Excimer Laser Complications and Their Management

7/28/2019 Excimer Laser Complications and Their Management

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Dr. Rupal Shah

New Vision Laser Centers

Vadodara-Mumbai-Amdavad


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Excimer LaserComplications and

their Management


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Complications

Complications common to LASIK and PRK

Complications of PRK

Complications of LASIK


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Overcorrection

Must be distinguished from slow healing


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Overcorrection


Characterized by high hyperopic overshoot

in the first week


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Overcorrection


Characterized by high hyperopic overshoot

in the first week

After PRK, hyperopic PRK after 6-8

months works well


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Overcorrection


Characterized by high hyperopic overshoot in the

first week After PRK, hyperopic PRK after 6-8 months

works well

After LASIK, holmium laser LTK may be a betteroption than hyperopic PRK


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UnderCorrection

Usually due to problems of laser calibration


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UnderCorrection


Should be distinguished from regression

after the treatment


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UnderCorrection


Should be distinguished from regression after the

treatment After PRK, retreatment after 3-4 months works

well, after tapering steroids quickly


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UnderCorrection


Should be distinguished from regression after the

treatment After PRK, retreatment after 3-4 months works

well, after tapering steroids quickly

After LASIK, lift the flap and retreat in the firstmonth itself


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Decentration

Not a very big problem in LASIK


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Decentration


Usually not a big problem in PRK-USE

LARGE ZONES


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Decentration


Usually not a big problem in PRK-USE

LARGE ZONES

In hyperopic treatments, centration is very

critical -USE LARGE ZONES


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Decentration


Usually not a big problem in PRK-USE LARGE

ZONES In hyperopic treatments, centration is very critical

-USE LARGE ZONES

Myopic decentrations can be tackled by enlarging

the zone while using masking fluids


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Epithelium Related


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Epithelium Related

Steroid Related


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Epithelium Related

Steroid Related

Wound Healing Related


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Epithelium Related-Filamentary

Keratitis Especially common when patient has a

cold or during summer


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Keratitis Especially common when patient has a cold

or during summer

Results in Foreign body sensation


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or during summer


Can be resolved by simple patching.


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or during summer


Can be resolved by simple patching.

If the patient is very uncomfortable,

filaments can be picked off with a fine

forceps on the slit lamp


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Epithelium Related-Heaping in

the centre Occurs in hyperopic treatments-no laser

energy in the centre

Looks like a central island on topography


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Reduced BCVA


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Reduced BCVA

Can be managed by polishing the cornea

after epithelial scraping


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Epithelium Related-Slow Growth

The defect created does not heal


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Can result due to systemic problems, the

use of extra thick Bandage Contact Lenses,or due to injury


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Can result due to systemic problems, the

use of extra thick Bandage Contact Lenses,or due to injury

Can be managed like a recurrent corneal

erosion


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Epithelium Related-Sterile

Infiltrates Usually because of use of NSAIDS for pain

relief during the healing phase


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Epithelium Related-Sterile

Infiltrates Usually because of use of NSAIDS for pain

relief during the healing phase

Give NSAIDS only under steroid cover


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Steroid Related-IOP Rise

Temporary increase of IOP even on FML


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Leads to loss of BCVA, and myopic shift

due to corneal oedema


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Relief by Betablockers


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Relief by Betablockers

Occassional recourse to Diamox


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Steroid Related-Cataract

Happens especially if the individual must

take recourse to systemic steroids


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Avoid all patients with even slight lenticularchanges pre-op


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Avoid all patients with even slight lenticularchanges pre-op

