Week 11 - Refractive surgery ( Pre/Post Op)

Question 1

Three types of refractive surgery procedures:

Answer 1

• Laser vision correction (LVC)
• Implantable collamer lens (ICL/Phakic IOL)
• Refractive lens exchange (RLE)

Question 2

What are the age Parameters for all types of surgical procedure?

Answer 2

• 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

Question 3

Consultation: History + symptoms

Answer 3

• Motivation for procedure

• Hobbies
• Occupation
• Driver

• General health
• Medications
• Allergies

• Ocular health
• Spectacles
• Contact lenses
- CLs out 7 days before surgery

• Family history

Question 4

Consultation: Refraction

Answer 4

• Prescription history
• Unaided Visual Acuity
• Manifest Refraction
• Cycloplegic Refraction
• Ocular Dominance

Question 5

Consultation: Ophthalmic examination

Answer 5

• Cornea
• Conjunctiva
• Lids and Lashes
• Tear Quality
• Anterior Chamber
• Ocular Muscle Balance
• Pupil Reflexes
• Lens
• Vitreous
• Dilated retinal Exam

Question 6

Consultation: Diagnositics

Answer 6

• Pupillometry

• Idesign
- Wavefront guided Rx

• Pentacam
- Pachymetry
- Keratometry

• OCT
• Intraocular pressure
• Visual fields
• Specular microscopy

• IOL master
- Biometry

Question 7

Optometrist role at consultantation

Answer 7

• 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.

Question 8

What is Laser vision correction?

Answer 8

• 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

Question 9

Intralase femtosecond laser:

Answer 9

• Typically thinner than that for mechanical microkeratomes
- 120um instead of 160um

Question 10

Procedure with LASIK:

Answer 10

1. The cornea is andesthetised and lid speculum inserted
2. A suction ring is applied to limbus to create an immobile cornea
3. The flap is created by IntraLase laser
4. The flap is lifted to expose the stromal bed, the hinge most often being placed at 12 o’clock
5. The eye tracker is engaged and the excimer laser is applied
6. The flap is washed with balance salt solution, replaced, and the edges are smoothed down

Question 11

Procedure for LASEK:

Answer 11

1. The cornea is andesthetised and a lid speculum inserted
2. 18% Ethanol is applied to the cornea in a corneal ring for around 30 seconds to loosen the epithelium
3. The edge of the loosened epithelium is lifted with a surgical treatment
4. The stromal bed is exposed and the laser is applied immediately
5. The epithelium is replaced (the procedure becomes PRK if the epithelium is discarded)
6. The bandage contact lens is applied which is removed by the optometrist between days 3-5

Question 12

Implantable collamer lens (ICL)

Answer 12

• 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.

Question 13

Refractive lens exchange (RLE)

Answer 13

• Refractive Lens Exchange
• Natural Lens Replacement
• Cataract Surgery

Question 14

Role of optometrist on day of surgery:

Answer 14

• 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.

Question 15

Post operative advice:

Answer 15

• 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.

Question 16

Post operative advice: activities

Answer 16

• 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.

Question 17

Optometrist role Post Op appointment:

Answer 17

• Refractive PO
• Discuss:
•How Vision and comfort has been since
•Eye drops regime.
•General discussions with outcomes, so f reaction.
• Record:
• Vision / BCVA
• IOPs

Question 18

LVC discharge medications

Answer 18

• 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.

Question 19

RLE/ICL discharge medications

Answer 19

• 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.

Question 20

Refractive surgery complications (LVC): Diffuse lamellar keratitis

Answer 20

• 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

Question 21

Treatment of Diffuse Lamellar keratitis (DLK)

Answer 21

• Stage 1 and 2
- Increase steroid to hourly - review 24/48hrs
• Stage 3 and 4
- surgeon management required

Question 22

LASIK Flap complications

Answer 22

1. Striae
   - Symptoms: Reduced BCVA & Affects QoV
2. Dislodged Flap
   - Management: Visually significant/Refer to surgeon

Question 23

LASIK complications Epithelial ingrowth

Answer 23

Symptoms
• Often asymptomatic but Discomfort / Light Sensitivity
• If progressive, induced Astigmatism (cyl)

Question 24

LASEK complications

Answer 24

• Slow Epithelial healing; Discomfort / Lacrimation BCL
• Corneal Haze (Mainly associated with LASEK)

Question 25

LVC complications - Dry eye

Answer 25

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.

Question 26

LVC complications - Ectasia

Answer 26

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

Question 27

RLE Complications

Answer 27

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