Month: January 2015

LASIK?

Q:
I have a 26 yo healthy female (only med is a birth control pill, which she has been on for years) with the following refractive error:
Current wear in glasses:
OD:  -2.50+1.00×83
OS:  -1.75+1.25x96Manifest June 2014:
OD: -2.25+1.75×80
OS: -1.75+1.50×100Manifest Dec 2014:
OD: -2.50+1.00×85
OS: -1.75+1.25×95

Her topos from June and December 2014 are attached in pdf format.  The inferior portion of the anterior float appears steeper. It is mild and not changing over a few months. The B-A curves are within normal limits.
I plan to reevaluate in June.

She wants LASIK. I suggested PRK as an option for her.  I am inclined to avoid LASIK given my concern with the inferior area.

Would you consider PRK to be safe in this situation. Or would you steer the patient away from refractive surgery all together?

A:

ASA (advanced surface ablation) is almost always safer in these cases. Done properly with her low age and Rx recovery should be quick and painless"</p

Lid margin disease

Q:

The conventional teaching for lid margin disease is to use an antibiotic oint to the lid margins at bedtime along with other therapy.

If we continue ointment once alone for a long period, for maintenance, are we not using a subtherapeutic dosage and will this not promote drug resistance.

Would it be better to use Ab. drops QID + same Ab. ointment at night for a week and then stop them abruptly.

One could repeat the same course after a few weeks if deemed necessary.

Would there be any indication to use antibiotic ointment once daily for a prolonged period of time.

Thanks

A:

That traditional teaching is, as you correctly observed, outdated and usually wrong
I never use an antibiotic ointment at bedtime for lid margin disease BC the etiology isn’t infectious and by doing so invariably you’ll confuse the patient into thinking the prescription ointment is the key, so they ignore their warm compresses and lid scrubs, which is actually the important part
Obviously MGD sometimes causes DES by interfering with the lipid component of the tear film. In these cases I sometimes add erythromycin ointment at bedtime. But I always tell them it’s for the lubricating properties of the vehicle, and patients often prefer that substance over something like lacrilube, plus medical insurance pays for it. Then they usually understand
Prior recent threads have discussed treatments for demodex
Hope this is helpful

 

49 yo after LASIK

Q:

a 49 year old presents 2 months ago; she had Lasik in Ecuador early, 2014 and still doesn’t see well

her exam shows an interface as to what appears an incomplete flap OU, just nasal to the visual axis and many nests of old epithelial cells in the interface OU also out of the visual axis

her vision is 20/70 uncorrected in each eye but she corrects to 20/20 in each eye

her refraction is

OD plano + 1.75 x 40

OS +1.75+ 150 x 15

her topos are typical post lasik and pachymetry is normal

any additional suggestions other than eyeglasses or contact lenses

A:

If she refracts to 20/20 the epithelial ingrowth is obviously not visually significant
Assuming the epithelial cells are dead, like they look loculated and aren’t in a sheet w a communication to the outside world, why not  just perform a LASEK on top of the flap with MMC?
That’s my standard method of retreating all LASIKs no matter how recent or old, because you avoid even the possibility of epithelial ingrowth, and you won’t by definition increase the risk of ectasia (because you’re not decreasing RSB)
I’ve done several hundred of these cases and haven’t found any nomogram adjustment to be necessary compared to my regular nomogram for ASA (LASEK or epiLASEK)
I also add oral steroids postop and use pred acetate over Lotemax because it prevents scarring better, plus Vit C and UV protection for a few months
With this regimen (and a compliant patient) the incidence of scarring on our last 100 LASIK retreatments w LASEK of the flap is 0%. Although we of course consent the patient anyway that they’re at risk of scarring and loss of BCVA

 

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