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
Must be distinguished from slow healing
Characterized by high hyperopic overshoot
in the first week
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Overcorrection
Must be distinguished from slow healing
Characterized by high hyperopic overshoot
in the first week
After PRK, hyperopic PRK after 6-8
months works well
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Overcorrection
Must be distinguished from slow healing
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
Usually due to problems of laser calibration
Should be distinguished from regression
after the treatment
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UnderCorrection
Usually due to problems of laser calibration
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
Usually due to problems of laser calibration
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
Not a very big problem in LASIK
Usually not a big problem in PRK-USE
LARGE ZONES
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Decentration
Not a very big problem in LASIK
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
Not a very big problem in LASIK
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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Complications of PRK
Epithelium Related
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Complications of PRK
Epithelium Related
Steroid Related
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Complications of PRK
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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Epithelium Related-Filamentary
Keratitis Especially common when patient has a cold
or during summer
Results in Foreign body sensation
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Epithelium Related-Filamentary
Keratitis Especially common when patient has a cold
or during summer
Results in Foreign body sensation
Can be resolved by simple patching.
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Epithelium Related-Filamentary
Keratitis Especially common when patient has a cold
or during summer
Results in Foreign body sensation
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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Epithelium Related-Heaping in
the centre Occurs in hyperopic treatments-no laser
energy in the centre
Looks like a central island on topography
Reduced BCVA
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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
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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Epithelium Related-Slow Growth
The defect created does not heal
Can result due to systemic problems, the
use of extra thick Bandage Contact Lenses,or due to injury
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Epithelium Related-Slow Growth
The defect created does not heal
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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Steroid Related-IOP Rise
Temporary increase of IOP even on FML
Leads to loss of BCVA, and myopic shift
due to corneal oedema
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Steroid Related-IOP Rise
Temporary increase of IOP even on FML
Leads to loss of BCVA, and myopic shift
due to corneal oedema
Relief by Betablockers
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Steroid Related-IOP Rise
Temporary increase of IOP even on FML
Leads to loss of BCVA, and myopic shift
due to corneal oedema
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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Steroid Related-Cataract
Happens especially if the individual must
take recourse to systemic steroids
Avoid all patients with even slight lenticularchanges pre-op
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Steroid Related-Cataract
Happens especially if the individual must
take recourse to systemic steroids
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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Wound Healing-Slow Healing
Must be distinguished from over correction
Patient treated for myopia stays hyperopic
for very long
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Wound Healing-Slow Healing
Must be distinguished from over correction
Patient treated for myopia stays hyperopic
for very long
Thinner Epithelium in the center of the
cornea
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Wound Healing-Slow Healing
Must be distinguished from over correction
Patient treated for myopia stays hyperopic
for very long
Thinner Epithelium in the center of the
cornea
Taper Steroids quickly
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Wound Healing-Slow Healing
Must be distinguished from over correction
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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Wound Healing-Haze and
Regression Peaks at 2 months in moderate myopia, and
even at 8 months in extreme myopia
Usually the haze is not visually significant,and this haze is not accompanied by
regression
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Wound Healing-Haze and
Regression Peaks at 2 months in moderate myopia, and
even at 8 months in extreme myopia
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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Haze and Regression-
Predisposing Factors Depth of the Ablation
Shape of the Ablation pattern
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Haze and Regression-
Predisposing Factors Depth of the Ablation
Shape of the Ablation pattern
UV Light Exposure
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Haze and Regression-
Predisposing Factors Depth of the Ablation
Shape of the Ablation pattern
UV Light Exposure
Fate of the fellow eye
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Haze and Regression-
Predisposing Factors Depth of the Ablation
Shape of the Ablation pattern
UV Light Exposure
Fate of the fellow eye
Hormonal changes-Pregnancy,HRT,Oral
Contraceptives
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Haze and Regression-
Predisposing Factors Depth of the Ablation
Shape of the Ablation pattern
UV Light Exposure Fate of the fellow eye
Hormonal changes-Pregnancy,HRT,Oral
Contraceptives
Previous Corneal Surgery-LASIK or RK
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Haze and Regression-
Management Give a Short burst of potent topical steroid
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Haze and Regression-
Management Give a Short burst of potent topical steroid
Epithelial scraping and polishing of the
haze-PROCEED WITH EXTREMECAUTION AND AFTER WAITING FOR
1 YEAR FOLLOWING TREATMENT
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Haze and Regression-
Management Give a Short burst of potent topical steroid
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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Intraoperative-Inadequate Flap
Keratome movement is interrupted during
the pass
Also happens in high and Low-K eyeswithout apparent reason
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Intraoperative-Inadequate Flap
Keratome movement is interrupted during
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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Intraoperative-Inadequate Flap
Keratome movement is interrupted during
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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Intraoperative-Free Cap
Can occur because of suction loss during
the keratome pass
Can also occur if hinge is too small andbreaks
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Intraoperative-Free Cap
Can occur because of suction loss during
the keratome pass
Can also occur if hinge is too small andbreaks
Cap sticks back without sutures
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Intraoperative-Free Cap
Can occur because of suction loss during
the keratome pass
Can also occur if hinge is too small andbreaks
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
Occurs because of mishandling of flap, or
due to the microkeratome itself
Place a BCL to allow abrasion to heal
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Epithelial Abrasion
Occurs because of mishandling of flap, or
due to the microkeratome itself
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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Post Op.-Displaced Flap
Always see on Day 1
Lift Flap, Clean interface, replace Flap
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Post Op.-Displaced Flap
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
Can happen as a result of excessive
washing, or because of a toxic chemical
reaction Resolves on waiting
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Flap Oedema
Can happen as a result of excessive
washing, or because of a toxic chemical
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
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