 Good morning, we're going to go ahead and get started. I wanted to welcome you all out to a new grand round series that is not terribly creatively called patient grand rounds. Really this was born out of the residents and some collective feedback that during our clinical faculty day or resident alumni day, a lot of the conversations and the interactions between the experts and the subspecialists were really beneficial. So we have asked each subspecialty to take a month and in general the fourth Wednesday of each month will be dedicated to patient presentations hoping again to foster discussion among the subspecialists. Dr. Moshefar graciously accepted the reins of both cornea and the refractive months and being that he has a fellow, I think he just wanted to make sure the fellow had an opportunity to present as many times as possible. So Carl Fenzel, please. It comes July, we get a wave of refractive issues come to us and some of these cases may actually look very similar, especially the last two cases and in one of them there is actually a take home message. We had a lot of other cases too that we could have presented but we wanted to show things that are obvious and quite frequently we see and not some zebra things that we see all the time and they are primarily have to do with the PRKs and basics and what happens when you enhance, what happens when they have had PRK and they have a long term course because as you know there has been a wave of PRK, many refractive surgeons now are shying away from basic and going toward the surface treatment and there is nothing wrong with either procedure in my opinion but today we focus more on problems with surface ablation and enhancements. Thank you. Thank you professor and just to introduce the professor's fellow Carl Fenzel, group in Florida is coming to us by way of New York Medical College. So without further ado turn the time over to Carl to keep in mind that the residents asked for this so they are fair game asking any question you want. Call them out individually, help but also realize they don't get any real refractive training until their chief year and none of them have completed their chief year yet so Jim Bell actually has completed their chief year. But he went to retina so I wouldn't ask him any questions but please. Once you go on to retina they completely forget about refractive treatment. Good morning everyone, it's a pleasure to be here. My name is Carl Fenzel and on behalf of Dr. Moshefar I'd like to present refractive surgical complications. So our first case I'd like to start with a 31 year old female. She has no medical history and no surgical history. She had a laser performed from myopia and astigmatism and she had a great result with her right eye. However she had some under correction of her left eye. That gave her a vision of 2050 and she was obviously quite displeased with that result. So she had an enhancement performed of the left eye about seven months later and subsequently her visual acuity decreased and she was found to have epithelial in growth with haze some mud cracks in the flap and so naturally the surgeon decided to go in there on the second post-operative day and he reused a relifting technique. He brushed out the epithelial cells with a beaver blade and he used a wax cell sponge and he applied alcohol afterwards. Pred forte four times a day was then prescribed and the visual acuity again decreased after that and Muro was prescribed. Over the next year there were quite a few interfaced abnormalities associated with this patient and the visual acuity declined to 2100 and this patient was referred to the Moran Eye Center. So as far as interfaced abnormalities go and corneal abnormalities after refractive surgery and LASIK there's a couple things on the differential diagnosis. Obviously epithelial in growth is important for this patient because they have a history of it previously but diffuse lamelloceratitis, infectious keratitis, interface debris, atrial toxic keratopathy, pressure induced domo keratopathy and also post-operative ectasia are also very important on this list. So here's a picture of the patient's eye. You can see that there's quite a significant amount of nests of epithelial cells all around the entire flap edge right here. There's some scalloping here. It's kind of difficult to see in this picture but that signifies flap necrosis and what we're really focused on here is the in growth of epithelial cells right here. You can see in this magnified version I have the arrows that shows right on the edge of the visual axis you can see the epithelial in growth. So as I just said we have severe epithelial in growth. We have actually an absence of the flap hinge which was superior, it must have been transected during either the enhancement or the flap lift and flap necrosis. So this patient had close follow-up which yielded an improvement in vision to 2060 however on a couple different follow-up appointments there was notice that there was advancement of the epithelial in growth in that exact two o'clock location and visual axis involvement was impending so it was deemed necessary to perform surgical removal to prevent any type of scarring within the visual axis. So I guess this is the time when I have to ask the residents what they want to do with this case. Do you guys have any recommendations for this? And because Eileen was nice enough to call me this morning I'll ask her what she thinks. You know obviously we're doing surgical a surgical correction right now so you know the patient already had a flap lift and had some alcohol application so you know is there anything else that you might want to do other than that to try to help prevent you know this epithelial in growth from coming back you know you don't want to keep doing scrapings over and over and over again. We're not going to go that far right now but so