Why?

9/11/2015
Dr. Tullo
TLC Vision – employee
Alcon – Advisory Board
Bill Tullo, OD, FAAO, Diplomate
Vice President Clinical Services
TLC Laser Eye Centers
Dry Eye
Flap Striae
Epithelial Ingrowth
DLK
Infection
Stromal haze
Slow re-epithelialization
IOP spike
Inflammation
Cataract
◦ Why?
Disruption of corneal nerves = decreased
tear production
Goblet cell damage from pressure during
flap creation
Change in corneal curvature
Changes how the tear film covers the cornea
More significant in hyperopic treatments
Eric Polk, O.D., and Paul M. Karpecki, O.D.Review of Optometry.9th Annual Dry Eye Report: Erase the
Dryness after LASIK. Feb 2008
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No corneal staining
TBUT greater than 10 seconds
No symptoms
Stable refraction
Stable aberrometry
Stable topography
Careful consideration
of risk factors
Gender (Risk Factor – Female)
Women 2:1 greater than men
Age (Risk Factor – Over 50)
Incidence increases with age
Race (Risk Factor – Asian)
Increase incidence with Asians
Rx (Risk Factor >-6, any +)
Increase with higher myope
Increase with hyperopes
Medicine (Most significant Risk
Factor?) Many, many medicines
cause dry eyes
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Preexisting dry eye
Degree of preoperative Rx
Depth of laser treatment
Flap size/hinge width
Flap maker
De Paiva et al. Am J Ophthalmol. 2006; Albietz et al. J Refract Surg. 2002; Albietz et al. J Cataract Refract Surg. 2004;
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Moss et al. Arch Ophthalmol. 2000; Albietz et al. Clin Exp Optom. 2005.
• Schallhorn n = 32,070
• Dry eye is the most common side-effect of LVC
• Symptoms are related to patient satisfaction
• There are predictive factors:
Strongly predictive
Gender - Females
Procedure type - PRK
Preop Rx - Hyperopia
Statistically significant, but
little/no predictive contribution
Age
TBUT
SPK
Ablation depth
Flap type
Age is not an independent
predictor
LASIK reduces the risk (vs PRK!!)
Hyperopic females with dry eye
symptoms before surgery and
undergo PRK are at higher risk
LASIK in asymptomatic hyperopic
females reduces the risk
Hyperopic males who undergo
LASIK have a lower risk than the
general population
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◦ Even at 12M, dry eye still affects
procedure satisfaction
◦
◦
◦
◦
◦ Younger, lower hyperopes have the most
dry eye complaints
About 85% have symptoms at one week post surgery1
About 60% have symptoms at one month1
11.3% have symptoms at 3 months2
Only 7% have symptoms at 12 months, representing a
majority return to baseline3
◦ Older, higher hyperopes have the least dry
eye complaints
1- Eric Polk, O.D., and Paul M. Karpecki, O.D.Review of Optometry.9th Annual Dry Eye Report: Erase the
Dryness after LASIK. Feb 2008
2- Schallhorn – Optical Express Data
3- Murakami, et al, Ophthalmology 2012
◦ Post-op dry eye is in your chair
Dry Eye Management:
◦ Education! Patients are unaware of dryness because
of the temporary neurotrophic effect of Lasik.
◦ Artificial tears at least qid (1-6 months)
Patients may present with no objective issues, but
complain of blurry vision or halos and glare.
◦ Consider viscous drops or gel HS
Dry Eye Management:
◦ Education! Patients are unaware of dryness because
of the temporary neurotrophic effect of Lasik.
Dry Eye Management:
◦ Education! Patients are unaware of dryness because
of the temporary neurotrophic effect of Lasik.
◦ Artificial tears at least qid (1-6 months)
Patients may present with no objective issues, but
complain of blurry vision or halos and glare.
◦ Consider viscous drops or gel HS
◦ Punctal occlusion (treat inflammation first)
Extended duration collagen plugs
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Dry Eye Management:
Cyclosporine 0.05 %
◦ The patients who received cyclosporine had better uncorrected visual
acuity following Lasik compared with patients who received artificial tears.
◦ A study found that using cyclosporine 0.05% prior to LASIK improved
refractive predictability.
◦ Education! Patients are unaware of dryness because
of the temporary neurotrophic effect of Lasik.
◦ Artificial tears at least qid (1-6 months)
69% of the cyclosporine group had a manifest refraction spherical equivalent
(MRSE) within ±0.50D of emmetropia at six months vs. 26% of those patients using
unpreserved artificial tears.
Patients may present with no objective issues, but
complain of blurry vision or halos and glare.
