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Free cap losted |
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A NEW message,"Re: The question posted by, Mariano Fernandez, MD,< marianofrnndz@yahoo.com > Guatemala, was sent by:
Fernando Rodriguez-Mier, MD (Spain)
Arun Gulani, MD (USA)
Pablo Suarez Saona, MD (Ecuador)
Klaus Ditzen, MD (Germany)
George Rozakis, MD (USA)
Robert Dotson, MD (USA)
Fernando Rodriguez-Mier, MD (Spain)
Guillermo Avalos, MD (Mexico)
Paris Royo, MD (USA)
Alexander Hatsis, MD (USA)
José Miguel Varas-Prieto, MD (Ecuador)
We would appreciate your reply if you have any comments about this subject.
Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.
Sincerely.
Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator
Mariano Fernandez, MD,
< marianofrnndz@yahoo.com>
CC:kmsg2007@kmsg.org
Web address:
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| The question read as follow:
Dear Collegues:
I would like your suggestions in reference to the following case:
Male
29 year old
OD -1.50 -0.50 65
OI -1.75 -0.75 145
Pachimetry OD 544 OI 563
K: OD 42.56 x 43.95 80
OI 42.40 X 43.81 105
July 21st 2007
Bilateral Lasik was performed. On the left eye I had a complication a " free cap", after the ablation was completed I relocated the flap according to the marks. Contact Lens was not recommended.
After one hour the patient was revaluated and the flap was in place. The eye was closed and I asked him to return that afternoon to the clinic. The patient was on time but the flap was gone (disappear).
Today October 16th the cornea has an epithelium formed and the present data of the patient is:
OD 0.00
OI -3.25 -1.75 74
Pachimetry OI 460
K OI 43.37 X 44.00 167
I am sending picture of the recent status of the interface and the recent topography.
We will appreciate your recommendations on this specfic case since the patient requests a second surgery to elminate the residual ametropy.
Regards,
Mariano Fernandez, MD
Guatemala
marianofrnndz@yahoo.com
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Last answers:
Dear Fellow!!!
I think that your patient is doing corneal ectasia. Please repeat you the pachymetry and corneal topography using a pentacam -if is possible for you.
Very interesting bibliography:
1.Randleman j, Russell B, Ward M et alls. Factors and Prognosis for corneal ectasy after lasik. Ophthalmology 2003, 110:267-275.
2. Kymionis g, siganos c, Pallikaris I et als. Management of post lasik corneal ectasia with intacs insert. Ophthalmology 2003; 121:322-326.
In this moment wait, I recommend soft contact lens use.
Best regards,
Fernando Rodriguez Mier
Figueres- spain
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Dear Dr Fernandez,
Yo have more myopia due to collagen deposit and epithelial hyperplasia (haze) on the ablated area also irrgular astigmatism as show in the topography.
Its posible that if the total amount of removed cornea (flap + ablation) it's under 100 microns the haze will be grade + to ++ and will not decrase V.A. significantly.
If total resection it's over 100 microns, haze will more severe.
I suggest : Pleace a C.L with E.E refraction and wait untill stabilization occurs (refractive and topography).
Depending on the haze degree you will need to do PRK with mytomicin, if irregular astigmatism perisit it will be a serius problem because custom ablation takes a lot of tissue and conventional ablation will not corrected the irregular astigmatism so it's posible that you will be able just to treat the sphere E.E. If haze it's severe you would need a new flap from a corneal donor, this will control the haze but VA in the postop it's not going to be very good do to impredictable postoperative refraction.
I beliave that the cornea in the preop was normal, topgraphy and pachimetry so I would not consider ectasia as a posibility. Never the less if serious instabillity occurs along the time ectasia must be considerated
Saludos
Raul Suarez S, MD
Instituto de Oftalmologia Conde de la Valenciana
Mexico
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| Dear Mariano
I wuold recomend to repeat the topography, and a maped pachymetry, because it looks like a ectasia and probably to fit a contact lens could
help.
Gabriel Quesada MD
Centro Panamericano de Ojos
El Salvador
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I agree with Dr. Avalos. Time is a very good fiend in this cases. Will you check the patient data between July and the las visit and you will see that your patinet is getting better. At last, when the cornea has stabilized, re-evaluate. I think that you will have enough cornea to perform a PRK. Good luck.
Juan Manuel Garcia Gil
Clínica Mayer
Sonora - Ciudad Obrego - Mexico
Dear Dr. Fernandez,
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You may explain to the patient that you wish to wait for complete healing. Contact lens to be used if not completely epithelialized. This will help in two ways:
1. Put a powered CL on this eye (so patient is seeing and less unhappy while he waits)
2. The CL will allow smooth epithelial remodelling (while you wait)
Re-eval monthly for 3 more months before making any final conclusions
"Epithelial remodelling is the Giant of Corneal healing compared to more commonly discussed pygmies like Wavefront, Custom laser, topographies etc"
PRK with MMC after all the healing will help him refractively after documenting absence of any induced pathology
Best Regards
Arun C. Gulani, M.D.
