Patient care critical Epi-LASIK component

Surgeons report their favorite pre-op and post-op Epi-LASIK patient
management techniques.

Improving patient management in Epi-LASIK can improve patient satisfaction and visual outcomes in this newer refractive procedure, according to surgeons experienced with it.
The procedure’s advantages show best when its drawbacks—such as more pain than with LASIK—are carefully controlled. A surgeon-prescribed pain control regimen allows patients to more quickly enjoy the return of vision, which is faster than with PRK, but still slightly slower than with LASIK, said Marguerite McDonald, M.D., clinical professor of ophthalmology, Tulane University School of Medicine, New Orleans.
“Epi-LASIK surgeons have discovered that the patients will gladly tolerate a few days of slight blurriness if they know that no sharp blades will be used during their surgery and that their pain will be controllable with medication,” said Dr. McDonald, in a written statement to EyeWorld.
Epi-LASIK patient management techniques can range from administering the latest pain control medication to using an ice pack of frozen vegetables on the eye post-op. Several experienced surgeons suggested some of their favorites to ophthalmologists new to the procedure.
“My best technique for pain control is to know what to expect and do a good job explaining to people what to expect,” said Thomas V. Claringbold II, D.O., assistant clinical professor, Michigan State University, East Lansing. “But these fine little tweaks are really what are going to make the difference. So as we learn more and are able to get people more comfortable and seeing better in those first few days, it is what is really going to make this procedure take off.”
Dr. Claringbold, who teaches pain management courses at the annual meetings of both the ASCRS•ASOA Symposium & Congress and the American Academy of Ophthalmology, also uses vitamin C in all of his refractive patients. He administers 1,000 mg of vitamin C for three to six months post-op, which he credits with preventing haze. The technique allows him to use no mitomycin C (MMC), even in patients up to –12 D.
Antibiotics
Dr. Claringbold eschews the newest fourth-generation fluoroquinolones for third- generation fluoroquinolones, such as Ciloxan (ciprofloxacin HCl, Alcon, Fort Worth, Texas). He also has found success with combination drops, like TobraDex (tobramycin and dexamethasone, Alcon). Patients may take combination drops four times a day for that first week and then taper that down over the next two to six weeks.
If he does use a fluoroquinolone, Dr. Claringbold also uses a prednisolone acetate, like Pred Forte (Allergan, Irvine, Calif.). Generally, Prednisolone acetate 1% (Allergan, Irvine, Calif.) four times a day is prescribed for at least the first week post-op, and then extended or tapered down depending on how the patient heals. These he suggests rapidly tapering down within three to four weeks.

Chill out

Dr. Claringbold has expanded his use of chilled balanced salt solution (BSS) from intra-op to pre-op in recent months, which he said “has made a huge difference in pain control.” Dr. Claringbold has long used chilled BSS intra-op following the ablation and before replacing the epithelial flap. He extended that practice to pre-op placement of 30 to 50 drops after the lid speculum is placed. He credits the new approach with much improved pain control in the first days post-op.
“Before trying this I would get one or two phone calls every day asking ‘Is this normal?’” he said. “Among the last few sets of patients, I have gotten no phone calls the entire week. It seems to have made a huge difference as far as pain control.”
Another critical area in epi-LASIK patient management is the use of the right bandage contact lens. Dr. Claringbold generally uses the Softlens 66 (Bausch & Lomb, Rochester, N.Y.) with a flat median base curve. His second choice is a flat base curve Biomedics 55 (The Cooper Companies Inc., Lake Forest, Calif.). Both lenses maintain position without becoming too tight and they have good oxygen permeability.
“Right now, this is where we could still use a pretty big breakthrough in getting a really good contact lens,” he said.
Patients that have never worn contacts and patients that are highly sensitive even to having their pressures checked may benefit from the use of dilute anesthetic drops, said Dr. Claringbold.

Educate patients

Dr. McDonald said surgeons should demonstrate the sounds of both the laser and the epikeratome to the patients, which may prevent their sudden movement during the procedure. It is also a good idea to advise the patients that the epikeratome will spray a little water on their faces during the surgery.
Dr. McDonald also suggests surgeons chill the cornea with “very cold” BSS held in a well on the cornea for 20 seconds before applying the epikeratome to the limbus. Use of chilled BSS throughout the case, especially after “the last shot from the laser,” significantly decreases post-op pain. Most surgeons also use a well on the cornea for this step, she said.
Her tips for bandage contact lens use include finding one that fits the patient’s pre-op base curve, unless there will be a significant steepening or flattening of the cornea. Leave the lens on for six days, Dr. McDonald said, even if the epithelium appears intact, to avoid recurrent erosion syndrome.
Ronald R. Krueger, M.D., medical director, department of refractive surgery, Cole Eye Institute, Cleveland Clinic, said he uses vitamin C in all surface ablation procedures. He suggests administering 1,000 mg daily for at least the first month post-op.
He has found Vigamox (moxifloxacin, Alcon, Fort Worth, Texas) use four times daily for one week post-op is beneficial. He usually accompanies that with a prednisolone acetate four times a day for a week, or more, and then tapers that down one drop per week for three more weeks.

Fluid use

Dr. Krueger said he uses cool BSS only when placing the flap back into position. More important than the quantity he uses is the ability to apply the chilled BSS to the surface immediately following laser ablation.
“Then I will wipe the fluid away and do a quick pachymetry measurement after which I add my drops or MMC depending on the magnitude of refractive error,” he said. “But when the laser is done, it is a good idea to put the chilled fluid on the eye in order to neutralize any heat that might have been generated by the laser.”
Dr. Krueger advised surgeons to be wary of too much fluid, which can “over-hydrate the epi-flap.” However, a very dry cornea should be avoided as well, because it prevents the flap from spreading out the way it should.
A less conventional tip is his suggestion that patients with post-op pain place an ice pack, or a package of frozen vegetables, over their eyes. Frozen vegetables offer the advantages of a granulated texture, which is easier to conform to the eye, while helping to control the pain.

Editors’ note: Dr. Claringbold is a consultant for Advanced Refractive Technologies (Irvine, Calif.). Dr. Krueger has no financial interests. Dr. McDonald receives financial support from Norwood AbbeyLtd., (Melbourne, Australia), and has a financial interest in Alcon (Forth Worth, Texas), Refractec (Irvine, Calif.), Santen (Napa, Calif.), and VISX (Santa Clara, Calif.).

Contact Information
McDonald: 504-896-1250, margueritemcdmd@aol.com
Claringbold: 989-802-8811, eyeboy@tm.net
Krueger: 216-444-8159, Krueger@ccf.org