Innovation Spotlight - Refractive Care

Good refractive care requires close patient involvement

Patients must have realistic expectations, guidance on preoperative, postoperative management

David R. Hardten, MD

By Alyson G. Yashar, MD
Reviewed by David R. Hardten, MD

Minneapolis-Good refractive surgery care begins with good preoperative management. Patients need to know what to expect and understand their preoperative and postoperative responsibilities, said David R. Hardten, MD.

Written protocols are essential for all patients, said Dr. Hardten, associate professor, University of Minnesota, Minneapolis, who has standardized the instructions as much as possible to reduce the amount of confusion that the patient or staff can have. This is especially important as surgeons add new refractive procedures to their practice, he said.

Preoperatively, patients stop using both soft and hard contact lenses, which can cause corneal edema by molding the cornea. Patients are told not to use rigid gas-permeable contact lenses for 3 weeks prior to surgery. If they wore soft contact lenses, their use was stopped 2 weeks prior to surgery to reduce the chance of corneal molding.

"Most patients are more willing to do this if they understand that the accuracy of their results may be improved," Dr. Hardten said.

Cleansing before surgery

Another important guideline is eyelid cleansing prior to surgery, he said. Blepharitis is almost 100% prevalent in his patient population. All his patients use lid scrubs the day before the surgery and the day of the surgery to reduce the bacterial debris, mascara, and other lid byproducts that are on the surface of the eyelids.

"We use longer therapy in patients who have severe blepharitis. It is not uncommon to treat patients with oral doxycycline or eyelid scrubs for even 1 month before the surgery to try to produce a cleaner interface with less debris," he said. "No makeup is allowed for the day before surgery and for 2 weeks postoperatively."

Before surgery, Dr. Hardten generally uses oral sedation, especially in the case of patients undergoing LASIK or receiving intrastromal corneal rings (Intacs, KeraVision).

"I prefer a lesser dosage of diazepam of 5 mg to prevent a patient from being uncooperative during the surgical procedure itself. I also find it helpful to give an oral pain medication about 30 minutes before the procedure to reduce the discomfort associated with the suction ring," said Dr. Hardten. "I prefer naproxen, but you can use ibuprofen, or acetaminophen with codeine. It also helps to have this available so that when the patient goes home, he or she has less postoperative discomfort."

Typically, for PRK the sedation is not necessary, but the pain medicine is still a good idea, he said. For phakic IOLs, a typical cataract regimen can be used.

Intraoperative preparation is similar for all of the different procedures. It is important to clean the eyelashes and eyelids carefully with povidone-iodine to reduce the amount of bacterial contamination. Drying the area before the surgery helps effectiveness and lessens the toxicity from the povidone-iodine, Dr. Hardten said.

Surgeons should use as little anesthetic as possible. Too much anesthetic too early not only loses its effectiveness, but can damage the epithelium, which can then get into the interface. This can lead to epithelial ingrowth and epithelial cysts.

It also can lead to changes in hydration if the patient is not blinking because of the anesthesia. This can lead to overcorrection in susceptible patients, he continued.

One drop of proparacaine before the preparation and one drop after the lid speculum is inserted is all that is needed for PRK and LASIK. With intrastromal corneal rings, it is important to anesthetize the conjunctiva more carefully because the suction ring has the positioning pins, which prevent rotation of the suction rings. Dr. Hardten uses a Chayet sponge for about 3 minutes on the conjunctiva during the dissection of the lamellar pockets.

Antibiotic use typically involves a fluoroquinolone four times a day until the bottle is finished. The drug also may be used preoperatively.

NSAIDs also are used for LASIK, intrastromal corneal rings, and phakic IOLs. One drop is used preoperatively and another postoperatively.

Lessening postop pain

To ease the postoperative pain associated with PRK, patients will continue to take NSAIDs, usually four times a day for the first day, then three times a day the next day, twice a day the following day, and then once a day on day four to try to reduce the possibility of complications, such as increased inflammatory infiltrates.

"In LASIK, the cornea is neurotrophic from severing the nerves, so watch your topical anesthetic and NSAID usage," Dr. Hardten said. "These patients do have pain, so make them comfortable with NSAIDs and a bandage soft contact lens. After PRK, patients also tend to have a neurotrophic cornea. You have to be careful that patients do not develop epithelial toxicity with NSAIDs."

Although steroids are probably not necessary in most eyes that have undergone refractive surgery, Dr. Hardten will typically treat with steroids four times a day, mainly for patient comfort and out of concern for an inflammatory reaction in the interface, such as diffuse lamellar keratitis (DLK).

Studies of steroids and PRK show that steroids are really not necessary for most eyes, especially for low myopia or low hyperopia. But he still uses steroids, because of comfort and concern for haze, in a tapering regimen over 4 months. The first month the dosing is four times a day, then reduced to once a day by the fourth month. Steroids may prevent the early stages of DLK in LASIK. With intrastromal corneal rings and phakic IOLs, steroids are used four times a day for 2 weeks.

Artificial tears are an important component of early postoperative LASIK and PRK care because the ocular surface has undergone surgical trauma and toxic medications are used postoperatively. There also has been devitalization of the nerve supply to the epithelium. Nonpreserved artificial tears are used especially in patients with preexisting dry eyes to try to prevent toxic epitheliopathy from a neurotrophic state.

Bandage contact lenses are typically not used in LASIK. Dr. Hardten will use a contact lens if he has an epithelial defect up to 20%, or if the defect is at the edge of the flap. This helps to decrease the chances of epithelial ingrowth from the epithelium growing underneath the edematous flap edges. In PRK, a bandage contact lens is used until the epithelial defect has healed, usually 3 to 7 days.

A clear protective shield is key because patients tend to rub their eyes, which could move the flap, IOL, or intrastromal implant. These may be used for longer in patients that are prone to eye rubbing.

Communication is key

"Careful attention to these details will help to improve patients' comfort, vision, and the safety of the procedure," he said. "You need to communicate to your patients that they also have a role in their surgery to help reduce the possibility of complications with these refractive surgeries.

"Surgery is a big deal in patients' lives, a once-in-a-lifetime experience," he said.

Ophthalmology Times / APRIL 15, 2000