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Home > Archive > Lasik Eyes Surgery > May 2005 > Fixing Problem-Flaps Post LASIK
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Fixing Problem-Flaps Post LASIK
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| gospa68@aol.com 2005-05-06, 5:58 pm |
| A look at the causes and solutions of problem flaps
by Rich Daly EyeWorld Staff Writer
Update will identify flap issues arising from surgical glue, laser
keratomes, and new technology.
New and experienced LASIK surgeons should beware of new wrinkles in the
perennial problems that arise from surgically created flaps, according
to a physician who plans to discuss the issue.
Ophthalmologists just beginning LASIK surgery and those that look to
expand their LASIK surgery skills are the focus of a course titled
"Expert management of LASIK flap complications" at this month's
ASCRS=B7ASOA Symposium & Congress, Washington, D.C.
Paul Dougherty, M.D., clinical instructor of ophthalmology, Jules Stein
Eye Institute, university of California at Los Angeles, will review
long-understood flap problems, as well as newer problems and their
solutions.
"One thing that I will talk about that may surprise many people is my
creation of flaps without a lid speculum," Dr. Dougherty said. "I
will show a video demonstration of it on a patient with a tight
orbit/lid that you can't get the speculum and the keratome in."
This technique and others are a key part of overcoming LASIK flap
issues by preventing such complications before they can arise. Another
key to that approach is using an effective nomogram, which Dr.
Dougherty also will review.
Dr. Dougherty will review a standard LASIK technique through the use of
a mechanical, nasal hinge microkeratome, and compare that to rotational
and laser keratomes.
Keratome options
Dr. Dougherty also will take a look at some of the limited literature
available on newer laser keratomes (IntraLase FS Laser, IntraLase
Corp., Irvine, Calif.).
His research convinced him not to move toward laser keratomes due to
concerns over increased pain, a higher risk of DLK, a higher incidence
of ripped flaps, and slowervisual recovery. Some surgeons may be
unaware laser keratomes leave small areas of residual stroma that have
to be broken when cutting a flap.
"I use the analogy of a perforated postage stamp that can usually be
ripped down the middle but not always," he said. "I'm just trying
to emphasize that although there is all of this marketing out there for
laser keratomes, it is not without its downsides."
Ripped flaps also appear to occur much more often with laser keratomes,
while irregular flaps occur more often in mechanical keratomes,
according to Dr. Dougherty.
He also will discuss the comparative advantages of nasal-hinged
microkeratome (K-4000, BD Ophthalmics, Franklin Lakes, N.J.) and a
rotational keratome (Hansatome, Bausch & Lomb, Rochester, N.Y.). He
conducted and presented a comparative study of the two keratomes that
convinced him to switch from one to the other.
Tips and tricks
Other highlights will include Dr. Dougherty's tips for minimizing
flap complications, his enhancement technique, a comparison of lifting
versus cutting for enhancement, and a discussion of intra-operative
flap complications.
His course is slated to cover the various types of intra-op flap
complications, including hemorrhage, epithelial defect or epithelial
slide, irregular or partial flaps, button holes, and deep keratectomy
or perforations.
There are also post-op flap complications for the LASIK surgeon to
consider, including those from epithelial ingrowth, diffuse lamellar
keratitis, microstriae, macrostriae, and ectasia.
A new method for addressing one post-op complication - epithelial
ingrowth - is through the use of surgical glue (Tisseel Glue, Baxter
Healthcare, Deerfield, Ill.). Dr. Dougherty will review a surgical
treatment that seals the flap edges to resolve recurrent epithelial
ingrowth cases. The glue, which he has used in at least 10 cases, has
provided good outcomes. He has had only one significant recurrence of
epithelial ingrowth when using it.
New technology
Dr. Dougherty also will provide a preview of the flap-complication
treating capabilities of a new advanced vision excimer laser system
from NIDEK (Gamagori, Japan). The system is a topography- and
aberrometry-driven custom laser that uses a time-based aberrometer.
