LASIK Following Radial Keratotomy and Glaucoma Patient Interaction

Transcription

1 AAO Atlanta 2008 Course 446 Nov 10th 2007, room A404 LASIK following previous eye Surgery A. John Kanellopoulos, MD Associate Clinical Professor, NYU Medical School Director: Laservision.gr Eye Institute, Athens, Greece 1

2 Indications Penetrating keratoplasy Pseudophakia Glaucoma Sx Radial / Astigmatic keratotomy Retinal Surgery PRK/ Lasik Bioptics 2

3 LASIK Following Radial Keratotomy Special Concerns Treat epithelial linclusions i and wound gapes prior to LASIK (re-suture if ness.) Careful surface marking Carefully handle flap to avoid tearing RK along incisionsi i Thicker flaps Enhancements difficult Higher incidence of DLK? 3

4 LASIK following Radial Keratotomy PERK Study: 43% of eyes had a 1D hyperopic shift at 10 years Following LASIK 91% improvement or no change in BCVA 1 Following LASIK no loss of 2 lines in BCVA 2 1 Attia. Journal of Cataract t and Refractive Surgery, Lindstrom. Ophthalmology,

5 LASIK following Radial Keratotomy Hyperopic shift/ Visual fluctuation may continue Ineffective for irregular astigmatism (except with wavefront-guided and/or topo-guided) 5

6 50 y/o male, s/p RK for about 8 UCVA 20/40-, 20/40 in USSR /25 (8/10) /25- (7/10) Significant night glare (dec) 6

7 Pre-op 7

8 Post-opop 8

9 46 y/o male 10 years s/p RK for x? and subsequent hyperopic shift 9

10 46 y/o male 10 years s/p RK for x? and subsequent hyperopic shift sc: 20/80 diplopia Rx x 17 gives 20/25 LASIK with the Moria M2 and the Allegretto-wave Post-op 3 months: Sc 20/30! x 40 20/

11 LASIK Following Penetrating Keratoplasty 39-70% of PK s are within 3D of emmetropia Mean cylinder following PK is 4-5 D Following LASIK 100% are within 3 D emmetropia 1 91% of eyes BCVA remained the same or improved 1 Contact lens remains standard of care 1 Donnenfeld. Ophthalmology,

12 12

13 LASIK Following Penetrating Keratoplasty Special Concerns Avoid graft-host interface Flap adherence 5 minutes Increased postoperative corticosteriods i Endothelial dysfunction and flap slippage 1 Keratoconus and progressive ectasia 1 Donnenfeld. ASCRS,

14 34 y/o male 2 years s/p Therapeutic PK for a CL-related ulcer Good cell counts: top= OD unaffected eye Bottom= OS eye with PK Rx x 56 with the Allegretto-wave Post-op 3 months: Sc 20/30! x 50 20/

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16 Wavefront Regular pattern Refraction differs with larger apeture 16

17 LASIK Following Cataract Surgery No significant concerns with PC/IOL Careful with endothelial dysfunction around phaco wound site (flap slippage, poor adhesion)? PRK with AC/IOL Future of cataract surgery 17

18 LASIK and the Glaucoma Patient Absolute Contraindications Filtering/Valve Surgery -End stage disease Significant ON damage and/or Visual Field Loss Uncontrolled Glaucoma More than 2 Medications 18

19 19

20 LASIK and the Glaucoma Patient Special Concerns Epithelial Sloughing: Discontinue topical meds pre-op Oral CAIs Nerve Fiber Layer Analysis(HRT, GDx) Post-operative IOP Measurement Mean Decrease in IOPi is 4.3 mm Hg 1 Beware of low IOP and progressive ON damage (interface fluid-maloney Ophathalmology2002) 1 Danasoury. Journal ofrefractive Surgery,

21 LASIK Following Retinal Detachment Pre-LASIK vitreoretinal consultation Avoid LASIK in high buckles-risk of poor suction/ irregular flap Treatment of asymptomatic holes controversial il Avoid silicone oil eyes 21

