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Flattening the Recalcitrant LASIK Flap Fold

admin — Wed, 08 Aug 2007 21:14:11 +0000

By: Sam Melki

Lasik flap folds can induce irregular astigmatism with optical aberrations and loss of BCVA especially if they involve the visual axis. ‘Macrofolds’ are easily seen by slitlamp exam and represent full thickness flap tenting in a linear fashion. On the other hand, ‘microfolds’ within the flap itself may represent wrinkles in Bowman’s layer or in the epithelial basement membrane. They are best seen as negative staining lines with sodium fluorescein. The incidence of folds requiring intervention ranges between 0.2% and 1.5%.

Flap folds result from uneven alignment of the flap edge and the peripheral epithelial ring. This can occur with unequally hydrated stromal bed prior to flap repositioning. Thinner and larger flaps tend to shift more readily with resultant surface wrinkling. Uneven sponge smoothing can result in radial (with centrifugal movement) or circumferential folds (with centripetal movement). A higher incidence of flap folds is usually found in higher myopes and is sometimes unavoidable. This is due to the reduced central convexity and stromal support resulting in flap redundancy that may be quite difficult to flatten.

Management ranges from simple lifting and refloating of the flap to placement of sutures to stretch the flap in position. Probst et al. described a technique using the red reflex as a way to better detect flap wrinkles during flattening procedures. Smoothing of the flap should aim towards an even distribution of forces applied to the surface. This can be performed with methylcellulose sponges or their equivalent. Instruments such as the Pineda corneal LASIK iron can also be used to flatten isolated flaps at the slit lamp or under the operating microscope by gently pressing on them. Other reported strategies include hydrating the flap with hypotonic saline (60-80%) which may facilitate leveling of the flap surface.

Fixed folds are sometimes encountered and probably occur when epithelial hyperplasia has time to form in the crevices formed by the folds. Superficial epithelial incisions or frank epithelial debridement over the wrinkled area may relieve contractures that occur secondary to the presumed epithelial hyperplasia in these longer standing folds. Recalcitrant wrinkling is reported to respond well to placement of running torque-antitorque 10-0 or 11-0 nylon sutures.

Epithelial Ingrowth after Lasik

Epithelium in growth under the corneal flap can cause irregular astigmatism and induced hyperopia secondary to stromal melting. A swift intervention is sometimes needed to prevent these complications.

Once the epithelium is noted to progress towards the visual axis or once a significant hyperopic shift or loss of BCVA is encountered, lifting of the flap and scraping of the epithelium should be performed promptly. This can be performed with a #69 blade or the equivalent. It is important to remember to scrape both the stromal bed as well as the stromal aspect of the flap. Flap folds connected to the peripheral epithelial ring are a special source of concern as they provide a conduit for epithelial cells infiltration. Similarly, an epithelial defect adjacent to the edge of the flap should be followed closely due to the presence of high epithelial mitotic activity.

Which epithelium is safe to leave? Small epithelial pearls are usually self-limited and do not progress. Epithelial tongues connected to the flap edge are more worrisome, they do not need to be scraped unless they exhibit a quick rate of progression or if they already involving/threatening the visual axis.

