 Yeah, so this is kind of like a hodgepodge lecture, so I'll mention I didn't get the lecture until like yesterday, so But but we're gonna go over kind of like the main point like how to assess who's a candidate And then in the end I'll talk about complications and And then I'll explain this to you way for a guide away from our advice because I didn't really understand it until like It's like what seems like a reed, you know, we're just like very cats or maybe not and Yeah, really like 20 times and then you still don't understand that's All right, so I Think the big thing, you know, everyone like you need to pick the right patient So some people have unrealistic expectations, which you know, this is a cosmetic surgery essentially And I mean it's it's functional, but if you've ever experienced like in your plastic screening people who have Cash-pay cosmetic group like there's a higher expectation That if it's functional in general, so you have to kind of really explain things to people because you don't want to have So, you know, I think obviously in foreign consent super important and You really want to you know, avoid promises like that's like something really vital for all you since you're probably not going to do much refractive surgery and residency is Kind of learning how to temper expectations for cataract surgery because you're all going to do a lot of cataract surgery And it's like people in the community people think because they're they're a friend in their neighbor Can see 2020 without their glasses that that's gonna be their outcome It's just like One thing Dr. Bifflin says that like I really like is especially for cataract surgery We treat it like it's a refractive procedure But it's really not because our lens choices only come in half-diatrics steps and so inherently There's gonna be some kind of most time there's gonna be some kind of refractive error afterwards And sometimes I can be visually significant and so you have to really talk to people about that You know those unrealistic expectations like I had a guy It's like one of my last I think it was awesome player doesn't seem you know as a VA he had a ruptured glow like 25 years before and had a central corneal laceration and had iris defect and a big nasty cataract and I was like he had like 10 actors of a regular corneal Stigmatism was like and he came he's like yeah doctor this outside doctor said I could go to VA and get this lens Stigmatism for free and I was like let's let's set your expectations, right? But we're gonna take out your cataract and probably help you see better But your vision is not gonna be perfect because like we can't correct this linear Really weird stigmatism right in the center of your corneal, and so you know I talked to my friend I think talked it for like half an hour every time Surgery went fine and then afterwards he was still like I don't get it I can't see very well These two other doctors said I could have this tort lens I was like do you need to Realize that this all we've been talking about either your heart contact or bosses or some prior contact to see well And anyway, so you can so explain stuff to people that they're not gonna get it But at least you've done your job, and then I'm super important is that documentation So we're gonna I have like a patient case and we'll just talk about what I would document for that so Like I said like you know do patients have What's like the motivation for getting refractive surgery a lot of times people come in because their contact lens intolerant and they hate wearing their Glasses and they're pretty near sighted and they just wanted to be glasses free and a lot of times that's fine And people do really well, but you know what if they're like 45 and they're minus 250 and both eyes are minus 150 And you know they they want to have really good distance and your vision because they They probably were contacts or something and they're kind of getting that presbyopic age You have to really talk about that because they have to make some choices and we do see patients where we do Refractive surgery on them and then in their mid 40s and a lot of times we try to convince them to try a lot of vision now So they can have the best both worlds or they just have to realize you have a sacrifice, you know one or the other so What's your social history, you know What do they do for the profession so we have you know, we're the providers for the Olympic ski team now. I don't know if you guys need that, but we had Someone who's gonna give the Olympics probably come in and you know, he wanted to have I should say this person So the record button You know, they want to refactor surgery because like maybe get a competitive advantage camera context because they're going super fast and drives out and he's classes and So because there's potential to like, you know, crash But like training this person was like training in Chile, but right now like started July It's gonna be there for the next six months So, you know So he always because you could come for a day and a half and then you guys go back, you know, are you a boxer? Like is that gonna happen? Maybe not the best to get basic because those flaps never truly heal all the way and we'll talk about that later, but We had a rock climber come in. He wasn't like professional, but kind of like really serious amateur and He does big traditional climbing and he says he gets like written dirt in his eyes all the time So he chose PRK because he's like, I don't want I want to be on the face and you know, I have a problem I can't see Contact on Zeus. I think this is probably like You know, if you do off the questions and you probably notice like there's this there's just a ridiculous amount of Refractive surgery questions and you're probably not gonna be tested on most of them But I think this is something maybe oh cap worthy How long do people need out of contacts before they have any val or refractive surgery? so typically like our policy here is any bail soft contacts for a week and This is straight from BCSC So it says three days to two weeks depending on whatever the surgeon preferences and in our contacts like we really follow this We say like two week minimum and technically it's like one month for every decade of life, but that's crazy like People don't want to do that people were at heart