Louis Probst. Commitment to Optometry. Cycloplegic Exam. Steroid free PRK. LASIK Enhancements made Ridiculously Simple 8/18/2017
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1 Louis Probst LASIK Enhancements made Ridiculously Simple Louis E. Probst MD National Medical Director, TLC Chief Surgeon, Central Midwest, USA TLC surgeon 22 years 7 books, 80 chapters, 50 papers, 11 instruments TLC National Medical Director 10 years 100% LASIK and PRK 100% Custom and IntraLase 100% co-managed with optometry X 18 years >110,000 LASIK procedures lasikwithprobst.com Cell: text or call Commitment to Optometry Annual meeting sponsorship CE meetings Grand Rounds/Live LASIK Viewing CPR courses Focus on Co-management news letter Respect for Optometry Presentation Title Goes Here 3 Steroid free PRK All PRK eyes are treated with 0.02% mitomycin C after the laser which eliminates the risk of haze No need for post op steroid Less drops/ inconveince Faster epithelial healing Less $$ for patient s drops Good UV protection sunglasses stil recommended after PRK Good for 90 days Cycloplegic Exam Try to do on the patients initial assessment so they do not have to return to your office after our consultation Trying to reduce the barriers to LASIK 1
2 LASIK/PRK Emergencies Dislodged flap Patients told to nap on back Wear eye protection first week Careful with eye drops and touching eye Flap striae are NOT an emergency Infection/Infiltrate Assume MRSA Needs topical Vancomycin ASAP Call center to arrange Patients Emergency Protocol Given ASK-DOCS in postop pack Doctors Call TLC center Day: speak to staff/doctor Night: call goes to emergency call center Call/text Dr. John Lehr Call/text Dr. Louis Probst Call ASK-DOCS LASIK Results last 12 months Probst, <6D with <2D cylinder, 3 months, n= % Postop UCVA - LASIK Probst <-6D sph w <-2D cyl, n= % 86.74% 87.22% 89.46% 90.74% 92.80% 81.67% 80.00% 74.55% 74.72% 75.43% 74.97% 70.00% 60.00% Percentages 50.00% 40.00% 34.73% 34.81% 30.00% 25.92% 29.89% 20.00% 12.64% 16.40% 14.29% 13.54% 18.35% 10.00% 9.00% 0.00% /15 or better 20/20 or better 20/25 or better 20/40 or better Alcon Wavelight Refractive Suite Risks for Enhancement High myopia (>6D) High hyperopia (>3D) High astigmatism (>3D) Monovision!! 2
3 LASIK Enhancement Indications > 1.00 D of myopia or hyperopia > 1.00 D of astigmatism UCVA 20/40 or worse 20/unhappy age Timing of Enhancements Immediate (1-3 days) Treatment error Early <12 months after primary LASIK Under/over correction Flap lift enhancements? PRK enhancement? Late >12 months after primary LASIK Epithelial hyperplasia Progressive myopia Presbyopic refractive changes Preoperative Healthy eye Cataract Retinal disease Stable refraction One month/se diopter correction 6 months minimum for hyperopia Contact lens trial Cycloplegic refraction Adequate corneal thickness Regular topography/tomography Risks of Enhancement Overcorrection Epithelial ingrowth Flap striae Infection Pain Enhancement Techniques PRK Side cut enhancement Flap lift enhancement Flap recut enhancement Microkeratome Femtosecond laser Enhancement Techniques Special Situations Lens exchange/ piggy back IOLs if large refractive error Cross linking if signs of corneal stability 3
