Lasik Complications
Content
Preoperative evaluation for lasik and prk
By Dr. Mohammad Mousa
Page 1
Introduction
• The purpose of the pre-operative assessment is: 1. • To determine by physical measurement whether it is possible to correct a patient’s individual refractive error. 2. • To determine by examination whether the ocular health is adequate for this procedure. 3. • To identify if there is any increased risk of complications specific to that patient.
Page 2
Evaluation
• History
– Age – Sex – Occupation – Stability – expectation
– General health
– Ocular health
Page 3
• Absolute general health contraindications • Relative general health contraindications • Absolute ocular health contraindications • Relative ocular health contraindications
Page 4
Absolute general health contra-indications
• Auto-immune disease e.g. RA,SLE, Thyroid disease. • Immune suppression – HIV or immune suppression drugs. • Pregnancy-wait 6 months after giving birth or cessation of breast feeding. • Systemic steroids • Amiadarone • 5-Hydroxy-tryptamine e.g. sumatriptan – there is an increased risk of vascular occlusion when the intraocular pressure is raised during treatment.
Page 5
Relative general health contraindications
• Tricyclics or lithium-based medication-the need
for such medication indicates that the patient
may have obsessive or compulsive personality or is suffering from a significant level of
depression. These patients can have
expectations of surgery that are too high and are unlikely to be satisfied following surgery.
Page 6
Relative general health contraindications • Diabetes – diabetics can have an increased
risk of epithelial complications after Treatment. Eyes which have signs of diabetic retinopathy are contra-indicated.
• Active atopy – any active or uncontrolled
atopic disease would be contraindicated until it is well controlled.
Page 7
Relative general health contraindications
• Epilepsy – the patient must be able to remain relatively still during the procedure. Therefore, only patients that have not had an epileptic episode for 12 months or more may be considered for treatment. • • History of frequent fainting – these patients may have a low threshold for vasovagal attack. Patients that have a low oculocardiac reflex would also be unsuitable. • • Hepatitis B and C – patients with these conditions will not be considered for surgery in many clinics due to the potential risk to surgical staff.
Page 8
Absolute ocular health contraindications
• Diabetic retinopathy – this is an absolute
contra-indication as it can accelerate the progression of diabetic retinopathy.
• Glaucoma – During LASIK treatment, the
intraocular pressure (IOP) is raised to above 65 mmHg which may cause further damage to the optic disc. The topical steroids used postoperatively may also affect IOP
• Corneal thinning dystrophies e.g.
keratoconus – in dystrophies where the cornea is abnormally thin, LASIK would reduce the corneal thickness.
Page 9
Absolute ocular health contraindications
• History of ocular inflammatory diseases. • Herpatic ocular disease • Sjoِ gren’s syndrome – these patients will have acute dry eye and their symptoms will be exacerbated by treatment. • Fuch’s endothelial dystrophy – endothelial decompensation and poor flap adhesion has been associated with this condition. • Unstable refractive error – the prescription must be fairly stable before treatment is considered. A change of more the 0.50 D equivalent in 12 months or less is deemed unstable. • Visually significant cataract – in cases where there is a significant lens opacity, cataract surgery with IOL implant provide good alternation to laser procedure.
Page 10
Relative ocular health contraindications
• Dry eye – in some patients their condition may
be temporarily worse after Treatment.
• Blepharitis – all signs of blepharitis must be absent prior to treatment as it may induce postoperative inflammation. • Nystagmus – not all lasers have a tracker that
can keep up with the involuntary eye
movements associated with nystagmus.
Page 11
Contra-indicated eye examination findings
• Unaided vision – patients with very good unaided vision and who only need spectacles to correct presbyopia are not suitable . • Binocular vision status – if the patient has prism controlled diplopia or where decompensate heterophoria is corrected by the use of prism in spectacles.
Page 12
Ophthalmic examination
• Vision assessment - VA - the level of vision achieved with and without spectacle correction. • Refraction – manifest and cycloplegic refraction where necessary.(young) • Focimetry of spectacles – together with the refraction results, it can be used to check prescription stability over a period of time. • Ocular dominance testing – this is carried out on all patients but is particularly relevant with presbyopic patients who are considering monovision.
