Sub-Bowmans
Keratomileusis (SBK)

AT CLARITY LASER VISION

WEEK 1

EXPECTED VISION

20/15 – 20/30

PATIENT EXPERIENCES

minor burning
minor FBS
minor dryness
minor vision fluctuation

TESTS TO PERFORM

UCVA
IOP
Slit Lamp Exam

POINTS TO DISCUSS

Minor discomfort possible
Review of medications
Review of activity restrictions

MEDICATION PROTOCOL

Discontinue all Omeds (unless inflammation)
Preservative free artificial tears q1-2 hours

Exam Walk Through:

Examine the flap

Examine the interface

Subconjunctival hemes are normal and are expected to subside in 2-3 weeks. Counsel the patient accordingly.

Pro Tip:

Remember to provide a drivers’ letter to remove glasses restriction once they pass the requirements

Contact Clarity Laser Vision

For More Immediate Assistance,
Call (403) 640-0400

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Sub-Bowmans
Keratomileusis (SBK)

AT CLARITY LASER VISION

DIFFUSE LAMELLAR KERATITIS

TREATMENT

First, do triage assessment (see below)
Pred Forte q1-2h with taper as it resolves

FOLLOW UP

q24-48 hours until resolved
If not responding to steroid within 24-48 hours, refer to surgery centre

WHEN TO REFER

Refer all DLK stage 2 or worse, and we encourage referring all DLK if possible

ADDITIONAL NOTES

Photodocumentaion
Appropriate

DLK Triage Assessment

1) Differentiate from SPK

Diffuse Lamellar Keratitis: looks more "fluffy" in appearance, whitish precipitates, and can congeal into waves of sand appearance. Usually extends from the flap edge towards the centre. Located in the interface.

Superficial Punctate Keratitis: Located on the epithelium. Unstained, DLK and SPK look similar and can be hard to distinguish the depth. Fluorescein staining will be the key to differentiating. If it stains, it isn't DLK.

2) Stage the DLK

Stage 1

White granular cells in the periphery, centre cornea is clear. Most common on Day 1 post op. Would be appropriate to treat with Pred Forte gtts hourly and follow up the next day before referring.

Stage 2

White granular cells in the periphery and involves the visual axis (central). Most common on Day 2-3 post op and is a result of migration of inflammatory cells from periphery inwards. Recommend referral.

Stage 3

White granular cells centrally, more dense. May have some peripheral clearing. Visual acuity may decline a line or two. Patient may complain of hazy vision. **Needs emergent triage to surgery centre

Stage 4

White granular cells centrally, more dense. Stromal melting and "mud cracks" (indicating central toxic keratopathy), bullae formation, significant reduction in visual acuity, and hyperopic shift. **Needs emergent triage to surgery centre

Pro Tip:

If we relift the flap and irrigate the DLK, there may be a bandage contact lens which should be removed Day 1. Vision may remain blurry until the BCL is removed.

Pro Tip:

When in doubt, refer. You never want to delay surgical intervention in these cases. If any central involvement, refer urgently.

Contact Clarity Laser Vision

For More Immediate Assistance,
Call (587) 390-8181

Sub-Bowmans
Keratomileusis (SBK)

AT CLARITY LASER VISION

EPITHELIAL INGROWTH

TREATMENT

First, do triage assessment (see below)
If not referring, monitor

FOLLOW UP

If within 2 months of surgery, follow up q1-2 weeks
If after 2 months of surgery follow, up q1-2 months

WHEN TO REFER

UCVA/BCVA affected
Epi Growth > 1 mm into cornea
Persistent FB sensation not
Relieved with artificial tears

ADDITIONAL NOTES

Photodocumentaion
Appropriate

Epithelial Ingrowth Triage Assessment

Differentiate from meibum debris

Meibum debris: looks like discrete tiny oil droplets fairly localized (you can see distinct edge to the focal area of debris). Can look like an isolated "island" in the middle of cornea (does not always extend from flap edge)

Epithelial ingrowth: amoeba-like blisters (can be clear or opaque), larger than meibum debris, more irregular shape than meibum debris. Usually extends from the flap edge towards the centre although rarely it can be an "island" of cells.

Is the vision affected?

