EyeWorld Asia-Pacific December 2011 Issue

December 2011 10 EW FEATURE mitomycin C, oral steroids, Pred Forte, vitamin C, and UV protection all the time, they are going to scar,” he explained. “Before we laser these sky-high prescriptions, I have to put the fear of God into them. I have to say to them, ‘You’re going to go blind and scar if you’re not compliant.’” Another key way to avoid haze is making sure the epithelial defect closes as quickly as possible. This requires following up with the patient frequently at 1 and 4 days post-op. If it turns out the patient isn’t epithelializing properly, change something. “Take that contact lens out and use a different one, take it out and patch the patient, or change the medication,” said Dr. Durrie. “Your goal is to get the epithelial defect to close as rapidly as possible, and then it won’t trigger the healing variability that we sometimes see if it takes longer than that to heal.” If the patient does develop haze, Dr. Durrie recommended putting the patient back on steroids and doing a slow taper like the one described by Dr. Chynn. The haze will eventually clear up and go away and not need any further intervention. “Where we’ve gotten into trouble is a lot of times either patients or doctors are impatient, and doctors try to scrape the haze or retreat patients with the laser when they are still in the active healing phase. Sometimes that turns the haze into a scar,” Dr. Durrie said. “Sometimes it’s hard to get doctors to do less. They want to help their patients and aid in recovery. It’s about being patient and sitting on your hands for a little bit and following the patient carefully.” Should scarring occur, Dr. Durrie recommended performing a transepithelial removal of the epithelium using a laser with phototherapeutic keratectomy (PTK) mode, such as the VISX (Abbott Medical Optics, AMO, Santa Ana, Calif., USA). Refer back to the patient’s chart and see where the refraction was at 1-month post-op. “The thickness of that haze is equivalent to the refractive error because the patient used to be plano before he or she grew that extra stuff on the cornea,” he said. When you perform the PTK, watch for the fluorescence of the epithelium. Each pulse of the laser removes a quarter micron of tissue, and eventually it will extend to the periphery. Then you program the refractive error into the laser, and use mitomycin C. “It’s fascinating because as you’re watching those pulses, you can actually see the last part of the haze go away because it fluoresces, too. It’s a very elegant way to get through the haze and the residual refractive error,” Dr. Durrie explained. If the practice doesn’t have a VISX laser, Dr. Chynn recommended putting the patient back on Pred Forte. It won’t get rid of the scar entirely, but the patient should regain most of the visual acuity. When surgeons add surface ablation to their practice, the pain, haze, and scarring possibilities can seem daunting. But these complications can be avoided if all appropriate steps are followed. “Each one of these pieces is giving a little more oomph to your armamentarium so the patient doesn’t have scarring,” Dr. Chynn said. EW Editors’ note: Dr. Chynn has no financial interests related to his comments. Dr. Durrie has financial interests with AMO and Alcon (Fort Worth, Texas, USA/Hünenberg, Switzerland). Dr. Stahl has financial interests with AMO, Alcon, and Bausch & Lomb (Rochester, NY, USA). Contact information Chynn: toplasikdoc@gmail.com Durrie: via Hattie McWhirt, hmcwhirt@durrievision.com Stahl: jstahl@durrievision.com © 0RULD 2QH 8VH 3OXV 6%. LV D VDIH DQG DFFXUDWH DXWRPDWHG PLFURNHUDWRPH IRU WKH FUHDWLRQ RI PLFURQ SODQDU ÁDSV ,W DOORZV UHIUDFWLYH VXUJHRQV WR SURYLGH KLJK OHYHO RI VDIHW\ VXUJHULHV IRU SDWLHQWV ZLWK D XQLTXH VLQJOH XVH VROXWLRQ ª LASIK Surgery 025,$ 6 $ UXH *HRUJHV %HVVH $QWRQ\ )5$1&( 3KRQH )D[ PRULD#PRULD LQW FRP ZZZ PRULD VXUJLFDO FRP • Thin, 100-micron, planar flaps • Accuracy and predictability equivalent to Femto-SBK • Smoother stromal bed • No femto-complications • … At a fraction of the cost Think Thin SBK without compromise François Malecaze, MD, PhD (Toulouse, France) 0DOHFD]H ) 6LQJOH XVH 6XE %RZPDQ·V .HUDWRPLOHXVLV SURFHGXUH ZLWKRXW D IHPWRVHFRQG ODVHU 0\ ÀUVW FDVHV WK (6&56 :LQWHU PHHWLQJ )HE ,VWDQEXO 7XUNH\ 0DOHFD]H ) 8WLOLVDWLRQ GX PLFURNpUDWRPH HQ FKLUXUJLH UpIUDFWLYH /HV &DKLHUV G·2SKWDOPRORJLH PDL 'RZQORDG ORQJ YHUVLRQ WHVWLPRQLDOV RQ ZZZ PRULD VXUJLFDO FRP 5RXQGWDEOH ZLWK LQWHUQDWLRQDO 6%. H[SHUWV $ $VN IRU D GHPR PRULD#PRULD LQW FRP 6%. QHZVOHWWHUV QRZ RQ OLQH .(5$720( 2QH 8VH 3OXV 6%. 0RULD 68&7,21 5,1*6 86(' 6LQJOH XVH GLVSRVDEOH 1% 2) (<(6 H\HV RI SDWLHQWV $&&85$&< PLFURQV 35(',&7$%,/,7< “ PLFURQV 5(352'8&,%,/,7< PLFURQV )/$3 352),/( PLFURQ GLIIHUHQFH IURP FHQWHU WR SHULSKHU\ ,175$23 )/$3 &203/,&$7,21 IUHH FDS LQFRPSOHWH ÁDS EXWWRQKROH ÁDS WHDUV 2%/ 326723 )/$3 &203/,&$7,21 1R HQHUJ\ UHODWHG NHUDWRF\WH DFWLYDWLRQ QR '/. QR SKRWRSKRELD QR KD]H Surface - from page 9