Refractive Surgery Complication Management Dr. Jeff Machat

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An extensive presentation on refractive surgery complication management by Dr. Jeffery Machat.

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Complication Management Jeff Machat MD :

Keratoconus – topography map:

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Optical Express I The Laser Clinic Keratoconus – Pentacam Significant elevation cone on ant. Surface LASIK contraindicated if “ Isolated island ” of elevation on Front surface >15 microns and Back surface >20 microns Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Displaced Apex - Normal:

LASEK:

Complication of Surface Ablation:

Optical Express I The Laser Clinic Complication of Surface Ablation Pain Infectious keratitis Sterile infiltrates Delayed Epithelial Healing Slow visual recovery Haze/scarring Glare/halos Central islands Dry eye Under/over correction Regression Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Corneal Haze/Scarring:

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Optical Express I The Laser Clinic Mild Reticular Haze Grade 1 This patient will not need retreatment and it won ’ t affect the visual acuity. This is common in post operative PRK patients. HAZE MANAGEMENT Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Optical Express I The Laser Clinic Focal Confluent Haze Grade 2 This pattern is confluent (dense) and focal (limited to one precise area) If this increases, consider removal with the laser. HAZE MANAGEMENT Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Optical Express I The Laser Clinic Moderate Confluent Haze Grade 3 Clinically significant haze reducing BCVA Patient will require PTK removal HAZE MANAGEMENT Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Optical Express I The Laser Clinic Dense Confluent haze Grade 4 Collagen plaque formed Requires laser PTK for the patient to regain visual acuity. HAZE MANAGEMENT Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Optical Express I The Laser Clinic Diffuse, Opaque Haze Plaque Grade 5 Dense diffuse pattern in the central cornea. Keloid former Significant myopic regression and Loss of BCVA HAZE MANAGEMENT Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

CORNEAL HAZE Management:

Optical Express I The Laser Clinic CORNEAL HAZE Management Topical steroids will NOT eliminate haze, it will thin the plaque, reduce induced myopia and make the patient happy BUT only for a short time Risks of continued steroid use: glaucoma, cataracts, dry eye… Wait, most haze clears with time unless Grades 3-5 Never treat residual myopia and haze, just haze. If Laser PTK is used to treat haze then myopia programmed, patient will end up VERY hyperopic Look at 1 week refraction, this indicates where patient will end up if Haze cleared with PTK and no myopia programmed Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

CORNEAL HAZE Management:

Optical Express I The Laser Clinic CORNEAL HAZE Management TREATMENT OPTIONS: MMC 0.02% applied 2 minutes to plaque surface and resolves over 9-12 months ( Schallhorn Technique) Scrap off Plaque, the MMC 0.02% +/- PTK PTK/PRK with Transepithelial approach with check @ Slit Lamp, then MMC x 30Sec and BCL ( Machat Technique but more clinical judgement needed ) Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

LASIK:

Infiltrates:

Optical Express I The Laser Clinic Infiltrates A collection of white blood cells which indicate: INFECTION or INFLAMMATION All infiltrates must be brought to the attention of a surgeon immediately Always remove Bandage CL if a question of infection exists Communication with a surgeon is key, almost always this is the treating surgeon Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Infiltrates:

Optical Express I The Laser Clinic Infiltrates Most inflammatory peripheral and multiple Typical infectious appearance is central and single Epithelium usually intact in inflammatory No discharge, no AC reaction with inflammatory Blepharitis KEY risk factor in inflammatory but can be associated with both “ Less pain ” , significant photophobia with inflammatory Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Infectious Infiltrates:

Optical Express I The Laser Clinic Infectious Infiltrates If central single infiltrate with no covering epithelium, any purulent discharge or AC reaction, TREAT as infectious. Scrap and Culture At least 2 broad spectrum or fortified antibiotics given hourly. Surgeon evaluation within 24 hrs minimum. NO BCL. Daily evaluations with hospital admission if not improving. Pain typically reduces within 24hr. Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Inflammatory Infiltrates:

