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LASIK
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DVD Contents
1. Flap Wars
2. Aberropia Video
3. Battle of the Bulge
LASIK
Editors
Amar Agarwal MS FRCS FRCOphth
Athiya Agarwal MD FRSH DO
Soosan Jacob MS FRCS DNB MNAMS
Agarwals Group of Eye Hospitals and Eye Research Centre
Chennai, India
dragarwal@vsnl.com
Foreword
David R Hardten MD
Minneapolis, MN
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Dedicated to
Robert Cionni
CONTRIBUTORS
Amar Agarwal MS FRCS FRCOphth
Dr Agarwals Group of Eye Hospitals and
Eye Research Centre, 19 Cathedral Road, Chennai, India
Athiya Agarwal MD FRSH DO
Dr Agarwals Group of Eye Hospitals and
Eye Research Centre, 19 Cathedral Road, Chennai, India
Soosan Jacob MS FRCS DNB MNAMS
Dr Agarwals Group of Eye Hospitals and
Eye Research Centre, 19 Cathedral Road, Chennai, India
Gaurav Prakash MD
Dr Agarwals Group of Eye Hospitals and
Eye Research Centre, 19 Cathedral Road, Chennai, India
Dhivya Ashok Kumar MD
Dr Agarwals Group of Eye Hospitals and
Eye Research Centre, 19 Cathedral Road, Chennai, India
Rahul Tiwari Dip NB, FERC, FICO
Dr Agarwals Group of Eye Hospitals and
Eye Research Centre, 19 Cathedral Road, Chennai, India
FOREWORD
x / LASIK
The authors have put together the standard images that
are needed for the preoperative assessment, management of
the patient with the newest wavefront and femtosecond
technology, and also for the management of complications of
LASIK.
Continue to grow your knowledge and awareness of refractive
surgery by putting this work to use in your practice. You will be
thankful that you did. As a surgeon and clinician, keep
advancing the field of refractive surgery.
David R Hardten MD
Minneapolis, MN
PREFACE
CONTENTS
1. Basics and Preoperative Assessment ............ 1
Amar Agarwal, Soosan Jacob, Athiya Agarwal
2. LASIK, Wavefront Guided LASIK ............. 51
and Femtosecond Lasers
Amar Agarwal, Soosan Jacob, Dhivya Ashok Kumar,
Gaurav Prakash
3. Complications ........................................ 101
Amar Agarwal, Soosan Jacob
4. Miscellaneous Topics .............................. 173
Amar Agarwal, Soosan Jacob, Rahul Tiwari
Index ................................................................ 235
1
Basics and
Preoperative
Phakonit
Assessment
and
Microphakonit
Amar Agarwal
Soosan Jacob
Athiya Agarwal
2 / LASIK
4 / LASIK
6 / LASIK
To summarize:
1. Curvature is not relevant in raytrace optics.
2. Elevation is complete and can be used to derive
surface curvature and slope.
3. Elevation is the standard measure of surface shape.
4. Elevation is easy to understand.
The problem we face is that there is a cost in converting
elevation to curvature (or slope) and vice versa. To go
from elevation to curvature requires mathematical
differentiation, which accentuates the high spatial
frequency components of the elevation function. As a
result, random measurement error or noise in an elevation
measurement is significantly multiplied in the curvature
result. The inverse operation, mathematical integration
used to convert curvature to elevation, accentuates lowfrequency error. The Orbscan helps in good mathematical
integration. This makes it easy for the ophthalmologist to
understand as the machine does all the conversion.
