The Routine LASIK Procedure

The Routine LASIK Procedure
Dan Z Reinstein MD MA(Cantab) FRCSC1,2,3,4
1. London Vision Clinic, London, UK

2. St. Thomas’ Hospital - Kings College, London, UK
3. Weill Medical College of Cornell University, New York
4. Centre Hospitalier National d’Ophtalmologie, (Pr. Laroche), Paris, France
A Step-by-Step Primer
to Starting LASIK in 2009
This course is sponsored by

the International Society of
Refractive Surgery of the
American Academy of
Ophthalmology (ISRS/AAO)
Visit the ISRS/AAO at the Membership Booth in

the Academy’s Resource Center (Booth #2939)
Financial Disclosure
The author acknowledges a financial interest in

Artemis™ VHF digital ultrasound (ArcScan Inc,
Morrison, Colorado)
The author is a consultant for Carl Zeiss

Meditec (Jena, Germany)
©DZ Reinstein 2008

dzr@londonvisionclinic.com
Femtosecond or Mechanical Microkeratome?
• Only 17% of global procedures in 2009 used a femtosecond laser
• This presentation will describe the microkeratome procedure
• Femtosecond lasers have been discussed earlier
60%
% Femtosecond Procedures / Year
52%
50%
US Global
40%
30% 29%
20% 18% 17%

12% 13%
10% 7%
4%
0% 2%
0%
2003 2004 2005 2007 2008
Data courtesy: Dave Harmon, MarketScope, Manchester, MO

©DZ Reinstein 2008
Routine LASIK Procedure
• Preparation
• Patient Positioning
• Microkeratome Checks
1. Exposing the Eye
2. The Suction Ring Psychological management of
the patient during the
3. The Microkeratome Head
procedure
4. Lifting the Flap
5. The Ablation
6. Repositioning the Flap
7. Removing the Speculum
• Immediate Post-op Check
©DZ Reinstein 2008
Standard Operating Procedure: LASIK
82 Steps
©DZ Reinstein 2008

LASIK Surgeon ≡ 747 Captain
• “A superior pilot is one who uses superior preparation

and judgment to avoid situations that require the use of
superior skill”
©DZ Reinstein 2008

Video of routine LASIK procedure
0:00 1:00 2:00 2:28

©DZ Reinstein 2008
• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Room Conditions
• Ensure standard room
atmospheric conditions are
achieved.
• Recommended 18–24°C,
and less than 50 % relative
humidity
• N.B. Ensure that there is no

fan or air-conditioner
blowing toward the patient’s
head/treatment area.
©DZ Reinstein 2008
Calibration
• Factors influencing energy stability:
– Perfume / deodorant / hair spray
– Alcohol wipe down
– Recent painting or building works
©DZ Reinstein 2008

Patient Identification
• Confirm that the correct patient is lying under the laser
(name and date of birth)
• Cross-check the refraction entered into the laser
software with respect to the medical record
• Verify residual stromal thickness of at least 250 µm
©DZ Reinstein 2008

• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Patient Positioning: Centration of Patient
• Head centration – forehead to chin (not nose!)
• Body straight and centered on laser bed, legs uncrossed
• Patient position should be attained with no muscular effort (do not
ask patient to raise or lower their chin into a position requiring
continuous muscular effort)
©DZ Reinstein 2008

Ocular Alignment
• Adjust the patient bed in the x, y and

z axes to centre the eye under the
laser
• Each laser has slightly different laser
alignment beams – refer to the
specific instructions
• Keep the z-axis positioning beams on
during the entire procedure
• Use this position to ensure that the
cornea is vertical below the laser (x-y
position) and at the right focal plane
(z-axis) aperture
©DZ Reinstein 2008

Psychological management
• The “virtual strait-jacket”
• Verbal anaesthesia
– Talk to the patient continuously,
delineating each step as you proceed –
this keeps the patient from becoming
startled
– Don’t describe what you’re doing,
describe what they’re about to feel
• Control the patient
– Curb any questions, curb any discussion
– Force their attention to the fixation target
at all times
• Use authority if needed
©DZ Reinstein 2008