contacts like really value They're super awesome vision and if you tell them they've been wearing We've had patients who've been wearing them for 55 years and coming for counter surgery Like we tell them that and they're like there's no way I can do that So what what we do is like say when you say your contacts for two weeks And then we have come back like every couple weeks and just see what is state the cornea is like really Stabilizes because over time it'll stabilize and yeah You might there might be a difference that one month and five months that they're wearing their heart RGPs for 55 years But it's not gonna be that big of a difference and then you just have to type our expectations saying your cornea to change shape after patterns or Or you know Refract surgery, but most people who are wearing RGPs Haven't worn there and want to get refractive surgery haven't been wearing them for 55 years. So And just kind of is an example So this was a patient who was actually gonna have cataract surgery and so they wore RGPs for like 30 years So you can see you know, you kind of have and they have care of comas So I'm giving that away, but you know, you can see kind of like this inferior steepening But it's not really like a typical Care to come to say picture So this is and then this next one is like this person was out of their RGPs for a month So you can see like it really changed shape quite a bit So just kind of for me hits point home that you know, these people use the people have to be patient We can't expect results right away. You just got to be wait for a procedure and I think we did kind of other considerations for refractive surgery like preoperatively is dry eye. So Dr. Mithra wants to say we live in the second dry state and there's a lot of pollution around here a lot of agriculture and factories and So there's a lot of dry eye And so people who have dry eye before especially in LASIK are probably going to dry eye after LASIK and maybe a lot worse and basically it's because you're just cutting all the coronal nerves from the flap and You know you get kind of this rejection. It's just like a nerd. It's basically a neurotrophic eye, but usually not current And so they get all these things here Injured and limbo goblet cells may be from like the suction that's applied for the fentilies I'm going to make the flap or back in the day when there's a micro carotone But you can see this eyes like super dry and we've had patients who like come in they have like mild dry eye We're like, you know, you should probably get PRK and then they won't be sick and they like four plus Epithelial erosions and like their vision is blurry. So most of the time though, I think it's on the next In this something was cut off by my sweet picture, but You know dry eyes sufferers don't want to wear contacts either And so like a lot of times people come in with dry eye because they want to be out of contacts and they hate their glasses So you just have to talk about dry eye like I had an evaluation I think I'm doing a case on Friday and she's got like a little asymmetric dry eye like maybe trace PK and one eye and I told her like, you know You could do LASIK, but you're probably gonna dry after and because of like work consideration stuff faster coverage You want to do LASIK over here? Okay, so I'll just remind her Afterwards, but I think this is like an important point like Uncorrected visual QD one year is no different people are dry and not and that's something I noticed being here for a couple months Is that people can have crazy ridiculous dry eye after LASIK, but they still see really well And that's part of the problem because they have neurotrophic cornea They see really well and they don't realize that their eyes like really dry So they don't want motivation to use tears. So but in general for LASIK we people on like Preserver free tears like four times a day for six months at usually PRK induces less dry eye because you're not Innovating the cornea And then, you know, there are ways to treat it like we'll do plugs tears Frigging me for people sometimes we buy and see doctors like things like that And then like, you know, there's some there's been a lot of research in one of papers So supporting that PRK is better than LASIK for dry eye and and like I mentioned this There's some theories behind why femto is better and maybe the thing of LASIK causes less nerve disruption and then the suction is a lot lower with the femto Then micro keratone. So maybe you have less damage to the lungs People can still higher practice surgery after having HSV But you just gotta be careful. So like if we Dr. Mifflin's policy is like if they've been quiet for three months and then he'll do it And you know, you got to make sure they're on the big scar or anything Things like that, but sometimes we'll increase the dose of their antiviral therapy during the really post-op period And you know, no one really knows what causes HSV to flare maybe these two things after who knows But yeah, like I said, you know, if they had a recent attack if they have a neurotrophic cornea scarring or if the cornea is really thin You probably should do refractive surgery And then keratoconus is like the big absolute cognitive education Indicate whatever I can't say the root. You can read our data to Ways revision correction and like back in the you know early in the 90s when like everyone was getting LASIK and they were doing like minus 14 minus 16 the after corrections Which actually the FDA has approved the LASIK of the minus 14, but like no one does that because it's crazy You know a lot of times back before to Margherty, which is like the penicam or the galley We're really in vogue like people are doing refractive surgery without without getting to Margherty So they can like a posterior cornea and a lot of times that's kind of the tiebreaker to decide whether someone has Keratoconus or not and so these people because they have a progressively thinning cornea When you up late, you know a third of their corneal thickness their corneas just gets thinner over time and they really unstable refractions So So like like it mentions here the trick is identifying some subtle cases and then this kind of big question I didn't include any slides on this, but so if you guys have patients, we just started cross-linking on Friday