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Latest techniques aim to limit postoperative complications
Mitomycin C and chilling the cornea are some of the approaches used to minimize haze and pain.
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Maximizing quality of vision while minimizing postoperative haze and pain are challenges that refractive surgeons face when performing advanced surface ablations.
“If your patient develops corneal haze, you can end up with a poor visual result. It is not only frustrating for the patient, but it is really frustrating for the doctor,” according to OSN SuperSite Section Member William B. Trattler, MD, adding that one unhappy patient due to poor vision from corneal haze could influence a surgeon’s decision on whether or not to offer PRK in the future.
“Many doctors will react to a single bad case. The key for prevention is understanding the risk factors for corneal haze following surface ablation,” he said.
Patients at increased risk for corneal haze include those who require deeper ablations (70 µm to 80 µm or more), those who have undergone previous corneal surgery such as LASIK, RK or corneal transplant, and those who are exposed to a lot of ultraviolet light.
Mitomycin C in advanced surface ablation has played a major role in changing practice patterns,
J. Bradley Randleman, MD, said, adding that dosage and duration vary from surgeon to surgeon, with many using a low concentration of 12 seconds to up to 2 minutes.
“In a high-risk patient who works or has hobbies that result in elevated ultraviolet light exposure such as boaters, I may increase the exposure time for mitomycin C 0.02% from 12 seconds to up to 30 seconds or even 1 minute to avoid postoperative haze,” Dr. Trattler said.
 Flap striae resulting from LASIK. |
 Intraoperative mitomycin C supports healing. Images: Trattler WB |
Managing discomfort
Optimizing the ocular surface before surgery by treating dry eye or blepharitis is one way to minimize postoperative pain, Dr. Trattler said. Chilling the cornea immediately after the ablation is another.
“One thing that we’re doing that seems, at least anecdotally, to be beneficial for both pain and haze is using chilled [balanced salt solution] especially immediately following ablation, and some people are doing this simply by … squirting the cornea for a prolonged period of time,” Dr. Randleman said.
Other practitioners have advocated using a corneal light shield, which is essentially a miniature sponge that is soaked in or frozen with balanced salt solution or a combination of balanced salt solution and other medication, such as an antibiotic. This shield is then applied to the corneal surface intraoperatively or postoperatively, he said.
Administering oral and topical medications, applying diluted tetracaine and topical NSAIDs, and applying a bandage contact lens may further aid in reducing postoperative discomfort.
Popularity of enhancements
“More and more doctors who were never interested in refractive surgery are now learning how to perform surface ablation for the first time,” Dr. Trattler said, “particularly to provide enhancements for presbyopic IOLs.
“Because surface ablation is so straightforward, new surgeons can be successful with this procedure. As well, surface ablation is effective as a technique for enhancements, especially for patients that have previously undergone LASIK. Instead of lifting flaps, which has been shown to have a high rate of epithelial ingrowth, we remove the epithelium and laser over the previous LASIK flap. This has been my enhancement procedure of choice for a number of years, and it appears to be increasing in popularity among refractive surgeons,” he said.
Dr. Randleman said more ophthalmologists should know about the advancements in PRK because PRK is technically much easier to perform than LASIK and the complications in LASIK are related to flap complications.
“The creation of the flap is certainly the most challenging step of the procedure, and PRK eliminates that step,” Dr. Randleman said.– by Pat Nale
- J. Bradley Randleman, MD, can be reached at Emory Eye Center, 1365-B Clifton Rd., Suite 4500, Atlanta, GA 30322; 404-778-2264; e-mail: jrandle@emory.edu.
- William B. Trattler, MD, can be reached at Department Center for Excellence in Eye Care, Baptist Medical Arts Building, 8940 N. Kendall Drive, Suite 400-E, Miami, FL 33176; 305-598-2020; fax: 305-274-0426; e-mail: wtrattler@gmail.com.