ramji pandey

1. Pre and post surgery Work up
protocol in cases of
refractive surgery
By. Ramji Pandey
C L gupta eye institute moradabad

2. What’s the difference between
LASIK and PRK?
• Both LASIK and PRK are refractive procedures
that can enhance vision and correct poor eyesight.
• Both LASIK and PRK are outpatient procedures
that can usually be completed in under 15
minutes.
• The basic difference between LASIK and PRK is
that LASIK correction is performed under a
corneal flap , while PRK surgery is performed on
the surface of the cornea.

3. PRE-SURGICAL EVALUATION
INITIAL EVALUATION
 Determine if the patient is a good candidate for laser
vision correction or ICL depend on refraction.
 Stability: The patient must be at least 18 years of
age, and 2 refractions (one year apart) must be stable,
with a +/-0.5 diopter, or less, in change.
 CL wearer (how old?, etc)
 To rule out whether there is a change in PGP.

4. Continue..
 MEDICAL HISTORY
• Allergies - including drug allergies.
• Medication - systemic and ocular .
• Systemic disease - a list of all medical illnesses.
• Pregnancy is a contraindication .
 OCULAR HISTORY
It is essential to record a complete ocular history,
including any history of amblyopia, ocular injury,
ocular surgery, retinal pathology.

5. EXAMINATION ELEMENTS
 Discuss the benefits of co-managing with the patient
 Perform refractions/ PGP(how old?)
 visualacuity(unaided/BCVA)measurements
 Keratometry/Pentacam/Wavescan.
 Measure I.O.P. and then fundus examination. Make
any recommendations regarding retinal issues.

6. Continue..
 REFRACTION :- Complete a thorough manifest and
cycloplegic refraction(if needed) to provide a basis to
calculate surgical parameters.
• EYE ALIGNMENT:- If patient has previous history
of strabismus or large phoria, document with cover
test.
• Corneal Findings:-Look for signs of Keratoconus
such as Fleischers ring, striae, apical thinning and
scarring, corneal guttata, epithelial disease, and
epithelial staining pattern

7. IRIS:- Pigment dispersion and iris transillumination
detect characteristics of pigmentary dispersion
syndrome, which could contribute to future elevations
of IOP.
CORNEAL TOPOGRAPHY:- Corneal topography is
performed to measure the curvature and elevation as
well as corneal thickness and any irregularities on the
surface of the cornea
RETINAL EVALUATION:-macular disease or
peripheral retinal pathology (i.e., more lattice
degeneration, hole, tear, or detachment) which is
common in myopes

8. Pre-op workup for LASIK
DETERMINING STABILITY AFTER CONTACT
LENSES ARE REMOVED
Soft lenses: 7 days
Toric lenses: 10-14 days
RGP lenses: 4 weeks or longer until refraction
is stable.

9. Post LASIK Follow-up
Follow-up evaluations should be performed at
1 day, 1 week, 1 month, 3 months, 6 months
and 1 year following refractive surgery.

10. Protocols to be followed post-
LASIK
 Review drops and restrictions in post-op one day of
any refractive surgery.
 Monocular and Binocular VA (unaided till one week),
distance and near
 Perform retinoscopy
 Coneal Flap check for striae, debris, inflammation,
SPK, or dislodged flap
 UCVA Within 1-2 lines of BCVA Pinholes if 20/30 or
worse
 Glare and Halos are accepted in post surgery.

11. continue..
 Following post-op one month:-
• Check current treatment
• VA assessment
• Perform refraction (Dry and Manifest)
• Slit lamp examination
• Schirmer’s test to rule out dry eyes
• Check IOP
• Artificial Tears/Restasis as necessary to manage Dry
Eye/ lid disease.
 Following one-year post refractive surgery:-
Comprehensive examination with fundus evaluation

12. MEDICATION PROTOCOL FOR
LASIK
PRE-OP
• Antibiotic:
Zymaxid/Vigamox/4
times a day,1 day prior
to surgery .
POST-OP
• Antibiotic: 4 times a day
for 1 week following
surgery
• Steroid: 4 times a day
for 1 week following
surgery
• Lubrication:
Optive/Systane/1 drop
every 1-2 hours for the
1 month, then as needed

13. RANGES FOR VISION CORRECTION
 MYOPIC CORRECTION:- -0.25 to -12.00D.
Myopic LASIK Can be combined with Astigmatic
Correction.
 HYPEROPIC CORRECTION:- +0.50 to +6.00 D
Hyperopic LASIK Can be combined with Astigmatic
Correction
 ICL:- -3.00 to -20.00D.
 Myopic Phakic IOL can be combined with LASIK or
PRK for additional treatment.
 ASTIGMATIC CORRECTION:- -/+0.25 to -/+6.0D.

14. CONTINUE..
 LASIK: Laser-assisted in situ keratomileusis
(LASIK) is the most comfortable vision correction,
and patients experience better vision almost
immediately. LASIK has a large range of correction
for myopia, hyperopia, and astigmatism. Most vision
needs can be addressed with this procedure.
 PRK/LASEK: Photorefractive Keratectomy and
Laser Epithelial Keratomileosis are available for
patients who are not candidates for LASIK. These can
be performed with custom Wavefront ablation or
Wavefront optimized ablations.

15. CONTINUE..
 Hyperopic LASIK: Currently, this procedure is
effective in correcting up to +6.00D of hyperopia,
with similar levels of astigmatism. Patients having
this procedure should understand that it will take
longer for a farsighted patient to see clearly at
distance.

16. LASIK CONTRAINDICATIONS
 OCULAR CONTRAINDICATION
• Active infections .
• Herpes zoster.
• Fuchs dystrophy.
• Severe dry eye .
• Progressive myopia .
 SYSTEMIC CONTRAINDICATION :
• Pregnancy.
• Autoimmune diseases (rheumatoid arthritis ).

17. CONTINUE..
 PROTOCOL FOR DIAGNOSING FORME
FRUSTE KERATOCONUS
• 1. Corneal topography (Orbscan/ Pentacam)
• 2. Pachymetry
• 3. Wavefront aberrometry

18. PROTOCOL FOR DRY EYE
EVALUATION
• Tear film evaluation with and without Fluorescein
• Tear Breakup Time (TBUT)
• Corneal/conjunctival evaluation with Lissamine
Green/Rose Bengal
• Lid evaluation for Blepharitis and/or MGD
Schirmer’s test

19. PATIENT SELECTION
 Highly motivated candidates
 Reasons for considering refractive procedure:
• Occupational .
• Recreational .
• Cosmetic .

20. RISKS AND COMPLICATIONS
• CONTACT LENSES AFTER SURGERY: A soft
contact lens may be fitted 1 month or sooner after
surgery, and a gas permeable lens as early as 3
months after surgery.
• GLARE AND HALOS :-Following any refractive
procedure, patients may experience glare or halos
around lights at night.
• CORNEAL DRYNESS