The general quad map in the Orbscan of a normal
eye (Figure 1.2) shows four pictures. The upper left is the
anterior float, which is the topography of the anterior
surface of the cornea. The upper right shows the posterior
float, which is the topography of the posterior surface of
the cornea. The lower left map shows the keratometric
8 / LASIK
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14 / LASIK
B
Figures 1.6A and B: General quad map of an eye with
keratoconus
16 / LASIK
Figure 1.7A
Figure 1.7B
Figure 1.7C
Figures 1.7A to C: Three-dimensional anterior float of an
eye with keratoconus
18 / LASIK
Figure 1.8: Quad map with normal band scale filter of an eye
with primary posterior corneal elevation
20 / LASIK
22 / LASIK
Figure 1.9A
Figure 1.9B
Figure 1.9C
Figure 1.9D
24 / LASIK
In the top right note the red areas which shows the elevation on
the posterior cornea. The anterior cornea is normal
26 / LASIK
28 / LASIK
30 / LASIK
Figure 1.11A
Figure 1.11B
Figure 1.11C
Figure 1.11D
32 / LASIK
Figure 1.11E
Figure 1.11F
Figure 1.11G
Figure 1.11H
34 / LASIK
Figure 1.11I
Figures 1.11A to I: Overview display from a patient with a history
of conductive keratoplasty and cataract using the Pentacam
(Courtesy-Tracy Swartz)
36 / LASIK
38 / LASIK
40 / LASIK
42 / LASIK
aims to increase the accuracy of the desired ablation and
resulting correction.
Courtesy: Benjamin F. Boyd, MD FACS, Editor-in-Chief
Atlas of Refractive SurgeryHighlights of Ophthalmology,
English Edition, 2000
44 / LASIK
46 / LASIK
48 / LASIK
2
LASIK, Wavefront
Guided
LASIK
and
Phakonit
Femtosecond
Lasers
and
Microphakonit
Amar Agarwal, Soosan Jacob
Dhivya Ashok Kumar
Gaurav Prakash
52 / LASIK
LWGLF LASERS/ 53
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LWGLF LASERS/ 55
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LWGLF LASERS/ 57
58 / LASIK
B
Figures 2.3A and B: Schematic illustration of the Bausch &
Lomb zywave aberrometer. A low-intensity infrared light is shown
into the eye; the reflected light is focused by a number of small
lenses (Lenslet-Array), and pictured by a CCD-camera. The
capture image is shown on the bottom left
LWGLF LASERS/ 59
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LWGLF LASERS/ 61
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Figure 2.4A
Figure 2.4B
LWGLF LASERS/ 63
Figure 2.4C
Figure 2.4D
64 / LASIK
Figure 2.4E
Figures 2.4A to E: Aberopia (A) Hartmann shack aberrometer;
(B) Illustration depicting defocussed wavefront; (C) Illustration
depicting spherical wavefront; (D) Illustration depicting plane
wavefront; (E) Illustration depicting irregular wavefront
LWGLF LASERS/ 65
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LWGLF LASERS/ 67
68 / LASIK
4 mm optical zone performed to create a central oblate cornea;
(C) Schematic diagram of a presbyopic cornea in which
hyperopic and myopic LASIK has been done. The patient can
thus focus for near and distance
LWGLF LASERS/ 69
70 / LASIK
Example 1
Let us take a patient who is plano for distance and is 20/
20. For near on addition of + 2 D the patient is J1. The
preoperative keratometer let us say is 41 D.
LWGLF LASERS/ 71
Example 2
Let us take a patient who is hyperopic for distance and is
20/20 with + 1D. For near on addition of + 3D the
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LWGLF LASERS/ 73
Example 3
Let us take a patient who is hyperopic for distance and is
20/20 with + 3D. For near on addition of + 3D the patient
is J1. The preoperative keratometer let us say is 44D.
The preoperative keratometer reading is 44D and we
have to correct 3D for distance and 3D for near. So if we
do presbyopic LASIK we will make the keratometer
reading 50 D. So, one should not treat such patients with
presbyopia LASIK.
Myopic Example
Now let us look at myopic patients.
Example 4
Let us take a patient who is myopic for distance and is 20/
20 with minus 2D. For near on addition of + 2D the
patient is J1. This means the patient is plano for near. The
preoperative keratometer let us say is 43 D.
