Q&A with Dr. Holzman

Dr. Holzman answers our questions about Laser Vision Correction in this section of OD Central. Actually, it is important to give him credit where it's due.  This section was actually Dr. Holzman's own idea!  

Every month, we'll hit him up with a series of questions covering the basic to advanced.  Stop by regularly to see what he has to say!

Also, if you've ever thought of a question that you wanted to ask Dr. Holzman, just let me know what it is, we can work together to develop a series of questions building off of yours, and then check back here for the answers!


  1. 1 Dry Eye Q&A
    1. 1.1 What prompted you to consider this change in artificial tears?    
    2. 1.2 How does using the IntraLase laser help you minimize dry eye symptoms post-LASIK?
    3. 1.3 Should PRK be a consideration for patients with moderate dry eyes pre-op and why?  
    4. 1.4 What are some risk factors that make a patient more prone to having dry eyes post-LASIK?  How does using Restasis proactively help these patients?   
  2. 2 Flap Striae Q&A
    1. 2.1 What is the best way to prevent striae?   
    2. 2.2 What are some ways to detect striae?
    3. 2.3 Once you have detected striae at your post-op visit, what should you do?
    4. 2.4 How is post-op monitoring different after a lift and stretch?
  3. 3 Adhesion Test Q&A
    1. 3.1 What is the adhesion test?  
    2. 3.2 How does the adhesion test help you decide what procedure the patient should receive and why?
    3. 3.3 Who is likely to have a positive adhesion test?  What are some ways to detect EMBD?
    4. 3.4 Had a patient with a positive adhesion test gone forward with LASIK without proper preparation or being switched to PRK, how would their LASIK results have been affected?
  4. 4 PRK Q&A
    1. 4.1 If you guessed that Dr. Holzman has been doing more PRK lately, you'd be right.  Is there any reasoning to this or is it just random?
    2. 4.2 Who is most likely to benefit from PRK?
    3. 4.3 What about your technique limits a patient's discomfort?
    4. 4.4 Who would not be an ideal PRK candidate?
  5. 5 Topography Q&A
    1. 5.1 I have a topographer in my practice to fit contacts.  What is better about the Pentacam?
    2. 5.2 How does Orbscan and Pentacam technology compare?  
    3. 5.3 What is a BAD display?
    4. 5.4 Is the Pentacam good for anything besides LASIK? 
  6. 6 Eye Rubbing Q&A
    1. 6.1 How does eye rubbing affect the eyes?
    2. 6.2 How does eye rubbing differ from keratoconus vs allergies?
    3. 6.3 Do you ask every patient about eye rubbing habits?
    4. 6.4 For average "oh, i'm so tired so i'm gonna rub my eyes" eye rubbing ... When could a patient do this without having to worry about moving their flap?

Dry Eye Q&A

With the recent change in protocol to using Refresh Optive Advanced, I asked Dr. Holzman a series of questions about dry eyes and refractive eye surgery.  I know dry eyes seems like such a played out topic, but you have to admit that it impacts a pretty large proportion of our patients!

What prompted you to consider this change in artificial tears?    

Thank you to all of the Doctors who participated in our survey by voicing their own opinions.  We used all of this data in making our decision to move to Refresh Optive Advanced.

The lipid layer is largely ignored by many of the artificial tears on the market, and as you all know, this is the outer layer of the tear film.  With Optive Advanced, the lipid component is bolstered and fortified and helps to decrease evaporative dry eye. This type of dry eye is many times due to computer usage, air conditioning or heating vents, fans, or simply larger apertures.  I personally tried the new Refresh Optive Advanced and found it to be very comfortable and long lasting without causing significant blur. 

How does using the IntraLase laser help you minimize dry eye symptoms post-LASIK?

The IntraLase creates planar-shaped flaps as opposed to meniscus-shaped flaps with a microkeratome.  This means that the peripheral flap thickness with IntraLase is the same as the central thickness - NOT twice as thick as can be the case in microkeratome flaps.  With less corneal tissue disrupted in the periphery, there is less disruption of the corneal nerves and neural loop which regulates tear function and lacrimation.  