22 LASIK after Previous PRK Central keratometry/ Orbscan Consider Epithelial hyperplasia (If suspected plan for thicker flap) Increased postoperative steroids 22

23 LASIK after Previous LASIK Relift flap if possible (unless limited by thin cornea) Ud Undercorrect consecutive ametropia 1 1 Jacobs. Journal of cataract and refractive surgery,

24 LASIK after Previous LASIK New flap should be larger and deeper than the original flap or narrower and thinner (the same MK will cut a thinner consecutive flap on a thinner cornea) Posterior flap ablation when residual stromal bed not adequate (not possible with flying-spot excimers) Personal preference: minimum i cornea thickness> 400nm 35<K s<

25 BIOPTICS: Artisan phakic IOL and staged LASIK A. John Kanellopoulos, MD Manhattan Eye, Ear and Throat Hospital ASCRS

26 Background Unable to correct high myopes > 12-14D with LASIK Growing interest in phakic IOL s Anterior chamber (haptics, iris fixated) Posterior chamber 26

27 Methods Evaluated 12 patients with myopia > 10 D Initial flap formation 2-5 days later Artisan implantation 6 weeks later LASIK enhancement for RE > 0.50 D Follow-up 1D, 1Week, 1 month, 3Months, 6 Months 27

28 Results 12 eyes mean RE: D At 6 weeks mean RE: -2.50D 10 eyes received enhancement Postoperative RE:

29 Results Va BCVA UCVA Preop 20/45 CF Postop 20/27 20/

30 Complications Artisa n IOP ECC Under Epi Glare spike s loss Crctn > 0.50 ingrowth Halos 0 +2 %! Enhan %! 0 1(Ns) 2 cement 30

31 Artisan/Verisyse 31

32 Endothelial cell counts 32

33 Case report 1 patient randomized for one IOL each eye Artisan OD: X 90 UCVA 20/25 ICL OS: UCVA 20/25+ Outflow facility: unchanged OD (0.285 to microl/min/mmhg), reduced from to 0.185) 35.5% OS 33

34 27y/o F 14.00,

35 OD Bioptics 6 months postop 20/

36 OS Lasik 8 months postop 20/

37 Conlcusions Good predictable approxim of emmetropia Artisan require more surgical skill and elaborative technique Away from K, angle, crystalline lens Minimal if any ECC loss 37

38 WG enhancement-poor result Pre: Post: 38

39 Some excellent results too: Kanellopoulos et al, AAO

40 Same pt other eye RMSH improved from 1,2 to 0.36 (!) LCS improved from C3 to C7 (!) 40

41 Enlarging myopic optical zone: Initially -10, 505µ LASIK: 4,5mmOZ, 125µ flap M2->plano ^BCVA 2 lines, but night halostopo-guided d Tx to enlarge OZ to6mm and adjusting Q value to -1,46Initially halos gone, RE

42 Post-trauma irregular astigmatism Old K perf, s/p CE, IOL,s/p LASIK for now -1, irregularbcva 20/40+Topo-guided, Q adjustment to -0.3 Postop: UCVA 20/30, BCVA 20/

43 Post-surgery surgery irregular astigmatism Complicated CE-Aphakia-Artisan IOL-in an old LASIK pt P BCVA 20/60 Postop UCVA 20/

44 Centering optical zone-hyperopia Initially: , plasik: UCVA 20/40 BCVA 20/25 ptopog: plano UCVA 20/

45 Enlarging optical zone-rk 10 year post-rk, Post-LASIK: +2,50-1,50Cyl, debilitating night vision. P topo-guided marked improvement 45

46 Enlarging optical zonehyperopia S/p LASIK for +4.50, now and night vision down C3, s/p topo-guided CS=C7 46

47 Post-keratitis irregular astigmatism Patient t with old severe Cornea ulcer and paracentral flattening irregular cyl UCVA 20/200 to 20/25 BSCVA from 20/40- to 20/

48 Re-centering OZ, smoothing irregularities (Loss of K sliver in recuts) 48

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50 Topo-guided epi LASIK with the Moria EpiK and Wavelight Eye-Q laser improve cyl 6 months 20/20-, cyl 50