Optical Express I The Laser Clinic Inflammatory Infiltrates If unclear etiology, treat as infectious initially. If atypical or IMMUNE RING, consider FUNGAL etiology If clearly inflammatory, with multiple peripheral infiltrates, no AC reaction or discharge and intact epithelium TREAT with Hourly PREDFORTE and MAXIDEX UNG QHS NO BCL DAILY EVALUATIONS Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Peripheral Focal Infiltrate epithelium intact:

3 Primary Post-operative Complications:

Optical Express I The Laser Clinic Epithelial Ingrowth Corneal Striae Diffuse Lamellar Keratitis 3 Primary Post-operative Complications Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Epithelial Ingrowth:

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Optical Express I The Laser Clinic Grade 1: Epith Ingrowth Minor Ingrowth may occur along the flap edge but has a demarcation line indicating sealed off. Grade 3: Epith Ingrowth This patient needs lifting and rinsing. They are at risk for corneal melt if left untreated. Grade 2: Epith Ingrowth “ nests ” of cells that may progress. Look for demarcation line to ensure stability . Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Epithelial Ingrowth:

Optical Express I The Laser Clinic Epithelial Ingrowth Grading System: Grade1: Hallmark is peripheral haze Grade2: Hallmark are large distinct translucent or vacuolated cell nests Grade 3: Hallmark is gray necrotic geographic cell nests with flap melting Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Grade 1 Epithelial Ingrowth:

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Epithelial Ingrowth Grade 1 with rolled Corneal flap edge and contraction:

Optical Express I The Laser Clinic Epithelial Ingrowth Grade 1 with rolled Corneal flap edge and contraction Demarcation Line Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Normal Corneal Flap Edge: Normal Scarring No Epith ingrowth:

Grade 2 Epithelial Ingrowth:

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Optical Express I The Laser Clinic Grade 2 Ingrowth with epithelial cells becoming necrotic and will release ‘ collagenase ’ and cause edge melting Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Grade 2 Epithelial Ingrowth moving to Grade 3 with flap edge melting:

Epithelial Ingrowth Grade 3 with necrotic epith cells in geographic cell nest pattern:

Optical Express I The Laser Clinic Epithelial Ingrowth Grade 3 with necrotic epith cells in geographic cell nest pattern Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Grade 3 Geographic Pattern:

Epithelial Ingrowth:

Optical Express I The Laser Clinic Epithelial Ingrowth Corneal flap melting from hypoxic epithelial cells which become necrotic and release collagenase Corneal flap melting can result in blurred vision, induced cylinder, discomfort & glare Risk of epithelial ingrowth recurrence is elevated as melted edge allows further epithelial cells to migrate in Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Grade 3 Epithelial Ingrowth:

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EPITH INGROWTH Management:

Optical Express I The Laser Clinic EPITH INGROWTH Management All significant Epithelial Ingrowth develops by 1 month Grade 1: No Treatment required. Less than 2 mm. Follow until 1 month. Watch for demarcation line to assure safe to discharge. Grade 2: Cell nests visible. Elevated edge on Fluorescein. Symtomatic often with FB sensation & cylinder. If NO Demarcation line, may advance, requires TREATMENT if beyond 2mm. Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

EPITH INGROWTH Management:

Optical Express I The Laser Clinic EPITH INGROWTH Management Grade 3: Urgent Treatment. Cell nests become WHITE, indicating necrosis. Cells release collagenase, resulting in corneal flap melting Corneal flap melting will induce asymmetrical night glare, irregular astigmatism, cylinder. Extremely difficult to treat once flap melting occurs Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

EPITH INGROWTH Management:

Optical Express I The Laser Clinic EPITH INGROWTH Management Treatment normally involves scraping BOTH the undersurface of the flap and the stromal bed. Scraping best accomplished with both a 64 Beaver Blade and Dry Surgical Spears Irrigate copiously under the flap and smooth into position. Bandage CL needed if epithelial disruption Recurrent cases: ? ETOH, Sutures, PTK, Flap Removal, Consider RK Blade stab incision if paracentral or flap edge melting Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Corneal Melting previous grade 3 epithelial ingrowth, scalloped edge :

