Transcript 近視屈光雷射之演講
眼科醫療-雷射近視
之感受
鄭永豐
雷射近視手術的演變歷史
雷射近視手術
放射狀角膜切開手術(RK)
上角膜晶片(Epikeratophakia)
準分子雷射(Excimer)
雷射屈光角膜切削術(PRK)
雷射原位層狀角膜塑形術(LASIK)
雷射上皮細胞下角膜切除術(LASEK)
基質內雷射光角膜切除術(IPAR)
雷射熱角膜切除術(LTK)
角膜塑形術(OK)
「雷射原位層狀角膜重塑術」
現代近視手術的主流
Laser in situ keratomileusis,簡稱LASIK。
層狀角膜手術結合了準分子雷射
美國衛生署 (FDA) 經過6年多之臨床評估,終於
在 1995年開放了常規使用,我國也跟在1995年
有限度開放使用 (visx)。
IBM公司發明用以切割晶片的「準分子雷射」
於眼角膜上 (Trokel) 。
BASIC PRINCIPLES of
LASIK
LASIK PRINCIPLES
Goals
Use of Excimer Laser
Use of microkeratome
LASIK Flap Thickness
LASIK PRINCIPLES
Why LASIK?
1st step in PRK is removal of surface
cells with brush, spatula, or laser
1st step in LASIK is creation of thin flap
of cornea with microkeratome
Remainder of procedure is the same
Flap
Laser sculpting
LASIK
“Perfect” Flap Characteristics
No epithelial damage
Smooth bed
Consistent diameter and thickness
?Predictable effects on topography and
refraction
– Influence of positioning, thickness, shape
LASIK PRINCIPLES
Excimer Laser
DIAPHRAGM
DISC
LASIK Principles
Laser Complications
Undercorrection-occurs when the laser has not
removed an adequate amount of tissue
Aftershave/perfume and/or any other scented
products
Tissue density and composition which can
modify the effect of the laser and the resulting
amount of tissue removed
Room Temperature and Humidity
Regression - In some instances, during the
healing process, portions of the treated tissue
returns to it's original state thus reversing the
results of the treatment
LASIK
Patient Preparation
Valium 5-10 mg 1 hr preop
Ocuflox or ciloxan
Tetracaine 1% X 3
Prep eye with Betadine
– Blot to avoid Betadine
beneath flap
Drape eye
LASIK Procedure
Assemble microkeratome
(組合角膜板層刀)
LASIK Procedure
Check suction
Check microkeratome
LASIK Procedure
Place speculum and assure good
exposure
– Cover lashes
– Avoid skin folds
LASIK Procedure
Mark cornea to facilitate flap
realignment
LASIK Procedure
Place suction ring
– Decenter slightly nasally (1mm) to give
good exposure to laser beam
LASIK Procedure
Avoid lid speculum and assure path for
microkeratome is clear
–
–
–
–
Speculum
Lashes
Drape
Conjunctiva
Chin up/chin down
LASIK Procedure
Assure complete suction
– Check with tonometer
– Avoid false meniscus
Warn patient that vision may darken
LASIK Procedure
Wet cornea with artificial tears, filtered
BSS, proparacaine
Remove excess with dry sponge
LASIK Procedure
Advance microkeratome by tapping
pedal
LASIK Procedure
Stop suction
Remove suction ring
Place “flap protector”
LASIK Procedure
Flip flap back
– Spatula, McPherson forceps
– Place over moist cellulose sponge
LASIK Procedure
Apply laser
– Nomogram
Can remove foot from pedal and
resume as needed
– With LADARVision, do not place
instruments in field
LASIK Procedure
Replace flap
Dry versus wet technique
LASIK Procedure
Gently float flap into position
LASIK Procedure
Stroke flap gently
LASIK Procedure
Dry gutter, assure symmetry
Wait 3-5 minutes for flap to read here
Endothelial pump dehydrates flap,
causing adherence
LASIK Procedure
Inspect for folds, sublamellar debris
LASIK
Postoperative Care
Place antibiotic, corticosteroid, NSAID
Remove lid speculum with care
LASIK
Postoperative Care
Examine at slitlamp
– Check flap position and adherence
– Check for folds
– Check for debris
LASIK
Postoperative Care
