Eyeworld

Reporting from the Asia-Pacific Academy of Ophthalmology (APAO) Congress March 1–5, 2017 Singapore EW MEETING REPORTER 182 Dr. Chan offered two techniques for lifting the flap: one for beginners and another for more advanced LASIK surgeons. Beginners should prep, drape, and mark the eye, and initiate flap dissection like an enhancement. He said they should use a two-instrument technique: one to stabilize the hinge and the other to dissect the flap in three parts, which he said uses less pressure. More experienced surgeons can use one instrument, wiggling their way under the flap away from the hinge. Another pearl Dr. Chan offered included locking the eye tracker on the pupil before lifting the flap in eyes with a dark iris where it might be more difficult to see the entrance of the pupil after lifting the flap. Due to advances in the laser systems, the risk of complications in LASIK surgery is very low, said Mo- hamad Rosman, MD, Singapore. However, flap complications can and do still occur. Eye movement and suction loss, for example, can lead to incom- pletely cut flaps. Dr. Rosman said if you're aware of these issues occur- ring during surgery, you can adjust your technique accordingly, dissect- ing those areas carefully to avoid complications. There are few options available to surgeons in the case of a punc- tured flap, Dr. Rosman said. You can have the patient come back another day, or proceed by trying to enter through the other side to continue dissection, avoiding extension of the puncture. In the case of air in the anterior chamber, Dr. Rosman said if the pa- tient doesn't have astigmatism, you can proceed with ablation without the tracker. Or, he added, you can ask the patient to wait a few hours and the air might dissipate. Another extremely rare compli- cation is flap dislodgement. In these cases, Dr. Rosman said it's important to thoroughly clean the eye and remove whatever epithelium there is. Then stretch the flap to try to get rid of any wrinkles. After reposition- ing, have the patient wear a bandage contact lens, he said. Sheetal Brar, MD, Bangalore, India, detailed complication man- agement in small incision lenticule April 2017 extraction (SMILE, Carl Zeiss Med- itec, Jena, Germany). Black spots, she said, are areas where the laser was not able to deliver energy due to meibomian secretions, dirt on the contact lens, marking ink, corneal dryness, or excessive topical anesthetic drops. If you have such black spots, dissec- tion can be difficult. As such, Dr. Brar said the contact glass should be cleaned with a wet sponge, and if that's not possible, it's encouraged to change the contact glass. Management of suction loss depends on the stage when loss oc- curred. If progress of the laser is less than 10%, it is possible to revise the treatment and start over from the beginning, Dr. Brar said. However, if the laser's progress is more than 10%, you need to convert to a LASIK flap. If suction loss occurs during the side cut, cap cut, or incision, a SMILE procedure can still proceed. Avoiding suction loss can be achieved with proper head position- ing, instructing the patient preop to focus on the green light, inform the patient that the green light will dis- appear when done, and countdown the time to help the patient. In addition, Dr. Brar said you dissect the deeper, inferior plane first, it becomes more difficult to dissect the superior plane. Stuck lenticules can be avoided with prop- er identification of the planes and observing the edge during dissec- tion. Infective keratitis highlighted in symposium The Asia Cornea Society Sympo- sium highlighted topics in infective keratitis. Dipika Patel, MD, Auckland, New Zealand, discussed in vivo confocal microscopy for microbial keratitis. With microbial keratitis, early diagnosis is crucial, Dr. Patel said, because late diagnosis can have a poor prognosis for vision and di- sastrous outcomes, including ongo- ing infection, permanent reduction in vision, and a need for corneal transplantation. To diagnose micro- bial keratitis, Dr. Patel said corneal scrape and corneal biopsy maybe be used, but the results of these tests can sometimes take days or weeks to come back. So, she suggested in vivo confocal microscopy (IVCM) as a tool. Advantages of IVCM are that it provides an immediate diagnosis and it's noninvasive, she said. It can be used for Acanthamoeba keratitis and fungal keratitis, though she noted it has limited use for bacterial keratitis. You can image all layers of the living human cornea, Dr. Patel said, noting that it's important to examine the patient at the slit lamp first to direct where you will use the IVCM. You want to try to image near the edge of the epithelial defect, re- gion of epitheliopathy, or infiltrate, she said. Imaging in multiple loca- tions and scanning the full thickness is also a good idea. However, IVCM does have its limitations, Dr. Patel said. It's us- er-dependent and requires a skilled operator. You can also get motion artifacts due to photophobia. An ex- perienced interpreter is also required to use this technology, she said. Dr. Patel then shared clinical examples of using IVCM to diag-

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