51 How do we select topo- or waveguided? 51

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53 Lost flap replacement 53

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55 Re-treatments: 1-Q value calculated at 20 degrees 2-Possible on almost 100% of cases 3-Little risk of making worse 4-Less tissue demands 55

56 RESULT at 6 months Post-op op Q values: OD: +1.2 to OS: +1.5 to +0.1 CS to from 5 to 7 at 12 degrees 56

57 Topo-wavefronts OD OS PRE POST 57

58 Wavefront maps 58

59 Rebuttal-part3 Retrospective analysis of the wavefrontguided enhancements I presented last year; and 35 cases of simple Q value adjusted enhancements we have done with 6 months follow-up Kanellopoulos et al AAO 2004 New Orleans 59

60 0.8 WFG Vs. Q adjusted- a comparison of 2 groups of C7 WF ZERNIKE (WFG) PRE & POST 35 patients C7 WF ZERNIKE (Qvalue) PRE & POST C7 pre C7 post C C7 pre C7 post C7 pre C8 WF ZERNIKE (WFG) PRE & POST C8 WF ZERNIKE (Qvalue) PRE & POST C7 pre C C8 pre C8 post C8 pre C8 post C8 pre C12 WF ZERNIKE (WFG) PRE & POST C12 TOPOs ZERNIKE (Qvalue) PRE & POST C8 prec12 pre topo C12 post topo C12 pre C12 post C C12 pre C12 pre topo

61 WFG Vs. Qadjusted Q value (20) (WFG) PRE & POST Qvalue (20) (Qvalue) PRE & POST Q value (20) pre Q value (20) post Q value Q value (20) pre Q value (20) post RMSh (WFG) PRE & POST Q value (20) pre Q value (20) pre 1.4 RMSh (Qvalue) PRE & POST RMSh pre RMSh post RMSH RMSh pre RMSh post RMSh pre LCST (WFG) PRE & POST LCST (Qvalue) PRE & POST RMSh pre CST pre (C) CST post (C) Contrast Sensitivity CST pre (C) CST post (C) CST pre (C) 61 CST pre (C)

62 Summary-Custom Q Q adjustment may be an effective and tissue sparing primary treatment and re-treatment approach It may not change unwanted Zernickes as in wavefront-guided It appears to improve the most predictable factor in night vision problems: Cornea asphericity or spherical aberration C12 It appears to optimise mesopic and scotopic visual quality 62

63 Our current protocol Myopia: 85% F-CAT with the Eye-Q, 400Hz, (Q- value adjustment customised treatment ) RMSH>0.4 Wavefront-guided High cylinder: topo-guided Hyperopia: 100% topo-guided with q- value adjustment (adjust for angle kappa) Enhancements: 100% customised (wave-, topo-, or asphericity it adjusted d ) 63

64 1 Drop of Alcaine My technique Betadine scrub and drape eyelids Aspirating speculum Lubricate blade and rotating parts with Alcaine!!! 64

65 Placement of the M2 Push down untill good suction, then lift 65

66 Microkeratome pass Observe patient anxiety and squeeze 66

67 My technique Fold flap onto itself to minimize Dehydration and exposure (minimal manipulation) Even bdhd bed hydration very dry technique (hinge ½ most moist) 67

68 ABLATION: Check parameters! (last chance to avoid error) Intraoperative moistute eq if needed 68

69 Irrigation of flap and careful wipe (remove fluid from interface) 69

70 My technique Irrigation very important Squeeze out excees fluid and Striae with moist Weck-cell Suspension-opaque drop (predforte 1%) to delineate gutter width, centration and possible striae 70

71 Attempt to compensate for irregular hydration state of the flap during the procedure (excimer, procedure speed) 71

72 Is the flap back in place? 72

73 1 observation interval Flap is evaluated with build-in slit-lamp 73

74 epilasik 74

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77 Conclusion With intelligent pre-operative selection and surgical planning, LASIK can be invaluable in the visual rehabilitation of patients following previous ocular surgery. 77

78 Thank you