you know you could lift and scrape it alone which you know I wouldn't recommend for this patient already had that done and already had alcohol placed before and you can apply alcohol, mitomycin C, you could do PTK. There's actually also been reports of using a YAG laser to application actually prevents some of the epithelial cells from moving in and progressing on the ingrown. Tissue glue is important for the flap edge and also suturing of the flap edge has been shown to be effective. Teseal I think can be used. So for this procedure actually Dr. Wilson in the 2012 JCRS article talked about what's called a flap erectus and he used a Sinsky and a forceps basically you delineate the about one clock hour of the edge of the flap with the Sinsky hook and then use the forceps to peel back the flap. Now this is important because if you're using some sort of device to actually go underneath the flap and all the way into the center and lift up the flap you have a significantly increased rate of epithelial ingrown afterwards because it's thought that maybe you're implanting the epithelial cells with that motion all the way out to the either the flap bed the stromal bed or the flap so this is performed with the coen forceps between the flap is lifted between 1030 and 330 and beaver blade was used a sponge irrigated the sponge was used again all to try to remove all the epithelial cells that were present and then a 10 12 10 oh nylon sutures were then used to suture the flap edge within that area and tissue glue was also used at the flap edge. So here's a photograph you can still see it's difficult to tell but you can still see that there's the epithelial cells down here were not removed it was purely this area it was retracted and then it was sutured again and you can't see any of the epithelial growth here anymore. So the postoperative regimen included predforte, vagamox, tears, a shield and these medications were tapered slowly sutures removed between seven and eight weeks and a bandage contact lens which was placed was also removed at about nine weeks and the patient had a good result in terms of visual acuity to 2025 but didn't notice some fuzziness and some ghosting but most importantly there was no recurrence of the superior ingroth that was removed and the inferior ingroth remained stable. So under our second case this is a 34 year old male with no medical or surgical history. He had recommended he went for refractive surgical intervention and yeah thank you that girl so that's a great point. That was uncorrected sorry about that yeah some of the terminology you know I had to look through a lot of the notes from the referring doctors and some of them didn't specify so we will sometimes jump back and forth between uncorrected and best corrected but that was uncorrected. I think suturing is considered a better treatment if you choose one or the other but you know both of them both were both yes might as well hey I would want both done on my eye so thank you Dr. Mosfar. Any other questions on case one? Okay so case two is a 34 year old male winner for refractive surgical evaluation was recommended to get PRK he was a rugby player he was worried about trauma then when he went on for the day where he was actually going to have the fracture surgery performed a different surgeon recommended that you know you might as well get LASIK it's great you'll have vision you know a day or two after and you'll be really happy so this patient went in for LASIK it was a lot of difficulty with the procedure he was really uncooperative thrashing about there was a partial thin flap that was created in the right eye that was not lifted and then the left eye they attempted but they weren't able to do anything for that so they aborted the procedure patient was given his money back then he went to a new surgeon for a consultation and 19 days later he was recommended to have PRK and he had a lot of pain and blurry vision afterwards in the right eye only which is the eye that had the partial flap and his vision at two weeks was about 2050-2030 his cornea was clear at that time Fred Forte was discontinued four months later his best corrective visual acuity was 2020 but he did was noted to have some subepithelial haze essentially in the right eye and this kind of makes sense because haze on average presents around three months and but no topical medications were initiated five months he's 2020 vision again he's had epithelial haze again subepithelial haze excuse me no medication was initiated at this time so this is quite a while ago a couple years over that time his vision began to decline he had went for evaluation with different refractive surgeons different contact lens specialists he tried rigid gas permeable contact lens but he was intolerant to these lenses even though it improved his vision significantly and he had really crippling glare and photophobia so he was referred to the Moran Eye Center and this is a picture of his eye you can see that he has these subepithelial areas of haze and some scarring centrally here's another view you can see on this view that it's really very anterior in position and here's a nice picture of two different cuts of intersegment OCT and you can see that you have these hyper reflective subepithelial deposits in multiple different areas of the cornea really goes from here all the way down to here so you know what is this is it just chronic haze is it fibrosis that's now occurring was there some dlk was there a low-grade infectious keratitis and you know like I talked about before the flap was actually de-centered infirm nasally there was epithelial fibrosis and there was central reticular haze so whenever you create any type of incision or insult to the cornea there's going to be an inflammatory response just tell our proteins are produced growth factors are produced and if you superimpose another event