4 PRK enhancement Epithelial Removal Brush EtOH Manual scrape Microkeratome LASEK Brush PRK Enhancement Hyperopic 8mm Amoils Brush Ring Fixation Healthy peripheral epithelium Heals in 3-4 days EToH PRK Enhancement Transepithelial PRK Enhancement 100 % EtOH for 10 seconds Attenuated peripheral epithelial Heals in 4-6 days 50 micron PTK Healthy peripheral epithelial Available on AMO/VISX Not available Alcon/Wavelight Side cut Enhancement Flap Lift Enhancement Femtosecond laser used to create new side cut inside original flap Risks of epithelial ingrowth and free wedge of tissue No longer performed at TLC Performed up to 3 years after primary procedure Risk of epithelial ingrowth increases from 0.5% to 5% after 3 years postoperatively Impossible to predict loose epithelium Greater ectasia risk 4
5 Microkeratome PRK enhancement Femtosecond Flaps are Harder to Lift Amadeus microkeratome used to removed epithelium Healthy peripheral epithelium Risk of damge to Bowman s membrane Flap lift Enhancement Classic LASIK Enhancement Protocol < 1 year postop enhancement > 1-3 years postop MMC lift flap PRK with New LASIK Enhancement Protocol Why switch to All PRK enhancements? LASIK has changed! PRK for ALL eyes! 1. Femtosecond flaps are harder to lift 2. The standard of safety is now higher 3. The rate of enhancements is lower 4. Enhancements performed on one eye 5
6 Inverted Side Cut Standard of LASIK Safety is higher Epithelial Ingrowth Risk (Caster, n=3866) Caster AI, Freiss DW, Schwendeeman FJ. Incidence of epithelial ingrowth in primary and retreatment laser in situ keratomileusis. J Cataract Refract Surg 2010;36:1: Cases of clinically significant epithelial ingrowth, defined as epithelial ingrowth impeding on the visual axis and negatively affecting UDVA, CDVA, or both Procedure Type Flap Technique Time of Flap Lift Time of Flap Lift 6
7 Age of Patient Post LASIK UDVA Probst < 6D sph, <2D cyl, f/u=3 months, n=11724, % 90.00% 80.00% 74.55% 74.72% 75.43% 74.97% 81.67% 86.74% 87.22% 89.46% 90.74% 92.80% 70.00% 60.00% Percentages 50.00% 40.00% 30.00% 25.92% 34.73% 29.89% 34.81% 20.00% 10.00% 12.64% 16.40% 14.29% 9.00% 13.54% 18.35% 0.00% /15 or better 20/20 or better 20/25 or better 20/40 or better PROBST Madison WI LASIK Wavelight Results 2016, n=382 (<6D Myopia,<2D Cylinder) Enhancement Rate % = A/B X 100 A = procedures over 6 months Date of measurement B = enhancements over 12 months Average follow-up: 9 months TLC Enhancement Rates (12 month ) , LASIK, n=537, % Probst LASIK Enhancements Rates by Type Conventional Custom Microkeratome Intralase Custom Intralase 15.00% 14.00% 13.00% 12.00% 11.00% 10.00% 9.00% 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% 8.00% 6.00% 4.00% 2.00% Custom Intralase Conventional Intralase Custom LASIK Conventional LASIK 0.00% Aug-04 Feb-05 Aug-05 Feb-06 Aug-06 Feb-07 Aug-07 7
8 Current Enhancement Rate Probst, 2016, n=5,500 eyes, Retreatment within 1 year of Primary Procedure TLC Chicago, IL 0.71% TLC Madison, WI 0.46% TLC Cedar Rapids, IA 0.60% TLC Tampa, FL 0.95% Epithelial Ingrowth Risk Anterior basement membrane dystrophy Neovascularization Previous ingrowth Greater patient age <3 year risk: 1% >3 year risk 7% Caster AI, Freiss DW, Schwendeeman FJ. Incidence of epithelial ingrowth in primary and retreatment laser in situ keratomileusis. J Cataract Refract Surg 2010;36:1: Epithelial Ingrowth 8
9 Ridiculously Simple PRK enhancement for all eyes Least complications Brush epithelial removal for all eyes Fastest epithelial healing MMC 0.02% for all eyes Eliminates haze No need for postop steriod PRK Enhancement with Amoils Brush Enhancement Laser Programming Refractive stability Myopia: one month per SE diopter Hyperopia: 6 months Contact lens trial Correct minimum myopia/hyperopia Check/reduce ablation depth microns per diopter Spherical aberration will increase depth Sprint4Flint Sprint4Flint Thank You 9
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