Epithelial ingrowth can sometimes cause a mixed astigmatism refraction- but remember, one can have a similar refraction within the first 1 month of surgery normally. It is only relevant later post operatively if you have documented a true refractive shift over time. Epithelial ingrowth may or not affect vision.

Is there foreign body sensation?

Clinically significant epithelial ingrowth can cause a persistent FB sensation that is not relieved with artificial tears. If this is the case, it is appropriate to refer to the surgery centre for evaluation.

Is there migration towards the centre?

If the epithelial ingrowth is extending more than 1 mm into the cornea, then it is appropriate to refer to the surgery centre for evaluation.

Pro Tip:

If you are monitoring and the cells change from clear blister-like appearance to more opaque plaque-like appearance, they are less likely to progress.

Pro Tip:

If we relift the flap and irrigate the debris, there may be a bandage contact lens which should be removed after a few days. Vision may remain blurry until the BCL is removed.

Sub-Bowmans
Keratomileusis (SBK)

AT CLARITY LASER VISION

Interface Fluid Syndrome

TREATMENT

First, do triage assessment (see below)
Combigan bid x 4 weeks (or other
glaucoma drop as appropriate)

FOLLOW UP

monitor monthly until either resolves or obvious that it will remain

WHEN TO REFER

1. persistent reduced vision
2. to assess endothelial health
3. to confirm diagnosis

ADDITIONAL NOTES

Council on good sleep
habits, hydration, eye
lubrication, and managing
stress levels

Persistent Interface Fluid Syndrome Triage Assessment

This is a rare condition but anytime you feel the vision isn't improving as it should, or the edema is persisting, or there is a hazy appearance to the cornea that isn't resolving, one should consider this as a differential.

Are there interface particles?

It can look similar to DLK and can mislead the clinician to prescribe steroids. The onset of the condition is key- IFS usually takes > 1 week to present clinically whereas DLK usually presents in the first week.

Is there edema?

Usually enough to obscure the iris structure Usually visual acuity is affected

Is there a "pocket" of fluid?

Occasionally can be seen on slit lamp using 40x mag and optic section beam

Best shown on corneal OCT where you see a black pocket of fluid

Is the IOP increased?

You can't judge this the regular way- any instrument testing central cornea will give a false low measurement. If you suspect this syndrome, take a Goldman IOP with the patient looking up (the IOP prism head should mostly be on the inferior portion of the cornea, with as little flap touch as possible). This will give a more accurate assessment of IOP especially if it is several points higher than the central measurement

How is the endothelial health?

Check for endothelial decompensation

Is there uveitis?

Check for uveitis and treat accordingly

Pro Tip:

It's important to differential from DLK because steroids can worsen interface fluid syndrome. There is a risk of optic nerve damage from prolonged IOP rise. So be careful to make sure your IOP measurement is accurate!

Sub-Bowmans
Keratomileusis (SBK)

AT CLARITY LASER VISION

FLAP WRINKLES

TREATMENT

First, do triage assessment (see below) If not referring, monitor

FOLLOW UP

Regular follow up
If a flap relift is done, follow up schedule starts over (day 1, week 1, etc.)

WHEN TO REFER

UCVA/BCVA affected Diplopia Persistent glare (if beyond 6 weeks post)

ADDITIONAL NOTES

Photo Documentaion
Appropriate

Flap Wrinkle Triage Assessment

Classify the flap wrinkle

Hairline: very fine, not visible on retroillumination, not visually significant. These are common with extreme starting prescriptions and no intervention is necessary

Microstriaie: fine, visible on retroillumination, may or may not be visually significant. If they bisect visual axis or are multiple then they are likely to impact vision. If VA is reduced or if you are unsure, refer for assessment.

Macrostriaie: large, visible on retroillumination, almost always visually significant. Refer for assessment as soon as possible. Likely requires a relift.

Is the vision affected?

You may not be able to judge this if it is early post operatively, as the edema may confound the issue. It is appropriate to monitor for a week before triaging to the surgeon unless they are macrostriaie or the VA is significantly reduced- in which case prompt referral is necessary.

Is there any stromal exposure?

The flap edges should line up with the original cut. If there is any stromal exposure, urgent referral is necessary.