Local Anaesthetic
• Instill local anesthetic drop into the
eye about to be treated,
explaining that it may sting for a
moment
• Tape the other eye shut
• Dry the lashes of tears produced

by the instillation of the anesthetic
(otherwise drapes or tape will not
stick properly to the lid margin and
eyelashes)
©DZ Reinstein 2008

• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Microkeratome Checks
• Vacuum checks • Running checks
• Blade checks
- 3.4 ”Hg
- 3.8 ”Hg
- 3.7 ”Hg
©DZ Reinstein 2008

• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Draping
• Drape or tape the lashes
• Check if there are any lashes

or tape in the surgical field
• Avoid abrading the cornea

with drape or tape
©DZ Reinstein 2008

Speculum Insertion
• Use of a speculum with solid
blades may obviate the need for
taping of the lashes while
reducing the chances of
expressing meibomian contents
into the field
• Insert the lid speculum – open it

gradually
• Ensure adequate exposure –

Ideally with equal exposure of
sclera surrounding the limbus
above and below
©DZ Reinstein 2008

Surface Marking
• Mark the surface of the cornea with ink
asymmetrically including the central 6
mm zone
• In flatter corneas, mark in preparation
for small hinges or free caps
• In steeper corneas, mark in
preparation for button holes
• Indent the surface with the marker to
break epithelial surface integrity to
ensure that you can re-stain these in
the event of a free cap in which the
marks have washed off
©DZ Reinstein 2008

• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Suction Ring Application
• In preparation for applying the
suction ring, if unequal scleral
exposure exists, ask patient to
alter head position to ensure
perfect and equal scleral
exposure all around the limbus
(e.g. Lift chin up or down or
turn head toward the nose to
move eye temporally within the
palpebral fissure)
©DZ Reinstein 2008

• Push aside any lid skin overhang onto the
speculum with one hand and approximate
the ring onto the eye with the other,
ensuring that any lid overhang lies above
the ring track
• “This is the part where it’s going to get a

little uncomfortable”
• One hand will be holding the post, the

other hand will be depressing the upper
and lower blades of the speculum using
the thumb and ring finger in order to
proptose the globe while your index finger
applies a counter force through the pivot
post downward
©DZ Reinstein 2008

• Centration is key: center the
ring in relation to the visual
axis, rather than the pupil or
the limbus if possible – this is
especially important in
patients with large angle-
kappa
• Create conjunctival/scleral
indentation by pressing the
ring down for 5 seconds
before activating the vacuum
©DZ Reinstein 2008

• Start suction
• Tell the patient “as the pressure
increases in the eye, the lights
will go dim”
• Keep downward force on the
speculum which also ensures
tightening of the conjunctiva to
produce adequate suction of the
sclera into the ring.
• Verify that suction level is
satisfactory – on the console of
microkeratome
• Ask the patient “Are the lights
dim?”
©DZ Reinstein 2008

Tonometry
• Ensure that the cornea is
not too wet before
applying the Barraquer
tonometer to test
pressure
• You may additionally use

the tip of your finger on
the cornea to verify
adequate firmness of the
globe if in any doubt
©DZ Reinstein 2008

• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Microkeratome Lubrication
• “You’re going to feel a little fluid
now”
• Flood the cornea with more
anaesthetic
(Not Balanced Salt Solution as
this can lead to salt deposits on
the microkeratome head)
• Wet the keratome track and/or
post with a lubricant to ease the
engagement of the microkeratome
head on the ring
©DZ Reinstein 2008

Microkeratome Engagement
• Buzz the microkeratome head before
engaging it
– Acclimatizes the patient to the sound
of the microkeratome
– Ensure free running mechanism
• Engage the head of the
microkeratome on the ring
• Check that the microkeratome head
trajectory is clear
• You may choose to tilt the post of the
ring slightly away from the proximal
lid at the beginning of the pass to
avoid ‘catching’ anything during the
forward passage
©DZ Reinstein 2008

