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LASIK offers instant, impressive results
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PHILADELPHIA - Laser in situ keratomileusis (LASIK) will become the refractive procedure of choice over the next few years because of quick visual recovery, spectacular results and extremely rare complications, according to Steven B. Siepser, MD, in private practice here.
He acknowledges, though, the difficulty of mastering LASIK in comparison to photorefractive keratectomy (PRK). "This is definitely not an operation for everyone to perform," he said. Therefore, "surgery will probably be concentrated in the hands of a few higher-volume practitioners, both for the safety of the patient and as a way to reduce liability exposure. Volume is protection."
Dr. Siepser began performing LASIK in October 1996 and to date has operated on a total of 230 eyes.
Three-month results
"In the real world, patients keep both eyes open and a look at their functional binocular vision gives practitioners an idea of why these patients are so happy," said Dr. Siepser.
In his -1 D to -4.75 D group, there are 32 eyes in 16 patients with more than 3 months of follow-up. Every patient was 20/40 or better with both eyes open, with 80% seeing 20/20 or better. Moreover, 10% were 20/15 or better.
In the -5 D to -8.75 D group of 45 eyes in 23 patients, again 100% were 20/40 or better; 86% were 20/30 or better; 80% were 20/25 or better; and 53% were 20/20 or better.
The initial results of the high myopes (-9 D to -15.75 D), without enhancements, are also highly encouraging: 85% were 20/40 or better, 71% were 20/30 or better; 64% were 20/25 or better; and 14% were 20/20 or better.
"In my hands, I have never performed an operation that is as effective and safe," said Dr. Siepser. "With LASIK, only one out of maybe 10,000 patients has a serious vision-threatening problem."
Technique
--- After the cornea is dried and sculpted the flap is moved back into position and carefully irrigated to remove any interface debris.
"Working with an integrated company like TLC, The Laser Center, has allowed me to provide our patients with the finest equipment," he said.
Before the patient is seated in the chair in the laser suite, the microkeratome is run under the microscope to ensure correct speed. "The blade and the travel of the blade are checked manually, as well as examined under high power," Dr. Siepser said. "It is not unusual to find blades that are chipped, irregular or have debris in the blade path."
The microkeratome is also run through the suction ring to guarantee that it moves smoothly. Dr. Siepser has developed his own pressure technique, called the Siepser V, which limits binding of the microkeratome head. He uses two heads, each with a different pressure. "It's a feel you develop over time," he said. "By using this positive pressure technique, I haven't had any miscuts or grindings down to a stop or binding during the past 160 surgeries."
Patients are acclimated to the sound of the laser, as well as to the sounds of the microkeratome and the suction ring. Patients are also instructed to signal the surgeon if there is inadequate suction during the procedure, by noting that their vision does not dim.
Once all the equipment has been checked out and the patient understands the procedure, the eye is prepped with Betadine (povidone-iodine, Escalon Ophthalmics). The patient is then moved under the laser, right eye first. The superior lashes are draped, a Slade (ASICO, Westmont, Ill.) speculum is used and the cornea marked with a double line.
The suction ring is placed, suction is administered, the pressure is checked and the patient is queried about dimming vision. The globe is irrigated with BSS (balanced salt solution, Alcon) and the microkeratome head is positioned. "I've changed the name of the flap because flap sounds too anxiety-producing to patients," noted Dr. Siepser, who prefers instead to use the name "crescent cut."
The microkeratome cuts the crescent (flap), exposing the bed. "We then change to oblique illumination to the cornea so the patient can fixate better on the red reflex light of the laser," he said.
The cornea is dried and the excimer laser is used to sculpt the correction, then the crescent is moved back into position and carefully irrigated to remove any interface debris. "Two minutes are then allowed to pass for the crescent to stabilize," Dr. Siepser said.
After taping the right eye shut, the left eye proceeds in a similar fashion.
Postop protocol
Since embracing LASIK, Dr. Siepser has reduced his postoperative drug regimen from almost 2 weeks of medications to only 4 days. Presently, patients receive TobraDex (tobramycin dexamethasone, Alcon) and Acular (ketorolac tromethamine, Allergan), one drop in each eye four times per day for 4 days. "This regimen has been a tremendous asset to comanagement, especially among primary care eye practitioners who are limited in drop manipulation," said Dr. Siepser. "The ODs' real value to the MD is skill in observing the health of the flap and the edge."
Patients are seen at 1 day, 1 week, 1 month, 3 months, 6 months and 1 year. "It is very important that at every visit the patient have fluorescein testing for any corneal epithelial breaks or erosions," he said. Further, "special care should be given to the edge of the flap, where erosions and epithelial ingrowth occur."
Practitioners need to elevate the superior lid in order to carefully evaluate the superior area. "This is the area that often has difficulty."
Complications rare
In extremely rare instances worldwide - perhaps one out of 40,000 cases - an eye has been lost due to perforation as a result of the microkeratome not being properly assembled.
"The microkeratome can cut through the cornea and continue through the iris and lens," said Dr. Siepser. However, there has not been a single case of irreparable damage among the 140,000 operations performed in the United States.
Nonetheless, Dr. Siepser is careful to personally inform his patients of this dreaded complication, as well as another unlikely serious problem - perforation of the cornea or damaging of the lens, which can cause a cataract. "There have been rare cases of this in the United States, resulting in corneal transplant and cataract removal with an implant," he related. Despite the extensive surgery, "all eyes have recovered with normal vision."
Follow-up care is important and "since I work in a network of eye care professionals, I know our patients are well cared for by their TLC, The Laser Center, trained doctors," he said.
There is also the possibility of an irregular flap cut. "I've had it happen four times," said Dr. Siepser, who opted in all these instances not to proceed.
"It happens from lack of experience over what to do when a patient moves. Interestingly, all four cases occurred within my first 20 surgeries."
Two cases of stromal melt were controlled with high-dose steroids and topical antibiotics. "They resulted in interface infiltrate," he noted. "However, both cases resolved with treatment and the patients are now 20/20."
Wide range of candidates
Any patient with myopia ranging from 1.5 D to 15 D, and up to 4 D of astigmatism, is a suitable candidate for LASIK, said Dr. Siepser. In addition, "we like patients to have a stable refraction and be at least 21 years old," he said, noting that some patients have been as old as 60.
When he first began performing LASIK, Dr. Siepser occasionally performed surgery on only one eye; today, it is virtually all bilateral. "That's how confident I am about this operation."
Over his lifetime, Dr. Siepser has performed more than 7,000 ocular procedures. "I have never had an operation that works as well as LASIK," he stated. "A year ago I was still performing a few PRKs, but today I am reluctant to do any. After all, what other operation has a patient walk into a room, look at a clock that they are unable to read, lie down, have the procedure, sit up and be able to read the clock?"
Dr. Siepser gave the example of an ophthalmologist on whom he performed LASIK at 7 p.m.; the following noon he was seeing patients, and two days later, he was operating.
Enhancements are also much easier with LASIK compared with PRK. "You simply elevate the flap at 3 months and perform additional treatment, while with PRK you have to go through the whole procedure again," he said.
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For Your Information:
- Steven B. Siepser, MD, in private practice, can be reached at 91 Chestnut Rd., Paoli, PA 19301; (610) 296-3333; fax: (610) 296-3030. Dr. Siepser has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.