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LASIK
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DVD Contents
1. Flap Wars
2. Aberropia Video
3. Battle of the Bulge
Jaypee Gold Standard Mini Atlas Series®
LASIK
Editors
Amar Agarwal MS FRCS FRCOphth
Athiya Agarwal MD FRSH DO
Soosan Jacob MS FRCS DNB MNAMS
Agarwal’s Group of Eye Hospitals and Eye Research Centre
Chennai, India
dragarwal@vsnl.com
Foreword
David R Hardten MD
Minneapolis, MN
Robert Cionni
CONTRIBUTORS
Gaurav Prakash MD
Dr Agarwal’s Group of Eye Hospitals and
Eye Research Centre, 19 Cathedral Road, Chennai, India
David R Hardten MD
Minneapolis, MN
PREFACE
Amar Agarwal
Athiya Agarwal
Soosan Jacob
CONTENTS
To summarize:
1. Curvature is not relevant in raytrace optics.
2. Elevation is complete and can be used to derive
surface curvature and slope.
3. Elevation is the standard measure of surface shape.
4. Elevation is easy to understand.
The problem we face is that there is a cost in converting
elevation to curvature (or slope) and vice versa. To go
from elevation to curvature requires mathematical
differentiation, which accentuates the high spatial
frequency components of the elevation function. As a
result, random measurement error or noise in an elevation
measurement is significantly multiplied in the curvature
result. The inverse operation, mathematical integration
used to convert curvature to elevation, accentuates low-
frequency error. The Orbscan helps in good mathematical
integration. This makes it easy for the ophthalmologist to
understand as the machine does all the conversion.
The general quad map in the Orbscan of a normal
eye (Figure 1.2) shows four pictures. The upper left is the
anterior float, which is the topography of the anterior
surface of the cornea. The upper right shows the posterior
float, which is the topography of the posterior surface of
the cornea. The lower left map shows the keratometric
BASICS AND PREOPERATIVE ASSESSMENT / 7
B
Figures 1.6A and B: General quad map of an eye with
keratoconus
BASICS AND PREOPERATIVE ASSESSMENT / 15
Figure 1.7A
Figure 1.7B
BASICS AND PREOPERATIVE ASSESSMENT / 17
Figure 1.7C
Figure 1.8: Quad map with normal band scale filter of an eye
with primary posterior corneal elevation
Figure 1.9A
Figure 1.9B
BASICS AND PREOPERATIVE ASSESSMENT / 23
Figure 1.9C
Figure 1.9D
Figure 1.11A
Figure 1.11B
BASICS AND PREOPERATIVE ASSESSMENT / 31
Figure 1.11C
Figure 1.11D
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Figure 1.11E
Figure 1.11F
BASICS AND PREOPERATIVE ASSESSMENT / 33
Figure 1.11G
Figure 1.11H
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Figure 1.11I
A B
C D
Figure 2.4A
Figure 2.4B
LWGLF LASERS/ 63
Figure 2.4C
Figure 2.4D
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Figure 2.4E
Example 1
Let us take a patient who is plano for distance and is 20/
20. For near on addition of + 2 D the patient is J1. The
preoperative keratometer let us say is 41 D.
LWGLF LASERS/ 71
Hyperopic Examples
Now let us look at presbyopic LASIK being performed in
a hyperopic eye.
Example 2
Let us take a patient who is hyperopic for distance and is
20/20 with + 1D. For near on addition of + 3D the
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Example 3
Let us take a patient who is hyperopic for distance and is
20/20 with + 3D. For near on addition of + 3D the patient
is J1. The preoperative keratometer let us say is 44D.
The preoperative keratometer reading is 44D and we
have to correct 3D for distance and 3D for near. So if we
do presbyopic LASIK we will make the keratometer
reading 50 D. So, one should not treat such patients with
presbyopia LASIK.
Myopic Example
Now let us look at myopic patients.
Example 4
Let us take a patient who is myopic for distance and is 20/
20 with minus 2D. For near on addition of + 2D the
patient is J1. This means the patient is plano for near. The
preoperative keratometer let us say is 43 D.