And it's super boring like you they the patient you to breathe their epithelium and then they Sit there for 30 minutes while you drop this riboflavin drop on their eye every two minutes for 30 minutes And then you make sure the corneas thick enough and then they stare at you if you like 30 minutes And you keep dropping drops on their eye for every two minutes So it's boring, but in Europe and someplace in the US that have been crossing for a while People who have like myocardoconus and the corneas are nice and thick and they've been cross-linked They will do PRK or some people do LASIK if they're a good candidate and there's some newer technologies you probably there's this new thing new-ish called topography guided Refractive surgery or LASIK And we actually have it on our machine. It's called Contura and basically what it does is it it kind of treats more of the The the corneal map versus just treating the refraction, which is what traditional PRK and LASIK does and so we just started doing it we got the upgrade like two months ago And we really just started doing it, but so I think in the future here probably not this year probably next year We'll start on select people who have been cross-linked. We'll start doing Refractive surgery so do you guys understand cross-linking every questions about it? Who so care to come so people have it like risk for ectatia so care to come as patients and then post LASIK Like if it's not super severe so the cornea has to be thick enough like the the FDA trials Their cornea had to be after you take out their epithelium had to be 300 microns The new FDA guidelines say has to be after you put all because when you put all these drops on actually they have the drops Dextran in them so it actually dehydrates the cornea as you're putting these drops on and You're supposed to check the central picumetry And the cornea supposed to be 400 microns thick or greater before you cross-link because there's some there's some idea Research that if the cornea is too thin when you use UV light, you're gonna actually cross-link the endothelium too and you can damage it so Essentially, it's like putting rebar and concrete to select California and all the houses are retrofitted for earthquakes are built to those standard quakes and the way they do that is they put You know pot of rebar inside the concrete when they set the concrete down it adds stability and strength And so that's essentially what we're doing to the cornea It's the same technology like if you go to the dentist and you need a cavity filled and they use a little UV light on the Resin that's cross-linking basically so so the idea is like you're gonna basically strengthen the cornea And then it might be stable enough that it's gonna stop getting ecstatic and hopefully prevent people from being cornea transpired Maybe for some people they could get To part with the guided refractive surgery afterwards. So Yeah, yeah Maybe Yeah, and really like they don't have to get worse so like even mile because like you don't know who's gonna progress I mean you you know like if someone's 16 years old and their cornea it has K's of 58 and 65 like they're probably gonna need a cornea transplant but you know we just saw a teenager yesterday his Cornea was six hundred and fifty microns thick and he had no fear of steepening And he had kind of this carried close to a picture and we're still gonna do crosses on him because he's 16 and carried conus patients tend to Get thinner as they get in the mid-20s So late teens early mid-20s is where they really progress. So we're gonna offer to everyone who kind of So Only a couple insurance providers here so like Blue Cross Blue Shield The get-nose but select health is not which a lot of you boss up through insurance your IHC So we're charging twenty five hundred dollars per eye, which is like pretty comparable to the other places that are doing it Yeah, it's like really takes really like 75 minutes and you can't like The machine itself has a timer for that first 30 minutes So like we thought at first like hey We'll we'll do it on one person and then 30 minutes after they start will bring a new patient in but you can't do that Because there's like this set timer so that so it's gonna we have a list of 300 patients just dr. Mifflin does You need you want it and and so you know that's gonna be a lot of time Yeah Yeah, so I mean it's not it's basically like Hopefully prevent them becoming from their cornees become thinner most people their cornees get a little bit flatter But it's not like this miracle where their case drop 10 diapters, you know, it's it's probably it's pretty mild It's usually like four or five doctors at the most. So, you know, it's it's definitely not like a Procedure where it's not a miracle procedure, but it's the best thing we have and so I've been telling her when you're probably Still be wearing the same contact you're wearing now Maybe a little bit different power, but you know if they're in soft contacts or probably staying soft contacts They're in hard contact. They're probably still being a hard one Depending on how steep their cornea is so no question. Yeah. Can you guys do it on polluted patients? Yeah I mean you can it just depends on if their cornea is too thin then they're not a good And that's really like the biggest thing and obviously like, you know Do you need to do cross-linking on a 70 year old who has carried a cone is probably not like their cornea Is probably as thin as it's ever gonna get so and we usually see a lot of people patients for cataracts Or do you like that first patient who or some people have carried a cone as it's not visually significant And they come in for cataract surgery and they just have you know a lot of the stigmatism a lot of the care to come Is patients they actually look over the cone and you know, so the cornea is actually flattering the center And so this a lot of times doesn't bother them We had a guy who is trying to become an army pilot like five helicopters and On his routine exam like down the last thing they found that he had care to come this but he's 2015 Uncorrected in both eyes. So it's like really mild mild case And so he was coming to dr. Mifflin to like kind of get ammunition so that he could go Be a pilot because like that's a contraindication to let someone be a pilot But he