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FLAP MAKERS

FLAP MAKERS. A Comparison of Flap Makers. Microkeratomes (Flap Makers). Flap makers have been around for 35+ years, previously used in ALK – Automated Lamellar Keratoplasty When they were used to produce a flap for LASIK, it was considered “off label” use of the Excimer.

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FLAP MAKERS

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  1. FLAP MAKERS A Comparison of Flap Makers

  2. Microkeratomes(Flap Makers) • Flap makers have been around for 35+ years, previously used in ALK – Automated Lamellar Keratoplasty • When they were used to produce a flap for LASIK, it was considered “off label” use of the Excimer. • Now, LASIK has become the procedure of choice for most patients and surgeons. • The following slides will show how a flap makers produces a plano flap and the different flap makers you may encounter.

  3. What to look for in a Flap Maker • It should be easy to place onto the eye with no interference from the speculum • It should be easy to dissemble, clean, sterilize, and reassemble. • It should give consistent flap thickness results with low risk of : no partial flaps from motor failure no loss of suction • It should be easy to test- manually run the head back and forth, easily heard motors, etc.

  4. TYPES OF FLAPMAKERS • Movement Type- • Linear – Flap maker travels in the temporal to nasal direction. Hinge located nasally • Rotational – Flap maker travels in a circular direction. Superior hinge location most common, some small profile rings can have the hinge location anywhere. • Manual – Flap maker is driven across the cornea by pressure from the surgeon’s hand • Automated – Flap maker is driven by a motor, cable or gears • Femtosecond – Laser Produced Flap

  5. Most Commonly Used Flap Makers • Bausch & Lomb • Hansatome • AMO – Amadeus • Intralase • Femtosecond Laser • Moria • CB • CB Single Use • M2 • ONE use • LSK

  6. Other Commonly Used Flap Makers • Nidek • MK-2000 • BD Ophthalmic Systems • BD K-3000 • LaserSight – • Ultrashaper • ADM (Disposable)

  7. Mechanical Flap Makers The keratome flattens the cornea & the oscillating blade cuts a circular flap of tissue Produces X microns in flap = varies with each unit and with each plate thickness used. Flap thickness is determined by the gap between the blade & the footplate

  8. How to Determine What the Thickness Really Is? • If you have a mechanical flap maker and you want to determine the “real” thickness of the flap- you must measure pre op Pachymetry AND • Intra-operative Pachymetry – that means you take a Pachymetry reading in the bed before ablation… • Steps: • Measure Pre op Pachymetry • Measure after the flap is made – before ablation – bed Pachymetry • The difference is in the flap.. • Several measures should be made, then you can rely on that plate to cut systematically after that point.

  9. TYPES OF MICROKERATOMES

  10. Bausch and Lomb Hansatome → ← Bausch and Lomb ACS

  11. BAUSCH AND LOMB HANSATOME AND ACS • Hansatome - Automated, gear driven • Rotational travel, superior hinge • Z16, Z18 and Z20 depth plates • 8.5 mm or 9.5 mm ring and micro ring choices, flap diameter determined by K readings • ACS - automated, gear driven (no longer is production) • Linear travel, nasal hinge • Variable flap thickness, 130, 160 180 • These are getting harder and harder to find- they are becoming obsolete with time, but still considered a great flap maker

  12. Moria CBMoria OneUseMoria LSK

  13. Moria Microkeratomes • LSK One – nasal hinge, linear travel, manually driven, non-disposable • LSK One Use – nasal hinge, linear travel, manually driven, disposable head • CB Manual – superior hinge, rotational travel, manually driven, non-disposable • M2 Automated – Superior hinge, rotational travel, dual motor drive, non-disposable

  14. MORIA • Single power box runs most Moria Keratomes • Power source - Auto-electric, Gas Turbine • Flap Diameter - 8-11 mm determined by vacuum rings and K readings

  15. AMO- Amadeus Microkeratome

  16. AMO Amadeus • Automated, linear movement, nasal hinge • 140, 160 and 180 Depth Plates. • 8.5mm, 9.0mm and 9.5mm ring sizes, flap diameter determined by K readings. • LCD Touch Screen • No on eye assembly- One-handed. • Two motors for separate control of blade oscillation and movement across the cornea.

  17. Nidek

  18. NIDEK MK2000 • Linear travel, nasal hinge • Flap diameter 8.5mm, 9.5mm, 10.5mm • Flap thickness -130 um, 160um, 180um • Dual motors: • one controls blade oscillation speed 9000rpm • 2.0mm p/sec advancement

  19. EPITHELIAL FLAPMAKERS

  20. EPI FLAPMAKERS Creates a flap the thickness Of the Epithelium by cleaving Or separating the corneal layers To expose the Stroma

  21. Epi Flap Makers - Upside • Biomechanical flap risks of LASIK such as ectasia, striae, and dryness may not be amenable to further improvement • Biochemical healing risks of surface ablation are improving and may be more easily controlled • Scarring and irregular collagen formation improving with smoother laser treatments and more viable epithelial flap

  22. Epi Flap Makers - Downside • Thin and delicate flap is easily damaged if mis-handled • Metal cannula allows for flap positioning without adhering to the flap as an ocular sponge • Slow and wet technique seems to provide the most viable epithelium

  23. Epi Flap Maker Complications • Motor failure or mechanical interference- lashes in the way, speculum stopped the unit prematurely • Partial flaps • Loss or Decrease in Suction/Pressure: • Thin flaps • Button Hole flaps • Partial flaps • Caps

  24. Femtosecond Laser:Intralase

  25. Indications of Use (FDA) The INTRALASE® FS Laser is an ophthalmic surgical laser which produces resection of the cornea for the following indications : “creates flaps of user-selected diameter, thickness, hinge position and hinge width”.

  26. Femtosecond Laser • Surgical effect is achieved through “Photo disruption” at a molecular level • No thermal or shock wave transmission to surrounding tissues • Laser pulses focused to precise intrastromal locations (+ 5 microns) • Computer controlled optical delivery system places thousands of pulses next to each other creating flap incisions, lamellar resections, keratectomy

  27. Clinical Indications and Benefits of Femtosecond over Mechanical Keratectomy • High powers • Thin corneas (c less than 300 µ beds) • Variable corneal thickness • Anterior basement membrane disorders • Very small or large corneal diameters • Steep (over 47) or flat (under 42) corneas • Patient “fears” of blade or cutting

  28. IntraLASIK™ Instrumentation The disposable applanation cone is attached to the laser aperture.

  29. The disposable docking suction ring is positioned on the eye & suction applied IntraLASIK™ Patient Preparation

  30. The applanation cone is centered over the patients eye & ‘docked’ with suction ring IntraLASIK™ Patient Preparation

  31. IntraLase • Precision • Uniform flap thickness • ± 5 Microns (per Intralase Company) • Adjustable, precise flap diameters • Custom hinge location & width • Precise edge architecture • Adjustable angle • “Manhole cover”

  32. The End

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