EPITH INGROWTH Management:

Optical Express I The Laser Clinic EPITH INGROWTH Management Corneal Flap Edge Melt: If corneal melting occurs, may be self-limited and have scalloped edge > do not need to lift or clean at this stage unless cells still evident If corneal flap melting, Do NOT lift for simple refractive enhancement, any re-lift will carry significant recurrence risk for epithelial ingrowth Recommend surface ablation with MMC if needed or possibly CK if hyperopic Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Corneal Interface Cleaning:

Corneal Striae:

Striae:

Optical Express I The Laser Clinic Striae Loss of BCVA Poor Visual Quality Induced Cylinder Glare from induced HOA Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Retroillumination best flap check if BCVA reduced:

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Optical Express I The Laser Clinic Striae can be subtle. Always easier to detect with retro illumination or with fluorescein. Consider lifting and smoothing the flap if the patient has any reduction in visual acuity or change in refraction ( cylinder). Risk of epithelial ingrowth increased. Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Corneal Striae Management:

Optical Express I The Laser Clinic Corneal Striae Management Pattern of Striae vertical, horizontal, oblique, diffuse pattern striae usually indicates with thin flaps Presence of Fibrosis indicates long-standing nature reduced success in management need for PTK Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Long-Standing Corneal Striae:

Corneal Striae:

Optical Express I The Laser Clinic Corneal Striae Treatment and success depends upon timing of intervention EARLY within 1 week, lift flap, clean bed especially margin edges with 64 Beaver Blade, scrape flap undersurface, close and irrigate, then smooth with cyclodialysis spatula or semi-dry surgical spear. Stretch flap toward bed margins. Epithelium should be dry and may break down. Stretch for 3-5 minutes. BCL usually needed. Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

GRADED THERAPEUTIC APPROACH FOR SYMPTOMATIC STRIAE:

Optical Express I The Laser Clinic GRADED THERAPEUTIC APPROACH FOR SYMPTOMATIC STRIAE Flap Massage: simple re-lift with stretching and smoothing Flap Lift and Smooth with hypotonic saline 4:1 dilution Flap Lift and smooth with epithelial debridement Anti-torque Suturing x 3 weeks PTK of undersurface in long-standing striae Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Corneal Striae Smoothing Technique:

Corneal Striae:

Optical Express I The Laser Clinic Corneal Striae Do not expect wrinkles to disappear immediately but rather overnight once stretched Use the approximation of the flap gutter to determine if flap re-alignment good If unable to approximate flap edge with bed edge (after interface surfaces and edges cleaned); remove epithelium and re-attempt Surface epithelium holds wrinkles and removal helps releases them but requires BCL Can also, re-hydrate flap with hypotonic saline 4:1 dilution which helps stretch out flap and clear striae Push Steroids post-operatively, Voltaren/Diclofenac 0.1% peri-operatively Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Corneal Striae:

Optical Express I The Laser Clinic Corneal Striae LATE: Same approach but will require several more minutes of smoothing & stretching Alternatively, can swell corneal flap with hypotonic solution even distilled water as this will swell corneal flap and remove striae Lastly, if severe long-standing striae, anti-torque sutures for 3 weeks. Beyond 6-12 months, prognosis very poor ALWAYS ensure flap quality & thickness good Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Oblique Corneal Striae must be relifted:

Corneal Striae Smoothed:

Asymptomatic Striae Outside Visual Axis No treatment :

STRIAE PREVENTION:

Optical Express I The Laser Clinic STRIAE PREVENTION Flap marking/Accurate reposition Full minute dry/ Attention to gutter and central pupillary area Post op rest with eye closure and abstinence from activity Aggressive rewetting beginning 2 hrs post op Eye protection Attention to epithelial defects Intra-Lasik Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Flap Dislodged / Dislocation:

Flap Dislodged:

Optical Express I The Laser Clinic Flap Dislodged “ Diagnose from the end of the Examining Room ” Cannot open eye, very photophobic, tearing, swollen eyelid Urgent treatment to reposition IMMEDIATELY Lift and clean interface and Bed Margin with Blade/Dry Spears, Irrigate copiously the float back into position, align edges Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

