REFRACTIVE SURGERIES

AND WORKUP

By: Dr Sanchita
Dr Aparna

Moderator: Dr Parul Jain

INTRODUCTION
The role of refractive surgery is to reduce dependence on contact lenses
or spectacles for routine daily activities.

In theory, the ideal refractive surgery would be:

• simple
• effective
• minimally invasive
• safe
• stable
• widely applicable procedure to correct all refractive errors.
• adjustable and reversible, allowing continuous correction
• recovery with minimal discomfort
Patient Evaluation
PRE-OP EVALUATION
• Patient expectations and motivations

• History
Social history
Medical history
Ocular history
• Ophthalmic examination
Uncorrected near and distance vision, ocular dominance
Manifest refraction (pushing plus)
Pupillary evaluation
Motility
Slit-lamp examination
Corneal topography/Tomography
Wavefront analysis, if indicated
Pachymetry
Cycloplegic refraction (refining sphere, not cylinder)
Dilated fundus examination
• Informed consent
PATIENT EXPECTATIONS

Patients need to understand that

• should not expect refractive surgery to improve their BCVA /CDVA

• It will not alter the course of eventual presbyopia
• It Will not prevent potential future ocular problems such as cataract,
glaucoma, or retinal detachment.
SOCIAL HISTORY
• Military personnel, firefighters, or police officers
• A patient who is active and at high risk of ocular trauma.
• Jeweler or stamp collector may be dissatisfied with post op emmetropia.
MEDICAL HISTORY

• systemic conditions - connective tissue disorders and diabetes

mellitus
• immunocompromised state
• Drugs - systemic corticosteroids or chemotherapeutic drugs
• generally contraindicated in pregnant and breastfeeding women -
possible changes in refraction and corneal hydration status.
OCULAR HISTORY

• previous and current eye problems, such as dry-eye symptoms, blepharitis,

recurrent erosions, glaucoma, and retinal tears or detachments
• potentially recurrent conditions such as ocular herpes simplex virus infection
• A personal or family history of keratoconus
• change in prescription for glasses or contact lenses

change more than 0.50 D in either sphere or cylinder,

or a change in cylinder axis of more than 10 degrees,
within the past year is thought to be significant
• A contact lens history –corneal warpage

• soft contact lenses for at least 3 days to 2 weeks

• rigid contact lenses for at least 2-4 weeks.
AGE , PRESBYOPIA AND MONOVISION
• monovision correction should be discussed with all patients in the age
groups approaching or affected by presbyopia.
• Generally, the dominant eye is corrected for distance, and the nondominant
eye is corrected to approximately –1.50 to –1.75 D
• testing ocular dominance -have the patient point to a distant object, such
as a small letter on an eye chart and then close each eye to determine
which eye he or she was using when pointing; this is the dominant eye.
EXAMINATION
Visual acuity
• UCVA at near and distance
• current glasses prescription and visual acuity with those glasses
• Manifest refraction -The sharpest visual acuity with the least amount of
minus (“pushing plus”)

Cycloplegic refraction
Pupil

• The pupil size.

• measuring pupil size - light amplification pupillometer and infrared
pupillometer.
• Pupil size and glare/halos

Ablation zone = mesopic pupil size + 2mm

 OCULAR MOTILITY AND CONFRONTATION VISUAL FIELDS

• Any tropia or phoria
• Confrontation field tests
Slit lamp examination

 The conjunctiva -scarring, conjunctivochalasis, pterygium or chemosis

 The cornea -surface abnormalities
 epithelial basement membrane dystrophy(EBMD) increases the risk of flap
complications during LASIK.
 Signs of Keratoconus
 The anterior chamber, iris, and crystalline lens should also be examined.
Dilated fundus examination

Dilated fundoscopy is performed to identify patients affected by

• progressive retinal tears
• atypical lattice degeneration
• unrecognized diabetic retinopathy
• myopic degeneration

Minimum 6 weeks gap between retinal laser and LASIK is required.

Corneal topography

Several different methods are available to analyse the corneal curvature,

including
o Placido disk – VKG(videokeratography)
o scanning slit-beam - Orbscan
o rotating Scheimpflug photography - Pentacam
o High frequency ultrasound– UBM
o Optical Coherence tomography – OCT

Pachymetry
calculate RSB and assess ectasia risk
Wavefront analysis

• For detecting higher order aberrations like coma, trefoil, quadrafoil etc.
methods:
• Hartmann-Shack
• Tscherning
• thin beam single ray tracing
• optical path difference, which combines retinoscopy with corneal
topography

excimer lasers -use this wavefront analysis information directly to perform

the ablation – a procedure called wavefront guided, or custom ablation.
Angle Kappa

• angle between the visual axis and the pupillary axis

• A large angle kappa is clinically significant as it may lead to

alignment errors during photo ablation in laser refractive surgery,
as well lens decentration in intraocular refractive surgery

• issue is most important in hyperopic patients, who tend to have

larger angle kappa values
 IDEAL CANDIDATE
• Age> 21 yrs
• Stable refractive error > 1 yr
• Not pregnant/ nursing or planning to conceive for 1 yr
• No systemic or autoimmune disease
• Adequately counselled and has realistic expectations
 CONTRAINDICATIONS

Ocular Systemic Drugs

Unstable refraction
Pregnancy Systemic corticosteroids

Severe dry eyes

Amiodarone
Progressive corneal ectasia Lactating

Uveitis Sumatriptan

Herpetic eye disease Systemic (diabetes)

Antihistaminics
Glaucoma
Autoimmune
isotretinion
One eyed
Special considerations IN LASIK
• Calculation of Residual stromal bed(RSB)

RSB = Central Corneal Thickness − Thickness of Flap − Depth of Ablation

RSB should be at least 250 µm or be greater than 50% of the original

corneal thickness.

• PTA (percent tissue altered )

greater than 40% PTA is associated with a higher risk of ectasia

PTA = [(LASIK flap thickness + ablation depth in µm) / total corneal

thickness (µm)] × 100
• CALCULATION OF ABLATION DEPTH (μm) Munnerlyn formula
CLASSIFICATION
• Refractive surgical procedures can be generally categorised as
1. Keratorefractive or corneal
2. Scleral
3. Intraocular

Keratorefractive procedures include

1) Incisional technique
• a) Radial keratotomy(RK)
• b) Arcuate keratotomy (AK)
• c) femtosecond laser-assisted arcuate keratotomy (FLAAK)
• c) Limbal relaxing incisions(LRI)
2) Laser ablation techniques
a) Excimer laser
• Photorefractive keratectomy (PRK)
• Laser in situ keratomileusis (LASIK)
• Laser subepithelial keratomileusis(LASEK)
• Epipolis LASIK (Epi-LASIK)

b)Excimer and femtosecond lasers

• Femto-LASIK

c)Femtosecond laser –
• ReLEx (refractive lenticule extraction)
• FLEx (Femtosecond lenticule extraction)
• SMILE (small incision lenticule extraction)
d) Inlays/onlays

e) Nonlaser Lamellar implants

• a) Epikeratophakia
• B) Intrastromal corneal ring segments(ICRS)

D) Corneal collagen shrinkage

• a) Laser thermokeratoplasty(LTK)
• B) Conductive keratoplasty(CK)

E) Corneal collagen crosslinking

Intraocular procedures include:

1) Phakic
a) Anterior chamber phakic IOLs
b) Iris fixated phakic IOLS
c) Posterior chamber phakic IOLS

2) Pseudophakic
a) Multifocal/accommodating IOL
b) Toric IOL
Different procedure and their ranges