Place clear shield, no patch
Use antibiotic/steroid QID X 1 week
LASIK
Postoperative Course
Rapid visual recovery
Pain is minimal
LASIK
Postoperative Care
Postoperative visits
– 1 day
– 1-2 weeks
– 2-3 months
– 6 months
– 1 year
雷射近視手術病人品質安全指引
一、施術醫師品質管控
二、雷射儀器每月定期維護保養及較正
三、手術耗材品質管控:
如手術用刀片必須更新
眼科醫學會監控
公告於醫學會網站:wwwophorgtw
高價雷射醫療器材之管控
健康商品化與醫病關係:
(Commodification of Health and the DoctorPatient Relationship: An Economic
Sociological Critique)(成大 許甘霖 助理教授)
健康商品化趨勢下醫 病關係中醫師自主性的弱
化;
<轉虛弱的病人為有力的消費者?健康商品化
與公民權初探>(From Weak Patient to
Powerful Consumer? Preliminary Remarks on
Commodification of Health and citizenship),
「公民權/統治術工作 坊」(東海大學)
主要探討健康商品化 趨勢下的病患權益的弱化。
併發症機率
輕症
眼症乾燥,敏感 …
< 5/100
重症
< 1~2/1000
(醫療爭議個案比白內障手術少)
Lasik Complications
Types of Complications
Intraoperative
Postoperative
Intraoperative Complications
Partial Flap
(部份層狀角膜瓣)
– Motor Failure
– Obstacle
– Assembly
Intraoperative Complications
Irregular Flap / Bed
– Manual Keratomes
– Gears
– Blade Quality
– Dirty Rings / Head
Intraoperative Complications
Epithelial Abrasions
– Excessive Dye / Anesthetic
– Dehydrated Epithelium
– Blade Quality
– Dirty Head
Intraoperative Complications
Intraoperative Bleeding
– Flap Diameter Too Large
– Contact Lens Users
Intraoperative Complications
Suction Loss
– Pump Failure
– Defective Ring
– Ring / Eye Compatibility
– Rough Handling
Intraoperative Complications
Free Cap
(層狀角膜瓣斷落)
– Suction Loss
– Very Flat K’s
– Ring / Eye Compatibility
– De-centered Ring
Intraoperative Complications
Button Hole
Intraoperative Complications
Button Hole
Intraoperative Complications
Button Hole
Intraoperative Complications
Button Hole
Intraoperative Complications
Button Hole
Intraoperative Complications
Button Hole
Intraoperative Complications
Button Hole
Intraoperative Complications
Button
Hole
Postoperative Complications
Corneal Ectasia
– Misread Pachymetry
– Poor patient selection
(角膜擴張)
Postoperative Complications
Dislocated Flap
– Poor Adhesion
– Eye Rubbing
Postoperative Complications
Flap Striae
– Flap Displacement
– Eye Rubbing
– Overseen
Intraoperatively
Postoperative Complications
Whrinkled
and Dislocation
Postoperative Complications
Diffuse Lamellar Keratitis (DLK, SOS)
– Inflammatory Response
48hours
Grade 3
Postoperative Complications
Epithelial Ingrowth
– Flap Displacement
– Intraopertive Flap Mismanagement
Postoperative Complications
Stromal Melting
Grade 4 epithelial
ingrowth with edge melt
at the 8 o’clock position,
2 months after LASIK
Grade 4 epithelial ingrowth
with a severe edge melt at
the 4 o’clock position, 6
months after LASIK
Postoperative Complications
Stromal Haze (scar)
Postoperative Complications
Infection
Prevention
Use talc free gloves
Broad spectrum antibiotic coverage
Appropriate lid prep prior to surgery
Treat blepharitis prior to procedure
Eye make-up and swimming should be avoided 2 weeks
preoperatively
Proper cleaning and sterilization of instruments
Avoid excessive intraoperative irrigation which causes an
influx of debris in interface
Use sterile technique
Postoperative Complications
Avoid complications that encourage
infections
– Dislocated flap
– Lost flap
– Perforated flap
– Epithelial ingrowth
– Corneal melting
– Debris in the interface
Postoperative Complications
Interface Debris
綜合討論