◦ Another study found that cyclosporine 0.05% increases goblet cell density.
◦ Consider viscous drops or gel HS
The researchers treated patients diagnosed with dry eye disease with artificial
tears or cyclosporine 0.05% for 12 weeks, and found that mean goblet cell density
increased by 17% in the cyclosporine group. The artificial tear group exhibited no
change in goblet cell density.
◦ Punctal occlusion (treat inflammation first)
Extended duration collagen plugs
◦ 2013 article by D. Hessert et al. found that the addition of Cyclosporine bid for
3 months after PRK or Lasik did not provide a significant benefit in the rate of
visual recovery, final UDVA, or patient symptoms. ????
◦ 2014 article by Torricelli, et al. found that cyclosporine is effective therapy for
treatment of new onset dry eye or worsened dry eye after surgery
◦ Treat MGD
Compresses, lid scrubs (flaps?)
Omega 3 Fish Oil supplements –varying quality
Oral doxycycline for several months
Eric Polk, O.D., and Paul M. Karpecki, O.D.Review of Optometry.9th
Annual Dry Eye Report: Erase the Dryness after LASIK. Feb 2008
And…
Wrinkling of the flap
Epithelial ingrowth
Diffuse Lamellar
Keratitis (DLK)
Bacterial keratitis
Classic presentation
A.
Go back to sleep the eye should feel better
in the morning
Patient phones you a few hours after
uneventful LASIK OU
B.
Take an OTC painkiller, that should help
C.
Use tears and we will check you in the
morning
D.
RTC now
“My right eye became very uncomfortable after
my post-op nap and now the vision is much
worse in that eye.”
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RTC now
Diagnosis: Wrinkled/Dislodged/Slipped Flap
Plan:
◦ Return your pt. to surgeon to lift and smooth flap
◦ Can place a bandage contact on the eye for
temporary comfort
Easier to see in Retro
against a dilated pupil
Fluorescein is a great differentiator between
full thickness striae and microstriae
Fluorescein is a great differentiator between
full thickness striae and microstriae
What’s the difference??
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Often not visible at 1-day check
Often not visible at 1-day check
Onset 24- 72 hours
Onset 24- 72 hours
Common high myopia
Common high myopia
Common deep ablations
Common deep ablations
Usually comfortable and usually not visually
significant
Document and Monitor
Inflammation -DLK
Inflammation -DLK
Epithelial Defects
Epithelial Defects
Dryness—lid interaction
Dryness—lid interaction
Trauma
Trauma
Inflammation -DLK
Epithelial Defects
Dryness—lid interaction
Trauma
Striae will
improve as
inflammation
or edema
resolves
Usually very uncomfortable or at least very
irritable, and vision is almost always
compromised
If flap has been moved by lids or by other
physical/mechanical means, it must repositioned
Striae will
improve as
inflammation
or edema
resolves
Only matters if
Loss BCVA or
subjective quality
of vision loss glare
or halos
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Caroball
smoothing
Flap Lift and Stretch
Flap Lift with Epithelial
Debridement/ hypotonic saline
Flap Suture
Therapeutic PTK
Classic presentation
Post LASIK enhancement (flap relift)
2 weeks-2 months out
Vision has declined in one eye over the past
week or two
Pt notices daytime glare that wasn’t there before
Eye may also be sore and/or scratchy
◦ Return your pt. to surgeon to lift and smooth flap
◦ Can place a bandage contact on the eye for
temporary comfort
Observe and measure from the flap edge to
“high water mark”
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Pupil encroachment
Moving centrally
The vast majority of epi ingrowth does
NOT need to be treated
Especially primary flaps created with laser
IF epi ingrowth results, likely to look like this:
Permanent, Irregular Astigmatism...
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By far
the most
common
By far
the most
common
By far
the most
common
Frequency of monitoring?
Decreased BCVA
Cells in pupillary zone
Persistent flap edge staining with NaFl ??
Progressive refraction (hyperopic
astigmatism) or topographic changes
Flap melt
Persistent sore eye
Daytime glare symptoms
location, size, water line, density/transparency
Monitor
Monitor
Monitor
Monitor
Document the following:
for changes in refraction
for decrease in BCVA
topography
patient subjective symptoms
Lift and scrape
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or
Prevents fluid egress from clear corneal incisions
Soft and lubricious surface barrier
100% synthetic and biocompatible hydrogel
Contains a visualization aid for ease of application
Gently sloughs off in the tears during re-epithelialization
Material hydrolysis occurs in approximately 7 days.
Hydrogel should be applied with good margins around the incision site.
YAG
Video courtesy of Parag Majmudar, M.D.