There are three steps in the presbyopic LASIK
treatment:
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LWGLF LASERS/ 75
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LWGLF LASERS/ 77
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Figure 2.7A
Figure 2.7B
LWGLF LASERS/ 79
Figure 2.7C
Figure 2.7D
80 / LASIK
Figure 2.7E
Figures 2.7A to E: Femtosecond laser flap creation
(Courtesy: Takeshi Ide and Terrence P OBrien)
LWGLF LASERS/ 81
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LWGLF LASERS/ 83
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LWGLF LASERS/ 85
Figure 2.8A
Figure 2.8B
86 / LASIK
Figure 2.8C
Figure 2.8D
LWGLF LASERS/ 87
Figure 2.8E
Figure 2.8F
Figures 2.8A to F: Zeimer femtosecond laser (Courtesy: Gregg
Feinerman). (A) Ziemer femto LDV femtosecond laser
(Courtesy: Gregg Feinerman); (B) The femto LDV handpiece
brings the laser optics within two mm of the cornea. This
88 / LASIK
significantly increases the numerical aperture. (Courtesy: Gregg
Feinerman); (C) Shows the Threshold for disruption scales with
pulse intensity many, many photons on the same place, at the
same time. Unwanted side effects (bubbles, collateral damage)
scales with pulse energy. Photon energy is converted into heat,
kinetics, and chemistry; (D) Shows volume of the femtosecond
laser spot scales with the numerical aperature NA = wL/f of the
focusing lens. The larger the NA, the smaller the focal spot. Two
ways to increase the NA are increasing the lens diameter
(IntraLase, etc.) or decreasing the focal length (Femto LDV);
(E) Shows two different concepts in photodisruption process for
higher pulse energy/lower laser frequency lasers the cutting
effect is driven predominantly by mechanical forces of the
expanding cavitation bubble (Figure D(a)). Conversely, MHz
laser frequencies (high frequency) can offer many more pulses
that are needed for cutting using lower pulse energies and larger
numerical aperture (Figure D (b)). Consequently, the size of the
cut is defined solely by the focal spot size, not the expanding
bubble; (F) Smooth stromal bed created with Femto LDV
LWGLF LASERS/ 89
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LWGLF LASERS/ 91
92 / LASIK
Figure 2.9A
Figure 2.9B
LWGLF LASERS/ 93
Figure 2.9C
Figure 2.9D
Figures 2.9A to D: SBK (sub-Bowman keratomileusis): Thin
flap LASIK (technique and enhancement procedure) (Courtesy:
Roberto Pinelli). (A) Thin flap LASIK SBK; (B) Thicker flap; (C)
Gebauer SL_PR_03 and (D) Single-use LASIK set
94 / LASIK
LWGLF LASERS/ 95
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LWGLF LASERS/ 97
Figure 2.10A
Figure 2.10B
98 / LASIK
Figure 2.10C
Figure 2.10D
Figures 2.10A to D: Femtosecond laser (IntraLase) assisted
keratoplaty. (A) Preoperative clinical picture of the patient
LWGLF LASERS/ 99
showing anterior stromal opacities with lattice lines and diffuse
stromal haze. Fluorescein staining shows loss of epithelium;
(B) Donor corneal tissue dissected femtosecond assisted
lamellar keratoplasty (FALK) with IntraLase FMTM Laser at 350
micron depth and 8.5 mm diameter; (C) Recipient corneal tissue
excised with IntraLase FMTM Laser at 350 micron depth and 8.5
mm diameter: and (D) Donor tissue placed over recipient bed
and sutured with interrupted sutures.
3
Complications
Phakonit
and
Microphakonit
Amar Agarwal
Soosan Jacob
102 / LASIK
Figure 3.1A
Figure 3.1C
Figure 3.1B
Figure 3.1D
COMPLICATIONS/ 103
Figure 3.1E
Figure 3.1F
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Figure 3.2A
Figure 3.2B
110 / LASIK
Figure 3.2C
Figure 3.2D
Figures 3.2A to D: Post-LASIK infections (Courtesy: Nibaran
Gangopadhyay). (A) Corneal ulcer with hypopyon after LASIK;
COMPLICATIONS/ 111
(B) Corneal defect staining with fluorescein; (C) Status Postpenetrating keratoplasty and (D) Reinfection with hypopyon after
penetrating keratoplasty
112 / LASIK
COMPLICATIONS/ 113
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Figure 3.4A
Figure 3.4B
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Figure 3.4C
Figure 3.4D
122 / LASIK
Figure 3.4E
Figures 3.4A to E: Deep anterior lamellar keratoplasty (DALK)
(Courtesy: Vladimir Pfeifer). (A) Injection of air bubble starting so
that one can dissect till the Descemets membrane; (B) Air bubble
injected; (C) Dissection started; (D) Anterior cornea removed.