There are three steps in the presbyopic LASIK
treatment:
74 / LASIK
Figure 2.7A
Figure 2.7B
LWGLF LASERS/ 79
Figure 2.7C
Figure 2.7D
80 / LASIK
Figure 2.7E
Figure 2.8A
Figure 2.8B
86 / LASIK
Figure 2.8C
Figure 2.8D
LWGLF LASERS/ 87
Figure 2.8E
Figure 2.8F
Figure 2.9A
Figure 2.9B
LWGLF LASERS/ 93
Figure 2.9C
Figure 2.9D
Figure 2.10A
Figure 2.10B
98 / LASIK
Figure 2.10C
Figure 2.10D
Figures 2.10A to D: Femtosecond laser (IntraLase) assisted
keratoplaty. (A) Preoperative clinical picture of the patient
LWGLF LASERS/ 99
showing anterior stromal opacities with lattice lines and diffuse
stromal haze. Fluorescein staining shows loss of epithelium;
(B) Donor corneal tissue dissected femtosecond assisted
lamellar keratoplasty (FALK) with IntraLase FMTM Laser at 350
micron depth and 8.5 mm diameter; (C) Recipient corneal tissue
excised with IntraLase FMTM Laser at 350 micron depth and 8.5
mm diameter: and (D) Donor tissue placed over recipient bed
and sutured with interrupted sutures.
Symptoms
Epithelial ingrowth may be mild, which is usually
asymptomatic and seen on routine evaluation. In
moderate cases, the patient may have foreign body
sensation, photophobia, congestion, pain, irritation,
ghosting, glare and haloes as well as loss of best corrected
visual acuity. The dry eye symptoms may be worse in
these patients as compared to others due to the irregular
COMPLICATIONS/ 105
Signs
The epithelial ingrowth may be seen as white or gray nests
of cells or as fingerlike extensions extending inwards from
the flap edges. Epithelial ingrowth may also be seen as a
thin sheet within the interface or sometimes as a
combination. Indirect slit-lamp illumination is sometimes
required to see the sheet like proliferation. It can also be
seen on retroillumination. Epithelial ingrowth is usually
located at the periphery but may occasionally begin from
the center of the flap, especially in cases secondary to
button-hole or central epithelial defects. In nasally hinged
flaps, it is seen most commonly at the temporal margin
whereas in superiorly hinged flaps, it is seen commonly at
the inferior margin and at the border of the hinge.
Fluorescein solution when instilled into the flap stains the
involved area. It may also delineate the area of ingrowth.
An increase in staining at the area of impending flap melt
may also be seen. One can also detect the potential for
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Figure 3.2A
Figure 3.2B
110 / LASIK
Figure 3.2C
Figure 3.2D
Figure 3.4A
Figure 3.4B
COMPLICATIONS/ 121
Figure 3.4C
Figure 3.4D
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Figure 3.4E
Figure 3.5A
Figure 3.5B
Figure 3.9A
Figure 3.9B
COMPLICATIONS/ 135
Figure 3.9C
Figure 3.10A
Figure 3.10B
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Figure 3.10C
Figure 3.10D
COMPLICATIONS/ 147
Figure 3.10E
Figure 3.10F
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Figure 3.10G
Figure 3.10H
COMPLICATIONS/ 149
Figure 3.10I
Figure 3.12A
Figure 3.12B
COMPLICATIONS/ 165
Figure 3.12C
Figures 3.12A to C: Femtosecond laser complications
(Courtesy: William Culbertson). (A) Gas bubbles in the anterior
chamber obscuring the patient’s view of the laser fixation light;
(B) Gas bubbles deep to the interface in the anterior stromal bed
(“deep OBL”); (C) Flap torn during attempt to forcefully dissect
flap with spatula.