was like 31 and like probably not gonna get worse So it's kind of interesting tricky situation and he may not get worse Anyway, so this is kind of like the if you guys heard this term for first care to conus It's like care to conus suspect. So someone who's Map looks care to conus or lose it like But they don't have visual problems And so you these are people you just watch and these are candidates for cross-thinking also but you know even these patients a lot of the The post-lasic ectasia patients probably had form first care to conus and there's just unrecognized and then it kind of When they got lazy to get pushed them into the care to conus ectasia world But you just gotta be really careful. This is like the big thing This is why we do imaging a lot of times on patients for refractive surgery screens because you don't want to Do a patient like this like you're we don't want to do harm You're setting yourself up for a huge lawsuit if you do something like this And you know, this is a carry conus doesn't have to look the same every time, you know, this person I don't know what dr. Mifflin case was but I mean this refraction is not very bad, right? And the central cornea not that steep, but this person definitely has care to conus. So you just gotta be careful Yeah, so and the big thing is in case because I didn't know very much until I actually started here about this But you want to look at the posterior cornea so the posterior elevation So if you get the on the penicam, you can do do you guys have penicam at the VA? Okay Anyways, you look at the elevation on the back side and if you see I'll show you a case later that Doesn't have care to conus But these numbers are all out of whack like from the central cornea all these numbers should be like within 10 to 15 So whether it's plus or minus But if you have this big plus like 30 like that that means that the cornea is bowing out the posterior cornea is coming Anteriorly and that's this is absolutely care to come so you wouldn't want to do a refractive surgery And then just just to show you what come like this patient we actually do she had cross-lunking then we had to do cornea transplant on her and Just like three weeks ago, but you can see like this had pose like she had lacy 15 years ago Courtney is like crazy steep looks like care to conus super bowed out. I can't see that number is but it's like Plus 82 so you know that cornea is gonna hard time seeing if you put them in So You can do your fact surgery on cornea transplants. You just have to be picked select people well Typically you want to wait till all the sutures are out In a lot of times like Dr. Mifflin's fairly conservative taking sutures out like he'll take him out until they have you know two Directors of stigmatism or less and then we'll just keep them in Because people can see what glasses with that, you know if they're they've 10 doctors of stigmatism You have a problem, but there are people who can't have A lot of times we'll do PRK you can't do Lisa on top of the transplant You just have to be careful. There are some considerations. I think I'm on my next slide, but did he talk about these like like Courtney relax incisions wet wet your section. Did he talk about that at all? So sometimes like we had a patient who had 10 doctors of stigmatism all of her sutures were out and she couldn't see very Well, so actually what we did is we on the steep axis of her cornea We took her to the OR and we basically broke open the the wound the graft hose junction and Try not to perforate the cornea and kind of relax and then just put in and put in some sutures at the Flat axis to make it tighter and steeper and I think we got her down like two doctors after that a wedger section Is like that's compression sutures a wedger section is like this extreme version Where essentially you break the graft hose down junction and then you cut a wedge of tissue out of the host Let's kind of like you know like like an ellipse basically so you kind of create this huge gap and then you sew it and you make the You basically you try to increase the stigmatism flat axis And then relax incisions are just like limbo relax incisions. You can do them in the graft or outside of the graft In the graft they have a really powerful effect because it's closer to the visual axis. So you have to be careful And then yeah, like I said, you want to make sure you know they have the practice ability a lot of PK patients are wearing RGPs and then you know with lysic It's kind of tricky because like you're going to put this suction cup on their cornea And if you've all ever seen a de-hist cornea like 12 years out like those ones ever healed And so you just got to be really careful and then Hayes with paraca will talk about that as a risk and then there's other things like Glaucoma, we don't know just like when you do a vast and injections, you know, you have this transient high-rise and IOP and there's always questions about whether that Increases the rate of progression of glaucoma seeing with putting on this is a micro keratone are you know doing like a Femtoflap or micro keratone does that increase pressure so much that damages out the curve And you got to be really careful about filter and blubs, you know You don't want to put like a crazy mad pressure on an eye that has a filter and blub because bad things happen But it's not it's not like a super crazy contra indication with glaucoma You could we would probably do PRK on those patients, and they probably do fine as long as they don't have a fish in the last room Can I ask a question about the previous slide? There was a thing about like a regular stigmatism. Can you do Yeah Yeah, that's a nice thing with like the new like wavefront guided wavefront optimized contura The topo guided it's like you can correct a regular stick the stigmatism Yeah, I like traditionally say which they were doing like 10 years ago not as much so But no one does that really more everything's like wavefront or contura the topo guided And you have to consider like steroids because after PRK especially people are going to have steroids for like three months You know you just have to be really careful document everything make sure their fields are full retinal disease obviously so So a lot of patients of high myopia forget refractive surgery and they're just an