LASIK: Post-op Complications:

Dislodged Corneal Flap:

FLAP DISLOCATION:

Optical Express I The Laser Clinic FLAP DISLOCATION Trauma/Rubbing Epithelial Defect with flap swelling Dryness Endothelial quality Pain with dramatic drop in BCVA Older patients Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Acute Flap Dislocation Management :

Optical Express I The Laser Clinic Acute Flap Dislocation Management Early repair critical – LASIK emergency Lift flap and define location of gutter Remove epithelial ingrowth Stretch flap 6-8 minutes Remove central epithelium Bandage contact lens 48-72 hours Manage secondary striae and ingrowth Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

DLK – “Sands of the Sahara”:

Diffuse Lamellar Keratitis:

Optical Express I The Laser Clinic Diffuse Lamellar Keratitis DLK is a sterile inflammatory reaction which develops within the interface within 48hrs post-LASIK Also known as Sands of the Sahara because of the “ sifted sands ” clinical appearance Interface haze is actually WBCs and is typically a reaction to bacterial cell wall protein (non-infectious), or secondary to High IntraLase Energy or Epithelial trauma Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Inflammatory Cells at level of Interface:

Diffuse Lamellar Keratitis:

Optical Express I The Laser Clinic Diffuse Lamellar Keratitis White quiet comfortable eyes unlike true LASIK infections Can be in one or both eyes Can follow primary or secondary LASIK Usually mild but can become severe affecting vision and refractive error Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Signs and Symptoms:

Optical Express I The Laser Clinic Signs and Symptoms Painless No conjunctival injection No AC reaction No NaFl stain Interface “ haze ” – can be separated from surface punctate keratitis by placing Fluorescein in eye, if difficulty telling which level involved Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

PRESENTATION:

Optical Express I The Laser Clinic PRESENTATION White/Grey “ sand like ” interface infiltration Initially at flap edge or hinge progressing centrally PMN lymphocytes from flap edge or surface Antigen driven immune response Asymptomatic early Vision may be clear if mild with white eye Blurred VA, if severe Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Diffuse Lamellar Keratitis:

Optical Express I The Laser Clinic Diffuse Lamellar Keratitis DLK Grading System Grade 1 DLK: (1% of LASIK) Trace PRK haze at level of interface not affecting vision or refractive error Typically sectoral but becomes diffuse, often confused with SPK Very steroid sensitive, treat with Predforte Q1H tapered over 2-3 weeks Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

GRADE 1:

Optical Express I The Laser Clinic GRADE 1 Mild powder like infiltration Localized or Sectoral Asymptomatic linear patchy Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Diffuse Lamellar Keratitis:

Optical Express I The Laser Clinic Diffuse Lamellar Keratitis Grade 2 DLK (0.2% overall) progresses from grade 1 if untreated Interface infiltrate more central with melting resulting in hyperopic refractive shift and 1-2 lines loss of bcva Hourly Predforte with interface cleaning within 1-7 days if not better Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Grade 2 Diffuse Lamellar Keratitis:

DLK Grade 2:

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GRADE 2 DLK:

GRADE 2:

Optical Express I The Laser Clinic Diffuse Infiltration BCVA may be slightly reduced Rx may be slightly hyperopic Mild if any discomfort Urgent Interface Cleaning and increased topical steroids GRADE 2 Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Diffuse Lamellar Keratitis:

Optical Express I The Laser Clinic Diffuse Lamellar Keratitis Grade 3 DLK occurs rarely (<0.02%), if Grade 2 DLK treated late or inadequately Dense central interface infiltrate like Grade 3 PRK haze Central striae common as stromal melting evident and significant hyperopic shift with loss of bcva Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

GRADE 3:

Optical Express I The Laser Clinic GRADE 3 Central Striae Flap thinning Central necrosis Irregular Astigmatism Haze Significant Hyperopic shift Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

DIFFERENTIAL DX:

Optical Express I The Laser Clinic DIFFERENTIAL DX Interface debris Meibomian secretions Epithelial ingrowth Infection Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