Should PRK be a consideration for patients with moderate dry eyes pre-op and why?  

PRK has been shown to disrupt even fewer corneal nerves in the periphery than IntraLase, so if a patient has moderate to severe dry eye pre-op, PRK may be more appropriate.  However, with the use of Restasis, omega three fish oils and lubricants like Refresh Optive Advanced pre-op, many of these patients do quite well with LASIK.

What are some risk factors that make a patient more prone to having dry eyes post-LASIK?  How does using Restasis proactively help these patients?   

Patients at higher risk for post-op dry eyes include patients that: have problems with their contact lenses, experience burning or stinging late in the day, have larger palpebral fissures, are over the age of 40, are female, have hyperopic prescriptions, or use medications known to contribute to dryness, like anti-depressants or anti-histamines.  We use Restasis pre-op for a few weeks and continue it post-op for a few months.  Restasis reduces inflammation in the lacrimal gland and likely also at the level of the conjunctival goblet cells.  This allows for a more healthy ocular surface and more consistent post op results. 

Check back periodically as we ask Dr. Holzman more clinical questions!  - jw

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Flap Striae Q&A

This time, we asked Dr. Holzman about a rare complication from LASIK surgery, flap striae.  For those of us lucky enough to have Dr. Holzman as our go-to refractive surgeon, this is indeed a rare complication because of his more-than-detailed surgical technique.  Every now and then, though, a patient might rub the flap by accident leading to striae.  This Q&A session reminds us about striae management.

What is the best way to prevent striae?   

The best form of treatment for striae is prevention. Meticulous surgical technique with an IntraLase-created flap should ensure a secure fit similar to a manhole cover in a manhole. I make sure flap edges are perfectly apposed to the outer bed edges and check for any small signs of misalignment. I use a marker on both sides of the wound to help with this alignment. These marks, along with a careful gutter check, will make extra sure that the flap is entirely secure and in proper position. Even small misalignments that aren't enough to create striae can affect best-corrected visual acuity as well as cause resultant chronic glare.
I also believe that using a superior-based hinge is helpful in striae prevention, especially in patients with active, strong blinks.  The vector forces are 'smoothing' and in line with the hinge axis with a blink in asuperior-hinged flap, as opposed to a 'crossing force' across the hinge axis if a nasal hinge is employed.

What are some ways to detect striae?

Striae are most likely to be detected at the one-day post-op visit.  There are a few good ways to detect striae.

Flap striae 1-day po

First, close visual observation using the slit lamp biomicroscope is imperative.  Retroillumination of striae though a dilated pupil is often helpful if the striae are not readily visible on routine evaluation.  Be especially mindful of striae when the uncorrected visualacuity does not match what you expect it to be.  Also, be sure to document pertinent negatives in this clinical situation, too.
If you were to observe striae at your post-op visit, the next step is to determine if the striae affect best-corrected vision.  While we usually do not refract on the 1-day visit, if you detect striae and the vision is not 20/20, an MR is valuable in detemining proper management.  Striae affecting vision will result in loss of best-corrected visual acuity on MR.  Another easy check is to do an auto-refraction.  These patients often have a lot of unexpected cylinder if the striae are prominent.  Striae that is affecting BCVA should be referred in ASAP for surgical correction.

Once you have detected striae at your post-op visit, what should you do?

If you suspect that your patient will need a lift and stretch to correct the flap striae, please call the Center ASAP and also remember to fax in your post-op findings.  Please also educate your patient to bring a driver to their same-day appointment to help with getting home after the procedure.
When I see significant striae that is symptomatic and across the visual axis, the faster we intervene surgically the easier it is to regain all BCVA.  I like to lift the flap and then apply significant force on the back surface of the flap in the axis opposite of the striae to stretch them out.  I also do the same on the front surface.  I am careful to remove all epithelium that has grown into the bed and onto the back surface of the flap.  I use a BCL and then place a pressure patch for 10 minutes immediately post-op.   Most often, this approach removes all striae and allows for rapid recovery of vision once the BCL is removed the next day.
For the eye that has had striae corrected, the medication cycle startsfrom Day 0 again.