Only Descemts membrane and endothelium left behind and
(E) Donor cornea placed on the reciepent bed and sutured
COMPLICATIONS/ 123
Figure 3.5A
Figure 3.5B
Figures 3.5A and B: (A) Buttonholing of the flap and
(B) Corneal scarring after buttonholing of a flap
124 / LASIK
COMPLICATIONS/ 125
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COMPLICATIONS/ 127
C
Figures 3.8A to C: Decented ablation (Courtesy: Ming Wang).
(A) Demonstrates curvature and elevation maps for a patient
128 / LASIK
with a decentered ablation. The elevation map shows a
decentration of the optical zone. Note the inferior decentration
of the treatment in this patient who previously underwent a
myopic LASIK treatment. The key observation on curvature maps
is the dioptric difference between the superior and inferior
keratometric readings. The key observation on elevation maps
is the misalignment of the center of ablation from the optical
center; (B) Curvature (left) and elevation (right) maps for a
keratoconic cornea are noticeably different. On the axial map,
keratoconus appears as an area of inferior steepening. On the
surface height map, the elevation appears superior to the area
of thinning; (C) The elevation map prior to hyperopic LASIK and
S/P hyperopic LASIK, with the difference map showing the
induced change.
COMPLICATIONS/ 129
130 / LASIK
COMPLICATIONS/ 131
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COMPLICATIONS/ 133
134 / LASIK
Figure 3.9A
Figure 3.9B
COMPLICATIONS/ 135
Figure 3.9C
Figures 3.9A to C: Mitomycin C application ( Courtesy:
Francesco Carones). (A) The microsponge soaked with 0.02%
MMC solution, positioned over the corneal stroma, immediately
after scraping; (B) A very severe haze (grade 4) that was evident
in a patient who was treated for 12.00 D correction by myopic
PRK; (C) The slit-lamp examination of the eye seven years after
treatment showed a transparent cornea, with no haze traces
136 / LASIK
COMPLICATIONS/ 137
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COMPLICATIONS/ 139
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Figure 3.10A
Figure 3.10B
146 / LASIK
Figure 3.10C
Figure 3.10D
COMPLICATIONS/ 147
Figure 3.10E
Figure 3.10F
148 / LASIK
Figure 3.10G
Figure 3.10H
COMPLICATIONS/ 149
Figure 3.10I
Figures 3.10A to I: (A) Diffuse lamellar keratitis ( Courtesy:
Ronald J Smith); (B) DLK in a 44 year M 3 days after LASIK
(performed in 1995 when astigmatic keratotomy, AK, was
performed under the flap to correct astigmatism). Fine granular
punctate infiltrates are diffusely scattered in the lamellar interface.
Smith RJ, Maloney RK. Diffuse lamellar keratitis: A new syndrome
in lamellar refractive surgery. Ophthalmology 1998; 105:172126; (C and D) DLK in a 33 year M 2 days after LASIK (combined
with AK under the flap). (C) Fine infiltrates are diffusely scattered
through the interface and best seen at the pupillary margin.
(D) Slit-lamp exam localizes the pathology to the flap interface.
Smith RJ, Maloney RK. Diffuse Lamellar Keratitis: A new
syndrome in lamellar refractive surgery. Ophthalmology 1998;
150 / LASIK
105:1721-26; (E) Central haze, hyperopia and folds. Central
Toxic Keratopathy after DLK. Corneal flattening with hyperopia
on topography and central haze and folds on slit lamp exam.
Corneal stromal healing takes place of the course of months to
years like PRK haze. Courtesy Dr. David R Hardten and
Dr. Richard Lindstrom; (F) Staph. aureus infection after LASIK.
Dominant focus with extension anteriorly posteriorly and
peripherally. The infiltrate does not respect the flap margins.
Redness and irritation were present on the first postoperative
day, and fluffy white infiltrates appeared on the second day after
LASIK. (Photographed 2 weeks postoperatively) Hovanesian
JA, Faktorovich EG, Hoffbauer JD, Shah SS, Maloney RK.