Page 13
Ophthalmic examination
• Tonometry – the IOP is measured as part of the examination to check for suitability for treatment and as baseline data. Tear film assessment – the patient’s tear quality and quantity will be evaluated. Anterior eye examination and dilated fundoscopy. Pupillometry – the pupil size in scotopic conditions. Pachymetry – the corneal thickness is measured Specular microscopy. For corneal endothelial state Orbit Configuration: Patients with small or Deep-set orbits and narrow palpebral fissures should be discouraged from having LASIK
•
• • • • •
Page 14
Ophthalmic examination
corneal curvature: Several different methods
are available to analyze the corneal curvature. Wavefront aberrometry – is a technique that can provide an objective refraction measurement and used in measure the optical aberrations of the eye. Certain excimer lasers can use this wavefront analysis information directly to perform the ablation, a procedure called wavefront-guided, or custom, ablation.
Page 15
Near vision
presbyopic patients must understand that reading spectacles will still be necessary after LASIK/PRK to correct their distance vision unless they opt for monovision. Myopes, aim is to undercorrection of the less dominant eye. hypermetropes it would mean overcorrection, which will probably worsen the unaided distance vision in the eye that has been corrected for near vision tasks. If the patient refuses to accept these options, then they are not suitable for LASIK/PRK.
Page 16
K- reading
Lenticular astigmatism Flat corneas (flatter than 40.00 D) increase the risk of small flaps and free caps. steep corneas (steeper than 48.00 D)
increase the risk of buttonholeflaps.
Excessive corneal flattening (flatter than approximately 34.00 D) or excessive corneal steepening (steeper than approximately 50.00 D) after refractive surgery may increase the
risk of poor-quality vision.
Page 17
Postoperative keratometry
Postoperative keratometry for hyperopic
patients is estimated by adding 100% of the
refractive correction to the average preoperative keratometry reading. Postoperative keratometry for myopic patients is estimated by subtracting
approximately 80% of the refractive
correction from the average preoperative keratometry reading
Page 18
Page 19
Residual Stromal Bed Thickness (RSBT)
• Residual stromal bed thickness (RSBT) is calculated by taking the preoperative central corneal thickness and subtracting the flap thickness and the calculated laser ablation depth for the particular refraction
• Each 1 refractive error subtracting 10microm from SBT.
Page 20
Page 21
THANK YOU
Page 22
By Dr. Mohammad Mousa
Page 1
Introduction
• The purpose of the pre-operative assessment is: 1. • To determine by physical measurement whether it is possible to correct a patient’s individual refractive error. 2. • To determine by examination whether the ocular health is adequate for this procedure. 3. • To identify if there is any increased risk of complications specific to that patient.
Page 2
Evaluation
• History
– Age – Sex – Occupation – Stability – expectation
– General health
– Ocular health
Page 3
• Absolute general health contraindications • Relative general health contraindications • Absolute ocular health contraindications • Relative ocular health contraindications
Page 4
Absolute general health contra-indications
• Auto-immune disease e.g. RA,SLE, Thyroid disease. • Immune suppression – HIV or immune suppression drugs. • Pregnancy-wait 6 months after giving birth or cessation of breast feeding. • Systemic steroids • Amiadarone • 5-Hydroxy-tryptamine e.g. sumatriptan – there is an increased risk of vascular occlusion when the intraocular pressure is raised during treatment.
Page 5
Relative general health contraindications
• Tricyclics or lithium-based medication-the need
for such medication indicates that the patient
may have obsessive or compulsive personality or is suffering from a significant level of
depression. These patients can have
expectations of surgery that are too high and are unlikely to be satisfied following surgery.
Page 6
Relative general health contraindications • Diabetes – diabetics can have an increased
risk of epithelial complications after Treatment. Eyes which have signs of diabetic retinopathy are contra-indicated.
• Active atopy – any active or uncontrolled
atopic disease would be contraindicated until it is well controlled.
Page 7
Relative general health contraindications
• Epilepsy – the patient must be able to remain relatively still during the procedure. Therefore, only patients that have not had an epileptic episode for 12 months or more may be considered for treatment. • • History of frequent fainting – these patients may have a low threshold for vasovagal attack. Patients that have a low oculocardiac reflex would also be unsuitable. • • Hepatitis B and C – patients with these conditions will not be considered for surgery in many clinics due to the potential risk to surgical staff.
Page 8
Absolute ocular health contraindications
• Diabetic retinopathy – this is an absolute
contra-indication as it can accelerate the progression of diabetic retinopathy.