Microkeratome Engagement
• Make sure there is no tension or pulling on the motor
cord and suction tubing
• Warn the patient not to move or squeeze as the

buzzing sound starts. “You’re going to feel some
buzzing now, don’t move, hold nice and steady, here
comes the buzzing”
• Tell the patient that there is only 8 seconds to go and

when there are 4 seconds to go
©DZ Reinstein 2008

Microkeratome Pass
• Watch the pass with particular attention to the patient’s lids
and speculum
• Look at the “end position” of the microkeratome head
• Have a particular land-mark on the ring memorized if this is
not already present to verify a full pass has taken place
©DZ Reinstein 2008

Microkeratome Disengagement
• Press the backward foot-
pedal to reverse
• Deactivate the suction
• Wait a brief moment
while pressing down on
the eye before removing
the ring to allow suction
to decline
– Avoids generating a
sudden “sucking sound”
that can startle the
patient
©DZ Reinstein 2008
Microkeratome Completion
• Remove the keratome head and ring
together for simplicity
• Try to avoid
– causing a displacement of the flap on
the stromal bed
– allowing fluid into the interface
• You may want to slightly loosen

speculum at this point (if very tight)
• Remind the patient to look at the

green flashing light – this will reassure
you to know that their vision has
recovered from the black-out caused
by the suction ring
©DZ Reinstein 2008

Patient Repositioning
• Reposition head to the “natural” effortless position, so
the patient is comfortable and relaxed again
• Realign the patient bed using the laser alignment
beams – this ensures that the cornea is vertically below
and therefore perpendicular to the laser beam
• Reassure them that “the hardest part is now done and
the rest is easy”
©DZ Reinstein 2008

Eye-tracker Activation
• Activate the laser’s eye tracking system
• Ensure that the eye is central within the tracking box
indicated on the laser screen
• Increase the magnification to 1.6x so that you can clearly
visualize the light reflexes from the cornea in order to lock
the eye tracker into the optimal position
• Remember: the tracker is eye movements, not bad
positioning
©DZ Reinstein 2008

Aiming Beam
• Verify both on the infrared monitor as well as on the
patient that the laser aiming beam has been
automatically placed in the center of the pupil if it is a
wavefront guided treatment
• Adjust if necessary
• For sphero-cylindrical cases (not wavefront guided)

you should manually adjust the position of the laser
aiming-beam to be superimposed over the 1st Purkinje
reflex of the cornea while the patient is looking at the
green flashing fixation light
©DZ Reinstein 2008
• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Sponge Placement
• Place a sterile moist sponge at the hinge, overlying the
conjunctiva to act as a sterile platform for the flap
during the ablation
©DZ Reinstein 2008

Flap Lift
• Lift the flap without pulling, stretching or bending,
preferably in one movement like opening a door
• Lay down the flap on the moist sterile sponge surface
©DZ Reinstein 2008

Time to Ablation
• Ensure consistent time interval from flap lift to start of
ablation
• Prevent excessive drying of the bed
• Provide consistent conditions for every eye to improve
nomogram accuracy
©DZ Reinstein 2008

Drying of Corneal Bed
• Perform a “drying sweep” of the
stromal bed and hinge (use
sponges that do not release
particles)
e.g. Versatool
• This should be standardized

and performed on every single
eye in the same way to ensure
homogeneous hydration and
lack of excess hydration of the
stromal surface before ablation
©DZ Reinstein 2008

• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Aiming Beam
• Switch on the red laser
aiming-beam telling the
patient to “continue looking
into the center of the big red
cloud”
• Warn the patient of the

“buzzing” of the laser about
to start
©DZ Reinstein 2008

Flap Hinge Protection
• You may need to protect the back of flap or hinge from
ablation with a dry spear-tip sponge
• Take care not to block ablation of the stromal bed
©DZ Reinstein 2008

Laser Activation
• During ablation you may need to apply one or all of the
following:
– Hold the patient’s head with one hand
– Protect the hinge/flap with a sponge in the other hand
– Keep encouraging the patient to look directly at the
fixation light “Keep looking in the middle of big red cloud”
©DZ Reinstein 2008