on top of that right after you're really at a significant risk of having haze inflammation you're activating those keratocytes and they're producing and so you know you really got to do something about it the first thing you can do is wait so you let the cornea calm down you let that flap settle down a little bit let those keratocytes calm down a little bit but if you really you know there has been some information in the literature about complications with flaps and people have wanted to they've wanted to correct those complications right away with PRK and they've done it right away and they've been successful because they've used mitomycin C and mitomycin C is important it's been shown to actually decrease production of matrix metalloproteinases growth factors and actually deactivate keratocytes so it's important to have the right plan when you're doing this and so as far as treatment for this patient you know he's three three and a half years out he has not only haze but he has fibrosis and you could see it on the OCT so you know there's a couple of options we're really trying to get rid of those sub epithelial deposits and you could do topography guided PRK with mitomycin C where you basically use alcohol to remove the epithelium and then you use topography guided PRK it's hard with this guy because he's had multiple procedures done so you really don't want to remove too much tissue but that's an option the other is just simply mitomycin C application and with this instead of using alcohol you actually scrape off the epithelium and then and while doing that you can actually remove some of the haze remove some of sub epithelial fibrosis and so you know if he didn't want another treatment that would be that would be definitely be an option in this case somebody is already consented for PRK they already have a mindset of PRK the surgeon who sees them on the day of surgery change the thought process of the individual to a different procedure I think that's a long time to do while the patient was prepped and was actually sitting there of course they didn't give the value to the patient if they had given the value it would have been very worse so without the value on they consented the patient you should get LASIK LASIK would be a much better choice for you and he was a very tight orbit squeamish at a very hard time they couldn't get the suction on eventually they got the suction and made the flap in one eye and the other idea couldn't even make the flap and so I think that was one mistake there that you know maybe they should have asked on PRK or the LASIK on another day with a better income consent the other issue is now the management of what we have on board I think 19 days later when he goes to see another copy both of them very respectable copy I don't think as as Karl mentioned I don't think we should be doing PRK on top of that flap or minus four down after correction first of all we have to ask ourselves there could be still inflammation going on in that area and if we continue zapping through that and we get to that interface because we are doing a four or five down to correction then you can actually create more inflammatory process so what I'm trying to say is that those particular patterns that you saw essentially those are very different from the hazes you're going to see in other cases this is not one of those hazes that you see six millimeter haze six point five millimeter haze that you see with the X-ray laser ablations this is a very small little cap of four millimeter three and a half millimeter little bit paracentral haze with a particular pattern that that pencil showed this indicates that the flap was thinner I'm sorry the flap was thicker than what they thought and when they when they went through it most likely after going through eighty nine in micron they eventually reached that interface of the anterior stroma and the posterior stroma of the flap and as a result a portion of the flap was completely ablated and now you have like a little donut if you want to say because some of the ablations still stayed in the flap but some of it went through the flap and hit the exposed stroma underneath there you see my point there so that's where you get this just a little centralized haze which is a little bit eccentric to the people whenever you see a generalized haze with a PRK you can assume that maybe the steroid wasn't given or the patient wasn't compliant and you need to but if you ever see a patient comes to you and has a very small eccentric four three millimeter haze you have to ask yourself why and I think in this case we zapped through the entire epithelium we zapped through the flap and we reached that interface 19 days after the original surgery that was one of the problem if it was maybe a year later or three months later maybe you couldn't have any problem the other problem was that we didn't use mitomycin C I think these are the cases that mitomycin C would have been good we all have seen black complications with the old micro keratons flaps would be six different pieces they would be completely severed and with those sometimes within a month or two we went back we didn't wait three months we now wait longer but we would use mitomycin C on a hot eye because we knew if you had a hot eye within the first month of the original surgery and you do anything to them you need to use mitomycin C otherwise there would be an accelerated recruitment of keratocytes which would convert to fibroblast and then they would lay these abnormal collagen fibroids so in this specific case this rugby player who used to be a professional now he is on disability but he cannot wear the keratin lens and they tried a rigid gas I'm sorry squirrel a large diameter lens he cannot tolerate that so he walks around with the 26th division the other eye is 20 we can always be the back seat driver and say oh well