Slide Original Tutorial  Compendium of LASIK Slit lamp  Refinements Thank you for taking time to view this area. This primer is designed to help you to perform the LASIK slit lamp refinement techniques that I have described. It will first identify the tools you will need, describing their mechanics. It will then go on to review the various manipulations required to achieve uniformly superior slit lamp appearances for your patients. These techniques are designed to work best with LASIK utilizing a superior-hinged flap technique, but many can also be utilized with nasal hinges. They are presented here in chronological fashion: The post-op period is broken down into immediate (minutes to hours), one day, and longer term. In the early post-op period, I will describe flap positioning and techniques to remove interface matter. I will then discuss the removal of debris and secretions beyond the immediate post-op period as well as how to address striae, flap slippage, and finally epithelial ingrowth. Next Slide This is the appearance of my typical tray set up for slit lamp refinement. For those of you doing higher volume surgery, it may be necessary to have your instruments flashed at some point during the day for replenishment. Back Next Slide It is the base of the saturated merocel, either its side or its face, that serves as an excellent smoothing device for striae or to reapproximate even the smallest of gaps between the flap and bed edges (merocel smoothing technique). Back Next Slide The accompanying schematic shows the vector forces which can be applied to the surface of the cornea without causing significant torque and displacement of the flap. The merocel should be completely saturated and the forces applied radiate from a plumb line perpendicular to the orientation of the hinge. The technique will become more apparent as you watch the accompanying videos. A speculum is not typically employed for most of the maneuvers, although one should be available in the event that the patient has a hard time keeping their eye open and no assistant is available to provide optimal exposure. Back Next Slide I use an 27G air injection canula with filter, although any canula with an angle to tip length of 3-5mm will work. It is used primarily for rinsing debris, scattered secretions and heme, as well as refloating flaps that are not positioned or draping optimally. I prefer to keep only about 1.5-2.0cc of BSS in the 3.0cc syringe since it makes the plunger more accessible to use in one-handed fashion. (Rhein Medical – Knolle Capsule Scraper, Sandblasted 60° top & bottom. Item #91sp7091-002) Back Next Slide The angle of a Kelman-McPherson Forceps is preferable over the non-angled structure of a jeweler’s forcep. This instrument can be used to remove small particles and fibers even if they are located axially. They can also be used in tip-down fashion to nudge a flap edge back to expose epithelial ingrowth and assist in its removal. Finally, it can also be used as an alternative to the merocel to reposition loose epithelium or epithelial edges. Back Next Slide I applaud Dr. Johnston for creating this devise which I have used at the completion of my LASIK procedures for 11 years now. It has not only eliminated any drying time in my primary cases but proves an excellent tool in the massaging of macrostriae while proptosing the globe using counter-pressure with a Barraquer speculum. For these purposes, I keep it on the tray as a supplement/alternative to merocel smoothing in the event that the patient’s epithelium is more friable (EBMD). Back Next Slide The Sinsky is typically not necessary in the first few days following the procedure since the forming epithelial facet at the flap bed junction is easily broken by blunt dissection. Back Next Slide This is a representative photo of the irrigation step. I will typically ask the patient to assist me by holding a few tissues on their upper cheek so that they (and the slit lamp won’t get wet). I first show them that the canula is a mini-squirt gun since most think it is needle. I instruct them to keep their hand in flat profile so that I can have access to the eye and to pull down slightly to expose more of the inferior fornix. In patients who are more apprehensive or light sensative, it may be necessary to have an assistant to hold the patient’s upper lid. Back Next Slide I will now review the videos. Below the first frame of each, you will find the accompanying text notes and comments. After reading each, choose the selection to start the streaming video. The “next” and “back” buttons will move you through the tutorial. If the videos are difficult for you to view, from the start menu, go into your control panel, go to display, select the settings tab, and adjust your screen resolution to the lowest possible setting. Back Next Slide This first video shows a small gap or gutter from the 5-7 o’clock position. Utilizing the base of a wet merocel it is easily closed. While perhaps not responsible for a line of best corrected vision, it may impact on visual quality/contrast sensitivity, etc. When this technique is not utilized, the gutter will quickly fill in with epithelium. This may not create an appearance of striae but may be responsible for the edematous (peau de orange) appearance sometimes seen in the early post-op period. Back Next Slide This gap is a bit more pronounced and associated with fine horizontal macrostriae. Though most surgeons would probably address this picture clinically, it would most likely occur in the laser suite. As you can see, this issue is easily resolved by using this technique. Back Next Slide In this example, a large gutter with associated vertical macrostriae is again observed. The sopping wet merocel is easily able to resolve this appearance. Back Next