Bilateral bacterial keratitis after laser in situ keratomileusis in a
patient with human immunodeficiency virus infection. Arch
Ophthalmol. 1999 Jul;117(7): 968-70; (G) Epithelial ingrowth
from the flap edge. A demarcation line is seen at the edge of the
ingrowth. In this eye, epithelial pearls are also prominently visible.
Wang MY, Maloney RK. Epithelial ingrowth after laser in situ
keratomileusis. Am J Ophthalmol 2000;129(6):746-51;
(H) Mycobacterial keratitis 20 days after LASIK. Focal round
corneal opacities at the interface. History was positive for intense
topical and oral prednisone for DLK during the first postoperative
week, and the patient was on a corticosteroid taper at the time of
presentation. Chandra NS, Torres MF, Winthrop KL, Bruckner
DA, Heidemann DG, Calvet HM, Yakrus M, Mondino BJ, Holland
GN. Cluster of Mycobacterium chelonae keratitis cases following
laser in situ keratomileusis. Am J Ophthalmol 2001;132(6):81930; (I) Multiple focal intrastromal infiltrates 49 days after LASIK.
The patient was receiving a long course of topical corticosteroids
and already had undergone a flap lift with antibiotic and
corticosteroid irrigation of the interface 3 weeks earlier. A 1 mm
COMPLICATIONS/ 151
diameter flap perforation in the inferior mid peripheral cornea
and epithelial ingrowth were also present. Ultimately required
flap removal and cultures grew Mycobacterium fortuitum. Seo
KY, Lee JB, Lee K, Kim MJ, Choi KR, Kim EK. Non-tuberculous
mycobacterial keratitis at the interface after laser in situ
keratomileusis. J Refract Surg 2002;18(1):81-85.
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Figure 3.12A
Figure 3.12B
COMPLICATIONS/ 165
Figure 3.12C
Figures 3.12A to C: Femtosecond laser complications
(Courtesy: William Culbertson). (A) Gas bubbles in the anterior
chamber obscuring the patients view of the laser fixation light;
(B) Gas bubbles deep to the interface in the anterior stromal bed
(deep OBL); (C) Flap torn during attempt to forcefully dissect
flap with spatula.
166 / LASIK
Intraoperative Complications
Suction Loss
During the creation of the flap the Intralase suction ring
may lose vacuum and the applanation plate may become
separated from the cornea. If this occurs during the
propagation of the lamellar interface there is no serious
consequence to the flap except that the interface is
incomplete. In this case the suction ring is reapplied, the
interface cut is performed again and the side cut is made
at the end. If suction is lost during the side cut then the
diameter of the side cut is decreased by 1.0 mm, the
suction ring is reapplied and the side cut is performed just
inside the outside diameter of the lamellar cut.
Interference by Gas Bubbles
COMPLICATIONS/ 167
168 / LASIK
Unliftable Flap
Occasionally the interface is insufficiently dissected and it
is difficult or impossible to the separate the flap from the
underlying stromal bed. Attempts to forcefully open the
interface with spatulas and blades may lead to torn flaps
or rough or irregular surfaces (Figure 3.12C). The etiology
of the inadequate dissection is uncertain but appears to
occur bilaterally in individual patients. When the
ophthalmologist is actually able to forcefully elevate the
flap there often is some keratocyte activation and
associated interface haze. The haze is corticosteroid sensitive
and resolves with treatment within three to four months.
There is no effect on vision. If the flap appears difficult to
COMPLICATIONS/ 169
Non-dissected Islands
If gas bubbles dissect through the stroma anteriorally, the
bubbles will come to lie between the applanation plate
and the corneal surface. The bubbles will spread ahead
of the advancing propagation of the laser raster pattern
and block the focused femtosecond laser light. This blocking
leaves an undissected zone wherever it occurs. The
interface then is not separable in this area. Forceful
attempts to delaminate the corneal collagen fibers in this
area can result in a tear through to the surface leaving an
isolated island of undissected tissue similar to the central
islands that may occur with blade microkeratome created
flaps. This phenomenon of dissection of gas bubbles
170 / LASIK
COMPLICATIONS/ 171
Keratitis
The second complication is intrastromal inflammation
localized around the edge of the flap which occurs two to
seven days following flap creation. The corneal stromal
tissue becomes hazy or white along the side cut and there
is associated cellular infiltration in the interface and in the
superficial cornea in a narrow band along the edge of the
flap. There may be some associated photophobia.