we shouldn't have done this or she shouldn't have done that my answer is that no we just need to learn from this and what we learn is from consensus should become better and the other thing is that once somebody already had a little insult to their eyes as Dr. Fanzel mentioned we make it through that interface especially if you're doing the minus 8, minus 6, minus 5 diameter now maybe if we were doing the minus 2 we would get lucky we wouldn't get that far into the interface of that flat because afterwards I'm not using mitomycin so what did you do with case 2? we waited for you know should we do this before the litigation is over because I really thought right it is and I'm still saying that you know we cannot say this was a medical malpractice that informed consent point that they're talking about that now which I don't have any expertise but this is not really a medical negligence but I think we could have done things differently so being a back seat driver we can always say stuff but what should we do now? one of the things that we have done we have done multiple maps of this eye and as you know there are some lasers now that have the capability of doing topography guidance and ablations with the epithelium on board you just put the fudge factor of that into it one of them is the wave light or the Allegra or the Alcon company laser and you can hook that up to the wave front map which is basically an Allegra analyzer and it gives you this map and then you try to do the treatment but as Dr. Penzel mentioned first you just take the epithelium off with alcohol very uneventful and then you can apply the mitomycin C but if you don't have the ability to do topography guided stuff and all that taxi stuff the thing that we can do is we take the good old beaver blade you find where the direction of the hinge is because you don't want to go against the direction of the hinge of the flap although very unlikely to lift it and you simply scrape the epithelium off and then you will continue to go toward the stroma except this is a situation here if you keep going down remember you have a button hole flat most likely there so if you keep doing it too fast you may start lifting the edge of that button hole in the middle so the stroke needs to be careful and once you pass the epithelium you will continue to use your beaver blade in the direction parallel to the hinge from hinge downward if you pick the fibrosis you can actually feel and you can hear that sound and then after that you put the mitomycin C on or we still do it in two minutes but there are some people who say that you can still go back to 20 or 30 seconds the only thing is in this one most likely the sponge needs to be cut and to expose the entire area to a 7mm sponge I think you can use a smaller Thank you Dr. Moshvar Now on to our third case this is a 34 year old female no medical or surgical history we went in for epilacic surgery on January 2014 for moderate myopia and mitomycin C was applied 0.3 mg per mL for 20 seconds then flushed with copious amounts of BSS the epithelial flap was actually removed so this is flap off epilacic and steroid antibiotic and NSAID were applied so just a little overview of epilacic basically you do a corneal epithelial flap that does not penetrate Bowman's membrane with the epicaritone and then you retract it you apply the laser treatment and then you can either do flap on where you put the epithelium back or you can completely transect that epithelial flap and so in this case it was done flap off so one week post-operatively the epithelial defect healed uncorrected visual acuity improved to 2040 and 2060 there was some mild haze noted but Pratt Forte was continued but however over the next two or three weeks the vision got worse there was more haze and the patient was referred to a corneal specialist who initially thought that because of the circular nature of it that it's possible it could have been infectious in etiology bacterial viral and parasitic cultures were performed and they were all negative so the patient followed up with their refractive surgeon and the vision continued to get worse in the right eye and it was noted that there were large bole stromal edema increasing haze and stromal puncture with bandage contact lens was performed afterwards and the bole actually resolved at the third month the vision got a little bit better in the right eye but then the left eye got a lot worse as a result of the same etiology there were bole, there was stromal edema and so Pratt Forte was decreased a little bit she was put on tears and muro and a bandage contact lens was applied and she was referred to the Moran Eye Center it's important to note that she had really extreme amount of photophobia as well as decreased vision and by the time she got to Moran her vision actually improved so this is her right eye and her left eye you can see that there's a decent amount two plus haze right here that extends all the way to the periphery and you know the treatment is usually about five to six millimeters but it actually extends all the way out to the eight millimeter size of the epicaritone created flat here you can really only see it centrally but it also extends all to an eight millimeter diameter so you know she was kept on bandage contact lens she was given a medril dose pack put on Pratt Forte for a few two hours and then tapered and Combegan was an important part of this management as well and she improved significantly to 2030 and 2040 the haze improved and she had subjective improvement with her photophobia Pratt Forte was decreased and the bandage contact lens was continued and these are her photos a few weeks to months later you can see that there's a decreased amount of haze here and here as well you know so what really causes you know we think that there's a couple different possibilities for this was it something