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PRK Management Tips from your TLC Clinical Team

posted Aug 16, 2012, 8:20 AM by Jen Weigel   [ updated Aug 20, 2012, 4:55 PM ]
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.
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%.

2.  Do not ask your patients to take the BCL off with their fingers.  In fact, don't take the BCL off with YOUR fingers.

3.  Do not alter the FML regimen and if you have reason to... please consult with TLC prior to making those changes.

4.  Lubricate, lubricate, lubricate!

5.  Have patience!

6.  Don't panic if you initially refract an increase in cyl.  It should be temporary.

7.  DO NOT remove the BCL day one to see how they are doing!!!

8.  When you do remove it, look at them again, maybe let them sit a few minutes and check again.  Make sure the epi stays on before they leave the office.  If loose, reinsert a new BCL.

9.  Lubricate.  Especially the day the BCL comes off.

10.  If we did PRK due to basement membrane dystrophy, Muro ointment at bed once BCL off.  Celluvisc for everyone else.


11.  Prepare the patient pre-op for their visual progression.  It’s a long slow process.

12.  DON'T refract the first month.  It doesn’t matter.  It just makes the patient worried.

13.  If the epithelium/wound is not closing, contact the Center.

14.  I was scared to manage PRK patients until a refractive surgery mentor of mine put it this way. She asked me, “Have you ever managed an abrasion with a BCL?”  When I replied yes, she told me that I had managed PRK already.  If you ever have questions during your first few cases of PRK management, call the Center at any time with any questions.  We’ll walk you through cases until you are comfortable!

15.  Manage expectations properly.  I tell patients that the first 5 days or so are going to suck because of the discomfort and blurred vision.  After that, they’ll feel TONS more comfortable, and their vision will slooooooooowly get better over the course of weeks.  Don’t tell your patient that they are done healing at two weeks with PRK!  I’ve seen patients return for their one-year check with improvement over their 6-month post-op.

16.  Check IOP while the patient is on their FML schedule.  Sometimes it’s easy to forget this step since our minds are in “refractive surgery” mode, but it’s still very important.

17.  When managing PRK over a previous LASIK flap, it’s possible to develop DLK within the flap.  Be on the lookout for this possible complication.

18.  Be on the lookout for corneal haze as a late post-op complication.  Certain patients are more likely to have corneal haze:  higher prescriptions, increased UV exposure, increased skin pigmentation.  For these patients, we up their Vitamin C up from the usual 1000 mg/day to 2000 mg/day.  We emphasize the importance of UV protection also.

                                Corneal haze s/p PRK.


19.  If the patient has EBMD, use Muro ung qhs for at least a week after BCL removal to help with epithelial healing.

20.  If we recommend PRK as the procedure of choice for your patient and the patient calls you for advice on this, play up the great parts of this procedure:  less complications, less dryness, less glare and halos, and PRK patients tend to subjectively like their vision better.


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