Regardless of how long LASIK has been around, doctors can always find methods to improve treatment quicker, safer, or better. From numerous experienced doctors, here are ten pearls to help you optimize your LASIK experience from preop through postop:
Anti-inflammatory medicine used before to the LASIK surgery.
“For the three days before the LASIK eye surgery, I utilize a fourth-generation fluoroquinolone and steroid q.i.d.,” explains Greensboro, N.C., surgeon Karl Stonecipher. “I believe it aids you by removing any blepharitis or meibomitis from the lid edges. Additionally, it cleanses the tear film, resulting in a much-improved picture when patients come in for preoperative wavefront analysis. This results in a decrease in the overall enhancement rate, since the data that is input is the data that is output.”
Dr. Stonecipher begins Restasis one to two weeks prior to the LASIK surgery and maintains it for one to two months or longer, depending on the patient’s symptoms.
Estimation of the depth of ablation using LADARVision.
With Alcon’s LADARVision technology, the surgeon really understands how much tissue the laser will remove on the day of operation after the patient is dilated and his wavefront photographed, which is then entered into the surgical planning software. Regrettably, if the surgeon predicts that it will remove too much, he or she may be forced to inform the patient on the day of the LASIK surgery that they are not eligible for LASIK.
Michael Taravella, MD, Clearvision Laser Centers’ national medical director, claims he’s devised a method for estimating the depth prior to the day of operation. “We take the overall root mean square of the patient’s higher-order aberrations and put it into a regression model that we devised [he will describe the formula in a poster presentation at the 2007 American Society of Cataract and Refractive Surgery conference].” “This always provides us with an accurate estimate of the quantity of tissue that the laser will ablate, to the nearest 5 m.” Checkout more information about LADARVision on https://clinicaltrials.gov/ct2/show/NCT00413881
According to Elizabeth Davis, MD, of Minneapolis, in order to get patients’ cooperation during the LASIK surgery, it is beneficial to prepare them for what is to come. “I tell them I’m going to insert an eyelid opener and it’s going to feel a little stretched, but to avoid squeezing their eyes,” she explains. “Second, I inform them that there will be times when their eyesight may weaken or perhaps go completely black, but that this is a positive thing. I need it as proof of a LASIK surgical procedure. Then I inform them that they will have a brief sensation of pressure or burning for around 20 seconds. If you do not inform them of these facts, they will either clench when the speculum is inserted, or they may panic and exclaim, ‘My eyesight is cloudy! Now everything is black!’ or ‘I feel like I’m on fire, but my buddies assured me it wasn’t!'”
Take care to avoid transcribing mistakes.
Dr. Taravella states that he always instructs his residents and fellows to “work backward” while transitioning from plus to minus cylinder notation in order to minimize transcribing mistakes during ablation planning. “First, you rotate the cylinder 90 degrees,” he says. “Then reverse the cylinder’s indication. Finally, you combine the sphere and cylinder to form the sphere.” As an example, suppose the refraction factor is -1 +2 x 85. To begin, the surgeon adds 90 degrees to the axis, bringing it to 175 degrees. He then alters the sign of the cylinder to negative. The sphere becomes +1 when the sphere and cylinder are joined. Thus, the refraction in the negative cylinder becomes +1 -2 x 175.
“If you’re doing custom transcription, you won’t encounter an error,” Dr. Taravella explains, “as long as you have the correct floppy disk [or whatever medium the patient file is on] for the correct patient.”
Andrew Caster, a physician in Los Angeles, offers a novel approach to monovision. “Some surgeons immediately prescribe modest monovision to all patients, assuming that the patient would favor the non-dominant eye for near,” he notes. “What I highly advocate is properly assessing each presbyopic patient for monovision using a trial frame, rather than immediately prescribing or refusing monovision.” I begin by correcting the distance in both eyes, then attempting a modest amount of monovision in the left eye and then the right, allowing the patients to choose which direction they prefer the monovision. If they despise it, we will not proceed.
If they agree, I’ll assess whether they prefer the left or right eye for close vision and then experiment with various intensities of monovision. They put on trial frames and walk around the office for these tests, then return to tell me which frames they prefer. We want children to gaze both far and close. It’s quite subjective—some individuals prefer their non-dominant eye to be used for distance.
“I’ve discovered that this system works extremely well. If the patient has exhausted all possibilities, he will feel as though he has exhausted all possibilities and has a firm grasp on a potentially confusing subject.” Dr. Caster is in charge of testing. “Time invested in the chair in advance will save countless hours later on attempting to assist dissatisfied patients,” he asserts. “It is uncommon for us to have a dissatisfied patient.”
“Ensure that the patient’s chin and brow are level,” Dr. Taravella advises. “The chin should not be elevated or lowered excessively. This becomes critical when working with trackers and iris registration, since you do not want shadows to cause these devices to malfunction. In rare situations, a deep-set eye may also confound both a tracker and registration.”
When Dr. Davis is ready to cut the flap, she presses the foot pedal for a brief while, advancing the blade, and then releases it before the blade contacts the cornea. “What this often results in is the patient jumping from the first buzz,” she explains. “I can then continue with the cut without having to worry about his leaping while I’m engaging the cornea.” After creating the flap, she decreases suction on the reverse pass to assist in reducing the frictional forces on the flap, hence eliminating epithelial flaws.