EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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Refractive March 2012 Stomping continued from page 91 LABS epithelial ingrowth. However, all femtosecond lasers are not the same. "It's buyer beware in that some femtosecond lasers do still give you somewhat of a sloped flap architec- ture," Dr. Desai said. One innovative method for ASCRS 2012 Booth #1824 Stab Knives for Side Port or Scleral Incision 15, 22.5, 30, 45 degree Phaco Slit Knives for Clear Corneal or Scleral Incision 2.5, 2.65, 2.75, 2.85, 3.0, 3.2, 3.5 mm Crescent Knives for Scleral Tunnel Incision 2.0 mm MVR Knives for Vitreoretinal Infusion Port for Paracentesis Incision 19, 20, 23 GA Straight 20, 23 GA Angled Clear Corneal Knives 2.75, 3.0, 3.2 mm Clear Corneal Knives, Parallel Sides 2.75, 3.0, 3.2 mm Double Bevel Sideport Knives 1.0mm, 1.2mm, 1.4mm 10201-A TRADEMARK STREET, RANCHO CUCAMONGA, CA 91730-5850 USA Toll Free: 800 782-6534 Ph: 909 481-0011 • Fx: 909 481-4481 FM 71198 www.eaglelabs.com • email: goeagle@eaglelabs.com © Eagle Laboratories 2012 0483 Yes! I Would Like To Evaluate A Sample Of The Following: The Complete EAGLE Ophthalmic Product Catalog Name Address Ci t y Phone# State Contact Name Please Return to Eagle, At tent ion: Customer Service Zip forestalling epithelial ingrowth after a LASIK enhancement is a technique dubbed flaporhexis, developed by Steven E. Wilson, M.D., professor of ophthalmology, Cole Eye Institute, Cleveland Clinic, Cleveland. Dr. Wilson reported on the technique in the January issue of the Journal of Cataract and Refractive Surgery. How- ever, he has been doing the tech- nique since as far back as 1998. With the technique, practition- ers mark the edges of the flap. Dr. Wilson uses a 3-mm circle with gen- tian violet in conjunction with a Sinskey hook. "If you take the Sinskey hook and press it into the epithelium at the limbus, drag it to- ward the center, you'll actually feel the flap edge," Dr. Wilson said. "The Sinskey hook will kind of catch right there and you know that's the edge of the flap." Then practitioners can go back and forth at that one spot one clock hour and open up the flap edge. He recommended tugging the edge of the flap a bit toward the cen- ter to demarcate this. Then he sug- gested using forceps to grasp the exposed edge and lift and peel it back to create a very smooth, per- fectly torn edge. Many times it is possible to then go on to the en- hancement. Other times there may be a little resistance. "If you feel you don't want to tug on it any more after you get about halfway back, you can use a tri-cellulose sponge and just by pressing on the flap you could press it back all of the way," he said. "After the laser ablation you take the cellulose sponge and go all the way around the edge of the flap and make sure that you haven't left any epithelial tags over the edge of the stroma." With this technique Dr. Wilson finds epithelial ingrowth is virtually unheard of. Innovative treatment options Of course, even with the best tech- niques practitioners may still find themselves battling an ingrowth case. Dr. Desai has found that one good way to combat this is to use ethanol on a Weck-Cel spear. He scrapes the back of the flap and the bed and uses the spear to devitalize any remaining epithelial cells. He also urged consid- ering 10-0 nylon suture use to make sure the flap remains down for those who feel that they can do so without creating stria. Jorge L. Alio, M.D., professor and chairman of ophthalmology, Miguel Hernandez University, Alicante, Spain, and medical direc- tor, Vissum Corporation, Alicante, has pioneered the use of the YAG laser in epithelial ingrowth cases. With the technique, practition- ers position the patient under the YAG laser and choose the smallest spot possible using minimal energy to begin. This is increased until a visible bubble is seen at the inter- face. Dr. Alio finds that 1.5 milli- joules of energy is usually sufficient here. "Once you have a bubble and the bubble is at the level of the ep- ithelial ingrowth, then you start doing the same in the surrounding areas," he said. "These bubbles have to be one by the other, not overlap- ping." In addition to the bubble itself, the shockwave destroys epithelial cells, allowing practition- ers to keep the needed number to a minimum. "I always start with the fistula, defining this as the place you know that most epithelial cells have been percolating inside the inter- face," Dr. Alio said. He stressed, however, that there are two different types of epithelial ingrowth—one composed solely of cells and the other of cells and mucin. Cases involving mucin are the one indication he sees for flap lifting. Otherwise, Dr. Alio has been very successful with the technique, which he stressed can be repeated if needed. Overall, Dr. Desai worries that with older patients becoming more interested in refractive options for cataract surgery and the like, if prac- titioners aren't careful, ingrowth rates will climb. "We're going to see a rise in rates of epithelial ingrowth if we're not careful to screen the pa- tients, adjust our treatment plan- ning, adjust our intraoperative technique, or guide the patient to a different option," he said. EW Editors' note: Dr. Alio has no financial interests related to this article. Dr. Desai has financial interests with Alcon (Fort Worth, Texas) and Bio-Tissue (Miami, Fla.). Dr. Packer has financial interests with AMO and Bausch + Lomb (Rochester, N.Y). Dr. Wilson has no financial interests related to this article. Contact information Alio: 34 670 33 33 44, jlalio@vissum.com Desai: 727-518-2020, desaivision@hotmail.com Packer: 541-687-2110, mpacker@finemd.com Wilson: 216-444-5887, wilsons4@ccf.org