Lift and stretch procedure by Dr. Holzman


How is post-op monitoring different after a lift and stretch?

In the rare instance that a patient actually has striae, their post-operative care is essentially unchanged.  The BCL placed on the eye after the lift and stretch is usually removed on the following day. Remind your patient not to rub the eyes.
Future follow-up appointments are at the same intervals as previously planned.  At each visit, you will expect the vision to slowly improve, and for the vast majority of patients, the original refractive endpoint is still met despite having had the striae.  Be mindful of other complications like epithelial ingrowth and DLK.  - jw 08/04/12 
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Adhesion Test Q&A

Many of you have taken time of your busy schedules to visit us at the Center on a surgery day.  After observing Dr. Holzman in the OR, we usually try to get some clinical observation into the visit.  One of the big topics that I like to cover is the Adhesion Test.  This is quite a unique clinical test that Dr. Holzman has taught me.  It one of the "secrets" to his surgical success!  This month, we asked Dr. Holzman to talk more about the Adhesion Test.

What is the adhesion test?  

The adhesion test is a way to look for a weak epithelial/basement membrane attachment, just as occurs in EBMD. 

A significant portion of EBMD is subclinical, i.e., unable to detect via slit lamp exam.   In order to find the subclinical variety, use a topical numbing agent, wait approximately one minute or so, and then gently and carefully swipe a weck-type sponge across both the superior and inferior epithelium.   If there is abnormal, weak attachment, the epithelium will shift or wrinkle.   A normal surface will not move at all. 

TLC ODs will perform this test on every patient that is considering LVC.  Here are some pictures of adhesion test results.

           Negative adhesion test:  After manipulating the epi, there will be SPK in that area.

Positive adhesion test:  After manipulating the epi, you can see the epi heaping up and the NaFl settles into that area.  Had we continued to move the epi, we would have created an abrasion.

(It's hard to take a photo of a wrinkled epithelium.  When the sponge is on the epi, you can see that the epi wrinkles, but when the sponge is removed, the epi bounces back into place.  I suppose we could do this if there were two of us in the room ... one to hold the camera and one to manipulate the epi.  Hmmmm ... I'll work on that one.  - jw)

How does the adhesion test help you decide what procedure the patient should receive and why?

Positive adhesion tests signify a weak epithelium or basement membrane attachments.  This places a patient into high risk category for epithelial disruptions during LASIK flap creation and lift.  These patients will most likely get PRK to avoid epithelial defects on LASIK flaps.  It is extremely important to avoid epithelial defects on the LASIK flap, as this complication can be followed by many other complications, making for an unhappy patient experience and complex management challenge.

Those with wrinkled epithelium on the adhesion test will receive slough precautions.  Pre-operatively, they will use Muro128 drops tid and Muro128 ung qhs for two weeks.  This will help to strengthen the epithelium.  On the day of surgery, we will use proparacaine judiciously.

Negative adhesion test results are by far the most common.  For patients over 35 years of age, those with red hair, and those with fair complexions, these patients will all be asked to use Muro128 ung qhs for one week pre-op. 

Using the adhesion test and Muro pre-operatively has helped decrease my rate of epithelial defects on LASIK flaps significantly. 

Who is likely to have a positive adhesion test?  What are some ways to detect EMBD?

After doing the adhesion test for a while, you'll start to get an idea of who might have a positive test.  Examples include older patients and those with EBMD.

Observing EBMD is sometimes difficult.  Sometimes, direct illumination is all you will need to observe epithelial changes in advanced EMBD. 

