Staying calm while navigating through LASIK complications

Encountering complications is inevitable for anyone who performs LASIK, and when the complication occurs intraoperatively, surgeons are often faced with the need to make a decision quickly, said Priyanka Sood, MD.

Preparedness for potential complications, minimizing risk factors, and knowing appropriate approaches for intervention are all important for achieving good outcomes.

Discussing management of LASIK flap complications at Refractive Surgery 2017, Priyanka Sood, MD, said she augments these strategies with a focus on “keeping calm and carrying on.” She calls her approach the “what went right method” and she illustrated it with two case examples.

Dr. Sood, a private practitioner in Boston, described her method as a take on the “compliment sandwich.”

“When a complication arises, I think first about what went right and what is in my favor,” Dr Sood said. “Next, I critically assess what went wrong.

“Finally, I go back to what went right and say to myself, how can I fix this problem to get a good outcome for my patient,” she said.

“For me, the ultimate what went right when it comes down to even showing up to the laser vision correction suite is that the literature is on our side,” Dr. Sood added. “Study after study after review after review have shown that LASIK is a very safe and effective procedure.”

The first case Dr. Sood presented involved a femtosecond laser flap that started out routinely, but about halfway through, she noted the sidecut was beyond the raster pattern.

Talking herself through the situation, Dr. Sood observed that the case could have a good outcome because the patient was a low myope with a small optical zone and there was a large raster pattern.

She decided to proceed, but as she prepared to lift the flap, instead of starting at the site she normally does, Dr. Sood began the lift at the opposite side where she knew there was no problem with the sidecut. As she slowly and deliberately worked to lift the flap, she encountered areas where it was not opening easily.

“I continued with the lift while telling myself that if I am unable to open the flap, I can lay it back down, wait 2 weeks, and bring the patient back to do an advanced surface ablation,” she said.

It turned out that Dr. Sood was able to lift the flap almost completely, and the one very small area where it was incomplete was dissected with a Vaness scissors.

“What went right in this case was that I was able to dissect carefully under most of the flap without issue,” she said “What went wrong was that there was 1 clock hour of incomplete flap, but what went right is that I could open it with the scissors, and when I lifted the flap, the stromal bed looked great.”

The case was completed and the patient had a good outcome.

The second case involved suction loss, which Dr. Sood noted is uncommon, but not rare.

The patient was a man who was both very anxious and had deep set eyes, and it took about 15 minutes and two raster passes to finish the flap creation. The case was completed, and the patient had a good outcome, but it was a traumatic experience for him.

“In retrospect I asked myself, what could have gone more right, and I thought it would have been nicer if after the third or fourth suction loss, when the patient really needed to take a break, if I could have converted to advanced surface ablation,” Dr. Sood said.

With that in mind she has made a change in her practice. Now, when operating on patients with risk factors for suction loss, she includes conversion to advanced surface ablation in the preoperative consent.

“Intraoperatively, when the patient has had diazepam, I cannot consent them,” she said. “One-third of my laser vision correction patients have PRK, and I tell patients that it is a great procedure.

“Comparing it to LASIK, I say they need not worry that they will have a worse outcome,” Dr. Sood concluded. “It just may take them a little longer to get their good vision.”