Director: Gulani Vision Institute
Jacksonville, Florida
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| Dear Dr. Fernandez:
First of all what kind of microkeratome did you use in this surgery? I analized the picture you sent in the email and the new epithelium is in the nasal periphery of the cornea. Maybe it is in the place of the hinge of the flap. Sometimes depending on the reason of the free cap we could have some irregularities in the hinge's place. I will wait at least two months: analize the new epithelium an may be a PRK with PTK will be the solution. I agree on the use of ciclosporine drops three times per day. Good Luck with the case and let us know the outcome.
Pablo Suarez Saona, MD
Ecuador
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Dear Dr.Fernadez,
Wait about half a year. In this time the patient ca wear a soft contact lens. Possibly you can measure topography,wavewfront aberrations,pachymetry and also the development of keratectasia.
If all datas are comparables after about 2 months I would prefer either a topography-guided or wafefront guided transepithelial PRK.
Klaus Ditzen,M.D.
Germany
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| Dear Doctor Fernandez,
I am very sorry to hear about your complication. First of all, I too would not have used a contact lens. You did what you needed to do which was repositioned the disc and you followed the patient properly afterwards. You are now three months after the procedure. The eye is myopic with astigmatism. The corneal topography is irregular with steepening below and nasal. The slit lamp photo shows clarity centrally and some scarring temporally.
If the patient is able to wear a rigid contact lens that would certainly be a logical first step to restore vision.
At this point I would allow another three months to elapse to see what the final topography looks like. It is too early to do anything.
If in six months the topography has not changed it may be difficult to plan a surface procedure because of the epithelium. If we assume that the epithelium will not play a role in the final outcome then obviously we would need to remove the epithelium and deliver a customized ablation. Probably the best way to do that is with topography guidance.
If you did want to go ahead and provide the patient a new disc you will need a microkeratome that allows for the ability to cut the right donor disc size preferably from another patient who has a normal cornea but a useless eye. I have done this. It is called a live lamellar homograft procedure. You would need to remove the epithelium and simply lay the donor disc and proceed as usual. No sutures would be necessary.
After healing you could then lift the donor disc and apply another laser treatment to correct any residual irregular astigmatism. I have done this with success but must admit it is frustrating.
Let's hope that the eye heals on its own over the next few months. Dr. Hatsis makes an interesting comment that there may be ectasia based upon the myopia. It is interesting thought. Hopefully careful observation will allow you to make such a determination.
George W. Rozakis, MD
USA
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Dr. Fernandez... Nearly ten years ago I had a patient similar to this who lost a flap when struck in the eye by a tree branch (he was about 2-3 months post-op LASIK with parameters much like your patient). After much soul searching, I decided to simply treat him as a PRK patient - he healed well. After letting him alone for about 3-4 months and after he was stable (with low residual error of about -1.50), I cut a new flap (had enough cornea to do this) and he did great... He returned to 20/20 after that and stayed there for many years after. He did manifest an unusual doughnut shaped ring of haze along the diameter of the flap... That, too, faded away over a couple of years... Good luck. I would expect the patient to do well with tincture of time...
Robert S. Dotson, M.D.
Oak Ridge, Tennessee
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| Dear fellow
I have some questions. You had an irregular or normal "free cap"? and In this momment the refraction is minus or plus 3.25 ?. The corneal topography is similar to decentered steep ablation, as hyperopic treatment.
Best regards,
Fernando Rodríguez Mier
Figueres - Spain
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Dear Dr. Fernandez:
Wait, wait,wait...Epithelial Hiperplasia after several months will diminish the induced myopia. Prescribe a Soft Contact Lens. Drops of Ciclosporine helps to prevent haze.
Guillermo Avalos MD
Mexico
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Dear Dr. Fernandez: A loose cap is always a dreaded complication of lasik. The loss of the cap is usually prevented by a bandage lens placement after realigning the prelasik marks. Unfortunately, there was no contact lens and the cap was lost. Approximately, 15 years ago I was working with Dr. Guillermo Avalos in the early days of microkeratome lenticule correction of myopia. I cut a very thin flap (ie. 80 microns) and was worried abot the accuracy of the microkeratome for the second cut. At this point Dr. Avalos said to just throw away my cap, which I finally did after some debate. To my surprise and elation after the cornea had reepithelialized the patient had a perfect correction and to this day still sees 20/20 with that eye. You still have 200 microns of safe cornea and I would vote for PRK within this margin.
Buena Suerte,
Paris Royo M.D.
Sacramento, California U.S.A.
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Dr. Fernandez,
The problem seems to be that after you flattened the cornea with Excimer it is steeper and there is a consecutive myopia. He is infact more myopic than pre-LASIK. I'm afraid there is an ectasia here and that it will progress. What is the pachymetry and the IOP? Intacs with X-linking may be helpful if the pachymetry is enough. In the meantime not much to do except lower the IOP, try a NSAID, UV block sunglasses and use a contact lens.
Alexander Hatsis, MD
USA
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| Dear Dr. Fernández:
The easiest way to correct this problem is to replace the lost cap with a new one, same thickness, same diameter (or slightly smaller). Nylon 10-0 sutures are not mandatory, however it would be prudent to use some.
Good luck,
JM Varas-Prieto, MD
Ecuador
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