Chicago Cornea Consultants
Hoffman Estates, IL
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9/11/2015
Classic presentation
Routine LASIK x 1 day or 1 week post-op
Patient reports a mild scratchy feeling that is
getting worse.
Patient may be asymptomatic
But you see a white snowstorm
Etiology:
Begins in the periphery in the flap interface
Looks like fine white “sand” particles
Typically unilateral
Tend to occur in outbreaks/sequential
patients
Can have late onset
◦ Even years later, particularly after corneal trauma
Unknown?
Bacterial endotoxins in the autoclave reservoirs
Contaminated sterilizer reservoir
Excessive corneal manipulation
Mold or fungal contamination
Trauma
Excessive Femtosecond energy (Unlikely with current
generation lasers)
Poorly manufactured blades (Rarely used anymore)
Identification and Management of
Grades 1, 2, & 3
DLK is much less common now due to
disposable instruments and lower energy
settings of the Femtosecond laser.
Grade 1 DLK
Signs/Symptoms
Focal, white/gray, granular material in
the flap interface
Normal VA
Treatment
Increase
topical steroids q1h
every 1-3 days
Taper steroid slowly (2-3 weeks)
f/u
Prognosis
Excellent
•Mild DLK may look similar to SPK,
but SPK is on the surface and will
stain with NaFL.
•Please report all DLK cases to
your surgery center.
Grade 1
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Grade 2 DLK
Signs/Symptoms
Diffuse, white/gray, granular material in
the flap interface
Normal VA or reduced 1-2 lines
Mild discomfort
Treatment
Increase
topical steroids q1h
irrigation (return to surgeon)
f/u every day
Interface
Prognosis
Excellent
after interface irrigation
•IOP must be closely monitored
during steroid treatment
•If IOP ↑ Change to a “softer”
steroid and add Glaucoma
medications
•Steroids are not
discontinued
Grade 3 DLK
Signs/Symptoms
Diffuse,confluent, white/gray, granular
material in the flap interface
Significantly reduced BCVA (hyperopic
astigmatism)
Discomfort and possible conj injection
Treatment
Should
not get to this stage
topical steroids q1h
Interface irrigation!! (return to surgeon)
f/u every day
Increase
Prognosis
Good
after interface irrigation
Grade 4 DLK
Signs/Symptoms
Diffuse,confluent, white/gray, granular
material in the flap interface
Intense central inflammation
Significantly reduced BCVA (hyperopic
astigmatism)
Discomfort and possible conj injection
Treatment
Should
not get to this stage!!!
topical steroids q1h
Interface irrigation!! (return to surgeon)
f/u every day
Increase
Prognosis
?? Possible reduced BCVA, irregular
astigmatism, residual hyperopia
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9/11/2015
Can
appear
similar to
DLK
• Elevated IOP
secondary to topical
or oral steroids
• Looks Like DLK
• Can lead to
aqueous fluid in flap
interface
• False low IOP
• Scleral IOP
Can easily be mistaken for DLK
◦ And vice versa!
History, history, history
PRK>>>LASIK
Onset weeks to months post-op
◦ Keratocytes become myofibroblasts to
heal the corneal wound
Not transparent
Extra-cellular matrix is disorganized and
denser which scatters light
A.
B.
C.
D.
E.
F.
Usually appears 1-6 months after surgery
More common with higher Rx
More common with older laser treatments
May be associated with myopic regression
Improves with topical steroid treatment
Usually improves slowly over 12-18 months
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Steroids (proper use with taper)
UV Protection
Vitamin C
Prophylactic 0.02% Mitomycin-c 10-60 sec.
• Allows for less haze
• Developed as a chemotherapeutic agent
• Acts to stop cells from proliferating by crosscross-linking DNA
which modulates wound healing
Smoother lasers, better blend zones
LASIK, LASEK, epi-lasik ?
Restasis ?, Doxycycline ?
Day 1: 20/80 or better
Day 3-4: 20/200 or better
Day 5: 20/80 or better again; cornea is rough
but re-epithelialized
VA rapidly improves 2-3 days after removal
of BSCL as epi thickens and smooths
Good vision at 1 week to 10 days
Excellent vision at 4-6 weeks
Healed at 3-6 months
Remove when epithelium is 100% closed
If in doubt: leave BCL in additional 1-2 days
Can remove BCL (carefully!!) reassess epithelium and
then replace with new BCL if necessary
◦ usually at day 4-5
◦ Caution: may increase pain and slow healing
◦ Always use an antibiotic if replace the BCL
Avoid removing BCL to simply change it for a fresh
lens because it looks “dirty”
Refit BCL if too loose causing physical discomfort or
too tight – “Overwear Syndrome”
Let patient know that VA immediately after BCL
removal may be worse or no change
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When the epithelium is healed:
◦ Remove the contact lens – FLOAT – don’t pull off the new
epithelium
Have the patient use lubricating drops every minute for
5-10 minutes to “float” the lens if it does not freely
move
The lens can then be removed by either gently
dragging it inferiorly and pinching it off, or by using a
forceps to remove at the slit lamp.