increase risk for an RD LASIK and PRK don't increase the risk probably but they People already had high risk so you have to be careful and tell them, you know, you need to look out for flashes and flutters Although this is kind of a thing like I'm sure you've seen an RD after a clear lens extraction From either here from somewhere in the community. We do them, but we usually try to wait until people are Older, but you know there is a higher age It's just like for the cardiac surgery like high myopes who have cardiac surgery are higher risk for an RD A lot of times people get clear lens extraction are in their mid 40s 50s and they're super myopic or and Like minus 17 minus 18. They just not a can for anything else like they have a little bit cataract so you can't do a ICL And so you just have to explain that because obviously they're paying a lot of money for cataract surgery that you know for kind of a Lifestyle cosmetic result you don't want Then they're really mad at you and then there's always like do buckles effects how well that the the Femtomo second laser can maintain section on the cornea You can do it up like this is like where doing like good refraction. This is important because Sometimes patients don't correct it 2020 or 2015 and like they're 2025 2030 you can still do Lays it for PRK, but you just have to temper their expectations So, you know best vision you ever had before surgery was like this and it's probably not gonna be probably wouldn't expect to be any matter Afterwards so that's kind of the point of the slide and it's apparently there are People had some kind of deviation wasn't recognized and they got unilateral refractive surgery and then they got deviation Which would totally suck Diabetes you can do refract surgery on people diabetes as we all know I think this is OCAP worthy High glucose means myopia pricey at the VA a lot and So you just have to be careful and then poor wound healing for these people so You know are they good for PRK if they have crappy epithelium probably not because it's gonna take a while to grow back so You can do Refractive surgery on HIV like they have these kind of like old-school extreme measures where like you wear You know one of these like Bioterrorism masks when you do the procedure because you're blading the cornea and cornea dust Can get in your eyes or because membranes, but it's never really been proven that that can cause anything so We would do it, but you know you'd want someone who wasn't like in full-blurred apes crisis And then autoimmune disease discovered you can do it But you have to be really careful obviously like and I looked at that anything on but you want to make sure that people are well-controlled Keyloids so like You can't get bad scar with Keyloids scars and we always ask about it, but like as long as you're as long as you're Really careful and like we use mitomycin C to decrease fibroblast growth with PRK and these patients They're probably gonna be fine. You just have to explain to them the risks And then this one I was we always get questions about me ask at I usually ask about it But this kind of like a general contraindication It's it's not because like refraction changes permanently during pregnancy and nursing But it's really like has to be more a corneal hydration status and you just don't get stable topography And so you just want to be careful and but they just need to wait three months after Some people do have a change in their refraction They can be pretty big and it can be permanent and mainly has to do with what their corneal shape is I Have some cases, but let's see what point this one was Yeah, I mean I will calculate as you probably learned our harder after cataract surgery not as accurate And so like when you're doing cataract surgery Make sure you temper expectations because it's not gonna be perfect especially if they got hyperopically sick because it's just not that accurate and But there's some really good calculators out there You just don't want to have a hyperopics surprise because these are people who had like super good vision forever And then all of a sudden the cataract surgery which all the friends had and they're not seeing as well So, you know, there's the asterisk calculator. There's other there's a lot of different methods to do post-lasic and PRK Surgery calc's I think like the one that's kind of what they like here is asterisk website Where I did my residency, I would just like to use a pentacam and I would take You know, there's like that central three millimeter ring You can actually like use your pointer and click on the spot until what the case are So I would take like eight points from the central three millimeter cornea And then one right in the center and I'd average those nine spots and divide by nine And I'd get like this average K and then I put that in the case it worked out really well So there's lots of different ways you just have to explain to people that this is not lacing It's not as accurate. And so it's all about expectations You Yeah, if they if it comes up they're like a lot of these people, you know, it's not like my standard talk I mean, especially when they're like 30. Yeah, but if later I but the thing is like we're actually really good, too I mean, it's not as big as deal because as we get more data on what formulas work Like they keep updating the askers calculator and it's really accurate And so I think just like with any cataract surgery the more data you have the more calculations and different methods like the more accurate Your outcome is going to be so that's what we look at. Sometimes you have a surprise and it sucks and you can do things about it So here's patient. So this is someone I'm doing surgery on on Friday So it's 28 non-contact ones where 2015 corrected both eyes. This is her like most recent refraction. So she's a high my ohp and And This is these are her corneas So is anything Stand up to anyone. Is there a sigmatism with the rule against the rule? Yeah, she totally does so she has like this Asymmetric bowtie. I mean red is not quite but you know little teeny bowtie on Superily and big huge one inferiorly So let's look at her tomography, which is penicam. So you can see the nice bowtie here again Corneal thickness penicam is really good for doing corner thickness. So you can see she's like 520 Which in