related to the epicaritone you know these epicaritones are designed they have a special blade that is designed not to penetrate bowmans and endostroma it's usually set at a specific depth now different companies make different depth epicaritones but for the most part they're really only supposed to cut through the epithelium but it's possible there have been case reports saying that it's actually gone through epithelium and there's been stromal dissection with these blades the second possibility is mitomycin related this was done at a surgical center they get their mitomycin they actually have to mix it there so they get it from a pharmacy is it possible that they didn't mix it properly it was too high of a dose and there's some sort of mitomycin related toxicity you know it could also be some sort of low grade infectious etiology and we'll talk more about this after the next case so case 4 was a very similar presentation 31 year old female no history happy lacy perform on the exact same day by the same surgeon at the same surgical center for mono myopia stigmatism she had the same amount of mitomycin C performed applied in the same fashion and it was flap off as well and she had steroid antibiotic and said drops applied on the fifth day her epithelial defects healed and her vision was really not that great but after three weeks she had a significant improvement to 2030 and 2040 with a minimal amount of haze then at the second month she started having problems in the left eye her vision declined to 2100 she had more haze in that eye and then two weeks later she started having the same issues that the last patient had she started having stromodema microsyscidema and bullion in the left eye the same management was continued in the right eye but 4040 was discontinued in the left eye and she had a bandage contact lens placed along with a subconjunctival injection of catalog and over the next seven days the bullion actually resolved this is a cross section of the cornea OCT of that patient with a bullion with a bullion excuse me so yes so at the third month she started having worsening of her right eye as well as worsening of the left eye with more bullion and she actually had three staining lesions that looked dendritiform so there was concern for herpes simplex epithelial keratitis the pressures were noted to be 10 and 22 and pred forte was discontinued in the right eye because of that dendritiform lesion and contact lens was applied so she was referred to the Moran Eye Center with a visual acuity of 2060 and 2150 best corrected the pressure actually increased slightly in the right eye to 16 and 22 in the left eye and she had moderate punctate epitheliopathy mild microcystic edema 2 plus haze and she had traced decimates foals but no dendritiform lesions were observed during that evaluation so here's a photograph of her right eye you can see that she has this haze it's really difficult on this photograph there are some decimates foals you can probably see it right here but it's difficult to really get an idea for the epitheliopathy here is a better photo you can see haze and dendritic edema with this sclerotic scatter photograph so this is an interesting part of the patient's history specular microscopy was performed in both eyes and while it's hard to see the morphology of the cells here the most important thing to look at is the cell density per millimeter squared it's extremely low here's the normal range and usually it's around 2,500 or even higher but she's at 1,385 here and 1,312 here so that's highly unusual you know we don't have a preoperative comparison but very unusual for a patient of this age so she was started on pred forte four times a day com began tears rostasis as well as a bandage contact lens and at two weeks she actually improved very significantly to 2020 2025 her epitheliopathy and decimates folds had completely resolved and she had corneal haze that was still about the same so the pred forte was tapered slightly and she was kept on all the other therapies over the next couple weeks she had some fluctuation in vision but she had improvement in haze and her bandage contact lenses were removed then after about two months which was a couple weeks after her bandage contact lenses moved she started having significant decrease in vision pain mucus discharge and photophobia solely in the left eye and her vision had dropped down to 2300 and it was noted that there were three feathery crystalline epithelial deposits with overlying epithelial defects in that left eye here's a photograph you can see that there's two about a millimeter maybe 0.75 millimeters in size feathery sort of crystalline it's hard to tell here sub epithelial areas with the overlying epithelial defect here it's kind of easier to identify this crystalline appearance you can see the third lesion right here so what could this be this patient has been on steroids and contact lenses for months so it could be a lot of different things we got to think about the normal flora staff epidermis would be the most common but we also got to think about fungal keratitis because of the history of the steroids and the contact lens use in this case Canada would be our most likely fungal etiology for that so you know infectious crystalline keratopathy is also something that we got to think about there's a tremendous amount of organisms that have been documented in the literature that have been have a crystalline appearance strep viridans, the alfihemolytics are the most common but you know Pseudomonas quite a few other different types Klebsiella have all been documented as having cases been involved in crystalline keratopathy so you know it's kind of hard to figure out what this is just based on looking at it so this patient was started on a vagomox every hour and Natomycin every hour and the Predforti was stopped in both eyes and as far as the