Laser Activation
• Ensure that the level of
hydration of the bed is
constant and homogeneous
during the ablation
• Continue monitoring the

stromal surface during the
ablation
• Beware! Fluid is drawn up by

capillary action into the hinge
area
©DZ Reinstein 2008
Laser Activation
• During ablation continuously talk to the
patient and continue to ensure that the
position of the z-axis lateral aiming
lights are together and in the centre of
the pupil throughout the ablation
• Encourage the patient to look to the

centre of the “big red cloud”
• Your technician should be calling out

the percentage of the ablation that is
completed so that the patient knows
how much more time to concentrate on
the “red cloud”
©DZ Reinstein 2008

• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Flap Repositioning
• Use the cannula / BSS to flush away any blood at the
hinge or around the edge of the bed
• Close the flap as atraumatically as possible – no
bending, stretching or pulling
©DZ Reinstein 2008

Flap Repositioning
• Irrigate under the flap with a single-hole 27G anterior chamber
type cannula on a 5 ml syringe
• Irrigation should be at high fluid pressure/velocity for a short time
to help remove debris from the interface while minimally
increasing the stromal bed or flap hydration
• This will ensure a good “fit” for the flap with minimal gutter
• Irrigation should usually consist of 1-ml over 1-2 seconds
Source: Eisner. Eye Surgery.

©DZ Reinstein 2008
Preventing Flap Crunch Syndrome
Flap edges flush Flap swells and Epithelium grows Flap expansion to
to side when contracts with into gutter natural state
created hydration obstructed by
epithelium…
…leaving microfolds
Solution: Do not leave a gutter!

©DZ Reinstein 2008
Flap Repositioning
• Before all the irrigation fluid has
left the interface, using a very
wet spear-tip sponge, very
gently brush-align the flap
• Alignment should be primarily

based on the corneal markings
(Gutter spacing may have
changed due to asymmetric
swelling of the flap during
hydration)
©DZ Reinstein 2008

Slit Lamp Exam
• Look under high-power magnification using a slit-lamp
for debris and alignment of the marks
©DZ Reinstein 2008

Second Eye Preparation
• Ask patient to continue to look at the fixation light,
while you start preparing for the procedure on the
second eye:
1. Print the treatment report for this eye
2. Load the treatment parameters for the second eye
3. Perform your microkeratome check after resetting it for
the second eye
• The time taken to perform preparations of the
second eye will ensure at least a 60 second
interval to ensure proper flap adhesion (longer if
you required additional irrigation)
©DZ Reinstein 2008

• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Speculum Removal
• Tell the patient to keep looking at the fixation light
• Remove speculum slowly from one lid, then the other,
while carefully holding lids, and reminding the patient
not to squeeze
©DZ Reinstein 2008

Drape Removal
• Remove tape/drape carefully
• Re-examine flap position with

blinking
• Tape the eye shut if you are

going to proceed to the other eye
at the same sitting
©DZ Reinstein 2008

• Preparation
1. Exposing the Eye
procedure
4. Lifting the Flap
5. The Ablation
©DZ Reinstein 2008
Slit Lamp Examination
• Remove tape from both eyes
• Take patient to the slit-lamp in the operating room to
check flap position and interface debris
• Use Fluorescein stain to see any flap positioning
errors, or flap tension
• Minor flap re-positioning can be carried out at the slit-
lamp using a sterile spear-tip sponge if necessary
©DZ Reinstein 2008

Recovery Room
• Have the patient go to the recovery room
and remain there for 20 min with their
eyes closed
• Re-iterate post-op instructions and

medications, including the use of the
eye-shields at night
• Allow patient to return home with their

accompanying person, instructing them
to keep their eyes closed as much as
possible until the 1 day post-op visit the
next morning
©DZ Reinstein 2008