Presumably this inflammation results from microscopic
cornea tissue damage caused by the laser photo disruption
perhaps exaggerated by exogenous inflammatory factors
in the tear film. Although this process may share some
172 / LASIK
4
Miscellaneous
Topics
Phakonit
and
Microphakonit
Amar Agarwal
Soosan Jacob
Rahul Tiwari
174 / LASIK
Figure 4.1A
Figure 4.1B
Figures 4.1A and B: Phototherapeutic keratectomy (Figure &
Text Courtesy: Jes Mortensen) cornea with Groenows dystrophy
pre- and postoperative after PTK
176 / LASIK
Figure 4.2A
Figure 4.2B
178 / LASIK
Figure 4.2C
Figures 4.2A to C: (A) Posterior chamber implantable collamer
lens. Toric ICL (Figure & Text Courtesy: Alaa El-Danasoury);
(B) The currently used ICL (model V4); note the 4 laser marks
engraved on the haptic: 2 orientation marks on the leading right
and trailing left footplates and 2 alignment marks on either sides
of the optic; (C) An eye with limbal pigmentation and high ICL
vault (about 800 m, red arrow); the ICL was oversized because
the actual the white-to-white measurement (green arrow) was
overestimated by the Orbscan II as Orbscan measurement
included the limbal pigmentation (yellow arrow).
180 / LASIK
Since the ICL was designed so that its haptic plate rests
horizontally on the ciliary sulcus, the length of the ICL
should ideally be equal to the horizontal sulcus diameter.
Nowadays there are 2 main methods to determine the
length of the ICL before implantation; the widely used
conventional method based on white-to-white
measurement and the relatively new method using high
frequency ultrasound imaging devices to measure the
actual sulcus diameter.
The conventional method for sizing of myopic ICL is
based on adding 0.50 mm to the horizontal white-towhite measurement for anterior chamber depth < 3.5
mm and 1.0 mm to the horizontal white-to-white
measurement for anterior chamber depth > 3.5 mm for
the myopic ICL model. In Asian eyes and due to some
anatomical differences from Caucasian eyes, Chang etal
recommended adding 0.5 mm to the horizontal whiteto-white measurement for eyes with anterior chamber
depth d 3.0 m, and adding 1.0 mm for anterior chamber
depth > 3.0 mm.
The white-to-white corneal diameter can be measured
manually with calipers, IOL master or Orbscan. The
conventional method is more widely used than the high
frequency ultrasound method because it is simple and
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ICL Loading
The inside of the insertion cartridge is lubricated with a
viscoelastic material (sodium hyaluronate or methyl
cellulose). The lens is removed from the sealed glass
container and is loaded inside the cartridge preferably
under the surgical microscope. For smooth injection of
the lens, it is important to load the lens with both
longitudinal edges of the haptic symmetrically tucked
under the edge of the cartridge with the lens vaulted
anteriorly, it is also helpful to align the two holes located
on the haptic of the ICL (or the laser engraved axis marks
on the toric ICL) with the longitudinal axis of the cartridge.
The coaxial forceps designed by Aus Der Au for ICL loading
(E Janach, Como, Italy) is used to pull the lens through
the cartridge tunnel. Inspection of the lens inside the tunnel
to exclude twisting of the lens helps making the injection
inside the anterior chamber symmetrical, smooth and
reproducible. If the lens is noticed to be twisted in the
cartridge tunnel it is preferable to take it out and reload
properly.
ICL Implantation
A clear corneal temporal incision is made with a diamond
knife or a metal disposable keratome. The size of the
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Figure 4.3A
Figure 4.3B
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Figure 4.3C
Figures 4.3A to C: Conductive keratoplasty (Figure & Text
Courtesy: Scott G Hauswirth, Elizabeth A Davis). (A) CK machine;
(B) Optical zones for CK; (C) Optipoint insertion
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Figure 4.4A
Figure 4.4B
Figures 4.4A and B: Conductive keratoplasty for post-cataract
surgery astigmatism. (A) Pre- and post-CK Orbscan pictures.
