Preoperative evaluation for lasik and prk

By Dr. Mohammad Mousa

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Introduction

The purpose of the pre-operative assessment is: 1. To determine by physical measurement whether it is possible to correct a patients individual refractive error. 2. To determine by examination whether the ocular health is adequate for this procedure. 3. To identify if there is any increased risk of complications specific to that patient.

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Evaluation
History
Age Sex Occupation Stability expectation

General health
Ocular health
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 Absolute general health contraindications Relative general health contraindications Absolute ocular health contraindications Relative ocular health contraindications

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Absolute general health contra-indications

Auto-immune disease e.g. RA,SLE, Thyroid disease. Immune suppression HIV or immune suppression drugs. Pregnancy-wait 6 months after giving birth or cessation of breast feeding. Systemic steroids Amiadarone 5-Hydroxy-tryptamine e.g. sumatriptan there is an increased risk of vascular occlusion when the intraocular pressure is raised during treatment.
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Relative general health contraindications

Tricyclics or lithium-based medication-the need

for such medication indicates that the patient

may have obsessive or compulsive personality or is suffering from a significant level of

depression. These patients can have

expectations of surgery that are too high and are unlikely to be satisfied following surgery.

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Relative general health contraindications Diabetes diabetics can have an increased

risk of epithelial complications after Treatment. Eyes which have signs of diabetic retinopathy are contra-indicated.

Active atopy any active or uncontrolled

atopic disease would be contraindicated until it is well controlled.

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Relative general health contraindications

Epilepsy the patient must be able to remain relatively still during the procedure. Therefore, only patients that have not had an epileptic episode for 12 months or more may be considered for treatment. History of frequent fainting these patients may have a low threshold for vasovagal attack. Patients that have a low oculocardiac reflex would also be unsuitable. Hepatitis B and C patients with these conditions will not be considered for surgery in many clinics due to the potential risk to surgical staff.
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Absolute ocular health contraindications

Diabetic retinopathy this is an absolute
contra-indication as it can accelerate the progression of diabetic retinopathy.

Glaucoma During LASIK treatment, the

intraocular pressure (IOP) is raised to above 65 mmHg which may cause further damage to the optic disc. The topical steroids used postoperatively may also affect IOP

Corneal thinning dystrophies e.g.

keratoconus in dystrophies where the cornea is abnormally thin, LASIK would reduce the corneal thickness.
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Absolute ocular health contraindications

History of ocular inflammatory diseases. Herpatic ocular disease Sjo grens syndrome these patients will have acute dry eye and their symptoms will be exacerbated by treatment. Fuchs endothelial dystrophy endothelial decompensation and poor flap adhesion has been associated with this condition. Unstable refractive error the prescription must be fairly stable before treatment is considered. A change of more the 0.50 D equivalent in 12 months or less is deemed unstable. Visually significant cataract in cases where there is a significant lens opacity, cataract surgery with IOL implant provide good alternation to laser procedure.
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Relative ocular health contraindications

Dry eye in some patients their condition may

be temporarily worse after Treatment.

Blepharitis all signs of blepharitis must be absent prior to treatment as it may induce postoperative inflammation. Nystagmus not all lasers have a tracker that

can keep up with the involuntary eye

movements associated with nystagmus.
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Contra-indicated eye examination findings

Unaided vision patients with very good unaided vision and who only need spectacles to correct presbyopia are not suitable . Binocular vision status if the patient has prism controlled diplopia or where decompensate heterophoria is corrected by the use of prism in spectacles.

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Ophthalmic examination
Vision assessment - VA - the level of vision achieved with and without spectacle correction. Refraction manifest and cycloplegic refraction where necessary.(young) Focimetry of spectacles together with the refraction results, it can be used to check prescription stability over a period of time. Ocular dominance testing this is carried out on all patients but is particularly relevant with presbyopic patients who are considering monovision.

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Ophthalmic examination
Tonometry the IOP is measured as part of the examination to check for suitability for treatment and as baseline data. Tear film assessment the patients tear quality and quantity will be evaluated. Anterior eye examination and dilated fundoscopy. Pupillometry the pupil size in scotopic conditions. Pachymetry the corneal thickness is measured Specular microscopy. For corneal endothelial state Orbit Configuration: Patients with small or Deep-set orbits and narrow palpebral fissures should be discouraged from having LASIK

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Ophthalmic examination

corneal curvature: Several different methods

are available to analyze the corneal curvature. Wavefront aberrometry is a technique that can provide an objective refraction measurement and used in measure the optical aberrations of the eye. Certain excimer lasers can use this wavefront analysis information directly to perform the ablation, a procedure called wavefront-guided, or custom, ablation.

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Near vision
presbyopic patients must understand that reading spectacles will still be necessary after LASIK/PRK to correct their distance vision unless they opt for monovision. Myopes, aim is to undercorrection of the less dominant eye. hypermetropes it would mean overcorrection, which will probably worsen the unaided distance vision in the eye that has been corrected for near vision tasks. If the patient refuses to accept these options, then they are not suitable for LASIK/PRK.
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K- reading
Lenticular astigmatism Flat corneas (flatter than 40.00 D) increase the risk of small flaps and free caps. steep corneas (steeper than 48.00 D)

increase the risk of buttonholeflaps.

Excessive corneal flattening (flatter than approximately 34.00 D) or excessive corneal steepening (steeper than approximately 50.00 D) after refractive surgery may increase the

risk of poor-quality vision.

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Postoperative keratometry
Postoperative keratometry for hyperopic

patients is estimated by adding 100% of the

refractive correction to the average preoperative keratometry reading. Postoperative keratometry for myopic patients is estimated by subtracting

approximately 80% of the refractive

correction from the average preoperative keratometry reading
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Residual Stromal Bed Thickness (RSBT)

Residual stromal bed thickness (RSBT) is calculated by taking the preoperative central corneal thickness and subtracting the flap thickness and the calculated laser ablation depth for the particular refraction
Each 1 refractive error subtracting 10microm from SBT.

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THANK YOU
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