A Regimen That Leads to Better Outcomes

By Karl Stonecipher, MD

Dr. Stonecipher is director of laser and refractive surgery at TLC Laser Eye Center, Greensboro, N.C. Visit his educational Web site at Laserdefinedvision.com.

The first and most significant pearl I have to offer is associated with preoperative and perioperative patient management. I am a big advocate of using corticosteroids and an antibiotic QID for 3 days prior to surgery. I recommend this regimen because it improves the patient's tear film, which improves lid hygiene and reduces the risk of infection. By improving the tear film, you get better recordings of a patient's manifest refraction, topography and aberrometry. This, in turn, allows you to input information into the computer that is more accurate. We have evidence that our postop day 1 vision following this regimen is greatly improved over using no drops at all.¹ The more accurate the information, the better the outcome.

Having your patients use drops prior to surgery familiarizes them with the protocol and allows you to find out if they may be allergic to the drops. It's better to know this prior to surgery rather than starting them on this regimen with a fresh incision.

Divide and Conquer

I divide patients according to their dry eye severity. With patients who have mild dry eye, I typically use the same regimen postop as I do preop and may start them on Restasis (cyclosporine, Allergan) at 1-2 weeks postop if they complain of fluctuation in vision. I encourage them to use an artificial tear (like Systane Ultra, Alcon or Refresh Optive, Allergan). In a moderate patient, I'll use Restasis 1-2 months prior to surgery, follow my preop regimen and continue Restasis up to 6 months postop. In severe dry eye patients, if we elect to operate on them at all, I'll use Restasis 4-6 weeks prior to surgery, and again 4-6 months postop. I tend to operate on these patients in the more humid months. These patients heal more quickly in humid months and are more comfortable. In all dry eye patients, we use an extended duration 90-day collagen punctual plug.

If a patient comes in with blepharitis or rosacea, then we will treat them with an acute agent, like tobramycin and dexamethasone drops (TobraDex, Alcon) 2 weeks prior to surgery and add Doxcycline 100 mg to clean the patient's lid margin disease. I want to treat any ocular surface disease first, and in those patients with threshold disease, the preoperative management will help them to get better outcomes.

Interoperative Insights

Interoperatively, the Wavelight (Alcon) laser is one of the fastest on the market. The advantages of this speed are reduced corneal dehydration, not exposing patients to the effects of temperature and humidity and increased safety because the patient is under the laser for less time. I think the speed of the laser leads to a faster healing time and less postop complications. It definitely makes a difference in postoperative vision.²

In order to get my patients to fixate, I ask them to look for the green blinking light–which is a fixation light on the laser. In addition, there are four bright stadium lights surrounded by four amber lights on the laser — these are part of the system's NeuroTrack system. The system allows for better registration in the astigmatic alignment of the patient. Again, this helps deliver better outcomes.

It behooves you to talk preoperatively to your patient about: 1) the femtosecond laser, that the light will go away, so the patient isn't nervous about its disappearance 2) the excimer laser–explain to the patient the importance of concentrating on the green blinking fixation target. 3) talk about the fact that the excimer laser is a cool laser and that it doesn't produce heat, but I also mention that there will be an acrid smell — so they are not frightened by it. This makes the patient more comfortable during the procedure. Walk the patient through the process before going under the laser. We also have a video that shows me having refractive surgery in which I'm interviewed before having the procedure, during and post-laser. (http://www.ophmanagement.com/video.htm)

Additionally, I have my technicians count down the length of time that the patient must fixate and the percentage of the procedure that has been completed at the different stages. It tells both the patient and surgeon their progress. Patients enjoy receiving this information, as it is their cue that there is a light at the end of the tunnel.

Postop Pearls

Postoperatively, I like to give the patients all of their instructions in advance and try to incorporate a family member in the process. They are already familiar with the drop regimen and I usually tell postoperative patients to continue their drop use QID for 2 weeks. I say this, expecting that they will be compliant for 1 week. Two weeks allows for the healing process to occur and maintains a nice tear film. After 2 weeks, they should use an artificial tear; this helps clean up the tear film and improve inflammatory healing.

Again, dry eye leads to enhancements. Promoting this preoperative and postoperative regimen leads to better visual outcomes, less fluctuation in visual acuities and decreased enhancements.

REFERENCES

1. Stonecipher, KG. Postoperative Day 1 Visions: Is it the laser or the regimen? How do we improve outcomes? Paper presented at: the European Society of Cataract and Refractive Surgeons; September 12-16, 2009; Barcelona, Spain.
2. Stonecipher KG, Kezirian GM, Stonecipher K. LASIK for mixed astigmatism using the ALLEGRETTO WAVE: 3- and 6-month results with the 200- and 400-Hz platforms. J Refract Surg. 2010;26(10):S819-S823.