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| An Online Resource for LASIK Refinements
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| An Online Resource for LASIK Refinements
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| Still and video images at this surgeons’ website show how to treat minor refinements following LASIK.
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| Rob Murphy, Contributing Editor
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Fort Lauderdale, Fla., refractive surgeon Cory M. Lessner, MD, has developed a series of slit lamp-based techniques with which to resolve minor early postoperative complications following LASIK.
Using these refinements, refractive surgeons readily can remove interface matter immediately following LASIK, remove debris and tear-film secretions in the intermediate postoperative period (one to several days), and address striae, flap slippage and epithelial ingrowth in the office at the slit lamp without having to return to the surgical suite.
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| In the intermediate postop period (one to several days), surgeons can address striae, flap slippage and other issues without returning to the surgical suite. |
Dr. Lessner developed the techniques over the past three years. “The first thing that I noticed was that people were having these little gaps around the [flap] edge,” Dr. Lessner says. “I said, ‘I wonder if you can seal this by brushing it with a wet Merocel?’ And sure enough, it closes right up.” Thus originated what Dr. Lessner calls the Merocel smoothing technique.
The Merocel is the most important instrument on your tray for these procedures, one that is used in almost all of Dr. Lessner’s methods of treating post-LASIK minor complications. After saturating the Merocel with BSS, then pressing out some of the BSS, you can use the Merocel’s tip to manipulate loose epithelium along the flap edges. The base of a saturated Merocel—either its side or its face—serves as an excellent smoothing device for striae or to close even the smallest gaps between the flap and bed edges.
Dr. Lessner developed further techniques through a series of discoveries. “I saw some fibers on the edge [in certain patients], and maybe they were under by half a millimeter,” Dr. Lessner explains. “I took a little forceps and I pulled it out. There was another one, maybe a little farther in, and I reached a little farther under it, and I found I could pull it out and it didn’t disrupt the flap. Then I discovered you could reach all the way into the visual axis, millimeters in, and not in any way disturb the flap. And if you needed to, you just smooth a little bit with the gap-smoothing technique.”
The angle of the Kelman-McPherson Forceps is preferable over the non-angled jeweler’s forceps for this purpose, Dr. Lessner says. The tool can be used to remove particles and fibers, even those located axially. Another useful tool is the Johnston LASIK applanator, which is an excellent instrument for massaging macrostriae while proptosing the globe using counterpressure with a Barraquer speculum.
Next, Dr. Lessner turned his attention to interface debris and tear-film secretions. “There are two patterns of debris in the interface,” Dr. Lessner says. “They’re either circumlinear around the edge of the flap, in about half a millimeter all the way around, where the secretions meander up through the nooks and crannies under the edge of the flap on that lumpy, bumpy bed, if you will. Or, if the flap kind of gets stuck to the lid a little bit and it pulls up, you’ll see just a layer straight across of debris in a half-circle, crescent shape.”
Dr. Lessner found that a 27-ga., air-injection cannula—or any cannula with an angle-to-tip length of 5 mm or greater—can be used to rinse away debris, scattered secretions and heme. This is followed by the Merocel smoothing technique. The cannula is also useful for refloating flaps that are not positioned or draping optimally. One pearl here is to keep only about 1.5 cc of BSS in the 3.0 cc syringe to make the plunger more accessible when used in a one-handed fashion.
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| A typical tray set up for slit-lamp refinement. For those doing higher volume surgery, it may be necessary to have instruments flashed during the day for replenishment. |
The discoveries continued, the next concerning epithelial ingrowth. “I discovered that you can identify epithelial ingrowth at one day, because it’s there and it grows very quickly,” Dr. Lessner says. “There’s a technique to look for it by putting fluorescein in and going back to white light, and you see a little green underneath. And I found I could peel this out with a forceps. And in certain cases it was easier—it takes on fluid very rapidly—so you go right under with the cannula on the edge. You hydrodissect, and it turns a little white, and then you can just peel it right out. I was peeling ingrowth out right at the slit lamp day one, day three, day four.”
Some formations of epithelial ingrowth can be resolved at the slit lamp while other configurations may require a return to the surgical suite. Easily removable at the slit lamp is ingrowth that migrates in from the periphery, typically hugging the bed. More difficult cases are those in which the ingrowth causes architectural changes in the flap, where the epithelium originates from the surface of the flap, curls around, and hugs the underside of the flap. These cases are better handled in the operating room.
The primary advantage of these postoperative LASIK refinements is that minor complications can be resolved quickly and easily at the slit lamp. For one thing, it doesn’t disrupt your schedule as would be the case if the patient required additional surgical manipulation. “If you’re doing any volume at all, it’s going to crush you,” Dr. Lessner says, referring to the time required for additional surgery.
These techniques are especially valuable for surgeons who contract for the use of another physician’s laser; they can be performed right in the office. Psychologically for the patient, he or she need not be alarmed at the thought of undergoing further surgery to remedy a postoperative complication. Dr. Lessner expresses the matter to the patient in positive terms. “I say, ‘I’m a perfectionist, I want this to just look perfect,’ ” Dr. Lessner says. The patient comes away believing he or she received attentive care with a simple modification to effect an optimal outcome.
Dr. Lessner is eager to share his techniques with other refractive surgeons. He will be presenting at the American Academy of Ophthalmology annual conferences. In the meantime, check out a video presentation of his postoperative LASIK slit lamp refinements on his website.
“This really was somewhat altruistic,” Dr. Lessner says. “And if people can use it to their benefit, and maybe even show me, ‘Hey, you know what, since you showed me that a + b = c, I just found that a + b + c = d.’ ” Further clinical discoveries that follow upon previous ones in this setting will no doubt redound to the patient’s benefit.
Visit SightTrust.com and look for the LASIK Slit Lamp Refinements link.
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Vol. No: 12:05Issue:
5/16/05
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AUGUST DIGITAL EDITION
Review of Ophthalmology
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