For more subtle EBMD, you can always stain the cornea and look for a ridge-like pattern to the epithelium.  Another trick is to do a TBUT to check for tear stability and EBMD.  If there is one location that consistently breaks up, I do the adhesion there as this spot might indicate subtle EBMD.  These are the best ways to look for EBMD other than direct observation.

Here are some photos of EBMD:

    On this view with direct illumination, you can see some subtle changes to the epithelium.

When NaFl is instilled, you can easily see the ridge-like pattern of the uneven epithelium created by diffuse EBMD.  This is the same patient as in the picture above.

Had a patient with a positive adhesion test gone forward with LASIK without proper preparation or being switched to PRK, how would their LASIK results have been affected?

An epithelial defect on the LASIK flap usually requires a BCL (which is usually removed on Day 1 post-op with forceps) and a slower visual recovery until epithelial edema settles.   This can mean an unhappy patient and a more challenging co-management experience.

There are number of complications that can follow an epithelial defect on a LASIK flap.  Some complications include:  irregular epithelial healing; increased glare and halos; blurred vision; loss of contrast; delayed healing; increased risk of DLK, infection, epithelial ingrowth; and decreased patient satisfaction.  Because so many things can happen after an epithelial defect, I try my best to prevent these defects so that we - you, the patient, and myself - can all be happy with the refractive outcome.  - jw 09/09/2012

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Relative to LASIK, PRK is not performed nearly as often, but it's recently tried to make a come back.  PRK co-management can be a rewarding experience just like it is with LASIK, if you know what to to look out for at each visit.  If you ever have a question about PRK post-op management, just call us at the Center, and we'll walk you through anything!

If you guessed that Dr. Holzman has been doing more PRK lately, you'd be right.  Is there any reasoning to this or is it just random?


The rate of PRK has been increasing across the profession and within our own clinical setting.  From Tysons Corner data, we were able to calculate out rates for LASIK and PRK.  From Sept 2010 - July 2011 ... 92.7% LASIK and 7.35% PRK.  From Sept 2011 - July 2012 ... 82.6% LASIK and 17.4% PRK.

The increasead utilization of PRK is the result of several different factors.  First, we have increased knowledge of biomechanics of corneal structure.  Second, we have more precise and detailed topographical information about the cornea as the result of using the Pentacam pre-operatively.  Third, we have better analysis programs like the Belin-Ambrosio Enhanced Ectasia Display.  The BAD uses Pentacam topgraphic data from the individual patient and then compares those numbers to a normative database, much like what visual fields and GDxs would do.  With the introduction of the BAD version 3 software update, we are now able to compare to both myopic and hyperopic databases, further increasing and fine tuning our abilities to evaluate the cornea before surgery.


Who is most likely to benefit from PRK?


Generally, those that benefit from PRK might fall into four general categories.

1.  Occupation/profression ... police offices in tough areas, those in the military, those considering these occupations in the future.

2.  High contact hobbies ... martial arts, rugby, boxing; generally super active adults that might consider these hobbies in the future.

3.  Anatomical considerations ... EBMD, tight eyelids, less than perfect scans, major lid squeezers.

4.  Patient's personal preference ... some patients just want PRK, maybe their friends or family members had PRK, or they can't deal with the idea of a flap being on their eye.


What about your technique limits a patient's discomfort?

In the past, people have been very leary of PRK because of the initial period of discomfort.  However, PRK now is totally not what PRK was way back when.  There are many ways that one can control discomfort that naturally occurs during the initial post-op period.  

In no particular order, some of my key techniques for limiting post-PRK discomfort include:


1.  Use of frequent, chilled artificial tears post-op,

2.  Intraoperative cooling of the cornea with frozen BSS prior to start of surgery,

3.  Smaller epithelial defects.

4.  Neurontin (oral gabapentin) before surgery to work more effectively and continued for the first few days post-op, 

5.  Bandage contact lens,

6.  Diluted tetracaine, known as the "comfort drop" for breakthrough discomfort (but it is rarely actually used),    

7.  Topical NSAIDs, and, of course, 

8.  Proper education on expectations.

It's important to educate your patients on what to expect with PRK healing.  Sugar coating it never got anyone anywhere, so just be honest.  With my personal techniques for limiting pain, most patients will experience discomfort during the first 5 days post-op.  During that time, the vision is also blurriest, so most patients take that time off from work.  Most patients are feeling much better starting the second week after surgery, and their vision is also improved so that they are comfortable with driving to familiar places.  Each week, the vision improves slowly with most patients starting to meet their endpoints at about 4-6 weeks post-op.  When patients understand what will happen, they are better prepared, less frustrated.

