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LASEK / EPIFLAP INSTRUCTIONS

 
  1. Proxymetacaine minims for anaesthesia - put in 5 mins pre op as well.
  2. 18-20% ethanol (usually made up as one part of 98% ethanol diluted with 4 parts of water) or, preferably, in BSS for 30 to 40 secs. (45 secs for re-treats). 9mm zone marker for myopia and 10mm for hyperopia. Slightly de-centre upwards if necessary to avoid hinge impingement. We keep the alcohol in the fridge until just before the surgery.
  3. Soak up the alcohol with spear. Wash  the epithelium with BSS and dry the margins to delineate the flap edge. The main idea is to keep the epithelium viable.
  4. (For high myopes, cool the cornea with the "Easifreeze" or similar).
  5. Make the flap, starting at 6 o’clock, using any suitable instrument. ( blunt spatula, back side of Beaver blade or spear)
  6. Do the ablation. Wash with BSS  straight from the fridge.
  7. One can now do a PTK polish of about 3-5 microns using a suitable masking fluid. Especially important for hyperopia as the surface is rougher. Some lasers are better than others.
  8. (Put a couple of drops of Voltarol or steroid  onto the cornea - optional)
  9. Float the epithelial flap back onto the cornea, rather like a LASIK. I use the BSS bottle with a Rycroft canula on it. Don’t be too rough with the epithelium. Dry it a little at the edges with a dry spear. The endothelium cell pump will suck it on like a LASIK flap. The flap is sometimes a bit bigger than the hole it came out of due to oedema and stretching. If using a contact lens it is  not necessary to trim the flap to size as it will shrink with time. (without a contact lens it should be trimmed to keep it lying flat on the cornea; this avoids it wrinkling up with blinking).
  10. Put on a silicone contact lens – high dK. G CPL from minim stat. Day and Night plano from Ciba Vision is the best I have found.
  11. Post op instructions as per attached sheet. Diluted proxymetacaine is made up by sucking up one drop of proxymetacaine into a minim of saline). Non-preserved drops are better than those with preservative.
  12. Remove lens on day 3 or 4. 
  13. Take off lens with care, pulling downwards with forceps at the slit lamp. Wet the cl first with proxymetacaine or saline. If done too roughly there is a risk of tearing off some of the epithelium.
  14. It is probably a good idea for the patient to use some Oc Chloramphenicol at night for a few days after the lens removal.
  15. Steroid drops – use is contentious,  as is which strength to use. However, for high myopes, I think that it is reasonable to use FML QDS from day 7 until the next post-op visit.
  16. Next visit in 4 weeks. 

SJD Dec 2002