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Lasik Flap Dilemmas

admin — Wed, 08 Aug 2007 21:11:13 +0000

By: Sam Melki

There comes a time in every laser eye surgical procedure when leaving the battlefield is the best of two (or more) evils. When is it best to reposition the flap, abandon the procedure and possibly attempt the LASIK procedure at a later time…?
Obtaining adequate suction to certain globes is occasionally an elusive target. This includes small hyperopic eyes, flat or small diameter corneas, narrow palpebral fissures… If the level of myopia permits, one has to remember that PRK is always an available option and patients must be made aware of this alternative and be consented for it prior to the procedure. A surgeon might be tempted to extend an incomplete flap with a crescent blade or similar instrument . This might lead to an uneven bed and scarring. The closer the hinge to the visual axis the riskier this maneuver will be. If the bed is large enough (not more than 0.5 mm of unexposed stroma at the hinge) laser treatment may be applied (with adequate protection to the underside of the flap).
A thin flap with an underlying shiny bed probably indicated an uncut underlying Bowman’s layer. It is not clear if performing laser in this situation has similar or higher risk of haze formation as PRK. Until more is known about this issue, it is probably safest to reposition the flap and abort the procedure especially in high levels of correction. An irregular flap indicates an irregular stromal bed and is best allowed to heal back in position rather than risk inducing irregular astigmatism.
If a buttonhole occurs, immediate laser ablation of a central epithelial island by scraping or by the laser was reported to lead to uneven ablation and loss of BCVA.

The Free Cap

A free cap results from unintended complete dissection of the corneal flap by the microkeratome head. If the cap is trapped in the keratome head, it should be gently retrieved, stretched and kept in a dessication chamber if the diameter of the exposed stroma allows laser ablation. A small cap (i.e smaller than the optical zone) should prompt the surgeon to replace it in position and avoid the laser ablation. If the cap cannot be recovered, the epithelium will grow centrally as after other “superficial” keratectomy procedures and may result in a significant hyperopic shift.
Intraoperative factors leading to a free cap are the same as those leading to a thin or perforated flap, a poor blade to cornea coupling. This is especially true for flatter corneas which are more prone to a smaller cap. Other maneuvers such as malpositioning and/or misadjusting of the flap thickness foot-plate during assembly of certain microkeratomes can lead to a free cap.
In certain instances, the microkeratome can jam preventing head reversal. This might prompt the surgeon to release the suction thus lifting the instrument with an incarcerated flap resulting in a free cap.
Placing corneal marks with gentian violet is time well spent prior to cutting a corneal flap. When recovered, a cap can be repositioned using the preplaced marks to allow proper orientation. A bandage contact lens is usually helpful to tamponade the cap and prevent slippage upon lid contact. Suturing is rarely necessary.
If the cap is lost, the corneal epithelium is allowed to heal as in PRK with a more profound central applanation effect. Laser treatment is deferred until refractive stability is achieved.

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Managing Lasik Flap Buttonholes

admin — Wed, 08 Aug 2007 21:08:33 +0000

By: Sam Melki

From all
href=”http://bostonlaser.com/lasik-boston-vision-correction.php”>Lasik
flap complication,
href=”http://bostonlaser.com/lasik-boston-vision-correction-fda-visx.php”>LASIK
flap buttonholes are the ones that lead most often to loss of
best-corrected visual acuity (BCVA). Why do they happen?

Thin, irregular and perforated flaps seem to result from a common
etiology; an inadequate coupling of the blade to the cornea. Steep
corneas have been compared to tennis balls that would buckle centrally
upon applanating pressure. This results in a central dimple missed by
the blade leading to a buttonhole. Another theory is that higher
keratometric values offer increased resistance to cutting when
applanated, leading to upwards movement of the blade. The latter is
probably more applicable to keratomes with lower oscillation rates.
Similarly, flat corneas may result in a thin and/or small flap as they
could be below the adequate cutting level in certain locations.
Inadequate blade to cornea coupling is often due to poor suction
(sunken globe/small diameter corneas with inadequate suction ring
placement, conjunctival incarceration in the suction port…). Non-angled
blades have equal chances of moving upwards towards the surface or
downwards towards the stromal side if faced with resistance. On the
other hand, inferiorly angled blades are more likely to be driven
towards the stroma.

If a buttonhole is encountered (especially centrally), most surgeons
prefer to abort the procedure, replace the flap and recut a deeper flap
(20-60 ?m deeper) approximately 10-12 weeks later. While some advocate
proceeding with scraping the epithelium and performing a PRK laser
ablation, we believe this approach may not be feasible in higher myopes
due to the appearance of unexpected haze. A higher index for epithelial
ingrowth should maintained around the margins of the buttonhole.

