser Activation <ul><li>Ensure that the level of hydration of the bed is constant and homogeneous during the ablation </li></ul><ul><li>Continue monitoring the stromal surface during the ablation </li></ul><ul><li>Beware! Fluid is drawn up by capillary action into the hinge area </li></ul>
    50. 50. Laser Activation <ul><li>During ablation continuously talk to the patient and continue to ensure that the position of the z-axis lateral aiming lights are together and in the centre of the pupil throughout the ablation </li></ul><ul><li>Encourage the patient to look to the centre of the “big red cloud” </li></ul><ul><li>Your technician should be calling out the percentage of the ablation that is completed so that the patient knows how much more time to concentrate on the “red cloud” </li></ul>
    51. 51. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    52. 52. Flap Repositioning <ul><li>Use the cannula / BSS to flush away any blood at the hinge or around the edge of the bed </li></ul><ul><li>Close the flap as atraumatically as possible – no bending, stretching or pulling </li></ul>
    53. 53. Flap Repositioning <ul><li>Irrigate under the flap with a single-hole 27G anterior chamber type cannula on a 5 ml syringe </li></ul><ul><li>Irrigation should be at high fluid pressure/velocity for a short time to help remove debris from the interface while minimally increasing the stromal bed or flap hydration </li></ul><ul><li>This will ensure a good “fit” for the flap with minimal gutter </li></ul><ul><li>Irrigation should usually consist of 1-ml over 1-2 seconds </li></ul>Source: Eisner. Eye Surgery.
    54. 54. Preventing Flap Crunch Syndrome Flap edges flush to side when created Flap swells and contracts with hydration Epithelium grows into gutter Flap expansion to natural state obstructed by epithelium… Solution: Do not leave a gutter! … leaving microfolds
    55. 55. Flap Repositioning <ul><li>Before all the irrigation fluid has left the interface, using a very wet spear-tip sponge, very gently brush-align the flap </li></ul><ul><li>Alignment should be primarily based on the corneal markings </li></ul><ul><li>(Gutter spacing may have changed due to asymmetric swelling of the flap during hydration) </li></ul>
    56. 56. Slit Lamp Exam <ul><li>Look under high-power magnification using a slit-lamp for debris and alignment of the marks </li></ul>
    57. 57. Second Eye Preparation <ul><li>Ask patient to continue to look at the fixation light , while you start preparing for the procedure on the second eye: </li></ul><ul><ul><li>1. Print the treatment report for this eye </li></ul></ul><ul><ul><li>2. Load the treatment parameters for the second eye </li></ul></ul><ul><ul><li>3. Perform your microkeratome check after resetting it for the second eye </li></ul></ul><ul><li>The time taken to perform preparations of the second eye will ensure at least a 60 second interval to ensure proper flap adhesion (longer if you required additional irrigation) </li></ul>
    58. 58. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    59. 59. Speculum Removal <ul><li>Tell the patient to keep looking at the fixation light </li></ul><ul><li>Remove speculum slowly from one lid, then the other, while carefully holding lids, and reminding the patient not to squeeze </li></ul>
    60. 60. Drape Removal <ul><li>Remove tape/drape carefully </li></ul><ul><li>Re-examine flap position with blinking </li></ul><ul><li>Tape the eye shut if you are going to proceed to the other eye at the same sitting </li></ul>