cultures that we performed Gramsciam was negative, fungal culture was negative but interestingly enough enterococcus ficalis was found to be the organism and sensitive to vancomycin and you know I did a pretty significant search of the literature and I did find one case of infectious crystalline keratopathy that had been associated with enterococcus ficalis so it is possible so because of the vancomycin sensitivities but also because we thought this was unusual and we didn't want to miss something you know it takes a long time for the fungal cultures to come back we put the patient on vancomycin every hour but we continued the vagomox for more broad spectrum antibacterial coverage so we kept the Natomycin on every two hours and after about three days it almost melted away there was no more crystalline deposits and the vision improved you know it was only 2080 because there were more focal areas of more significant haze underneath where those deposits had been and you know this is not the greatest picture but I just saw her recently and you can see the more focal areas of haze here it's really hard to see the baseline haze that she had had before but obviously a lot better than what she when she had the fungal or the enterococcus ficalis problem so as far as the last two cases are concerned you know we think that there may be multiple reasons why she had this problem so like I talked about before epicaritone stromal penetration is a significant problem of the reports in the literature some people had left the stromal dissection intact for a couple of months three to four like we had talked about before that would be the appropriate thing to do and then they had performed PRK afterwards and they had no issues they didn't use minomycin C and then one other account actually kept the flap down to the patient and decided to actually perform PRK or just the eczema laser ablation right over that stromal dissection and they used minomycin and they did have a worsened effect on that compared to the other so there was some complication there was some small amount of stromal antistromal opacity so it is important to really think about these cases appropriately minomycin toxicity could have been could have had some sort of thing to do with this we're not really sure why the endothelium has decreased in count per millimeter squared but you know it's less likely than some problem related to the epicarit keratome stromal penetration I don't know if anyone else has any thoughts on this Petrolsen I've talked about literature on this how the world does epi laser well I'll answer that question the normal literature is quite but we know the PRK we also know something called lace egg with the E we also know something called epi lace sick with the I so the PRK you guys are quite familiar with is what we do here Dr. Mithlin does with the residents we remove the epithelium and the epithelium can be removed mechanically or with the laser or with alcohol and then we do the laser treatment and the epithelium is not even there anymore so that's PRK lace egg with the E is you actually use a form of a much lower concentration of alcohol maintain your flaporexis as was described in Cleveland clinic and you basically remove that epithelium and put it in the corner you still have it you do your treatment and then you put that epithelium back down like a circle so it's still a flap of epithelium but you separated that by using a very diluted alcohol and you put it back on and you put the bandage on so by definition a better movement next time is doing the case and even though he's using if he finishes and then he puts his epithelium on then you cannot call that PRK you have to call that lace egg with the E okay now what is epilacic with the eye epilacic with the eye is when you use a mechanical modality to create a shearing force to separate that seven layers of your epithelium from the underlying surface now it could be over the moments or under the moments you still have a hard time knowing that so is it taking the entire basement remembering of that's the challenge we don't know but when we say epilacic which was done in this case it was with the mechanical machine which was a Moria epicaritone so did that answer your question then but in terms of the hype about it but this is the difference between is there any study that shows that no actually not and because of these ambiguities so the take home message first of all from this is that you can be a great surgeon that I know of I have a lot of respect for this individual there's nothing wrong with this captain did but this captain is at the mercy of this guy who brings the epicaritone to him and wants him to try it and it's assured I'll try the epicaritone and also at the mercy of the person who is diluting the mitomycin C so then at the end he's the one who has to get blamed even though there were other factors involved but at the end everyone's going to blame the surgeon even though who knows who made that mitomycin C correctly or the epicaritone that this sales rich guy brought and he was trying it the fact is both of these cases happen on the same day and it's very hard to know was it a mitomycin C and was it the epicaritone but the fact is that the haze unlike the other case was diffuse you could see this haze almost like 8, 8.5 millimeter you could chase it to the edge so the fact is there was a flap that was amputated and cast out but the question is that flap as Dr. Olson is trying to mention was it really 40, 42 micron or was it in some area 42 micron in some area 65 micron or maybe throughout the whole thing was about 65 micron now as you know when we do lasik we do 100, 110 microns we used to do 160 microns now we do 100, 110 microns now sometimes we do 90 micron and what is that? that's called sub bowman keratomalusis it's thin flap lasik sub bowman keratomalusis or SPK this