Who would not be an ideal PRK candidate?


There are a lot of similar relative contraindications to LASIK, but several that are different:


1.  Keloid formers, 

2.  Those with increased skin pigmentation, 

3.  Those with increased UV exposure, 

4.  Those that cannot be compliant with Vitamin C and sunglass protocol, 

5.  High myopes, 

6.  Those with tiny prescriptions, 

7.  Hyperopes, and 

8.  High cylinder.

PRK can be rewarding for both the managing clinician and the patient, assuming we use proper pre-operative patient selection criteria, properly educate the patient on post-op expectations, and patiently wait for the awesome outcomes that PRK is able to deliver.  - jw 10/26/12

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Topography Q&A

I have a topographer in my practice to fit contacts.  What is better about the Pentacam?

Traditional topographers are excellent for contact lens fitting because of their detailed keratometry information, so they are important for clinical practice.  However, when it comes to surgery, the analysis of the cornea must be more precise, and that is where the Pentacam comes into play.

The information that we usually look at in LVC is mostly found on what is called a Quad Map.  On the Quad Map, there are four different maps that describe anterior elevation, anterior curvature, posterior elevation, and pachymetry.  These measurements are quite precise, even when compared with that of an Orbscan which was used just a few years ago.

When considering one of your patients for LVC, it might be good to do an ultrasound pachymetry (still considered the Gold Standard for pachymetry readings) and a topography, if you have them, in your own office to help determine candidacy.  If there are irregularities, go ahead and educate your patient on avoiding eye rubbing, starting some tears, and discontinuing contacts at least for a few days prior to their Pentacams at the Center. 


How does Orbscan and Pentacam technology compare?  

The information gained from the Pentacam is better on many different points:  it's more accurate, it can be used for more clinical applications than just topography analysis, and there is normative database comparison just like you would see on visual field or rNFL analysis.

Here is an example of a "normal" Pentacam Quad Map and Belin-Ambrosio Display (normative database comparison):

It's certainly hard to read the tiny numbers on these pictures, but it's easy to appreciate the symmetry of each map on the Quad Map.  In general, the top should look like the bottom of each map, and the left should look like the right of each map.  

On the BAD, the bottom two circles represent an analysis of anterior and posterior elevations.  When looking at those circles, think of traffic signals:  green means go, yellow means pause, red means stop (and if you don't, a traffic camera will be taking your picture!).  The graphs on the side depict the rate of change of thickness from center to periphery.  Your red line should fall between the upper and lower black line.  There are a number of different indices in rectangles throughout the map.  Those rectangles will be highlighted in yellow or red if the index is significantly different from the normative database.  There is a different normative database for myopes and hyperopes.

Like visual fields, one always evaluates Pentacams bilaterally.  


The Pentacam has proven to be much more precise than the Orbscan.  While patients visiting consult centers for their initial visits will have Orbscans done as part of their visit, every patient eventually has a Pentacam anaylsis performed when they visit Surgical Centers.  The Pentacam is increasingly considered to be the standard of care for corneal analysis.

Here is an example of a non-candidate Pentacam printout:

Check out the asymmetry on all four maps of the Quad Map.  Also, the BAD is totally red on a significant amount of parameters.  This person probably has early KCN.  This patient is a non-candidate for elective surgical vision correction.  

What is a BAD display?