our the refractive surgery world is fairly normal But then look this is that elevation map that talked about like the posterior elevation You can see like there's not a lot of variation between Kind of the central cornea and then the periphery. So there's none of those bumps where it's like plus 30 minus 30 And then same with her left eye, which is the one that had even kind of larger asymmetric bowtie 518 central corneal thickness, but the posterior map looks really good. So so like Do you think well? I already gave the answer coming during the refractive surgery on her on Friday, but You know, what do you think we should do? She would do lacy PRK Why Surgery ectasia. Yeah Yeah, I mean essentially so when you when we make a flat for lacy gets 100 microns thick. So that's 20% of the cornea The anterior corneal stroma is stronger Biomechanically than the posterior cornea. So when you cut that off, you're Making the cornea weaker naturally. She might be at a higher risk for ectasia We don't know but based upon kind of like the care to cone is criteria. She doesn't really need it But but you just have to be really careful. She's a she's a higher my oak Do you have a question? No, no, so like if she was yeah for What I would want this to have like some kind of elevation like that, you know, like plus 20 plus 30 Then I would call her like form fruits carry cone is a character kind of suspect And then I wouldn't do refractive surgery on her. I'd say we could do Crosslinking on you because you have carried a cone is and then probably consider it but for her. No, but The big thing is is, you know, the risk for ectasia in refractive surgery is one out of 2,000 Now which is interesting me is the risk for carried cone is an adjourn population So I know it ever ran With the criteria for like kind of ruling out character conus people as candidates They've had one case of post-lacic ectasia in like the last 20 years that so, you know, you can be super careful Sometimes it's gonna happen, but it's really rare So I told this patient I explained the risk for ectasia. I said I wouldn't do lacy on you We would do PRK and just explain their coverage a little bit longer But it'd be worth it safe and you're probably gonna do really well But you just have to know that there's this one in 2,000 brist that you could get thinning over time And when you tell them like it's one out two thousand like people aren't usually okay with it seems acceptable enough Lacy complications amidst the dry ectasia showed that flap issues. I talked about this in the grand rounds, but you know, you're creating a new space So you can get infections you can get melts Usually from infection or from epithelial and growth where epithelial cells kind of go in the flap Most of time it's not visually significant with femto laser the the risk for epithelial growth is lowered But if it gets in the center cornea you have to lift the flap you have to scrape it off You have to use like my my sensee to stop fibrograss growth and then de-hissing so I Like I never forgot this. So when I was a med student I rotated here with Dr. Miffin and He told me like we're like doing lacer lacy one day. He's like it's like 10 years ago I had a resident call me crying because the patient who just had lacing like the dude forgot a car accident and came in with like bilateral giant abrasions and basically the lacy flap said de-hissed and the resident peeled them off peeled off the flaps and Obviously like I think the patient I'm doing okay, but like you screwed their cornea when you do that So I never forgot that and so when I was a second-year resident I had there's a cop and he got hit by a bungee cord in the eye and like he had a lacy flap Because this lacy was 12 years before And so I like irrigated it really well and I put it back down And I think they have to be like they had it Decapitated eventually because like you got a bunch of epithelial growth, but I never forgot that so you can get that Years and years down the road. So just if you see like these, you know flat things Superily it's probably always ask about their surgery history and There are some people who do that but it's more common to put the hinge superiorly so I think there was someone here who Did them temporarily but the vast majority of people do superiorly so Yeah, I'm sure that was changing. Yeah. No, it's I think it's fine both ways But the newest like the new like sexy thing is like to make the flap thinner But we did a study so the nice thing about our we like the newest Alcom laser and it actually does like interoperative optic optical Machinery and so, you know you program like the thickness of the flap of the fender second laser But we were finding that the flap is actually ending up being thinner than we would program like almost without fail like 20 microns So we do we set our flaps at 120 microns and usually end up between 120 and 100 And the reason why if you have a thin flap then you can it's just less stable and it can be as easier Um, PRK so the reason PRK PRK was like a pure buddy at daily two years before a lacy, but it became really popular pretty much right after a lacy came out And it's because of haze So obviously you can have a little complications with like having a huge epithelial defect But we put everyone banished contact lenses their own antibiotics and I don't think we've ever had an infectious post PRK case here ever We've seen them because they get comfortable outside But haze was like the big thing because basically what happens is you have late Bowman's layer when you do Refractive surgery probably doesn't matter because they found that the epithelium probably increases the number of hemi desmosomes after refractive surgery But when you get this kind of remodeling of the anterior stroma epithelial border You can have like cauldron fiber oils that are you know instead of being like geometric and straight They kind of go all over and so you get this haze Most time it's not visually significant But if it is it can be like really annoying for people they can have pretty crappy vision and almost without fail It always goes away on its own, but it could take like years So we had a patient come in from an outside provider just like last month And he was like 2050 in one eye and this was someone who like didn't keep his follow-ups He didn't