Intraoperative Complications
Suction Loss
During the creation of the flap the Intralase suction ring
may lose vacuum and the applanation plate may become
separated from the cornea. If this occurs during the
propagation of the lamellar interface there is no serious
consequence to the flap except that the interface is
incomplete. In this case the suction ring is reapplied, the
interface cut is performed again and the side cut is made
at the end. If suction is lost during the side cut then the
diameter of the side cut is decreased by 1.0 mm, the
suction ring is reapplied and the side cut is performed just
inside the outside diameter of the lamellar cut.
Unliftable Flap
Occasionally the interface is insufficiently dissected and it
is difficult or impossible to the separate the flap from the
underlying stromal bed. Attempts to forcefully open the
interface with spatulas and blades may lead to torn flaps
or rough or irregular surfaces (Figure 3.12C). The etiology
of the inadequate dissection is uncertain but appears to
occur bilaterally in individual patients. When the
ophthalmologist is actually able to forcefully elevate the
flap there often is some keratocyte activation and
associated interface haze. The haze is corticosteroid sensitive
and resolves with treatment within three to four months.
There is no effect on vision. If the flap appears difficult to
COMPLICATIONS/ 169
Non-dissected Islands
If gas bubbles dissect through the stroma anteriorally, the
bubbles will come to lie between the applanation plate
and the corneal surface. The bubbles will spread ahead
of the advancing propagation of the laser raster pattern
and block the focused femtosecond laser light. This blocking
leaves an undissected zone wherever it occurs. The
interface then is not separable in this area. Forceful
attempts to delaminate the corneal collagen fibers in this
area can result in a tear through to the surface leaving an
isolated “island” of undissected tissue similar to the central
islands that may occur with blade microkeratome created
flaps. This phenomenon of dissection of gas bubbles
170 / LASIK
Postoperative Complications
Transient Light Sensitivity
There are two minor complications which are encountered
following LASIK with the IntraLase laser. The first is the
transient light sensitivity (TLS) syndrome or good acuity –
photophobia syndrome (GAPS) in which patients with
COMPLICATIONS/ 171
Keratitis
The second complication is intrastromal inflammation
localized around the edge of the flap which occurs two to
seven days following flap creation. The corneal stromal
tissue becomes hazy or white along the side cut and there
is associated cellular infiltration in the interface and in the
superficial cornea in a narrow band along the edge of the
flap. There may be some associated photophobia.
Presumably this inflammation results from microscopic
cornea tissue damage caused by the laser photo disruption
perhaps exaggerated by exogenous inflammatory factors
in the tear film. Although this process may share some
172 / LASIK
Figure 4.1A
Figure 4.1B
Figure 4.2A
Figure 4.2B
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Figure 4.2C
Since the ICL was designed so that its haptic plate rests
horizontally on the ciliary sulcus, the length of the ICL
should ideally be equal to the horizontal sulcus diameter.
Nowadays there are 2 main methods to determine the
length of the ICL before implantation; the widely used
conventional method based on white-to-white
measurement and the relatively new method using high
frequency ultrasound imaging devices to measure the
actual sulcus diameter.
The conventional method for sizing of myopic ICL is
based on adding 0.50 mm to the horizontal white-to-
white measurement for anterior chamber depth < 3.5
mm and 1.0 mm to the horizontal white-to-white
measurement for anterior chamber depth > 3.5 mm for
the myopic ICL model. In Asian eyes and due to some
anatomical differences from Caucasian eyes, Chang etal
recommended adding 0.5 mm to the horizontal white-
to-white measurement for eyes with anterior chamber
depth d” 3.0 m, and adding 1.0 mm for anterior chamber
depth > 3.0 mm.
The white-to-white corneal diameter can be measured
manually with calipers, IOL master or Orbscan. The
conventional method is more widely used than the high
frequency ultrasound method because it is simple and
182 / LASIK
ICL Loading
The inside of the insertion cartridge is lubricated with a
viscoelastic material (sodium hyaluronate or methyl
cellulose). The lens is removed from the sealed glass
container and is loaded inside the cartridge preferably
under the surgical microscope. For smooth injection of
the lens, it is important to load the lens with both
longitudinal edges of the haptic symmetrically tucked
under the edge of the cartridge with the lens vaulted
anteriorly, it is also helpful to align the two holes located
on the haptic of the ICL (or the laser engraved axis marks
on the toric ICL) with the longitudinal axis of the cartridge.