PROGNOSIS:

Optical Express I The Laser Clinic PROGNOSIS With timely diagnosis and management: Excellent prognosis Always progresses from Grade 1 but may be missed and first diagnosis is late at 1 week Poorer outcomes with stromal melt Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

POSSIBLE ETIOLOGY:

Optical Express I The Laser Clinic POSSIBLE ETIOLOGY * Bacterial endotoxin *Bacterial exotoxin *Blepharitis *Epithelial defects *High IntraLase Energy *Trauma/Flap dislocation Microkeratome oils Meibomian secretions Glove powder A/C vent silica Povodone Iodine Methylcellulose Detergents *Atopy/ Contact dermatitis Enhancements Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

TREATMENT OPTIONS:

Optical Express I The Laser Clinic TREATMENT OPTIONS Pred Forte (Prednisolone Acetate) 1% Q1 hr Systemic Steroids 60-80mg for 5 days(Venter) Flap Lift and washout Daily observation Poor outcomes with delay of treatment When in doubt Lift and Clean Interface Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

DLK Management:

Optical Express I The Laser Clinic DLK Management Mild Grade 1 DLK: Hourly Predforte 1% Surgeon approval Should be at least 50% better in 48 hours, if not, consider “ Flap Lift and Cleaning ” of interface Recheck in 24-48 hours Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

DLK Management:

Optical Express I The Laser Clinic DLK Management Moderate DLK Grade 2: Surgeon “ Lift and Clean ” interface with several dry spears on the corneal bed and undersurface of the flap Must be assessed by surgeon Irrigate copiously Can use 1 drop steroid to re-float flap back into position Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

DLK Management:

Optical Express I The Laser Clinic DLK Management Grade 3 Severe DLK: Usually late diagnosis, at 1 week plus Dense Coalescence of WBCs centrally Stromal melting secondary to Collagenase from white blood cells Central corneal striae Hyperopic astigmatic shift Reduced BCVA & Irregular astigmatism Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Diffuse Lamellar Keratitis:

Optical Express I The Laser Clinic Diffuse Lamellar Keratitis Treatment for Grade 3 DLK is surgical followed by topical steroids Corneal flap is lifted and infiltrate wiped, then often hyperopic ablation. PTK and irrigation also used to clean interface. New theory “ Hydration Therapy ” Retreatment often needed at 1-4 months Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

GRADE 3 DLK:

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“Sands”:

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Button-Hole Flap :

Button-hole Corneal flap:

Button-holed Corneal Flap:

Button-hole Flap Management: NEVER Ablate, close and recut deeper in 6-12 months +/- IntraLase or EK with MMC at 3 months:

Optical Express I The Laser Clinic Button-hole Flap Management: NEVER Ablate, close and recut deeper in 6-12 months +/- IntraLase or EK with MMC at 3 months Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Late LASIK Complications:

Optical Express I The Laser Clinic Late LASIK Complications Dry eyes Very common, very normal during healing phase Be aggressive in management with lubricating drops and ointment, punctal plugs, managing any blepharitis, and if severe: Restasis and/or Topical steroids FML 0.1% TID-QID Night glare Very common, very normal during healing phase Can retreat with Wavefront if persistent Ensure all residual myopia treated or corrected with spectacles Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Late LASIK Complications:

Optical Express I The Laser Clinic Late LASIK Complications Regression Treat Px very carefully Don ’ t rush into retreat-is it best to leave Rx alone? Consider un-intended monovision Make sure of Rx stability If patient happy, leave alone even if regression of Rx Explain benefits with presbyopia If dominant eye worse, usually unhappy patient Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Optical Express I The Laser Clinic The information provided in this PowerPoint presentation is for your personal informational purposes only. It is not medical advice, medical diagnosis or treatment, or recommendation for medical care or treatment. All medical questions or concerns about a medical condition, care, diagnosis or treatment should be presented to a medical physician, health care provider, or health care professional. You acknowledge that your use of this information is at your sole risk, and that you assume and accept full responsibility for all risk associated with any reliance upon the information presented. Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.