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Note steepening of the central cornea; (B) Agarwal nomogram
for post-cataract astigmatism of a patient with + 1.0 D sph with +
1.5 D cyl at 90 degrees. In this case 8 spots at 8 mm corrects the
sphere and 4 spots at 7 mm corrects the cylinder. These 4 spots
are placed at 180 degrees.
8 Spots
8 mm
+1.25 to +1.75 DS
8 Spots
7 mm
+2.00 to +2.50 DS
16 Spots
7 and 8 mm
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Table 4.2: Agarwals nomogram for post-cataract surgery astigmation
DS
Plano to + 0.75 DS
4 at 8
4 at 7
+0.75 to +1.00 DS
8 at 84 at 8
8 at 84 at 7
+1.25 to+1.75 DS
8 at 74 at 8
8 at 74 at 7
+2.00 to+2.50 DS
16 at 7 and 84 at 8
16 at 7 and 84 at 7
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Figure 4.6A
Figure 4.6B
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Figure 4.6C
Figure 4.6D
Figure 4.6E
Figure 4.6F
Figure 4.6G
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Figure 4.6H
Figure 4.6I
Figure 4.6J
Figure 4.6K
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Figure 4.6L
Figures 4.6A to L: Mirlex:bimanual phaco/phakonit/MICS.
(A) Clear corneal incision made with a special knife (MST, USA).
Note the left hand has a globe stabilization rod to stabilize the
eye (Geuder, Germany). This knife can create an incision from
sub 1mm to 1.2 mm; (B) Rhexis started with a needle; (C) MST
Rhexis forceps used to perform the rhexis in a mature cataract.
Note the trypan blue (blurhex- Dr. Agarwal Pharma) staining the
anterior capsule; (D) Two designs of Agarwal irrigating choppers.
The one on the left has an end opening for fluid (Microsurgical
Technology). The one on the right has two openings on the
sides (GeuderGermany); (E) Duet handles from MST, USA.
The advantage of these handles is that one can change the
irrigating chopper tips; (F) Various irrigating chopper tips designed
by various surgeons. These can be fixed onto the duet handles.
(MST, USA); (G) Phakonit irrigating chopper and phako probe
without the sleeve inside the eye; (H) Phakonit done. Notice the
irrigating chopper with an end opening. (Figure Courtesy: Larry
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Bimanual phaco
Microincision cataract surgery
Microphaco
Bimanual microphaco
Sleeveless phaco.
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Hydrodissection
Hydrodissection is performed and the fluid wave passing
under the nucleus checked. Check for rotation of the
nucleus.
Phakonit
After enlarging the side port a 20 or 21 gauge irrigating
chopper connected to the infusion line of the phaco
machine is introduced with foot pedal on position 1. There
are various irrigating choppers. Depending on the
convienence of the surgeon, the surgeon can decide which
design of irrigating chopper they would like to use.
The Agarwal irrigating chopper with a special design
of Larry Laks from USA has been made by the MST
(Microsurgical Technology) company. This is incorporated
in the Duet system Other excellent irrigating choppers by
various surgeons are present with the same company.
The phaco probe is connected to the aspiration line
and the phaco tip without an infusion sleeve is introduced
through the clear corneal incision Using the phaco tip with
moderate ultrasound power, the center of the nucleus is
directly embedded starting from the superior edge of
rhexis with the phaco probe directed obliquely downwards
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Figure 4.9A
Figure 4.9B
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Figure 4.9C
Figure 4.9D
Figure 4.9E
Figure 4.9F
Figures 4.9A to F: Correcting astigmatism through the use of
limbal relaxing incisions (Figure & Text Courtesy: Louis D. Skip
Nichamin)
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Figure 4.10A
Figure 4.10B
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Figure 4.10C
Figure 4.10D
Figure 4.10E
Figure 4.10F
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Figure 4.10G
Figure 4.10H
Figure 4.10I
Figure 4.10J
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Figure 4.10K
Figure 4.10L
Figure 4.10M
Figure 4.10N
Figures 4.10A to N: Microphakonit (700 micron cataract surgery).