The coaxial forceps designed by Aus Der Au for ICL loading
(E Janach, Como, Italy) is used to pull the lens through
the cartridge tunnel. Inspection of the lens inside the tunnel
to exclude twisting of the lens helps making the injection
inside the anterior chamber symmetrical, smooth and
reproducible. If the lens is noticed to be twisted in the
cartridge tunnel it is preferable to take it out and reload
properly.
ICL Implantation
A clear corneal temporal incision is made with a diamond
knife or a metal disposable keratome. The size of the
184 / LASIK
Figure 4.3A
Figure 4.3B
188 / LASIK
Figure 4.3C
Figure 4.4A
Figure 4.4B
Figure 4.6A
Figure 4.6B
198 / LASIK
Figure 4.6C
Figure 4.6D
MISCELLANEOUS TOPICS/ 199
Figure 4.6E
Figure 4.6F
Figure 4.6G
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Figure 4.6H
Figure 4.6I
MISCELLANEOUS TOPICS/ 201
Figure 4.6J
Figure 4.6K
202 / LASIK
Figure 4.6L
Synonyms
1. Bimanual phaco
2. Microincision cataract surgery
3. Microphaco
4. Bimanual microphaco
5. Sleeveless phaco.
Incision
In the first step a needle with viscoelastic is taken and
pierced in the eye in the area where the side port has to
be made. The viscoelastic is then injected inside the eye.
This will distend the eye so that the clear corneal incision
can be made. Now a temporal clear corneal incision is
made. A special knife can be used for this purpose. This
keratome and other instruments for Phakonit are made
by Huco (Switzerland), Gueder (Europe) and
Microsurgical technology (MST-USA).
Rhexis
The rhexis is then performed of about 5-6 mm. This is
done with a needle In the left hand a straight rod is held
to stabilize the eye. This is the Globe stabilization rod. The
advantage of this is that the movements of the eye can
get controlled as one is working without any anesthesia.
Microsurgical Technology (USA) have designed an
excellent rhexis forceps for Phakonit. This goes through a
1 mm incison. Those comfortable with a forceps in phako
can use this special forceps in phakonit.
206 / LASIK
Hydrodissection
Hydrodissection is performed and the fluid wave passing
under the nucleus checked. Check for rotation of the
nucleus.
Phakonit
After enlarging the side port a 20 or 21 gauge irrigating
chopper connected to the infusion line of the phaco
machine is introduced with foot pedal on position 1. There
are various irrigating choppers. Depending on the
convienence of the surgeon, the surgeon can decide which
design of irrigating chopper they would like to use.
The Agarwal irrigating chopper with a special design
of Larry Laks from USA has been made by the MST
(Microsurgical Technology) company. This is incorporated
in the Duet system Other excellent irrigating choppers by
various surgeons are present with the same company.
The phaco probe is connected to the aspiration line
and the phaco tip without an infusion sleeve is introduced
through the clear corneal incision Using the phaco tip with
moderate ultrasound power, the center of the nucleus is
directly embedded starting from the superior edge of
rhexis with the phaco probe directed obliquely downwards
MISCELLANEOUS TOPICS/ 207
Figure 4.9A
Figure 4.9B
218 / LASIK
Figure 4.9C
Figure 4.9D
MISCELLANEOUS TOPICS/ 219
Figure 4.9E
Figure 4.9F
Figures 4.9A to F: Correcting astigmatism through the use of
limbal relaxing incisions (Figure & Text Courtesy: Louis D. “Skip”
Nichamin)
220 / LASIK
Surgical Technique
In most cases, the relaxing incisions are placed at the outset
of surgery in order to minimize epithelial disruption. The
one exception to this rule occurs when the phaco incision
intersects or is encompassed within an LRI of greater than
40 degrees of arc; if it is extended to its full arc length at
the start of surgery, significant gaping and edema may
result secondary to intraoperative wound manipulation.
