Eyeworld

EW REFRACTIVE SURGERY 36 May 2016 by Mitchell Gossman, MD Some feel a tighter contact is more comfortable, and others feel the opposite. I have observed that an uncomfortable tight contact replaced with a loose one, and vice versa, may help. However, many commented that routine replace- ment of a contact the first day helps with comfort. The fourth question was, "What brand of contact as a bandage lens do you normally use?" The prevailing opinion is that a dry stromal bed will result in deeper ablations and a wet stromal bed will result in less deep ablations. Person- al nomograms can account for these technique differences and even prevailing humidity. I personally perform no intraoperative wipe in an effort to have a uniform stromal ablation, unless obvious pooling is visible. Part 2 of a 2-part series I n this month's column, we con- tinue the discussion started in the April 2016 issue of EyeWorld on how ophthalmologists are performing refractive surgery. A survey was performed of 34 practicing ophthalmologists who volunteered to participate from the ranks of participants of the eyeCONNECTIONS online commu- nity and volunteers around the U.S. Responses are anonymous in order to encourage candor. There were fewer respondents in this follow-up survey perhaps because primarily LASIK surgeons opted not to partic- ipate. The first question was, "After epithelium is removed via your favored method, how do you prepare the stromal bed?" How does PRK fit into our refractive practices and how are we performing it? Pulse of ophthalmology: Survey of clinical practices and opinion Wipe with a dry spear to obtain a uniform appearance 35% Leave it alone if it looks normal, i.e., uniform appearance 29% Wipe with a slightly damp spear (i.e.,moistened then squeezed out thorough- ly) to obtain a uniform appearance 27% Wipe with spatula for a uniform appearance (write-in response) 6% Wipe with a fairly wet spear to obtain a uniform appearance 3% The third question was, "What 'tightness' of your contact do you prefer?" Until appears epitheliali- zed through the contact 50% At a specific number of days unless not yet epithelialized 44% Remove contact at each visit, eliminate when epithelialized via direct observation 6% Loose, i.e., larger base curve 48% Tight, i.e., small base curve 39% Based upon preop Ks 13% Based upon predicted postop Ks 0% Acuvue Oasys (Johnson & Johnson Vision Care) 76% Air Optix Night & Day (Alcon) 18% PureVision (Bausch + Lomb) 3% O2 Optix (Formerly Ciba, no longer produced) 3% The fifth question was, "If you always, or from time to time, use alcohol-assisted epithelium removal, what method do you use to apply the alcohol?" The sixth question was, "What form of alcohol do you use?" "LASEK well" 64% Alcohol-soaked round sponge 36% Yes, some purchase Everclear from a liquor store and draw the almost pure ethanol from the bottle. My own practice is to use pharma- cist-prepared 95% ethanol in a stan- dard vial with rubber seal and dilute as desired. In my opinion, for PRK, there is no reason to spend extra on 100% pure absolute alcohol since you are going to dilute it with water, and the difference in effect between the eutectic 95% ethanol and 100% pure chemical reagent quality is not significant. The seventh question was, "What percentage of alcohol is closest to what you apply?" Ethanol from a pharmacy 48% Isopropyl alcohol from a pharmacy 14% Isopropyl alcohol from the drug store 14% Ethanol from a chemical reagent supplier 7% Isopropyl alcohol extract- ed from sterile isopropyl alcohol "skin prep pad" 7% Isopropyl alcohol from a chemical reagent supplier 3% Ethanol from the liquor store (such as Everclear) 0% The eighth question was, "Do you apply multiple drops of an- esthetic in an effort to loosen the epithelium before removal?" 20 41% 80 14% 30 10% 40 7% 70 7% 100 (absolute alcohol) 7% The ninth question was, "What do you usually use to scrape off the epithelium? Pick the one that does most of the work if you use multi- ple. Skip if you use the Amoils on all." Yes 62% No 38% The tenth question was, "Do you feel that adjusting steroids can modulate the refractive result?" Tooke knife or similar blunt tool 42% Cellulose spears 11% LASEK hoe 6% As always, the patient decides what he or she wants. If you and the patient are attracted to the safety aspects of PRK—especially for some occupations and vocations such as police, boxers, and other profes- sional athletes (Roman Harper of the Carolina Panthers recently had his LASIK flap dislodge from a hit during the NFC Championship)— you should go that route. But if the patient cannot afford to be visually compromised for several weeks, either do 1 eye at a time with PRK or proceed with LASIK. I hope this survey will help validate your own good practice and perhaps inspire you to try alter- native methods. EW Editors' note: Dr. Gossman is in private clinical practice at Eye Surgeons & Physicians, St. Cloud, Minnesota. He has no financial interests related to his comments. Contact information Gossman: n1149x@gmail.com Yes 52% No 48% 95 (conventionally "pure" azeotrope alcohol from suppliers) 3% The second question was, "If you use a bandage contact lens, how long do you leave it in place?" Mitchell Gossman, MD

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