by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer
Nightmare scenarios in refractive surgery
31
EW SHOW DAILY
ASCRS•ASOA Symposium & Congress, New Orleans 2016
A
ll the nightmares came on
the 4th day of the 2016
ASCRS•ASOA Symposium
& Congress in a video-
based course in refractive
surgery. A "galaxy of stars"—the
presenters are "no less than stars,"
said course director Athiya Agarw-
al, MD, Chennai, India—presented
their worst-case scenarios and how
they managed them.
Relative nightmares
Sometimes, Dr. Agarwal said, the
nightmare is purely mental. She
recently had to treat a cousin for bi-
lateral keratoconus with crosslinking
(CXL). Although her cousin's first
eye was crosslinked without a hitch,
she later came back after having
the second eye done due to severe
corneal haze.
Soosan Jacob, MD, Chennai,
India, who had crosslinked the pa-
tient, also took on the management.
Dr. Jacob treated the eye systemical-
ly with intravenous methylprednis-
olone 1 g once a day for 3 doses and
oral steroids 1 mg/kg body weight/
day for 11 days and topical prednis-
olone acetate and lubricants hourly,
and cyclosporine 2% and tacrolimus
twice daily.
Dr. Agarwal said that post-CXL
haze occurs in 10–90% of patients,
usually temporary with crosslinking
up to 60% depth. The haze usually
decreases in severity from 6 months
to 1 year and is associated with the
amount of keratocyte loss, corneal
epithelium debridement techniques,
and other factors. She said that it is
caused by changes in the crystalline
proteins of migratory keratocytes,
leading to an increased scattering of
light and a possible increase in haze.
In this particular case, the haze
was causing non-uniform applica-
tion of ultraviolet radiation—the
machine had fallen and had to be
replaced during the procedure.
However, the real nightmare,
Dr. Agarwal said, was the nightly
streams of angry messages from
her cousin's daughter, which lasted
through the entire 2 months of her
cousin's treatment.
To prevent haze, Dr. Agarwal
recommended avoiding very thin
corneas, avoiding very steep cor-
neas, avoiding poor ocular surfaces
and dry eyes, adding a pre-corneal
riboflavin film, possibly leaving the
epithelium on, and calibrating, cal-
ibrating, calibrating your machines
and instruments.
continued on page 35