"That is completely different from Hartmann-Shack aberrometer-driven
systems (Laszlo Dosa, Fort Lauderdale, Fla.) that are currently used,
which can't even make diagnosis on complexly irregular corneas," he
said. "Whereas, this one can both diagnose and treat these complexly
irregular corneas with the excimer laser using a multipoint
ablation."
Dr. Dougherty already used this system to treat such cases
internationally. He will discuss case reports on its use in irregular
astigmatism after a button hole and irregular astigmatism after a deep
keratectomy.
Editors' note: Dr. Dougherty is a consultant for BD Ophthalmic
Systems and an investigator for NIDEK Inc.=20
Contact Information
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| Glenn - USAEyes.org 2005-05-06, 10:52 pm |
| The presentation by Dr. Dougherty I attended at ASCRS was very
interesting and included many techniques for the prevention of flap
complications and the resolution of complications when they occur.
The increased accuracy of the LASIK flap created with the femtosecond
laser (IntraLASIK) was discussed, as well as the relative advantages
of moving to a surface ablation technique for mild myopes and
hyperopes, such as PRK and its cousins LASEK and Epi-LASIK.
Nobody wants flap related complications, so it is good to see the open
exchange of prevention and resolution techniques at medical
conferences and in published papers. Dr. Dougherty was one of many
providing this kind of insight to his peers.
Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance
Email to glenn dot hagele at usaeyes dot org
http://www.USAEyes.org
http://www.ComplicatedEyes.org
I am not a doctor.
| |
| serebel 2005-05-06, 10:52 pm |
|
gosp...@aol.com wrote:
> A look at the causes and solutions of problem flaps
>
> by Rich Daly EyeWorld Staff Writer
>
> Update will identify flap issues arising from surgical glue, laser
> keratomes, and new technology.
>
>
This would be a GOOD thing Wizzer, relating how to improve one's
technique is how things get better. Not that you would know.
SErebel
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| Sandy - LASIKdisaster.com - LASIKmemorial.com 2005-05-07, 8:57 am |
| He was one of many because there are so many surgeons with so many
patients with so many flap problems.
| |
| Ragnar 2005-05-07, 8:57 am |
| He should have made the focus of his presentation to be the
differences between the microkeratome flap and the intralasik flap -
not which one is better.
One difference is that the intralasik method is capable of making a
thinner flap, however, a thinner flap usually isn't a better thing.
On Fri, 06 May 2005 23:39:03 GMT, Glenn - USAEyes.org
<glenn.hageleSTOPSPAM@USAEyes.org> wrote:
>The presentation by Dr. Dougherty I attended at ASCRS was very
>interesting and included many techniques for the prevention of flap
>complications and the resolution of complications when they occur.
>
>The increased accuracy of the LASIK flap created with the femtosecond
>laser (IntraLASIK) was discussed, as well as the relative advantages
>of moving to a surface ablation technique for mild myopes and
>hyperopes, such as PRK and its cousins LASEK and Epi-LASIK.
>
>Nobody wants flap related complications, so it is good to see the open
>exchange of prevention and resolution techniques at medical
>conferences and in published papers. Dr. Dougherty was one of many
>providing this kind of insight to his peers.
>
>Glenn Hagele
>Executive Director
>Council for Refractive Surgery Quality Assurance
>
>Email to glenn dot hagele at usaeyes dot org
>
>http://www.USAEyes.org
>http://www.ComplicatedEyes.org
>
>I am not a doctor.
| |
| Ragnar 2005-05-07, 8:57 am |
| You should have said "with so FEW flap problems" instead of "so
MANY".
LASIK surgery has the fewest complications of any surgery ever done
and also has fewer complications than contact lenses.
On 6 May 2005 23:34:37 -0700, "Sandy - LASIKdisaster.com -
LASIKmemorial.com" <sandy@savvysneaks.com> wrote:
>He was one of many because there are so many surgeons with so many
>patients with so many flap problems.
| |
| Glenn - USAEyes.org 2005-05-07, 11:55 am |
| The course I attended showed that the rate of flap related problems
such as epithelial abrasion, buttonhole flap, incomplete flap,
irregular flap, thin/thick flap, flap striae, etc. all have been
dramatically reduced. This is partly because of greater use of higher
technology mechanical microkeratomes, better quality blades, and the
increasing popularity of flaps created with the femtosecond laser.