    61. 61. Routine LASIK Procedure <ul><li>Preparation </li></ul><ul><li>Patient Positioning </li></ul><ul><li>Microkeratome Checks </li></ul><ul><li>Exposing the Eye </li></ul><ul><li>The Suction Ring </li></ul><ul><li>The Microkeratome Head </li></ul><ul><li>Lifting the Flap </li></ul><ul><li>The Ablation </li></ul><ul><li>Repositioning the Flap </li></ul><ul><li>Removing the Speculum </li></ul><ul><li>Immediate Post-op Check </li></ul><ul><li>Psychological management of the patient during the procedure </li></ul>
    62. 62. Slit Lamp Examination <ul><li>Remove tape from both eyes </li></ul><ul><li>Take patient to the slit-lamp in the operating room to check flap position and interface debris </li></ul><ul><li>Use Fluorescein stain to see any flap positioning errors, or flap tension </li></ul><ul><li>Minor flap re-positioning can be carried out at the slit-lamp using a sterile spear-tip sponge if necessary </li></ul>
    63. 63. Recovery Room <ul><li>Have the patient go to the recovery room and remain there for 20 min with their eyes closed </li></ul><ul><li>Re-iterate post-op instructions and medications, including the use of the eye-shields at night </li></ul><ul><li>Allow patient to return home with their accompanying person, instructing them to keep their eyes closed as much as possible until the 1 day post-op visit the next morning </li></ul>
    64. 64. Routine Post-Operative Management
    65. 65. Routine Post-Operative Management <ul><li>Routine follow up visits </li></ul><ul><ul><li>1 Day </li></ul></ul><ul><ul><li>1 Week </li></ul></ul><ul><ul><li>1 Month </li></ul></ul><ul><ul><li>3 Months </li></ul></ul><ul><ul><li>6 Months </li></ul></ul><ul><ul><li>1 Year </li></ul></ul><ul><ul><li>Annually </li></ul></ul>
    66. 66. 1 Day Follow Up Visit <ul><li>Discuss patient comfort </li></ul><ul><li>Measure uncorrected visual acuity </li></ul><ul><li>“ Quickie” refraction check </li></ul><ul><li>Check the flap </li></ul><ul><ul><li>Alignment </li></ul></ul><ul><ul><li>Microfolds / nanofolds </li></ul></ul><ul><ul><li>Infiltrates </li></ul></ul><ul><ul><li>Inflammation / DLK </li></ul></ul><ul><ul><li>Epithelial defects </li></ul></ul><ul><ul><li>Foreign material under flap </li></ul></ul><ul><li>Reiterate drop regime and importance of wearing plastic eye shields at night </li></ul>
    67. 67. 1 Week Follow Up Visit <ul><li>Discuss patient comfort </li></ul><ul><li>Measure uncorrected visual acuity </li></ul><ul><li>Manifest refraction check </li></ul><ul><li>Check the flap </li></ul><ul><ul><li>Alignment </li></ul></ul><ul><ul><li>Microfolds / nanofolds </li></ul></ul><ul><ul><li>Infiltrates </li></ul></ul><ul><ul><li>Inflammation / DLK </li></ul></ul><ul><ul><li>Corneal melts </li></ul></ul><ul><ul><li>Epithelial ingrowth </li></ul></ul><ul><li>Punctate epithelial staining / Dry eye </li></ul>
    68. 68. Regular Follow-Up Checks <ul><li>Discuss visual stability, night vision, dry eye symptoms </li></ul><ul><li>UCVA – distance and near vision </li></ul><ul><li>Manifest refraction (BSCVA) </li></ul><ul><li>Contrast sensitivity </li></ul><ul><li>Slit lamp examination </li></ul><ul><li>Topography </li></ul><ul><li>Wavefront </li></ul><ul><li>IOP </li></ul><ul><li>Dilated fundus examination (annually) </li></ul>
    69. 69. Final Words <ul><li>Never be a hero in refractive surgery </li></ul><ul><li>There are old pilots and bold pilots, but there are few old, bold pilots </li></ul><ul><li>E. Hamilton Lee (1892-1994) </li></ul><ul><li>U.S. Post Office Air Mail Service </li></ul><ul><li>Flew 4.4 million miles in his lifetime </li></ul>
    70. 70. Thank You Dan Z Reinstein MD MA(Cantab) FRCSC DABO [email_address]
    71. 71. Minimum Age? Refractive Stability? <ul><li>34 yo male </li></ul><ul><li>Refraction history obtained </li></ul><ul><li>2.00 D change in sphere between 27 and 33 </li></ul>

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