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 is 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. 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 is very important in detecting any tear film abnormalities. Testing can include: Tear break up times, anesthetized Schirmer’s, fluorescein and lissamine green staining and LipiView meibomian gland imaging.

Pre-op measurements:

• Visual Acuity: with and without correction, distance and near

• Manifest refraction

• Cycloplegic refraction

• Pupil size: photopic and scotopic

• IOP

• Slit lamp exam: Anterior and Posterior, with a dilated fundus exam

• Endothelial cell count: examination for any guttata or endothelial irregularities

• Oculus Pentacam

• ORA: Ocular Response Analyzer

• **See: Diagnostic Technology Advances Tab for the 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. Conversations with patients about their visual goals after surgery are critical to manage patient expectations. Depending on the patient’s goals and test results, we are then able to 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 for surgery. When appropriate, punctal plugs [temporary collagen plugs or permanent silicone plugs], OTC lubricating drops, and/or prescription medication [ie. Restasis, Xiidra, etc], can be used prior to surgery to maximize outcomes and minimize the risk of delayed healing.

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

Patient expectations should be managed before, during, and after surgery. Counseling them before they have surgery on LASIK healing times and increased dryness during the post-operative period, helps provide reassurance and comfort to those patients who have longer healing times. Ensure patients are properly managing their ocular surface after surgery. Healthy tear films provide improved visual acuity, more predictable healing, and overall patient comfort: improved gritty or scratchy sensations that are common after LASIK. It is common to be temporarily drier after surgery for about 6-8 weeks; however, some individual’s dry eyes will persist past this time and proper education can help manage patient expectations before they decide to undergo surgery.

General Rules:

• No make-up for 1 week.

• No water-related activities for 2 weeks: Hot tubs, Pools, Ocean.

• No rubbing of the eyes.

Follow drop instructions. See below.

Day of Surgery:

We tell our patients that moderate hazy or foggy vision is also normal for the first 4-6 hours after surgery. 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.

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. Patients who have prior dry eyes may be instructed to useErythromycin ophthalmic ointment at bedtime for the first week or so.

During surgery it’s important to have an experienced surgeon and 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. At Vance Thompson Vision, we use enhanced eye tracking and lasers to create LASIK flaps, to provide the most accurate treatments possible.

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

1 Day Post-op:

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

The day following surgery is when most patients feel their vision has improved the most. Patients are not only comfortable, but feel as if they can proceed with their normal day to day activities. It is common to see dryness at the one day post op appointment. Ensure patients are using artificial tears and possibly night time ointment every day to ensure proper healing. Punctal plugs (temporary or permanent) are also an option for those individuals suffering from more significant dryness.

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 and are okay to monitor in most situations, as these will usually resolve within the first few weeks.

1 Week Post-op:

Tests to Perform: Visual acuity, IOP, slit lamp exam, refraction (if patient is having visual concerns)

This is when your patient will typically start tapering their combination 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. If the patient is presenting any DLK, we should be notified.

1 Month Post-op:

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

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

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 want to ensure a stable refraction before considering an enhancement. If we are considering an enhancement, a cycloplegic exam, tear film assessment, corneal thickness and topography must also be performed. In many situations, if a patient has not achieved their target following LASIK, it is secondary to an underlying dry eye. For the patient’s safety, we will ensure there is a minimum of 400 microns of total corneal tissue and at least 300 microns of untouched corneal tissue under the flap, before considering re-lifting the flap. If the residual corneal bed is not optimal, we will consider 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.