keep on hysterics for three months like he's supposed to and he was like really mad and you want to be Retreated but dr. Mifflin's like you know, this is gonna go away. It's just gonna take a while You just got it It's gonna take time If people are on steroid and they come in with haze and they're doing everything they're supposed to we'll Go to stronger steroid. Usually we use like after the first two weeks. We use like FML for three months So we'll switch back to Prad. We'll do rostasis because you know it has some kind of anti-inflammatory effect We'll do vitamin C. There's some idea that UV light can damage the that kind of interface that's And so it can increase haze formation. So if I don't see my help doxycycline obviously is an anti-collageny. So that might help too But most people even if they have a little bit haze see really well So and you haze formation is increased if people are like pigment to skin or they're higher Higher my hope So we use mitomycin C on those patients usually from like 12 to 20 seconds depending on There's no set things just kind of what dr. Mifflin like they have they're like a minus eight Let's use 15 seconds. So anyways, but it works well You just gotta make sure you wash off mitomycin C Oh, yeah, so okay. I didn't do a silence. But so there's wavefront optimized and there's wavefront guided so The the two biggest most popular lasers are the alagretto which is it's like the Wave light alagretto wave light and that's from alcon. That's what we have And that laser in the united states is way for an optimized and then the other most common one is the vizx Which we used to have here A couple years ago. They had both and that's a way for guided So the whole idea is like when you do an ablation like, you know With you're trying to make a mountain into a mesa. We're trying to flatten the cornea So there's this transition zone where you're not ablating the peripheral cornea and people get higher order aberrations Kind of at that interface where the ablation was and so older lasik Didn't really there was like a small transition zone between kind of normal cornea and laser cornea And so the the idea behind wavefront optimized is you take someone's refraction and you treat that on the cornea And then but it kind of like smooths out that transition zone So you get less higher order aberrations So like when people have large peoples or their peoples are dilated like they get less kind of purple light rays Screwing up their vision Wavefront guided is is more where you you treat the refraction But also there's like this complex algorithm where they they kind of treat the topography also And so it's not true like topography guided, which is a new thing But they they kind of take maps and stuff. Have you guys seen the wave scan? It's like this It's on the fourth floor. It's a machine and it basically like You take some pictures of the eye and it tells you like what Ratio of higher order aberrations. They have like sphere of collaboration and comma and trifoil comma And all these are quadrufoil and all these other ones that I don't remember their names But basically you take those maps and you input it into the the vizx computer And then you take the refraction and it it does like this algorithm And it does an ablation to get rid of higher order aberrations They both work super well. We did like a head-to-head fellow eye trial here like four years ago and found that both Cause less higher order aberrations and traditional asic and then both people will see just as well with with both of them so They're both popular The vizx is really popular because they it's a roll-on roll-off laser So like, you know, if you're if you don't do that much refraction surgery But you want to do some and you can't afford a half a million dollar laser You can like have a company come in and they'll like bring a truck and they'll bring the laser in for like a day So you can treat all your patients and the vizx laser does that so the the alegrito doesn't so So that in the community that's probably more popular, but like places that do a lot of refraction surgery They are trending towards getting the Wavelight Alcon refraction suit like we have because it's probably It's newer. It's faster making the flaps And it's it's faster blation and it can do this topography guided, which is basically topography guided It it you basically just you treat the topography So you have to take all these like measurements of the cornea and then when you kind of input your Refraction of stuff into their system It it tries it does more of a Treatment of the corneal shape than actually the wafer and guided does and so you get the whole idea is to decrease Spear collaboration, which can you be like not my opium things like that? So We just started doing it like like I said, I think like a month and a half ago So I don't know if it's gonna be any better because our Our way front optimized outcomes are so good now and dr. Miffin tends to He tends to like look at the topography and he'll take someone's refraction And if they have cylinder, he'll tend to push the Instead of treating whatever acts to say like in their glasses, he'll tend to try to treat the axis that's in the topography anyways so I don't know if it's gonna be better than what we do now, but we're the fellow study This the second half of the year and then next year and probably the year after we're looking at like Wafer and guided. I mean topography guided in one eye and wait for an optimize in the other eye Of the patients to see if it's there's any difference. So Any questions How about like some people like they're late sick will only last like Do you talk to patients about that beforehand and Yeah, the information because like our book didn't say much about good question So the rates are are So so kind of they they call it it sounds really fancy. Remember a doctor talked about dr. K spear That was like his the guy he invented this term called it. You're you needed an enhancement So it's not a touch-up. It's not, you know, it's an enhancement. So it sounds really fancy. But basically, yeah and at Our patients five percent of patients get a little nearsighted over time and it typically happens in between like eight to ten years and so So if they need to be retreated and they have like enough residual Stormo bed left and