Must warn Asthamatics about possibility of

cataract


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Wound Healing-Slow Healing

Must be distinguished from over correction


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Patient treated for myopia stays hyperopic

for very long


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for very long

Thinner Epithelium in the center of the

cornea


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for very long

Thinner Epithelium in the center of the

cornea

Taper Steroids quickly


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Patient treated for myopia stays hyperopic for very

long Thinner Epithelium in the center of the cornea

Taper Steroids quickly

Use a Bandage Contact Lens to stimulateepithelial healing


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Wound Healing-Haze and

Regression Peaks at 2 months in moderate myopia, and

even at 8 months in extreme myopia


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Usually the haze is not visually significant,and this haze is not accompanied by

regression


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Usually the haze is not visually significant,and this haze is not accompanied by

regression

Visually significant Haze is alwaysaccompanied by regression


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Haze and Regression-

Predisposing Factors Depth of the Ablation


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Shape of the Ablation pattern


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UV Light Exposure


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UV Light Exposure

Fate of the fellow eye


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UV Light Exposure

Fate of the fellow eye

Hormonal changes-Pregnancy,HRT,Oral

Contraceptives


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UV Light Exposure Fate of the fellow eye

Hormonal changes-Pregnancy,HRT,Oral

Contraceptives

Previous Corneal Surgery-LASIK or RK


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Management Give a Short burst of potent topical steroid


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Epithelial scraping and polishing of the

haze-PROCEED WITH EXTREMECAUTION AND AFTER WAITING FOR

1 YEAR FOLLOWING TREATMENT


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Epithelial scraping and polishing of the haze-

PROCEED WITH EXTREME CAUTION ANDAFTER WAITING FOR 1 YEAR FOLLOWING

TREATMENT

Wait, Wait, Wait.., and the haze (but not the

regression) goes away


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COMPLICATIONS OF LASIK

Intraoperative

Immediately Post Operative

Long Term


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Intraoperative-Inadequate Flap

Keratome movement is interrupted during

the pass


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the pass

Also happens in high and Low-K eyeswithout apparent reason


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the pass

Also happens in high and Low-K eyes If Hinge is 2 mm beyond pupil center,

reduce optical zone and proceed


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the pass

Also happens in high and Low-K eyes If Hinge is 2 mm beyond pupil center,

reduce optical zone and proceed

Else, wait for 3-4 months, and repeatkeratome cut with greater depth


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Intraoperative-Free Cap

Can occur because of suction loss during

the keratome pass


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the keratome pass

Can also occur if hinge is too small andbreaks


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the keratome pass


Cap sticks back without sutures


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the keratome pass


Cap sticks back without sutures

PARARADIAL AND RADIAL MARKSVERY IMPORTANT


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Thin Flap

Occurs because suction is not adequate

If thinner than 70-80 microns, abandon

procedure, repeat at a later date


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Thin Flap

Occurs because suction is not adequate

If thinner than 70-80 microns, abandon

procedure, repeat at a later date Else, if attempted correction is not high,

convert to PRK, by cutting off the hinge


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Epithelial Abrasion

Occurs because of mishandling of flap, or

due to the microkeratome itself


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Epithelial Abrasion



Place a BCL to allow abrasion to heal


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Epithelial Abrasion



Place a BCL to allow abrasion to heal Put patient on a higher steroid regimen


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Post Op.-Displaced Flap

Always see on Day 1


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Always see on Day 1

Lift Flap, Clean interface, replace Flap


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Always see on Day 1

Lift Flap, Clean interface, replace Flap

Place a Bandage Contact Lens and a drop ofviscoelastic on top of the lens


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Flap Oedema

Can happen as a result of excessive

washing, or because of a toxic chemical

reaction


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Flap Oedema



reaction Resolves on waiting


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Flap Oedema



reaction Resolves on waiting

Hypertonic Saline may be tried


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Acute Inflammatory Reaction

Can happen because of toxic chemical

reaction


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Acute Inflammatory Reaction

Can happen because of toxic chemical

reaction

Must try a short dose of a potent topicalsteriod


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Long Term-Haze

Happens Very Rarely


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Long Term-Haze

Happens Very Rarely

Occurs with thin flaps and or epithelial

abrasion


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Long Term-Haze

Happens Very Rarely

Occurs with thin flaps and or epithelial

abrasion Treat as in PRK


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THANK YOU

Excimer Laser Complications and Their Management

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