Pro Tip:

After a flap relift there may be a bandage contact lens which should be removed after a few days. Vision may remain blurry until the BCL is removed.

Sub-Bowmans Keratomileusis (SBK)

AT CLARITY LASER VISION

EXPECTED VISION

PATIENT EXPERIENCES

TESTS TO PERFORM

POINTS TO DISCUSS

MEDICATION PROTOCOL

Exam Walk Through:

Pro Tip:

Contact Clarity Laser Vision

For More Immediate Assistance, Call (403) 640-0400

Contact Us Now and Receive a Free Case Evaluation

Our Testimonials

Sub-Bowmans Keratomileusis (SBK)

AT CLARITY LASER VISION

TREATMENT

FOLLOW UP

WHEN TO REFER

ADDITIONAL NOTES

FB Under Flap Triage Assessment

Is the material organic or inorganic?

Is the vision affected?

Is there any inflammation?

Sub-Bowmans Keratomileusis (SBK)

AT CLARITY LASER VISION

TREATMENT

FOLLOW UP

WHEN TO REFER

ADDITIONAL NOTES

DLK Triage Assessment

1) Differentiate from SPK

2) Stage the DLK

Stage 1

Stage 2

Stage 3

Stage 4

Pro Tip:

Pro Tip:

Contact Clarity Laser Vision

For More Immediate Assistance, Call (587) 390-8181

Sub-Bowmans Keratomileusis (SBK)

AT CLARITY LASER VISION

TREATMENT

FOLLOW UP

WHEN TO REFER

ADDITIONAL NOTES

Refractile Debris Triage Assessment

Differentiate from DLK

Is the vision affected?

Is there any surrounding inflammation?

Pro Tip:

Contact Clarity Laser Vision

For More Immediate Assistance, Call (587) 390-8181

Sub-Bowmans Keratomileusis (SBK)

AT CLARITY LASER VISION

Interface Should Be:

Meibum Debris

Diffuse Lamellar Keratitis

Epithelial ingrowth

Foreign Body under flap

Persistent Interface Fluid Syndrome

Refractile debris

Contact Clarity Laser Vision

For More Immediate Assistance, Call (587) 390-8181

Transepithelial PRK (TSA)

POST OP COACHING

Pro Tip:

Contact Clarity Laser Vision

For More Immediate Assistance, Call (587) 390-8181

MONTH 4: ASSESSING CHAMBER

Pro Tip:

Transepithelial PRK (TSA)

POST OP COACHING

Contact lens should be:

Pro Tip:

Contact Clarity Laser Vision

For More Immediate Assistance, Call (587) 390-8181

JUDGING VAULT

How to Judge Vault

Pro Tip:

Sub-Bowmans
Keratomileusis (SBK)

For More Immediate Assistance,
Call (403) 640-0400

Sub-Bowmans
Keratomileusis (SBK)

Sub-Bowmans
Keratomileusis (SBK)

For More Immediate Assistance,
Call (587) 390-8181

Sub-Bowmans
Keratomileusis (SBK)

For More Immediate Assistance,
Call (587) 390-8181

Sub-Bowmans
Keratomileusis (SBK)

For More Immediate Assistance,
Call (587) 390-8181

For More Immediate Assistance,
Call (587) 390-8181

For More Immediate Assistance,
Call (587) 390-8181

Sub-Bowmans
Keratomileusis (SBK)

WHY DOES CLARITY STILL SEE
MY PATIENT YEARLY?

GLASSES ARE NOT OUR BUSINESS!
WE DO NOT PRESCRIBE GLASSES OR
CONTACT LENSES

Sub-Bowmans
Keratomileusis (SBK)

WHY IS THE REFERRAL PROCESS
SO DIFFERENT BETWEEN
CLARITY AND SEEMA?

WHY IS THERE A BANDAGE
CONTACT LENS ON MY SBK
PATIENT?

Sub-Bowmans
Keratomileusis (SBK)

For More Immediate Assistance,
Call (587) 390-8181

Sub-Bowmans
Keratomileusis (SBK)

Sub-Bowmans
Keratomileusis (SBK)

For More Immediate Assistance,
Call (587) 390-8181

Sub-Bowmans
Keratomileusis (SBK)