1. By The Right Contact Team http://www.therightcontact.com

2.  Although optometrists do not perform laser vision correction here in the United States, they can still provide a valuable role in this procedure that is gaining unprecedented popularity.  According to recent data, a record 16 million people have had LASIK vision correction in the US though 2011 1.  This is an amazing opportunity for optometry. Whether it is screening good candidates, co- managing post-ops or managing complications, there is a lot the optometric profession has to offer.

3.  LASIK  Wavefront LASIK  Intralase  LASEK  EPI-LASEK  PRK

4.  Pre-Op  Post-Op  Complications

5.  There many issues that a practitioner should review when considering candidacy for laser vision correction.  The following are a few concerns to be addressed prior to referring the patient for the procedure. ◦ Candidacy as defined by the FDA ◦ Anterior surface concerns ◦ Patient habits

6.  INDICATIONS *Age 18 years of age or older with stable refraction for one year. *Myopia (nearsightedness) up to -14 diopters either without astigmatism or from -0.5 to -5 diopters of astigmatism *Hyperopia (farsightedness) from +1 to +4.5 diopters with less than 1 diopters of astigmatism *No history of eye disease, corneal scarring or retinal problems *Not pregnant or nursing for 3 months and not planning a pregnancy in the 3 months following surgery  CONTRAINDICATIONS Laser refractive surgery is contraindicated: * in patients with collagen vascular, autoimmune or immunodeficiency diseases. * in pregnant or nursing women. * in patients with signs of keratoconus or abnormal corneal topography * in patients who are taking one or both of the following medications: isotretinoin (Accutane®) or amiodarone hydrochloride (Cordarone®). Who is a good candidate for laser vision correction? Since its FDA approval in 1995 2, many factors have remained unchanged

7. Dry Eye  Ideally you want to identify dry eye during the pre-op period  Spend at least a few weeks to months treating it.  Utilizing tools such as artificial tears, punctal plugs, cyclosporine eye drops and nutritional therapy (omega-3 fatty acids) 3 can prove very useful. Blepharitis  Laser vision correction causes significant inflammation in normal eyes. Consider the consequences surgery can have when handling patients that already suffer from anterior surface disease.  Treatment options include ◦ oral tetracycline ◦ topical macrolide antibiotics ◦ combination steroid/antibiotic drops ◦ nutritional options (such as flaxseed oil). 4

8.  Does the patient work or live in environments of excessive heat?  Does the patient suffer from allergies or habits that pre-dispose them to eye rubbing? Avoiding these issues can greatly affect the potential outcome of the procedure.

9.  Most surgeons recommend a very specific follow-up schedule to ensure proper healing.  An average schedule would include ◦ 1 st day ◦ 1 st week ◦ 1 st month ◦ 3 – 6 months  Each post-op appointment has very specific concerns that are to be addressed.  Each visit should take the opportunity to re- educate the patient on their status and the overall healing process.

10.  During this visit, the practitioner will access vision and make a corneal evaluation. The corneal evaluation will obviously vary depending on the procedure performed. ◦ If the patient has undergone LASIK, than flap evaluation will take place. ◦ If PRK or LASEK was performed, the corneal evaluation will be done under the bandage contact lens.  Patient instruction is very specific at this visit. ◦ Remind the PRK and LASEK patients that discomfort within the first few days is common but will subside. After a discussion about all topical post-op medications, patient’s activities need to be discussed.  Aggressive rubbing should be addressed. ◦ The patient should be discouraged from performing any tasks that could potentially hit the eye. Be specific, state avoiding things like water striking the eye during bathing, make-up (no mascara or eyeliner), sports, and exercise. The patient should wear a protective shield at night. Provided the vision is adequate, the patient is definitely able to resume deskwork or driving immediately.

11.  At this visit a re-assessment of vision and corneal integrity is taken.  As compared to their first post-op, patients that underwent PRK and LASEK should note a dramatic increase in comfort and vision.  Many times topical medications are discontinued at this visit.  The patient is often informed that they can begin a moderate level of activities including exercise, swimming, hot tubs and contact sports.

12.  The 1 month post-op evaluation again evaluates the vision and corneal surface.  At this stage the cornea should be completely attached and the patient is able to resume all activities. ◦ These activities would include those that were previously restricted such as gardening, scuba diving, etc.

13.  These visits are routine health evaluations.  At this time, many doctors will have to manage issues associated with dryness.

14.  When discussing any type of surgery you always have to be aware of the risks associated with the procedure.  Even though laser vision correction has a very good track record, sometimes there are unfortunate results that have to be addressed.  The following is a listing of possible complications that can occur with laser vision correction.

15.  Doctors are trained not to be over concerned about initial signs of overcorrection. ◦ This is because immediate post-ops can show correction issues secondary to expected corneal swelling. ◦ The patient should be educated that these symptoms will subside within a few days to two weeks.  Despite extensive pre-testing, sometimes the eyes do not respond in a predictable fashion. Regardless of the reason, the patient still has options. ◦ If the patient is interested in additional surgery, an enhancement may be considered. ◦ Non-surgical treatment options include glasses and contacts.

16.  Visual distortion can arise from several areas. Quite often this is related to the size of the treatment zone 5. ◦ If the pupil is wider than the treatment zone the patients may report glare or haze.  Retreatment is a possibility, but optic zone size can also be addressed with topical drops. ◦ The patient may be given a drop that has mitotic effects for things like night driving.

17.  Wrinkles  Epithelial Ingrowth  DLK (Diffuse Lamellar Keratitis)

18.  During surgery, if the flap is not made correctly, either to thin or to thick, it may not correctly adhere to the corneal surface. ◦ This can cause microscopic wrinkles, or striae which will interfere with the patient’s visual outcome.  Wrinkles may also occur due to patient compliance issues. A patients rubbing or squeezing the eye too tightly within the first few hours of the procedure could also result in wrinkles. ◦ Patients should be discouraged from this behavior for the first 24-48 hours after the procedure.