The occurrence of some problems have stayed about the same, such as
DLK. Fortunately the course of DLK is well understood, easily
recognizable, and resolves well with steroid eye drops. The key to
DLK, which has been understood for some time, is early diagnosis,
early treatment, and a culture if it does not immediately respond to
treatment..
Of course, another reason flap problems have become less common and
with less severe results is because of papers and courses like the one
Dr. Doughtery provided showing other doctors how to avoid flap related
problems and resolve them when they occur.
But then again, if the patient elects to have a surface ablation
technique such as PRK or its cousins LASEK and Epi-LASIK, there is no
stromal flap and no possibility of a problem. No possibility is
always better than low probabilities.
Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance
Email to glenn dot hagele at usaeyes dot org
http://www.USAEyes.org
http://www.ComplicatedEyes.org
I am not a doctor.
| |
| Glenn - USAEyes.org 2005-05-07, 11:55 am |
| This was a part of the course, but it mostly focused on prevention of
problems, diagnosis, and treatment when they occur.
There were many, many presentations singing the praises of the
femtosecond laser microkeratome (Intralase).
Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance
Email to glenn dot hagele at usaeyes dot org
http://www.USAEyes.org
http://www.ComplicatedEyes.org
I am not a doctor.
| |
| Ragnar 2005-05-07, 5:54 pm |
| were the results compared in the same time period? comparing
buttonholed flaps of 1998 to non-buttonholed flaps of 2005 is not a
valid comparison.
On Sat, 07 May 2005 15:53:46 GMT, Glenn - USAEyes.org
<glenn.hageleSTOPSPAM@USAEyes.org> wrote:
>The course I attended showed that the rate of flap related problems
>such as epithelial abrasion, buttonhole flap, incomplete flap,
>irregular flap, thin/thick flap, flap striae, etc. all have been
>dramatically reduced. This is partly because of greater use of higher
>technology mechanical microkeratomes, better quality blades, and the
>increasing popularity of flaps created with the femtosecond laser.
>
>The occurrence of some problems have stayed about the same, such as
>DLK. Fortunately the course of DLK is well understood, easily
>recognizable, and resolves well with steroid eye drops. The key to
>DLK, which has been understood for some time, is early diagnosis,
>early treatment, and a culture if it does not immediately respond to
>treatment..
>
>Of course, another reason flap problems have become less common and
>with less severe results is because of papers and courses like the one
>Dr. Doughtery provided showing other doctors how to avoid flap related
>problems and resolve them when they occur.
>
>But then again, if the patient elects to have a surface ablation
>technique such as PRK or its cousins LASEK and Epi-LASIK, there is no
>stromal flap and no possibility of a problem. No possibility is
>always better than low probabilities.
>
>Glenn Hagele
>Executive Director
>Council for Refractive Surgery Quality Assurance
>
>Email to glenn dot hagele at usaeyes dot org
>
>http://www.USAEyes.org
>http://www.ComplicatedEyes.org
>
>I am not a doctor.
| |
| Glenn - USAEyes.org 2005-05-07, 5:54 pm |
| Over the continuum. The techniques to resolve a buttonhole flap today
is about the same as it was 3-6 years ago. The techniques to avoid a
buttonhole flap are current to today.
Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance
Email to glenn dot hagele at usaeyes dot org
http://www.USAEyes.org
http://www.ComplicatedEyes.org
I am not a doctor.
| |
| LASIKtruth 2005-05-07, 10:52 pm |
| If you end up with a buttonhole your vision is garbage for life.
"Glenn - USAEyes.org" <glenn.hageleSTOPSPAM@USAEyes.org> wrote in message
news:1v7q71ldk028q5ajra1v2rhu43cu6887om@4ax.com...