The Belin-Ambrosio Display Enhanced Ectasia Display is an analysis program that builds off information in the traditional Quad Map.  Drs. Belin and Ambrosio developed a database of thousands of myopic and hyperopic Pentacams.  From this, they started calculating trends like average K's, average pachs, etc ....  Each patient's raw data is then compared to this normative database to see where the patient stands relative to everyone else.  This gives you a sense of how "normal" the scan is.

The BAD helps us in our clinical decision making.  There are times where you might look at the Quad Map, and think ... "There is something different about this scan."  Looking at the BAD can help you determine if that "difference" is something minor or significant.  If minor, then the BAD will look pretty normal.  If significant, there will be red flags on the BAD.  


Is the Pentacam good for anything besides LASIK? 

The Pentacam captures information about the entire anterior segment.  Therefore, the Pentacam can be used for monitoring the progression of cataracts, proper IOL calculations, anterior chamber eval for ICL or glaucoma management (especially narrow angles), corneal density measurements, monitoring Intacs location, and detecting the thickness of lamellar transplants.  - jw 01/19/2013

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Eye Rubbing Q&A

We talk about rubbing with contact lens cleaning.  And, we always tell our allergy patients to avoid eye rubbing because that just makes their itching worse.  But, what about patients in general?  Are we good about educating them on the importance of eye rubbing avoidance?  Last week, I saw a man just going at his right eye before he ordered his meal at the Red Hot and Blue by my house.  I really, really wanted to tell him about all the bad things that he was doing for his eye.  Instead, I decided to do a Q&A with Dr. Holzman on eye rubbing since I thought I would not be as well received by this guy as his upcoming Memphis-style BBQ.

How does eye rubbing affect the eyes?

Eye rubbing, especially when consistent and of a particular style, is highly associated with keratoconus and post-LASIK ectasia.  Eye rubbing can also worsen allergies by causing the release of more histamines when mast cells are disturbed.  Depending on the duration and magnitude of the eye rubbing, corneal topography can be distorted and eye pressure can also increase during the activity.  

How does eye rubbing differ from keratoconus vs allergies?

Not all eye rubbing is the same.  Allergic eye rubbers are different from that or keratonconic eye rubbing.

With allergic eye rubbing ...

- usually involves finger tips,

- involves rubbing across the entire surface of the lid and is more focused on the caruncle, 

- goal is focused on getting rid of itch, and

- involves short-lived timing.

With keratoconic eye rubbing ...

- usually involves knuckles so that more pressure can be applied to the eyes, 

- involves concentrated pressure directly over cornea, 

- goal is to get overall satisfaction, and 

- involves prolonged timing.

Do you ask every patient about eye rubbing habits?


This helps us assess their ectasia risk, which we want to know for every patient.  There is more leniency in determining candidacy for a non-eye rubber.  However, you have to be more strict in allowing the admitted eye rubber to proceed with surgery.

Sometimes we need complete cessation of eye rubbing in order to get valid scans.  Irregular scans can be the result of contact lens wear, eye rubbing, dry eyes, or actual anatomical variation.  we can control the first three to some extent.  If a patient coming in for the first time has irregular scans, then we tell them to stop contact lens wear, stop eye rubbing, and use some lubricating drops.  If their scans are equivalent, we may consider PRK or no surgery, depending on the magnitude of irregularities.  If their scans improve, we do like to get a duplicate scan demonstrating consistency of those improved scans, and then we can more confidently proceed with plans for surgery.

Eye rubbing is highly associated with keratoconus and post-lasik ectasia, so it's our job as eye care providers to educate our patients properly.  Our aim is to get rid of the more aggressive eye rubbing like one would see in a keratoconus patient.

For average "oh, i'm so tired so i'm gonna rub my eyes" eye rubbing ... When could a patient do this without having to worry about moving their flap?

I'd recommend waiting at least a few weeks on this.  

While most striae that are visually significant will be detected at the one-day post-op (see Striae Q&A), it's still important to strongly limit contact with the eye while the cornea is actively healing.  - jw 04/20/13

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