LASIK

LASIK

• Age — patient must be at least 18 years old and have a stable refraction.
• Myopia* — up to -11.00 D
• Hyperopia* — up to +6.00
• Astigmatism* — up to -6.00 D

*The above indications are only valid if there’s enough corneal thickness.

• Corneal Thickness — at least 500 microns of total corneal tissue prior to surgery.

Corneal Thickness Following LASIK:

• The posterior residual cornea should be equal to or greater than 300 microns
• The total corneal thickness should never be less than 400 microns

Make sure patients are not rubbing their eyes.

Treat dry eye aggressively pre- and post-op.

Be on alert for epithelial ingrowth, especially with enhancements.

Non-preserved Artificial Tears: prn or as directed for the first three months. After that, it’s ok to use an artificial tear with a preservative

*All drops should be spaced out 10 minutes to avoid washing the first drops out.

EVALUATION

As with all refractive procedures, an exhaustive ocular examination is performed to ensure LASIK as the best procedure for our prospective patient. Further, to get the most accurate measurements, we like to have our patients out of their soft contact lenses 3 days and their RGPs 4-6 weeks prior to getting pre-operative measurements. Also, to minimize post-operative complications, it’s important to be very sensitive to surface dryness. A thorough evaluation of the meibomian glands and tear film (TBUT, anesthetized shirmers, flurouscein and lisamine green staining and LipiView meibomian gland imaging) is very important in detecting any tear film abnormalities

Pre-op measurements: VA (with and without correction, distance and near), manifest refraction, cycloplegic refraction, pupil size (photopic and scotopic), IOP, slit lamp exam, endothelial cell count (if any guttata are seen), Oculus Pentacam, ORA (Ocular Response Analyzer), Wavefront Analysis, and a dilated fundus exam (See: Diagnostic Technology Advances Tab for description of these instruments). While all these pre-operative measurements are very important, it is equally important to take into consideration the patient’s dominant eye, age, occupation, goals and expectations. Also, we like to have a good discussion with the patient regarding how they use their vision on a daily basis. With this information, we can tailor the best, safest refractive surgery procedure to meet their goals and expectations allowing them to perform these daily activities with less dependency on their glasses or contacts.

During the pre-operative examination it is important to not only get the appropriate measurements (Refraction, Topography, Corneal thickness, Wavefront, Cycloplegic refraction and Tear film assessment), but this is also an important time to set appropriate patient expectations and discuss the different types of LASIK technologies, e.g. Blade vs. Bladeless LASIK, Custom vs. Conventional. The pre-operative examination is also a critical time to prepare the ocular surface when appropriate with plugs and/or prescription dry eye medication prior to surgery to maximize outcomes and minimize risk.

POST OP

During the post-operative period it’s important to be able to manage patient expectations and counsel them on the LASIK healing process as everybody has different healing tendencies. This is the time to “keep the pedal to the metal” on treating dry eye as well. The tears are critical in helping the patient feel comfortable, see clearly and heal predictably and accurately during this post-operative period.

General Rules:

• No make-up for 1 week.
• No water-related activities for 2 weeks.
• No rubbing of the eyes.
• Follow drop instructions. See below.

Day of Surgery:

We tell our patients that some hazy or foggy vision is also normal. Much like driving through morning fog. The haziness will improve throughout the day. We also tell them to expect 2-6 hours of some discomfort immediately following surgery. This discomfort can range from a mild, foreign body sensation to severe burning, watering, photophobia and stinging. However, no matter what type of discomfort the person has, it will typically only last 2-6 hours.

If their discomfort lasts longer than 6 hours or if it feels like there is a contact lens is balled up in their eye, we instruct them to call us immediately. We also instruct our patients not to sleep for 4-6 hours following their procedure. If they have documented dry eye we may have them use Erythromycin ophthalmic ointment at bedtime for the first week or so.

During surgery it’s important to have an experienced surgeon along with ALL the different technologies to allow a procedure to be matched to a patient’s surgical needs. It’s important to not only have Wavefront guided, but also Wavefront optimized technology. Eye tracking is also a must. Making flaps with a laser instead of a blade has been one of the biggest advances in LASIK technology.

Follow-up Regimen: 1 Day, 1 Week, 1 Month, 3 Months, 6 Months, 1 Year.

1 Day Post-op:

Tests to Perform: visual acuity, refraction, slit lamp exam

The day following surgery is when most patients feel their vision has improved a lot. Most patients are not only comfortable, but drive to their 1 day post-op exam and go back to work this day. Your patient can have some dryness on this visit. If so, artificial tears and possibly night time ointment can be added at this stage. Of course, punctal plugs (temporary or permanent) are also an option. Diffuse lamellar keratitis (DLK) will sometimes be seen at this time. If so, notify us and then we can determine whether to increase steroids or consider a potential lift flap and interface rinse. If there are any flap striae, we should also be notified for a potential lift and smooth. Subconjunctival hemorrhages can be noted at this visit. We are not too concerned with this, as these will usually resolve within the first few weeks.

1 Week Post-op:

Tests to Perform: Visual acuity, refraction, slit lamp exam

This is when your patient will typically start tapering their drops. If your patient is not correctable to the preoperative visual acuity, and you can see some striae, it would be appropriate to have our surgeon smooth the flap. Evaluate the flap edge for epithelial ingrowth. This is another time DLK can be observed, and we should be notified.

1 Month Post-op:

Tests to Perform: Visual acuity, refraction, slit lamp exam, IOP (if applicable)

Patients sometimes complain of photophobia at this visit due to a rebound inflammation. This can usually be remedied with a steroid qid for 1 week.

3 Month Post-op:

Tests to Perform: Visual acuity, refraction (if considering enhancement), slit lamp exam, IOP (if applicable).

This is typically the earliest we will want to consider an enhancement. Although we would prefer to wait until the six month post-op exam. We also want to see a stable refraction before considering an enhancement. If we are considering an enhancement, then a cycloplegic exam, corneal thickness and topography must also be performed. Before considering an enhancement it’s also important to assess the tear film. In many situations, if a person has not achieved their target following LASIK, it is secondary to an underlying dry eye. If we are going to consider an enhancement, we want to ensure that there’s a minimum of 400 microns of total corneal tissue and at least 300 microns of untouched corneal tissue under the flap before we will consider re-lifting the flap, as well as the duration of time since their primary procedure. If we are uncomfortable with lifting the flap, we will perform a PRK enhancement instead of a LASIK enhancement.

6 Month Post-op:

Tests to Perform: visual acuity, refraction, slit lamp exam, IOP (if applicable)

If we are considering an enhancement, then a cycloplegic exam, corneal thickness and topography must also be performed. We also want to a stable refraction at this point before considering an enhancement.

1 Year Post-op:

Tests to Perform: visual acuity, refraction, slit lamp exam, IOP

If we are considering an enhancement, then a cycloplegic exam, corneal thickness and topography must also be performed. A stable refraction is also important for a successful enhancement.