> Over the continuum. The techniques to resolve a buttonhole flap today
> is about the same as it was 3-6 years ago. The techniques to avoid a
> buttonhole flap are current to today.
>
> Glenn Hagele
> Executive Director
> Council for Refractive Surgery Quality Assurance
>
> Email to glenn dot hagele at usaeyes dot org
>
> http://www.USAEyes.org
> http://www.ComplicatedEyes.org
>
> I am not a doctor.
| |
| Glenn - USAEyes.org 2005-05-07, 10:52 pm |
| The normal response to a buttonhole flap is to stop the procedure on
that eye, reposition the flap, being sure to clear any epithelium at
the buttonhole, sometimes put the patient in a bandage contact lens,
then let the patient heal for 3-6 months. After healing, the
procedure can almost always be done with a new flap at the proper
thickness.
Very, very few patients who experience the very, very few buttonhole
flaps that occur have long-term problems.
Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance
Email to glenn dot hagele at usaeyes dot org
http://www.USAEyes.org
http://www.ComplicatedEyes.org
I am not a doctor.
| |
| serebel 2005-05-07, 10:52 pm |
|
Glenn - USAEyes. org wrote:
> The normal response to a buttonhole flap is to stop the procedure on
> that eye, reposition the flap, being sure to clear any epithelium at
> the buttonhole, sometimes put the patient in a bandage contact lens,
> then let the patient heal for 3-6 months. After healing, the
> procedure can almost always be done with a new flap at the proper
> thickness.
>
> Very, very few patients who experience the very, very few buttonhole
> flaps that occur have long-term problems.
>
Now Glenn, please don't confuse Sandy / Lasiktruth with facts, they
really can't handle it.
SErebel
| |
| Glenn - USAEyes.org 2005-05-08, 8:57 am |
| I can assure you that my responses to these statements are seldom for
the benefit of the authors. They are for those who read these
statements and may not fully understand the implications, or lack
thereof.
Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance
Email to glenn dot hagele at usaeyes dot org
http://www.USAEyes.org
http://www.ComplicatedEyes.org
I am not a doctor.
| |
| Ragnar 2005-05-08, 8:57 am |
| That's amazing LasikTruth.. considering that in PRK ALL that tissue is
ablated.
In the very rare case of a buttonhole, there is always the option of a
corneal transplant.
Trying to scare people into thinking there is some risk of ruining
one's vison for life is disgusting.
On Sat, 7 May 2005 19:55:01 -0400, "LASIKtruth"
<LASIKtruth@Yahoo_nospam.com> wrote:
>If you end up with a buttonhole your vision is garbage for life.
>
>
>"Glenn - USAEyes.org" <glenn.hageleSTOPSPAM@USAEyes.org> wrote in message
>news:1v7q71ldk028q5ajra1v2rhu43cu6887om@4ax.com...
>
| |
| Ragnar 2005-05-08, 8:57 am |
| I wasn't thinking in my post of a few minutes ago... I forgot that
buttonholes are handled immediately after they happen and not a
long-term problem.
Buttonholes are so rare these days that it's misleading to even
discuss them.
On Sun, 08 May 2005 02:02:07 GMT, Glenn - USAEyes.org
<glenn.hageleSTOPSPAM@USAEyes.org> wrote:
>The normal response to a buttonhole flap is to stop the procedure on
>that eye, reposition the flap, being sure to clear any epithelium at
>the buttonhole, sometimes put the patient in a bandage contact lens,
>then let the patient heal for 3-6 months. After healing, the
>procedure can almost always be done with a new flap at the proper
>thickness.
>
>Very, very few patients who experience the very, very few buttonhole
>flaps that occur have long-term problems.
>
>Glenn Hagele
>Executive Director
>Council for Refractive Surgery Quality Assurance
>
>Email to glenn dot hagele at usaeyes dot org
>
>http://www.USAEyes.org
>http://www.ComplicatedEyes.org
>
>I am not a doctor.
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