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March 2012 Refractive February 2011 EW FEATURE 91 priately sized so that practitioners don't cut too close to the limbus. When laying the bigger hyperopic flap back down, he suggested care- Tricks for avoiding intraoperative ingrowth In keeping ingrowth at bay, Dr. Desai suggested the following: • Avoid giving the patient too many anesthetic drops • Make sure that the anesthetized patient is not sitting around for long periods before treatment • If there's an epithelial abrasion at the flap edge, brush the epithelium back and place a contact lens • Irrigate just the right amount, making sure that there are no cells under- neath the flap or at the edges, but not so much as to swell or thicken the flap • After the flap is down, squeegee any fluid toward the edge to maximize flap adherence Poll Size: 593 fully examining the margins of the bed and the flap and making sure that you don't see epithelial material anywhere. Dr. Desai suggested an ovoid flap may be one appealing option, particularly in hyperopic cases. "That seems to allow us to have a wider diameter flap to avoid the ab- lation zone or the treatment zone or the blend from interfering with the edges of the flap," he said. Another possibility might simply be to in- crease the diameter of the flap and shift to a temporal hinge to limit the number of corneal nerve bundles cut, forestalling dry eye, which may predispose patients to ingrowth. How the flap is made may also be an important factor here. "Micro- keratomes famously give you a shal- low sloped flap architecture, which allows the path of least resistance for those epithelial cells to go straight downhill," Dr. Desai said. "The femtosecond laser, in particular the IntraLase (Abbott Medical Optics, AMO, Santa Ana, Calif.), is one of the other technologies that is allow- ing us to do either a very steep side cut or a 70- or sometimes an 80-de- gree side cut." With the IntraLase, Treating continued from page 89 this would exclude many people who could have done well. But pa- tients should at least know about this risk. I'd say 90% of my [neural- gia] patients have thoughts of sui- cide. Just imagine, you open your eyes in the morning and you know the whole day you're going to have tremendous pain. The despair is in- credible." Although this disease can be de- bilitating, it's important to stress its rarity. Some patients with autoim- mune disease may develop corneal neuralgia, but certainly not all. Corneal neuralgia may need further study before refractive surgeons begin to list autoimmune disease as a decisive contraindication for sur- gery. We do know enough about the disease, however, to say with ab- solute certainty that these patients aren't crazy. "The most important thing is these patients aren't dismissed," Dr. Hamrah said. "Just because you can't see it on the slit lamp doesn't mean it's not there. It's important, if [pa- tients have] symptoms, to send them to centers that have the capability of analyzing them further instead of just telling [them], 'It's nothing.'" EW Editors' note: The doctors mentioned have no financial interests related to this article. Contact information Cason: john.cason@med.navy.mil Hamrah: pedram_hamrah@meei.harvard.edu Rosenthal: perry.rosenthal@comcast.net he pointed out it is even possible to do a reverse bevel keystone cut, which locks the flap in and prevents continued on page 92 Question 2 Question 3 Question 4 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-6 question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email ksalerni@eyeworld.org and put EW Pulse in the subject line; that's all it takes. Copyright EyeWorld 2012 Question 6 Question 7