More PRK procedures:
Over the past year, we've actually more than doubled the amount of PRK procedures performed. To be exact, at least in Tysons Corner, this number has gone up from 7.35% to 17.4% in the last year. Since we're all under Dr. Holzman's leadership, it's likely that TLC Rockville and Charlottesville have experienced similar shifts.
A lot of this has to do with how we analyze a patient's Pentacam Quad Map and the Belin Ambrosio Display which builds off Quad Map data and also compares the patient to a normative database. The better that normative database becomes and the more trend analysis you can do with that data, the more we know about the good old cornea. By default, it also becomes harder to be classified as completely 100% "normal" to qualify for LASIK, and thus PRK frequency goes up, most especially for younger patients and those with higher prescriptions.
Because we've done more PRK procedures, we have also been getting more PRK management questions from Affiliates. Dr. Holzman does plan on doing a PRK CE soon. He'll touch on it lightly at the VOA Fall Conference for which he is a speaker on Sunday late morning.
To hold you over until then, let's review some expecteds during the post-op period and then review some management tips.
Expecteds:
Discomfort: Tell your patient to expect their discomfort level to be maximal on Days 2-3 post-op. It's nice for patients to know this ahead of time so that they know it to be normal.
Vision: During the same period that their discomfort is at its peak, also expect their vision to be blurriest.
At your post-op visits, there are some general trends for expected VAs. The lower the pre-op rx, the better their vision will be compared to below. The higher the pre-op rx, the blurrier their vision will be compared to below.
Day 1 post-op: 20/50-60
Day 5 post-op: 20/40-50
2 weeks post-ops: 20/30-40
1 month post-op: 20/20-25
Management Tips:
I've quizzed all the TLC Clinical ODs to come up with a list of PRK management tips. They are listed in no particular order of importance. If there is a duplicate response, that just underlines the importance of that tip. : )
1. Do not take BCL off before epithelium has healed 100%. 11. Prepare the patient pre-op for their visual progression. It’s a long slow process.
19. If the patient has EBMD, use Muro ung qhs for at least a week after BCL removal to help with epithelial healing.
21. Refract at 1-month post-op and onward. Refracting earlier will only lead to anxiety for you and your patient. Refracting earlier will result in an MR that has lots of cylinder and the sphere will be off.
22. Don’t treat PRK like a second class procedure like some patients mistakenly perceive it to be. PRK really is more appropriate for specific patient populations, just like LASIK.
23. For patients in certain occupations or sports, prepare them for PRK before they come to TLC so that the patient is not shocked when we discuss it with them. Examples of occupations that are better suited for PRK would be military or some types of law enforcement. Examples of hobbies that are better suited for PRK would be martial arts, rugby, MMA.
24. For BCL removal, it is ideal to use forceps to remove the BCL at the superior edge of the BCL while the patient is looking inferiorly. You can use topical anesthesia or not. Instill some artificial tears prior to BCL removal to help lift the lens.
25. What exactly are you looking for when you evaluate the cornea post-PRK: clear cornea (no signs of infection or abnormal healing … the only exception might be a prominent healing line that might look opaque), no conjunctival injection.
26. If your patient has increased photosensitivity at the one-day post-op visit, instill one drop of your strongest cycloplegic drop OU.
27. Remember Dr. Holzman’s FML taper: qid x 3 weeks, tid x 1 week, bid x 1 week, qd x 1 week, then stop. Tapering early or late will alter the refractive endpoint.
28. The higher the patient’s pre-op prescription, the longer it takes for them to heal from PRK. For example, a -1.00 myope might hit 20/20 at 2 weeks out, but a -8.00 myope might take up to 2 months to reach their endpoint. Reassure your patient during this healing time.
29. Dr. Holzman tries to avoid hyperopic PRK whenever he has the option to do so. Not as reliable as a myopic PRK.
30. When might Dr. Holzman consider doing PRK enh over a previous LASIK flap: when the flap margin is not visualized, when the flap margin is visualized but irregular, when the flap was originally created with the microkeratome. - jw |
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