• Glaucoma – During LASIK treatment, the
intraocular pressure (IOP) is raised to above 65 mmHg which may cause further damage to the optic disc. The topical steroids used postoperatively may also affect IOP
• Corneal thinning dystrophies e.g.
keratoconus – in dystrophies where the cornea is abnormally thin, LASIK would reduce the corneal thickness.
Page 9
Absolute ocular health contraindications
• History of ocular inflammatory diseases. • Herpatic ocular disease • Sjoِ gren’s syndrome – these patients will have acute dry eye and their symptoms will be exacerbated by treatment. • Fuch’s endothelial dystrophy – endothelial decompensation and poor flap adhesion has been associated with this condition. • Unstable refractive error – the prescription must be fairly stable before treatment is considered. A change of more the 0.50 D equivalent in 12 months or less is deemed unstable. • Visually significant cataract – in cases where there is a significant lens opacity, cataract surgery with IOL implant provide good alternation to laser procedure.
Page 10
Relative ocular health contraindications
• Dry eye – in some patients their condition may
be temporarily worse after Treatment.
• Blepharitis – all signs of blepharitis must be absent prior to treatment as it may induce postoperative inflammation. • Nystagmus – not all lasers have a tracker that
can keep up with the involuntary eye
movements associated with nystagmus.
Page 11
Contra-indicated eye examination findings
• Unaided vision – patients with very good unaided vision and who only need spectacles to correct presbyopia are not suitable . • Binocular vision status – if the patient has prism controlled diplopia or where decompensate heterophoria is corrected by the use of prism in spectacles.
Page 12
Ophthalmic examination
• Vision assessment - VA - the level of vision achieved with and without spectacle correction. • Refraction – manifest and cycloplegic refraction where necessary.(young) • Focimetry of spectacles – together with the refraction results, it can be used to check prescription stability over a period of time. • Ocular dominance testing – this is carried out on all patients but is particularly relevant with presbyopic patients who are considering monovision.
Page 13
Ophthalmic examination
• Tonometry – the IOP is measured as part of the examination to check for suitability for treatment and as baseline data. Tear film assessment – the patient’s tear quality and quantity will be evaluated. Anterior eye examination and dilated fundoscopy. Pupillometry – the pupil size in scotopic conditions. Pachymetry – the corneal thickness is measured Specular microscopy. For corneal endothelial state Orbit Configuration: Patients with small or Deep-set orbits and narrow palpebral fissures should be discouraged from having LASIK
•
• • • • •
Page 14
Ophthalmic examination
corneal curvature: Several different methods
are available to analyze the corneal curvature. Wavefront aberrometry – is a technique that can provide an objective refraction measurement and used in measure the optical aberrations of the eye. Certain excimer lasers can use this wavefront analysis information directly to perform the ablation, a procedure called wavefront-guided, or custom, ablation.
Page 15
Near vision
presbyopic patients must understand that reading spectacles will still be necessary after LASIK/PRK to correct their distance vision unless they opt for monovision. Myopes, aim is to undercorrection of the less dominant eye. hypermetropes it would mean overcorrection, which will probably worsen the unaided distance vision in the eye that has been corrected for near vision tasks. If the patient refuses to accept these options, then they are not suitable for LASIK/PRK.
Page 16
K- reading
Lenticular astigmatism Flat corneas (flatter than 40.00 D) increase the risk of small flaps and free caps. steep corneas (steeper than 48.00 D)
increase the risk of buttonholeflaps.
Excessive corneal flattening (flatter than approximately 34.00 D) or excessive corneal steepening (steeper than approximately 50.00 D) after refractive surgery may increase the
risk of poor-quality vision.
Page 17
Postoperative keratometry
Postoperative keratometry for hyperopic
patients is estimated by adding 100% of the
refractive correction to the average preoperative keratometry reading. Postoperative keratometry for myopic patients is estimated by subtracting
approximately 80% of the refractive
correction from the average preoperative keratometry reading
Page 18
Page 19
Residual Stromal Bed Thickness (RSBT)
• Residual stromal bed thickness (RSBT) is calculated by taking the preoperative central corneal thickness and subtracting the flap thickness and the calculated laser ablation depth for the particular refraction
• Each 1 refractive error subtracting 10microm from SBT.
Page 20
Page 21
THANK YOU
Page 22
