As I See It

The Curious Case of the Finicky Flap

A series of mishaps reveals a need to focus on the fundamentals.

By Paul S. Koch, MD, Editor Emeritus

Have you ever had a day like this? Let me tell you a story and see if any of this sounds familiar.

It was a busy refractive laser day, and when we checked the LASIK flaps before discharging each patient, about one in 10 had a few subtle vertical striae just in from the temporal edge of the flap. In each case, I repositioned the flap and the next day they were all fine. No cause for concern in any of that, right?

On my next laser day, I had a couple more. It wasn't a big deal, and after repositioning the flaps they were fine. But then there were some on my next day — and again on the next after that. Not many, just one or two, but it began to bug me. I felt like a major league pitcher in a slump.

Looking for Answers

I mentioned this to a friend and he told me that I was using too much fluid under my flaps, giving them the opportunity to skid. Aha, I thought, and used less the next time. And that didn't help at all.

So, I mentioned this to another friend and he told me I was using too little fluid. I squirted a little extra the following week, but that didn't help either.

I called another friend, and he asked if I was drying the flap before repositioning it, because I should do that to help the flap seal down to the bed. Good idea, I thought, but then my next friend told me the problem was that I shouldn't be drying the flap because that causes shrinkage.

I tried it both ways, but still had to reposition two or three flaps.

I have lots of friends. The next one told me I should use sodium chloride drops at the end of the case to stimulate the adhesive pump and help the flap stick down into place. I did that, and guess what? It didn't work either.

Back to Basics

And so, right about now I'm feeling a little depressed — and that's when I get an e-mail from one of my technicians. She first reminded me that when my sailing team tanks a few races, we always go out and practice the basics, and then she got to the meat of it.

"Dr. Paul," her email message read, "I know this is bothering you and, if you don't mind, I have an idea."

She wrote that she didn't want to hurt my feelings, but maybe I also needed to get back to basics. She had taken the liberty of searching for articles on how to handle flaps, with particular attention to articles written more than 10 years ago. These were articles written for novice laser surgeons, giving very basic advice.

Reviewing these articles was a true "back to basics" journey, taking me to where I was over a decade ago, when I was more nervous and less complacent as a surgeon. Back then, everything was a brand new experience, not a weekly routine.

If you had watched me my next laser day, you would not have noticed any apparent change from the previous weeks, but perhaps I was just a bit slower, just a bit gentler and a wee bit more careful. And that day, all the flaps were snug.

The next day they were pristine, all except for that one had… what? Dislocated completely! She had rubbed her eye when she got out of bed, followed by a burst of pain. Okay, whew. My momentary panic was unfounded.

Turning it Around

We all make small changes in surgical technique from time to time, and after a while our protocol bears little resemblance to what we had been doing initially. If the new method is better, the birds are singing and all is well with the world.

When, however, we are facing a few burps and hiccups, it might not be a bad idea to revisit a simpler time and technique, when we concentrated on the basics and took the time to understand why each step mattered, not just how to do it. The answer to a slump usually begins there. OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, R.I. His e-mail is: paulkoch@kocheye.com.