(A) 0.7 mm phaco tip (microphakonit) as compared to a 0.9 mm
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phaco tip (phakonit); (B) 0.7 mm irrigating chopper;
(C) Illustration showing normal anterior chamber when case is
started. Air pump is not used; (D) Illustration showing surge and
chamber collapse when nucleus is being removed. Air pump is
not used. Note the chamber depth has come down. When we
use the air pump this problem does not occur; (E) 0.7 mm
irrigation probe used for bimanual I/A compared to the 0.9 mm
irrigation probe; (F) 0.7 mm aspiration probe used for bimanual
I/A compared to the 0.9 mm aspiration probe; (G) Microphakonit
started. 0.7 mm irrigating chopper and 0.7 mm phako tip without
the sleeve inside the eye. All instruments are made by MST,
USA. The assistant continuously irrigates the phaco probe area
from outside to prevent corneal burns; (H to K) Illustration showing
the nucleus removal; (L) Microphakonit completed. The nucleus
has been removed; (M) Bimanual irrigation aspiration started
with the 0.7 mm set; (N) Bimanual irrigation aspiration completed
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INDEX
Aberropic 66
Ablation diameter 27
Advancements in the treatment of
post-LASIK ectasia 117
Ammetropias 2
Anterior chamber depth 181
Anterior cornea 115
Anterior corneal elevation 20
Artisan implants 40
Autoimmune diseases 46
Behcets disease 47
Deep anterior lamellar keratoplasty
Best corrected visual acuity 66
119
Best-fit sphere 24
Descemets membrane 122
Binocular infrared pupillometers 43 Diffuse lamellar keratitis 151
Bowmans membrane 111
Dioptric curvature 129
C
Complication 103
signs 105
symptoms 104
Amar Agarwal
Soosan Jacob
Early keratoconus 24
Rahul
Ehlers-Danlos
syndromeTiwari
47
E
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Hypermetropia 72
Elevation data 131
Hyperopia treatment 72
Epipolis laser 56
Hyperopic treatment 55, 84
Epithelial cell ingrowth 103
Epithelial fistulas 106
Epithelial ingrowth after LASIK 103
I
Epithelial layer 104
Epithelium barrier 53
Iatrogenic keratectasia 26
Etiology of visual loss 136
ICL implantation 183
ICL loading 183
Intacs segment 118
F
Interference by gas bubbles 166
Femtosecond laser technology 81
gas bubbles in the anterior
Flap complications 136, 140
chamber 166
Flap mobility 57
gas bubbles in the cornea 167
Flap tear 142
non-dissected islands 169
Frank keratoconus 19
unliftable flap 168
Intersected flap 142
Intracorneal ring technology 210
G
Intraocular pressure 27
Intraoperative complications 166
Gebauer product 95
Glaucoma 76
Graves disease 75
INDEX/ 237
Microkeratomes 3
Refractive surgery 15
Monocular infrared pupillometers 43 Residual bed thickness (RBT) 27
Monocular portable infrared
Rheumatoid arthritis 47
pupillometers 42
Rulers and reference diameters 42
Saddle pattern 37
Scheimpflug imaging 35
Severe haze 136
Sub-Bowman keratomileusis 89
Surgical technique 221
P
Penetrating keratoplasty 119
Pentacam ocular scanner 34
Pentacam system 35
Peripheral iridotomies 182
Phototherapeutic keratectomy 107,
126
Polymerase chain reaction 113
Posterior corneal elevation 20
Postoperative complications 170
Predicted phoropter refraction 60
Prevention of diffuse lamellar
keratitis 156
Prolate and oblate cornea 68
Provocative test 159
Q
Quad map 6
T
Technique of phakonit for CA 204
anesthesia 204
hydrodissection 206
incision 205
phakonit 206
rhexis 205
Thickest corneal pachymetry 18
Thinnest pachymetry value 18
Three-dimensional map 11
Transepithelial ablation 142
Treatment of diffuse lamellar keratitis
160
Two point touch 37
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Ultrashort pulse 82
Wavefront aberrations 65
Visante technology 95
Visiogen synchrony 216
Visual field defects 76