is an ultimate SPK I think the flap was most likely a 60 or a 55 micron flap and in some areas most likely it took some of the stroma off and in some area the stroma was intact so when the laser treatment was done there were some areas that you basically had no flap on and for those of you who had the experience of amputating the flap the patients afterwards developed almost a 7.5 or 8.5 millimeter epithelial I mean stromal haze so I personally think that there wasn't an issue with the mitomycin C and it was primarily a depth abnormality with the epicaritone and is it good to put an epithelium down on the eye instead with alcohol or shearing force absolutely not it actually creates what doctor also is trying to refer to it creates this reduplication recurrent corneal erosion sometimes microcystic changes and it can create problems that's why we always toss that out and when we started doing lace egg we used to put the epithelium I actually thought that we should put the epithelium they would heal faster but the truth is that they claim that's a very nice epithelium you put it down you're not using alcohol you're not using 20% or 18% alcohol so you should not have any problem that epithelium is still alive the challenge is that it still causes epithelial problems at the edge and patients can get erosion this case though the surgeon very wisely just discarded it because he knew that it would retard the healing but why this patient still developed these chronic epithelial slough that sometimes you are the captain blaming for other people's responsibility the other thing is that both of these patients one of them is a head nurse and one of them is an endodontist and they're both suffering right now and they're getting better the third home message why did I use com began on this case the fact that this patient has been on and off on steroids when I saw them the epithelium was very ragged both of them were extremely sensitive to life by the way those pictures are not done by the gym they're all done by the iPhone holding the eye open so we're just using our iPhone we don't want to trouble you but the fact is both of them are quite sensitive and the literature that talks about mitomycin C can cause chronic photophobia for a long time so is it epithelial chronic erosions that made mitocystic changes made them sensitive was it mitomycin C made them sensitive I don't know but I still think erotome related problem and the diffuse haze is going to hopefully get better conia remodeled that's an amazing thing about conia you see somebody with a terrible scar you see them 20 years later sometimes that scar may not even be their epithelium and the cratocytes remodel the conia nicely so we're hoping that these patients will get better with time why do I use com began it has alpha-gan in it and when somebody has had kennelog injections and this and that I don't know what the pressure is is it 22 or 30 so what I do when I see patients like this with very bad epithelopathy I put bandage lens on them for six, seven weeks as if I'm treating erosions and I put them on com began with steroids because I think that com began is going to bring the pressure down and the alpha-gan part of the com began is going to constrict the blood vessels so there would be less of inflammatory mediators getting into that eye into that epithelium and they're going to stay whiter they're blanched and they would be more comfortable too makes the pupils smaller so they are less sensitive to life so that's why you like to use com began in these cases that I have no good grasp of it along with the steroids along with extended bandage lens both of these patients are doing well the endotontist still cannot go to work one last at home message this lady has a home what is it take home nurse as a home childcare we think the enterococcus picalis was actually from the diaper she does take care of little kids with diaper and that was my fault that this patient got enterococcus picalis because I have this patient in contact lens with steroids on board I caused infection because if there was no contact lens and there was no steroid on board this one may never have gotten the enterococcus so the reason sometimes we put these patients in contact lens we have to watch because there is this risk of infection so the take home message is watch out for the patients that you put in contact lens for erosions or whatever and you put them on steroids this is not my first time I've seen this in my own practice but this infection was as a result of our management patient and God did well we were on top of it but the enterococcus picalis crystals we always don't think it's streptococcus no I have seen crystals with everything so crystals we don't know but this one was enterococcus picalis thank you and now one other take home message remember instrument gene knives in many many many different ways and there's conflicting reports on the effect of mitomycin in terms of patients who have PRK but there's definitely large studies that show changes in morphology and endothelial cell count after its application and there was a study that analyzed patients who had epilacic their flaps afterwards using microscopy and actually show that there really was no functionality of the flap that actually epithelial cells were growing underneath it and replacing it so it's probably not the best thing to be using right? are these post refractive patients or just patients in general? I think the first thing you got to check is the pressure if the pressure is sky high that's exactly why they have edema but they could be having epitheliopathy for a different reason that could look like microcystic edema so definitely check both those things it really depends on the exact scenario but likely it's an effect on the endothelium if there's stromal edema and microcystic edema any other questions? thank you