Week 11 - Refractive surgery ( Pre/Post Op) Flashcards
Three types of refractive surgery procedures:
• Laser vision correction (LVC)
• Implantable collamer lens (ICL/Phakic IOL)
• Refractive lens exchange (RLE)
What are the age Parameters for all types of surgical procedure?
• Primary LVC
- 18-59: Hyperopic
- 18-69: Myopic
• RLE*
- Presbyopic Px of 40yrs older, however younger px (36-40) who are hyperopic may benefit
• ICL/PIOL
- 21-50yrs
• Visually significant cataract
- Any age
Note: These take into consideration the spherical equivalent
Consultation: History + symptoms
• Motivation for procedure
• Hobbies
• Occupation
• Driver
• General health
• Medications
• Allergies
• Ocular health
• Spectacles
• Contact lenses
- CLs out 7 days before surgery
• Family history
Consultation: Refraction
• Prescription history
• Unaided Visual Acuity
• Manifest Refraction
• Cycloplegic Refraction
• Ocular Dominance
Consultation: Ophthalmic examination
• Cornea
• Conjunctiva
• Lids and Lashes
• Tear Quality
• Anterior Chamber
• Ocular Muscle Balance
• Pupil Reflexes
• Lens
• Vitreous
• Dilated retinal Exam
Consultation: Diagnositics
• Pupillometry
• Idesign
- Wavefront guided Rx
• Pentacam
- Pachymetry
- Keratometry
• OCT
• Intraocular pressure
• Visual fields
• Specular microscopy
• IOL master
- Biometry
Optometrist role at consultantation
• Visual outcomes: Distance and Near. ( Presbyopia)
• Risks Infection / Inflammation / Poorer outcomes
• Regression
• Further surgery (LVC Enhancement / Cataract development/ Yag laser)
• Consent - Surgeon, Ophthalmologist / Patient declaration.
What is Laser vision correction?
• Laser vision correction (LVC) involves reshaping the cornea by removal of corneal tissue, to reduce or eliminate the need for spectacles or contact lenses.
• Most commonly performed LVC procedures are LASIK and LASEK
Intralase femtosecond laser:
• Typically thinner than that for mechanical microkeratomes
- 120um instead of 160um
Procedure with LASIK:
- The cornea is andesthetised and lid speculum inserted
- A suction ring is applied to limbus to create an immobile cornea
- The flap is created by IntraLase laser
- The flap is lifted to expose the stromal bed, the hinge most often being placed at 12 o’clock
- The eye tracker is engaged and the excimer laser is applied
- The flap is washed with balance salt solution, replaced, and the edges are smoothed down
Procedure for LASEK:
- The cornea is andesthetised and a lid speculum inserted
- 18% Ethanol is applied to the cornea in a corneal ring for around 30 seconds to loosen the epithelium
- The edge of the loosened epithelium is lifted with a surgical treatment
- The stromal bed is exposed and the laser is applied immediately
- The epithelium is replaced (the procedure becomes PRK if the epithelium is discarded)
- The bandage contact lens is applied which is removed by the optometrist between days 3-5
Implantable collamer lens (ICL)
• Clear implantable lenses are surgically placed either between the cornea and iris or just behind the iris, without removing the natural lens of the eye.
Refractive lens exchange (RLE)
• Refractive Lens Exchange
• Natural Lens Replacement
• Cataract Surgery
Role of optometrist on day of surgery:
• General health checks:
- Blood pressure check.
- Further checks of GH and medications.
• Pre operative assessments - repeat (Vision/RX / diagnostic scans - OCT, IOL Master)
• Dilation (administer eye drops)
• Marking of the eye
• Discussions:
- On what to expect.
- Post operative medications.
- Signs and symptoms of complications to look for, restrictions on activities.
- Eye cleaning.
- Any Pain management.
- Details of next appointment.
Post operative advice:
• Standard advice given to patient: Refractive patients
• Rest for 24 hours
• Wear an eye shield (RLE) or goggles (LVC) whilst sleeping for 1 week
• Do not drive until advised by an Optometrist /Surgeon(Day 1 PO)
• Take pain killers if necessary (Paracetamol, Ibuprofen, Co-Codamol)
• Clean hands before handling eyedrops.
• Do not rub the eyes.
Post operative advice: activities
• Do not wear make-up for 1 week.
• Avoid getting shampoo/soap in the eyes.
• Do not exercise intensely for 1 week.
• Do not to swim for 2 weeks.
• Do not play contact sports for 4 weeks.
Optometrist role Post Op appointment:
• Refractive PO
• Discuss:
•How Vision and comfort has been since
•Eye drops regime.
•General discussions with outcomes, so f reaction.
• Record:
• Vision / BCVA
• IOPs
LVC discharge medications
• After a LVC procedure it is widely accepted we should use 3 types of medications
• Antibiotic - the incidence of microbial keratitis is very low at 0.0046% with LASIK, but higher with LASEK and CL wearers
(Higher incidence with
• Anti-inflammatory - required to reduce post-operative inflammation (DLK) and to help relieve dry eye symptoms.
• Lubricants - help manage the dry symptoms after eye surgery.
RLE/ICL discharge medications
• After a RLE/ICL procedure it is widely accepted we should use the following medications:
• Antibiotic
• Anti-inflammatory (Steroid + NSAID) - required to reduce pain and post-operative inflammation.
• Lubricants - help manage the dry symptoms after eye surgery.
Refractive surgery complications (LVC): Diffuse lamellar keratitis
• Less than 1% of patients develop serious complication
• Diffuse Lamellar keratitis (DLK)
- diffuse sterile inflammation
- occurs within 24/48hrs post-op
- Lasik patients only
- Non-specific inflammatory response
Treatment of Diffuse Lamellar keratitis (DLK)
• Stage 1 and 2
- Increase steroid to hourly - review 24/48hrs
• Stage 3 and 4
- surgeon management required
LASIK Flap complications
-
Striae
- Symptoms: Reduced BCVA & Affects QoV -
Dislodged Flap
- Management: Visually significant/Refer to surgeon
LASIK complications Epithelial ingrowth
Symptoms
• Often asymptomatic but Discomfort / Light Sensitivity
• If progressive, induced Astigmatism (cyl)
LASEK complications
• Slow Epithelial healing; Discomfort / Lacrimation BCL
• Corneal Haze (Mainly associated with LASEK)
LVC complications - Dry eye
Aetiology:
Suction effects on goblet cells / mucin layer
• Alteration in corneal curvature with alteration in
• Surface wetting
• Corneal denervation with flap creation
• All LVC patients experience transient dry eye symptoms, normally for around 1-3months.
LVC complications - Ectasia
Signs and Symptoms
• Reduced vision
• Quality of vision / Induced as
Timescale
• Months - Years post-op
Location
• Corneal, often inferiorly
Appearance
• Often normal cornea/Advanced: cone shape
RLE Complications
NLR / Cataract surgery
• Infection occurs in less than
• Approx. 1 in 1,000 people (0.1%)
• Inflammation - Endophthalmitis
• A rare but severe sight-threatening complication of surgery.
• URGENT surgeon review/HES emergency referral
Cystoid Macular Oedema (CMO)
• It usually occurs two to eight weeks after surgery.
• Reduced Vision.
• First-line treatment of postsurgical CMO can include
• Topical eye drops: Pred Forte, Acular and Acetazolamide.
• Increased IOPs ( Steroid responder)
• Retinal Detachment
• IOL displacement
• Posterior capsular pacification (Yag laser