Slide When the folds become too significant, it is usually best to gently refloat the flap with a short stream of BSS or a 27G canula, then employ the smoothing technique. Back Next Slide Back Next Slide Epithelial Memory in Macrostriae Folds s/p Slipped Flap Repositioning. Back Next Slide This patient’s flap edge (6-8 o’clock) had flipped under within an hour of leaving the laser center. As such, no epithelium had grown onto the stromal bed. By utilizing the 27G canula tip with a small amount of BSS followed by the merocel smoothing technique, I was able to save this patient a trip back to the laser suite. Back Next Slide This clip shows SL treatment of patients who dislodged their flap on the evening following their procedure and were not seen until the following day. Unlike the flap presented on the same day patient discussed earlier, this demonstrates how quickly epithelium will migrate to cover the exposed stromal bed. This tissue will always reflect back off the bed very easily. The leap of faith is that the macrostriae are gone. Flap will approximate to a tight gap in the bed if interface hydration is limited. Although the striae seem to persist, retro illumination confirms they are gone and only in the epithelium in memory: They should be gone the following day. Back Next Slide Irrigation can also be used in the immediate post-op period to rinse small amounts of heme from under the flap. Back Next Slide Isolated fibers and particles are typically easy to remove from under the flap with forceps. Here, an extraxial fiber is removed without disturbing the position of the flap using an angled Kelman-McPherson forcep. Back Next Slide This is true even for particles that are axial in position. Interface fibers that escape detection during the flap check performed immediately following the procedure can still be easily removed at the one day post-op exam. Patients can help you to perform this maneuver by looking in a location opposite to the point of interface entry. Back Next Slide Back Next Slide We will now review the treatment of interface debris and secretions on post-op day 1. These secretions are presumably drawn up in a meandering fashion in the early hours following LASIK by the same hydrostatic forces that hold the flap in place. As just discussed, following irrigation of the secretions, this patient was put on a short course of q1 hour topical steroid as prophylaxis against DLK. Back Next Slide Experience has shown that the membrane-like sheet of EI swells readily with BSS (hydrodeliniation), and is easily coaxed out of the interface (hydro- extrusion). This maneuver is accomplished with a 27G canula on a half full 3cc syringe of BSS. This patient’s right eye shows 4-5 clock hours of variable 0.5-2.0mm EI at a 2 week post-op visit. Back Next Slide In this video, 5-6 o’clock hours of EI were noted at 5 days post-op. This video illustrates an excellent example of the hydrodeliniation and hyrdoextrusion technique. The redundant epithelium is carefully stripped from the flap edge and then smoothed with a wet merocel. Back Next Slide Here, a well-defined four o’clock hour sheet of 1.5-2.5mm monolayer EI is seen three weeks post lift enhancement. Removal is accomplished with hydrodelineation and angled non-toothed forceps are used to strip out the sheet of cells. Back Next Slide This video illustrates the removal of 3 o’clock hours of 1mm ingrowth on a patient who had LASIK over RK. Primary rational for SL removal of EI is two-fold. Visualization for attempted removal in the OR isn’t nearly as good and 2) carries risk of incision splay along previously unaffected incisions with potential for subsequent new EI. Back Next Slide This segment shows an excellent example of post-op 1 removal of fine vertical macrostriae and an oblique level of meibomian debris. This appearance was most likely present shortly following the patients procedure upon discharge. Copious lubrication is encouraged to prevent this occurrence. Back Next Slide As we are all familiar with following corneal abrasions or PRK, uncontacted corneal epithelium will rapidly migrate to cover any exposed stromal bed. This is also seen in patients who dislodged their flaps on the evening after LASIK and are not seen until the next day. Fortunately, the advancing epithelial edge will always reflect back very easily using the inverted tips of a Kelman or dry merocel. The flap can then be floated back down on a stream of BSS and painted back in place with a saturated merocel or Johnston Applanator. Back Next Slide One main advantage in utilizing these techniques to remove EI, is that any recurrence is confined to the initial distribution of treatment. When EI is treated by lifting the flap in the refractive surgery suite, recurrence can potentially affect areas previously not involved. Back Next Slide I hope that you have found this primer to be useful and informative. It is my further hope that whether profound or small, the impact of these techniques on your refractive practice will help to improve the care that your vision correction patients receive. As I mentioned in the e-mail sent to many of you, this is a work in progress. I will be updating this site as needed until these techniques are fully refined. In the interim, please feel free to contact me at if I can answer any question you may have please email this presentation to any of your colleagues you feel my benefit and have some way of getting a notification of anyone who does forward the presentation in an email and who  they forward it to if you haven’t already done so please register at so that we can add your name and practice to our international database of surgeons who have viewed this tutorial and are familiar with these techniques ro guide consumers with EI on their options. Back Next