In this setting, the phaco incision is first made by creating
222 / LASIK
Figure 4.10A
Figure 4.10B
226 / LASIK
Figure 4.10C
Figure 4.10D
MISCELLANEOUS TOPICS/ 227
Figure 4.10E
Figure 4.10F
228 / LASIK
Figure 4.10G
Figure 4.10H
MISCELLANEOUS TOPICS/ 229
Figure 4.10I
Figure 4.10J
230 / LASIK
Figure 4.10K
Figure 4.10L
MISCELLANEOUS TOPICS/ 231
Figure 4.10M
Figure 4.10N
B D
Behcet’s disease 47 Deep anterior lamellar keratoplasty
Best corrected visual acuity 66 119
Best-fit sphere 24 Descemet’s membrane 122
Binocular infrared pupillometers 43 Diffuse lamellar keratitis 151
Bowman’s membrane 111 Dioptric curvature 129
Amar Agarwal
C
Complication 103
E
Soosan Jacob
Early keratoconus 24
signs 105 Rahul
Ehlers-Danlos syndromeTiwari
47
symptoms 104
236 / LASIK
Elevation data 131 Hypermetropia 72
Epipolis laser 56 Hyperopia treatment 72
Epithelial cell ingrowth 103 Hyperopic treatment 55, 84
Epithelial fistulas 106
Epithelial ingrowth after LASIK 103
Epithelial layer 104 I
Epithelium barrier 53 Iatrogenic keratectasia 26
Etiology of visual loss 136 ICL implantation 183
ICL loading 183
Intacs segment 118
F Interference by gas bubbles 166
Femtosecond laser technology 81 gas bubbles in the anterior
Flap complications 136, 140 chamber 166
Flap mobility 57 gas bubbles in the cornea 167
Flap tear 142 non-dissected islands 169
Frank keratoconus 19 unliftable flap 168
Intersected flap 142
Intracorneal ring technology 210
G Intraocular pressure 27
Gebauer product 95 Intraoperative complications 166
Glaucoma 76
Graves’ disease 75
K
Keratometric mean curvature 20
H Keratometry 4
Hartmann-Shack wavefront sensor Kyphoscoliosis 48
59
Haze recurrence 137
High astigmatism treatment 84
L
High myopia 180 Lamellar flap 135
High myopic astigmatism 180 Lamellar keratitis 152
Hockey spatula 57 LASIK technique 94
Howland’s aberroscope 59 Limbus 55
INDEX/ 237
M R
Microkeratomes 3 Refractive surgery 15
Monocular infrared pupillometers 43 Residual bed thickness (RBT) 27
Monocular portable infrared Rheumatoid arthritis 47
pupillometers 42 Rulers and reference diameters 42
O S
Ocular pemphigoid 137 Saddle pattern 37
Orbscan 5 Scheimpflug imaging 35
Severe haze 136
Sub-Bowman keratomileusis 89
P Surgical technique 221
Penetrating keratoplasty 119
Pentacam ocular scanner 34
Pentacam system 35
T
Peripheral iridotomies 182 Technique of phakonit for CA 204
Phototherapeutic keratectomy 107, anesthesia 204
126 hydrodissection 206
Polymerase chain reaction 113
incision 205
Posterior corneal elevation 20
Postoperative complications 170 phakonit 206
Predicted phoropter refraction 60 rhexis 205
Prevention of diffuse lamellar Thickest corneal pachymetry 18
keratitis 156 Thinnest pachymetry value 18
Prolate and oblate cornea 68 Three-dimensional map 11
Provocative test 159 Transepithelial ablation 142
Treatment of diffuse lamellar keratitis
Q 160
Two point touch 37
Quad map 6
238 / LASIK
U W
Ultrashort pulse 82 Wavefront aberrations 65
V Z
Visante technology 95 Zeimer femtosecond laser 87
Visiogen synchrony 216 Zylink™ software 60
Visual field defects 76 Zyoptix™ 59