it's totally reasonable to retreat them. And so um, we here we like Part of I talked to everyone about that. I say, you know, there's like this five percent chance Some people are at higher risk for that. So like young people like they're 21 female High myopic corrections are at a higher higher chance for needing an enhancement down the road. So We I tell everyone about it and I say, you know, if you need it It's like four hundred dollars and basically it's just a cost of the quick fee for using the laser Here some places have like a lifetime guarantee Which is kind of like it's really ingenious and tricky because like basically they say We'll treat you for free down the road if you ever need it But usually come into our office every year for a full eye exam And so by the time they need one they're going to spend more money on co-pays and whatever So we just like 400 bucks, you know, if you ever need it and and I think that you know, our rates are fairly low I've seen dr. Miffin retreat a couple people but a lot of times like they're like minus one minus 150 And usually they're like already in their mid 40s and like they kind of have this nice like monovision and so most people are like, yeah, it's it's fine Yeah, yeah for like regular so there's always things so like with the new topography guided like there's an extra $65 click fee on top of What's your what what the least a click fee is? so, yeah, it's Ingenious the company charges you half a million dollars for the laser and then Every every use it's cost more money. So Um, but yeah, it's good if you guys I think dr. Miffin lets you guys do Refractive surgery if you can find someone you get the fellow discount Which is like actually like the least expensive way in a while such for them to get like high quality Refractive surgery one thing I learned and you know, have you ever seen like advertisements and they're like yeah Come in 250 bucks for leasing What they do with that is it's like a la carte. So like if you're like a minus one minus two it'll be 250 dollars with like a Two previous generations ago laser But then if you want to get like the wayfront guide or optimize In Europe like a minus five you're gonna be paying the same prices if you go anywhere So it's kind of what does it read like if I'm a fellow to do it again, um It's I think it's cheaper for residents. Is it cheaper for us? I think it's the same. Oh, if you you mean cheaper for residents if you get it done I think they just switched it all so they just raised the price So it's 1400 dollars per eye and then I think there might be a little bit of a discount if you're like a new employee maybe So yeah, but that's like pretty I mean they charge I think it's like about 2000 and I for Like if the attendees do it The cheapest other like to get what we offer Anywhere else like the cheapest price I found is um 1800 bucks per eye. So it's it's like a really good deal And I'm amazed that people want to get it Fellow like they want to pay four thousand dollars It's like Yeah, I don't know Yeah You know, so so if you think about it actually the the lifetime risk of having an Ocular complication where in contacts is higher than getting refractive surgery if you're a good candidate. So for some people that's enough, you know and I mean, I don't wear glasses. I was blessed like perfect eyeballs It seems super annoying my wife was contacts. I'm like It just sucks. Like, you know, if you forget them or falls on the ground like that's It's safe. I've been camping before where they froze. Oh, yeah, that's crazy So refractive surgery is good. You just have to have the good a right cabinet and you know Doing the procedures not hard when you encounter surgery That's way harder to do But it's like the brain sweat that goes into deciding who's a candidate is the hard part. So But yeah, if you guys ever have anyone's interested just have them You know, they can come in to see you for like a screening and you can call us and we can tell you what you need to do and stuff and I think it you know kind of sells itself if someone's interested That's it I don't know if dr. Mitchell went over this last time. So maybe you guys who were there say Like, you know, one thing I think that might come up on ocapsis like steeper corneas and like the flap complications Obviously, it's not now since they're all But why do steeper corneas Like are more likely to buttonhole and why flatter corneas are more likely to have like a Transection with a flap is totally loose. I should have read about that. I always forget that one. Um, I think it has to do with Actually, I'm not gonna say because I don't want to sound like it. I don't want to give you a black pearl Wrong wisdom It does have to do with like the how the The the suction occurs And like what it does because I know like with um, like when you you actually use the same pretty much the same keratone when you cut The And you know cutting off and you'd be a different size buttons depending on how much suction is applied So, yeah, I wish I should have read about that So So like flatter corneas are more likely to Have the The flap get cut off totally so it doesn't have a hinge And then like steeper corneas are more like lead a buttonhole. I guess there's like a hole Yeah Yeah Inside the yeah That's that's what we've actually seen that Right. That's correct. We've seen on patients. We've had their flap set too thin And they come in and they've they've had a button hole It's less common with the femto than we are doing like manually with the blade, but it still can happen It's kind of annoying. So this patient we ended up doing pure k-on So let let the patient heal for like a year and then did pure k-on so Anyways, I hope that was helpful. I mean, you know, there's not a lot I don't think it's I don't even think surgery is very high yield for ocaps to be honest like last last year I don't remember like maybe like one or two questions but Definitely off the questions has way too many effect surgery questions that are like You know really minutiae type garbage that you just don't need Yeah Yeah I basically remember essentially like for every every doctor of myopia. You're you're relating 14 to 15 And in general, I mean when you have a stigmatism, it gets more complex, but that's basically kind of how I like so that's how I figure out what my