19.  Epithelial ingrowth is another rare but potentially serious complication. ◦ Studies continue to show that early detection is vital. ◦ The use of optical coherence tomography has proven to be a useful tool in diagnosing this abnormal finding 6.  Not all cases of epithelial ingrowth need to be treated and therefore careful monitoring is required.  Surgical removal of epithelial accumulation is indicated before the formation of a scar 7.

20.  Diffuse lamellar keratitis (Sands of Sahara) is accumulation of white blood cells between the flap and stroma. These cells develop at the stromal interface and create unwanted inflammation. ◦ This presentation is usually evident 1-5 days after LASIK but can occur many months after the procedure 8. ◦ With slit-lamp evaluation this finding appears as waves of sand. ◦ Patients present with pain, photophobia, foreign body sensation, and /or decreased vision.  The cause of diffuse lamellar keratitis is unknown. ◦ These infiltrates are sterile, but the cornea attacks them causing serious damage. Because these infiltrates are not alive, these cells are able to elude proper sterilization techniques.  Quick diagnosis is a must, and topical or oral treatment is often adequate. Common treatment would include topical antibiotics and steroids. ◦ Accepted dosaging is every 2 hours on both, and possibly an ointment at night. ◦ If topical treatment is inadequate re-lifting the flap, and removal of the infiltrates may be required.

21.  Subconjuntival hemorrhages ◦ These often occur with no long term side effects. ◦ No topical treatment is required. ◦ The most important issue would be educating the patient on its presentation.

22.  Keratectasia is a very difficult complication to mange. This finding results in an increase in refractive error due to the progressive steepening of the cornea 9.  Corneal ectasia can occur as quickly as one week after the procedure but can also manifest several years post-operatively.  Managing this condition may eventually begin with specialty contact lenses, but may mature to the need for additional surgery like a penetrating keratoplasty or intacs 10.

23.  Technology continues to advance. One of the more recent advances would involve wave front technology. These methods now allow for an extremely precise individualized vision correction. ◦ The procedure addresses higher order aberrations, something earlier designs couldn’t come close to affecting.  Post-operative care is also being modified. Researchers are looking at developing contact lenses designed to release a continuous supply of medication during the post-op period. These designs use vitamin E to help release the drugs automatically overtime 11. Although optometrists cannot perform the procedure, as you can see, we can play quite an active role in the patient pre- and post care.

24. 1. 2011 Market Scope, LLC 2. FDA. (2010). FDA-Approved Lasers for PRK and Other Refractive Surgeries. Retrieved from http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/ucm192110.htm http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/ucm192110.htm 3. Saadia Rashid, MD; Yiping Jin, MD, PhD; Tatiana Ecoiffier, MSc; Stefano Barabino, MD, PhD; Debra A. Schaumberg, ScD, MPH; M. Reza Dana, MD, MSc, MPH. Topical Omega-3 and Omega-6 Fatty Acids for Treatment of Dry Eye. Arch Ophthalmol. 2008;126(2):219-225. 4. Goldman D. Treating blepharitis to maximize surgical success. Cataract Refractive Surgery Today. 2009 May:61-3. 5. Gregory W. Schmidt, MD; Michael Yoon, MD; Gerald McGwin, PhD; Paul P. Lee, MD, JD; Stephen D. McLeod, MD. Evaluation of the Relationship Between Ablation Diameter, Pupil Size, and Visual Function With Vision-Specific Quality-of-Life Measures After Laser In Situ Keratomileusis. Arch Ophthalmol. 2007;125(8):1037-1042. 6. Alissa Coyne, O.D., and Joseph Shovlin, O.D.AS-OCT Technology: Analyzing the Anterior Segment. Review of Optometry. Continuing Education. April 2012; 7. Irene Naoumidi, PhD; Thekla Papadaki, MD; Ioannis Zacharopoulos, MD; Charalambos Siganos, MD, PhD; Ioannis Pallikaris, MD, PhD. Epithelial Ingrowth After Laser In Situ KeratomileusisA Histopathologic Study in Human Corneas. Arch Ophthalmol. 2003;121(7):950-955. 8. Bennie H. Jeng, MD; Jay M. Stewart, MD; Stephen D. McLeod, MD; David G. Hwang, MD. Relapsing Diffuse Lamellar Keratitis After Laser In Situ KeratomileusisAssociated With Recurrent Erosion Syndrome. Arch Ophthalmol. 2004;122(3):396-398. 9. Beeran Meghpara, BA; Hiroshi Nakamura, MD; Marian Macsai, MD; Joel Sugar, MD; Ahmed Hidayat, MD; Beatrice Y. J. T. Yue, PhD; Deepak P. Edward, MD. Keratectasia After Laser In Situ KeratomileusisA Histopathologic and Immunohistochemical Study. Arch Ophthalmol. 2008;126(12):1655-1663. 10. George D. Kymionis, MD, PhD; Charalambos S. Siganos, MD, PhD; George Kounis, BSc; Nikolaos Astyrakakis, OD; Maria I. Kalyvianaki, MD; Ioannis G. Pallikaris, MD, PhD. Management of Post-LASIK Corneal Ectasia With Intacs InsertsOne-Year Results. Arch Ophthalmol. 2003;121(3):322-326. 11. Peng CC, Burke MT, Chauhan A. Transport of topical anesthetics in vitamin e loaded silicone hydrogel contact lenses. Langmuir. 2012 Jan 17;28(2):1478-87. Epub 2011 Dec 22.