The incidence of perforated flaps (as well as thin and irregular ones)
may be reduced if the surgeon ensures adequate suction, inspects the
blades and adjusts the keratome plate thickness according to corneal
curvature. Other helpful measures include ensuring adequate intraocular
pressure before cutting the flap. Measurement may be most valuable with
a pneumotonometer as other means were reported to provide imprecise
readings at times. Care should be taken to avoid conjunctival clogging
in the suction port, which could lead to discrepancy between the
intraocular pressure and the suction pressure recorded on the
microkeratome vacuum console. Newer microkeratomes have a safety
mechanism to automatically abort the procedure or to activate
additional suction but are also prone to similar problems if IOP
measurements are not obtained to ensure adequate suction.

Some surgeons inspect the microkeratome blade under the operating
microscope before engaging it in the suction ring in order to rule out
manufacturing or other preoperative damage to the blade. It is best to
keep the microkeratome away from hard surfaces after assembly to avoid
subsequent blade damage.

Author Bio:
Adapted from: “101 Pearls in Refractive, Cataract and Corneal Surgery”
Samir Melki MD PhD and Dimitri T. Azar MD editors, Slack inc.
www.slackinc.com Dr. Melki is a experienced
href=”http://bostonlaser.com/lasik-boston-vision-correction-lasik-affordable.php”>Boston
affordable LASIK surgeon, Laser Eye Surgery, Vision Correction and
href=”http://bostonlaser.com/lasik-boston-cosmetic-procedures.php”>Cosmetic
Surgery

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Managing Lasik Keratome Complications

admin — Wed, 08 Aug 2007 20:59:12 +0000

By Sam Melki
State of the art LASIK technology avoids the following problems during quality laser eye surgery

The Sliding Suction Ring

Application of adequate suction is essential for intraocular pressure upsurge and dissection of good quality corneal flaps. On occasion, the suction ring slides prior to the buildup of adequate vacuum and the flap is decentered from the pupillary axis. This is reported to happen more frequently with the Hansatome microkeratome due to a slower rise in vacuum. Applying equal downwards pressure on the ring through its handle and at the base knob for about 3 seconds prior to initiating vacuum has minimized this problem.

On occasion, the initial vacuum results in a decentered ring with a large slant requiring the surgeon to release the vacuum to reposition the ring. It is not uncommon to see the ring sliding back in the conjunctival groove created by the initial suction. Decentering the ring in the opposite direction prior to activating suction may achieve good centration as the vacuum level may be high enough by the time the ring slides close to the center to prevent further slide towards the initial groove.

Another approach is to change the ring size (e.g. from 8.5 to 9.5 mm), hence avoiding the chemotic conjunctiva. Some surgeons advocate applying Vasocon-A (Alcon Laboratories, Fort Worth TX) allowing a decrease in conjunctival swelling prior to reattempting the procedure 30 minutes later. If this does not resolve the conjunctival chemosis, further difficulties might be encountered and it is best delaying the surgery for another day

The Mid-Cut Jam

The suction ring has fit well, the keratome slides easily in place and the cut is proceeding smoothly until….it stops half-way and does not respond to either forward or backwards pedal commands. This unpleasant situation can occur secondary to a mechanical or electrical failure of the keratome. The main goal of the surgeon in that situation is to protect the flap and the bed from the keratome blade. Although resuming forward movement may result in an uneven cut, we have not encountered this in our experience. A quick check of electrical wiring may reveal a loose connection especially at the connection with the keratome motor. Every keratome should be handled differently in this situation and the surgeon should inquire about the best approach to handle such a situation. For the Hansatome, if no movement can be initiated, careful release of suction and sliding the keratome-suction ring as one unit backwards will ensure that the flap is not incarcerated under the blade. The keratome head cannot be reversed along the track manually. On the other hand, with the Automated Corneal Shaper (ACS), releasing suction might trap the flap under the footplate. It is therefore preferable to disassemble the keratome head from its base without releasing suction.

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