Routine Post-Operative
Management
Routine Post-Operative Management
• Routine follow up visits
– 1 Day
– 1 Week
– 1 Month
– 3 Months
– 6 Months
– 1 Year
– Annually
©DZ Reinstein 2008

1 Day Follow Up Visit
• Discuss patient comfort
• Measure uncorrected visual acuity
• “Quickie” refraction check
• Check the flap
– Alignment
– Microfolds / nanofolds
– Infiltrates
– Inflammation / DLK
– Epithelial defects
– Foreign material under flap
• Reiterate drop regime and importance of wearing
plastic eye shields at night
©DZ Reinstein 2008

1 Week Follow Up Visit
• Discuss patient comfort

• Measure uncorrected visual acuity
• Manifest refraction check
• Check the flap
– Alignment
– Microfolds / nanofolds
– Infiltrates
– Inflammation / DLK
– Corneal melts
– Epithelial ingrowth
• Punctate epithelial staining / Dry eye
©DZ Reinstein 2008

Regular Follow-Up Checks
• Discuss visual stability, night vision, dry eye symptoms

• UCVA – distance and near vision
• Manifest refraction (BSCVA)
• Contrast sensitivity
• Slit lamp examination
• Topography
• Wavefront
• IOP
• Dilated fundus examination (annually)
©DZ Reinstein 2008

Final Words
Never be a hero in refractive surgery
There are old pilots and bold pilots, but there are few old, bold pilots
E. Hamilton Lee (1892-1994)
U.S. Post Office Air Mail Service
Flew 4.4 million miles in his lifetime
©DZ Reinstein 2008

Thank You
Dan Z Reinstein MD MA(Cantab) FRCSC DABO
Minimum Age? Refractive Stability?
Right Eye
• 34 yo male -4.00
SEQ
Sphere
180
160
• Refraction history obtained -3.50
-3.00
Cyl
Axis 140
• 2.00 D change in sphere -2.50

120
Refraction (D)
100
between 27 and 33 -2.00
80
-1.50
60
-1.00
40
-0.50 20
0.00 0
26 28 30 32 34 36
Age
Left Eye
SEQ
-4.00 180
Sphere
-3.50 160
Cyl
-3.00 Axis 140
120
-2.50
Refraction (D)
100
-2.00
80
-1.50
60
-1.00
40
-0.50 20
0.00 0
26 28 30 32 34 36
Age
©DZ Reinstein 2008


The Routine LASIK Procedure

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The Routine LASIK Procedure

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The Routine LASIK Procedure

Dan Z Reinstein MD MA(Cantab) FRCSC1,2,3,4

1. London Vision Clinic, London, UK

This course is sponsored by

Visit the ISRS/AAO at the Membership Booth in

The author acknowledges a financial interest in

The author is a consultant for Carl Zeiss

©DZ Reinstein 2008

20% 18% 17%

Data courtesy: Dave Harmon, MarketScope, Manchester, MO

©DZ Reinstein 2008

• “A superior pilot is one who uses superior preparation

©DZ Reinstein 2008

0:00 1:00 2:00 2:28

• N.B. Ensure that there is no

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

• Adjust the patient bed in the x, y and

©DZ Reinstein 2008

©DZ Reinstein 2008

• Tape the other eye shut

• Dry the lashes of tears produced

©DZ Reinstein 2008

©DZ Reinstein 2008

• Drape or tape the lashes

• Check if there are any lashes

• Avoid abrading the cornea

©DZ Reinstein 2008

• Insert the lid speculum – open it

• Ensure adequate exposure –

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

• “This is the part where it’s going to get a

• One hand will be holding the post, the

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

• You may additionally use

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

• Warn the patient not to move or squeeze as the

• Tell the patient that there is only 8 seconds to go and

©DZ Reinstein 2008

©DZ Reinstein 2008

• You may want to slightly loosen

• Remind the patient to look at the

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

• For sphero-cylindrical cases (not wavefront guided)

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

• This should be standardized

©DZ Reinstein 2008

• Warn the patient of the

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

• Continue monitoring the

• Beware! Fluid is drawn up by