◦ Avoid use of topical anesthesia
99% of patients completely rere-epithelialized
by day 5
If epithelium not healed:
◦ Consider Infection (MRSA) or Herpes
Simplex
◦ Continue to monitor daily
You want the patient to be able to tell you how the eye
feels after the contact is removed
During
Epithelial Healing
◦ Antibiotic & steroid until epithelium healed
◦ NSAID bid X 2-4 days then D/C
◦ D/C antibiotic once epithelium is healed
◦ Topical anesthetic drops (only as an escape
from pain, potentially can delay healing)
◦ Vitamin C 500mg bid
Cold (Ice packs)
Topical NSAID
Topical Anesthetics*
Bandage Contact Lenses
Oral Medications
◦ NSAID
◦ Steroids
◦ Narcotics
Steroid
4
3
2
1
x
x
x
x
Taper:
day
day
day
day
for
for
for
for
Preservative
1
1
1
1
week
week
week
week
Free Lubricants
frequently
Pain Cocktail (Off(Off-label)
label)
◦ 225 mg Naproxin Sodium
◦ 600mg Ibuprofen
1 Aleve + 3 Advil PO q8h
or
2 Aleve + 2 Advil PO q8h
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Pregabalin – Lyrica
◦ Schedule V
◦ 50mg, 75mg & 100mg CAPS
Dosage 75mg q6h PO
GabapentinGabapentin- Neurontin
◦ Schedule V
◦ 100, 300mg CAPS
Dosage up to 300mg q8h PO
Presentation very similar to corneal ulcer
Presentation very similar to corneal ulcer
Can present post LASIK or PRK
“My eye hurts and is sensitive to the light. My
vision is getting blurry in that eye. The other
eye feels fine.”
Can present post LASIK or PRK
“My eye hurts and is sensitive to the light. My
vision is getting blurry in that eye. The other
eye feels fine.”
When should you see this patient?
When should you see this patient?
◦Immediately
The most common time frame for the
occurrence of infectious keratitis following
PRK or LASIK is 1 to 10 days postoperatively
Most common pathogens are
◦
◦
◦
◦
MRSA/MRSE
Streptococci
Staphylococci
Pseudomonas
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IOP spike
Cataract
Inflammation
Sizing too large (excessive vault)
◦ Narrowing of angle, crowding of iris and chamber
◦ IOP elevation
◦ Consider exchanging for shorter ICL
Call your Refractive Surgery Center immediately!!!
Increase antibiotic (Zymaxid q1h)
Add fortified antibiotic (Vancomycin)—your laser
center should have it
D/C Steroid
Lift flap and culture
Follow daily until resolution
◦ (1- 2 visits per day)
Long-term
◦ Flap smoothing
◦ PTK
◦ Flap removal
◦ PK
Pupillary block glaucoma
◦ Relieves with pupillary dilation
◦ Iridectomy performed as part of ICL procedure
a few days to a few weeks prior to ICL
Sizing too short (shallow or absent vault)
◦ Lens rests on anterior capsule
-Theoretical risk of
cataract formation
-Some patients with
zero vault show no
cataract many years
post ICL
- Consider exchanging
for longer ICL
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7/526 (1.3%) Incidence
All Had ≥ 12.75D PrePre-op Myopia
None Of The 420 Cases With < 12.75D PrePre-op
Myopia Had AS Cataract
Cataract Incidence 10 Times Greater For
Patients ≥ 40 Years Old (3% Vs. 0.3%)
None Lost BSCVA After Cataract Extraction,
Compared To PrePre-ICL
Cataracts
◦ Everyone prone to cataracts
◦ Typically see patients under 45 for ICL
surgery
FDA Study
1.3% cataract rate in total patient population
0.3% in patients younger than 40 and myopia under 13.00
◦ High myopes greater risk for cataract (even without
ICL)
◦ Cataract surgery very common and simple
procedure
Endophthalmitis
◦ Only 1 confirmed case in over 80,000 ICLs
◦ Patient suffered no visual loss
Management virtually indentical to
management of post-cataract
endophthalmitis
bill.tullo@tlcvision.com
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