Sub-Bowmans
Keratomileusis (SBK)

AT CLARITY LASER VISION

DAY 1

EXPECTED VISION

20/20 – 20/40

PATIENT EXPERIENCES

minor burning
minor FBS
minor photophobia

TESTS TO PERFORM

Vision (with BCL)
IOP
Slit Lamp Exam

POINTS TO DISCUSS

Minor discomfort possible
Review of medications
Review of activity restrictions

MEDICATION PROTOCOL

Durezol q1h for 1st 48 hours then qid x 7 days then stop
Vigamox qid x 7 days then stop
Preservative free artificial tears q15-20 minutes
Tetracaine as needed but to not exceed more than 1 drop per hour in 1st 48 hours then no more than four times a day for next 48 hours.

Exam Walk Through:

Is there a BCL?

Examine the flap

Examine the interface

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

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)