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Subhadri Manna
PGT,CNMC&H
WHY OPT FOR REFRACTIVE
SURGERY??
Surgery to correct refractive errors.
PREVIOUSLY
• vocation
• sport
• spex/C/L intolerance
NOW
• cosmesis
• frustration with use of spex and C/L
• Improved unaided VA
CLASSIFICATION OF REFRACTIVE
PROCEDURES
A. keratorefractive Automated lamellar keratoplasty(ALK)
Small incision lenticule extraction
procedures corneoplastique
1.Incisional refractive techniques
3.Laser ablation corneal
Radial keratotomy
procedures
Astigmatic keratotomy(AK)
PRK
Hexagonal keratotomy
Laser subepithelial
Limbal relaxing incision(LRI) keratomileusis(Lasek)
Opposite clear corneal incision(OCCI) LASIK
2.Lamellar corneal refractive E-LASIK
procedures C-LASIK
Freeze keratomileusis 4.Corneal shrinkage refractive
Epikeratophakia procedure
Non freeze keratomileusis Thermal laser keratoplasty(TLK)
keratomileusis in situ Conductive keratoplasty(CK)
5.Corneal implants c. Combined lens and
Intracorneal contact lenses(ICL)
Intrastromal corneal ring
corneal refractive
segments(Intacs) procedures
6.Corneal tissue moulding Bioptics
Orthokeratology Trioptics
B. Lens-based
refractive procedures
Phakic refractive lenses(PRL)
Refractive lens exchange(RLE)
PREOPERATIVE EVALUATION
Involves-
• Screening,
• History taking
• Preoperative examination & counselling
OPHTHALMIC EXAMINATION
• The length of the knife blade and the associated depth of the
incisions were set based on the corneal thickness, which was
usually measured with an ultrasonic pachymeter.
• The ideal depth of RK incisions was 85%-90% of the corneal
thickness.
Indications
• Anesthesia
• Removal of corneal epithelium
• Pt. asked to fixed to aiming beam laser
• Laser(Nd-YAG or Excimer or Nd-YLF Pico second) apply to
ablate bowman and superficial stromal layer
• patching
• Mitomycin C (0.02%) some time applied for 90 secs
Post op. care
• 24 hrs patching
• Cycloplegic
• Steroid
• Topical steroid
• Tear drop
• BCL
Complications
• Pain
• Decentration of ablation zone
• Corneal haze
• Night glare and halo
• Delayed epithelial healing
• Central island
• Corneal ulser
• Diminished corneal sensation
• Increase IOP
• Sub retinal hemorrhage.
LASIK(Laser in situ Keratomileusis )
• LASIK or Laser in situ Keratomileusis reshapes the cornea using
laser beam.
• Introduced by Barraquer in 1949.
• Corrects vision by altering refractive power of the eye by
calculated change in the corneal curvature.
• Used to treat low to high refractive errors including astigmatism.
HISTORICAL REVIEW
• Barraquer first described lamellar refractive surgery in 1949
• Dr. Ruiz introduced microtome propelled by gears & keratomiluesis
in situ in early 1980s
• Dr. Leo Bores performed 1st keratomiluesis in situ in 1987 in the
US
• Burrato reported use of excimer laser in situ after a cap of corneal
tissue was removed
• Pallikaris – idea of combining precision of excimer laser with
lamellar corneal surgery
• LASIK was introduced & developed at the Univ. of Crete, Greece
• Wavefront-guided LASIK became available in the US in 2003
PATIENT SELECTION
• Visual acuity
• S/L examination
• IOP
• Measurement of pupil size(OZ>pupil size)
• Corneal topography.
• Corneal pachymetry ( corneal thickness 450-500μ)
• Cycloplegic refraction to assess the exact power.
• Indirect Ophthalmoscopy for retinal examination
SURGICAL PROCEDURE
• Anesthesia.
• Corneal marking
• Fixation of suction ring to raise IOP 65mm Hg.
• Cornea is moistened with BSS for smooth movement.
• Using a MICROKERATOME a thin flap(130-160μ) of corneal
tissue is raised.
• Suction pressure removed
• Flap moistened ,surface dried.
• Excimer laser reshapes the cornea by removing a pre-determined
precise amount of tissue.
• The corneal flap is repositioned nasally.
FLAP: Microkeratomes
• 1st generation
Linear cutting
• 2nd generation
Translational + rotational
• 3rd generation
Oscillatory/pendular
• 4th generation
Laser “bladeless”( hydrokeratome)
POST-OP
MANAGEMENT
• Anaesthesia
• Trephining
• Alcohol(20%) treatment for 1 min
• Separation of epithelium
• Stromal ablation with excimer laser
• Reposition of epithelial flap
• BCL over flap
• Advantages over LASIK • Thin cornea
• Less corneal ectasia
• Flap related complications
less
• Myopic correction more
• Aberration less
• Post op. dry eye less
• Laser ablation
C-LASIC systems
Consist of
• Corneal topography & Wave front aberrometry systems
• Less invasive
Indications
• Presbiopic age with Ref. C/I:-
error and cataract • Retinal diseases
• High myopia(>10D) or • Occupational night driver
hyperopia(>5D)
Multifocal IOL
Collagen Cross Linkage
Anesthesia
BCL applied
CONDUCTIVE KERATOPLASTY
steepens cornea