Transepithelial PRK (TSA)

POST OP COACHING

MONTH 12:
WHAT IS
REFRACTION?

  • Refraction should be at expected outcome
  • If UCVA is reduced, first check if monovision target, or if amblyopic
  • If UCVA is reduced and/or you suspect regression, start monthly refractions to prepare for enhancement
  • Prioritize ocular surface management to ensure refractions are accurate
  • Require 3 consecutive stable refractions (within +/- 0.50D) prior to considering enhancement

Pro Tip:

When referring for enhancement, please either include last 3 refractions, or a comment on stability of refraction

Contact Clarity Laser Vision

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

MONTH 4: ASSESSING CHAMBER

Chamber should be well formed with no reaction. If any issues, likely unrelated to cataract surgery and should be investigated as appropriate.

Pro Tip:

Any uveitis at this stage of healing is likely unrelated to surgery. Need a second opinion, or just want someone else to manage a uveitis? Send to me and I’ll manage the acute condition, while you remain the primary eyecare provider!

Transepithelial PRK (TSA)

POST OP COACHING

DAY 1:
BANDAGE CONTACT
LENS FIT

Contact lens should be:

  • Centred
  • Have some movement but not excessive

Pro Tip:

If lens is too tight as evidenced by excessive conjunctival conjestion and excessive pain, consider removing and replacing the BCL

Contact Clarity Laser Vision

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

JUDGING VAULT

***Ideally done undilated. Patient may arrive still dilated in the first few days after surgery, which will affect your assessment

How to Judge Vault

How many "corneal thicknesses" can you fit in between the crystalline lens and the ICL?
  • Use your optic section beam at 45 degree angle
  • Look at the central corneal thickness (for reference)
  • Focus the beam on the anterior crystalline lens capsule
  • Pull your joystick towards you slightly to focus on the ICL
  • Look at the space between the back surface of the ICL and the front surface of the crystalline lens
  • Vault= how many corneal thicknesses you can fit in that space
Noted as 0.75, 1.00, 1.25, 1.50, 1.75, etc.

Pro Tip:

The fenestrated ports in the EVO ICL design have significantly lowered the risk of cataract formation. If vault is 0.5 or less, consider sending to the surgery centre for more exact measurement/monitoring. If vault is greater than 2, watch closely for pupil block.

Pro Tip:

You can also measure vault in microns on some OCTs and Pentacam

Signs of Pupil Block

  • +/- high IOP
  • +/- hazy cornea
  • +/- mid dilated pupil
  • iris interacting with ICL creating a "seal" to impede aqueous flow
  • volcano effect (iris pushing forward)
  • shallow chamber formation with +/- iris to cornea touch
  • shallow or closed angle

Pupil Block is an ocular emergency and should be emergently sent to Clarity Laser Vision to manage. Surgical intervention may be required.

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

You may have noticed that the patient experience is quite different between the two clinics. Seema Eye Care is a very popular specialty clinic that sees a very high volume of patients, striving to help all those in need of our care. For this reason, it takes more time to process patients through the system. There is also an expected waiting time for surgery for AHS covered cataract surgeries, which is influenced by AHS policies and outside the control of Seema Eye Care centre. Clarity is designed to offer a higher touch, premium experience for our private pay Refractive clients. Clarity sees less volume, therefore can accommodate more timely referrals and appointments.

CONTRAINDICATIONS TO SURGERY

Patients with these conditions should absolutely not consider refractive surgery:

  • pregnant or nursing
  • unstable refraction
  • severely reduced BCVA

Pro Tip:

We evaluate each individual as a whole and carefully weigh the risks/benefits of surgery. If refractive surgery is not in their best interest, we won't do the surgery. If you are unsure, send them our way- be sure to include any questions/concerns you may have!

DECEMET DETACHMENT

***looks like a rolled up carpet

- a small detachment can be observed

- a large detachment needs to be assessed by the surgeon

TASS VS ENDOPHTHALMITIS

***both are required to notify the surgeon. It is imperative
to differentiate the two so you can implement timely
treatment correctly

Maassen JL, Folk JC: Endophthalmitis: 82-year-old male status post phacoemulsification in the left eye with acute decrease in vision. Eyerounds.org. December 5, 2005; Available from: http://www.EyeRounds.org/cases/45- Endophthalmitis-After-Cataract-Surgery.htm.

Pro Tip:

Both require urgent attention by the surgery centrenotify the surgeon immediately. If you suspect endophthalmitis this is an emergency and every hour counts!

YAG CAPSULOTOMY

It is recommended to wait a minimum of 3 months after surgery before performing a YAG capsulotomy to ensure a stable capsule/zonule system.

Some symptoms that would suggest considering a YAG are:

  • Blur
  • Glare
  • Starbursts
  • Photophobia

Send for YAG capsulotomy if patient is symptomatic and they present with one of the following in the posterior capsule:

  • Haze
  • Striaie
  • Fibrosis
  • Elshnig Pearls

Pro Tip:

Sometimes if a patient has an unwanted residual refractive error, we will perform a YAG capsulotomy prior to intervening with more invasive surgery to see if the IOL placement would be improved.

CHOROIDAL EFFUSION

***looks like "lobes" of choroidal elevation in up to 4 quadrants

- differentiate from retinal detachment

- can have shallowing of the anterior chamber

- may have increased pain

- look for wound leak

- look for hypotony

- although some small choroidal effusions can be monitored for self resolution, it is best to notify the surgery centre, as this can potentially be a vision-threatening condition requiring surgical intervention

Contributor: Jesse Vislisel, MD
Photographer: Brice Critser, CRA

TRIAMCINOLONE RESIDUE

***injectable corticosteroid during cataract surgery - used in complex cataract cases to help reduce inflammation and visualize vitreous especially if there was trauma during surgery

Will self resolve in 72 hours

Contributor: Eric Chin, MD
Photographer: Cindy Montague, CRA

Phimosis

Phimosis is a fibrotic metaplasia of the anterior capsule causing the anterior capsulotomy to "shrink" and create visual disturbances.

It is recommended to wait a minimum of 3 months after surgery before performing a YAG capsulotomy to ensure a stable capsule/zonule system. However if the phimosis is visually significant, can send sooner for surgeon to evaluate.

Contributor: Jesse Vislisel, MD

Photographer: Stefani Karakas, CRA

http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/capsular-phimosis/index.htm

Some symptoms that would suggest considering a YAG are:

  • Blur
  • Glare
  • Reduced VA
  • Photophobia
  • Maddox rod effect: When the pt describes streaks of light at night that go perpendicular to the striaie you observe. (See Pro Tips on how to identify.)