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眼科醫療 - 雷射近視 之 感受 鄭永豐

眼科醫療 - 雷射近視 之 感受 鄭永豐 . 雷射近視手術的演變歷史. 雷射近視手術. 放射狀角膜切開 手術 (RK) 上角膜晶片 (Epikeratophakia) 準分子雷射 (Excimer) 雷射屈光角膜切削術 (PRK) 雷射原位層狀角膜塑形術 (LASIK) 雷射上皮細胞下角膜切除術 (LASEK) 基質內雷射光角膜切除術 (IPAR) 雷射熱角膜切除術 (LTK) 角膜塑形術 (OK). 「雷射原位層狀角膜重塑術」. 現代近視手術的主流 Laser in situ keratomileusis ，簡稱 LASIK 。

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眼科醫療 - 雷射近視 之 感受 鄭永豐

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  1. 眼科醫療-雷射近視之感受鄭永豐

  2. 雷射近視手術的演變歷史

  3. 雷射近視手術 • 放射狀角膜切開手術(RK) • 上角膜晶片(Epikeratophakia) • 準分子雷射(Excimer) • 雷射屈光角膜切削術(PRK) • 雷射原位層狀角膜塑形術(LASIK) • 雷射上皮細胞下角膜切除術(LASEK) • 基質內雷射光角膜切除術(IPAR) • 雷射熱角膜切除術(LTK) • 角膜塑形術(OK)

  4. 「雷射原位層狀角膜重塑術」 • 現代近視手術的主流 • Laser in situ keratomileusis，簡稱LASIK。 • 層狀角膜手術結合了準分子雷射 • 美國衛生署 (FDA) 經過6年多之臨床評估,終於在 1995年開放了常規使用，我國也跟在1995年 有限度開放使用 (visx)。 • IBM公司發明用以切割晶片的「準分子雷射」於眼角膜上 (Trokel) 。

  5. BASIC PRINCIPLES of LASIK

  6. LASIK PRINCIPLESGoals • Use of Excimer Laser • Use of microkeratome

  7. LASIK Flap Thickness

  8. Flap Laser sculpting LASIK PRINCIPLESWhy LASIK? • 1st step in PRK is removal of surface cells with brush, spatula, or laser • 1st step in LASIK is creation of thin flap of cornea with microkeratome • Remainder of procedure is the same

  9. LASIK“Perfect” Flap Characteristics • No epithelial damage • Smooth bed • Consistent diameter and thickness • ?Predictable effects on topography and refraction • Influence of positioning, thickness, shape

  10. LASER VISION CORRECTIONLASIK PRINCIPLESExcimer Laser DIAPHRAGM DISC

  11. LASIK PrinciplesLaser Complications Undercorrection-occurs when the laser has not removed an adequate amount of tissue • Aftershave/perfume and/or any other scented products • Tissue density and composition which can modify the effect of the laser and the resulting amount of tissue removed • Room Temperature and Humidity • Regression - In some instances, during the healing process, portions of the treated tissue returns to it's original state thus reversing the results of the treatment

  12. LASIKPatient Preparation • Valium 5-10 mg 1 hr preop • Ocuflox or ciloxan • Tetracaine 1% X 3 • Prep eye with Betadine • Blot to avoid Betadine beneath flap • Drape eye

  13. LASIK Procedure • Assemble microkeratome (組合角膜板層刀)

  14. LASIK Procedure • Check suction • Check microkeratome

  15. LASIK Procedure • Place speculum and assure good exposure • Cover lashes • Avoid skin folds

  16. LASIK Procedure • Mark cornea to facilitate flap realignment

  17. LASIK Procedure • Place suction ring • Decenter slightly nasally (1mm) to give good exposure to laser beam

  18. LASIK Procedure • Avoid lid speculum and assure path for microkeratome is clear • Speculum • Lashes • Drape • Conjunctiva • Chin up/chin down

  19. LASIK Procedure • Assure complete suction • Check with tonometer • Avoid false meniscus • Warn patient that vision may darken

  20. LASIK Procedure • Wet cornea with artificial tears, filtered BSS, proparacaine • Remove excess with dry sponge

  21. LASIK Procedure • Advance microkeratome by tapping pedal

  22. LASIK Procedure • Stop suction • Remove suction ring • Place “flap protector”

  23. LASIK Procedure • Flip flap back • Spatula, McPherson forceps • Place over moist cellulose sponge

  24. LASIK Procedure • Apply laser • Nomogram • Can remove foot from pedal and resume as needed • With LADARVision, do not place instruments in field

  25. LASIK Procedure • Replace flap • Dry versus wet technique

  26. LASIK Procedure • Gently float flap into position

  27. LASIK Procedure • Stroke flap gently

  28. LASIK Procedure • Dry gutter, assure symmetry • Wait 3-5 minutes for flap to read here • Endothelial pump dehydrates flap, causing adherence

  29. LASIK Procedure • Inspect for folds, sublamellar debris

  30. LASIKPostoperative Care • Place antibiotic, corticosteroid, NSAID • Remove lid speculum with care

  31. LASIKPostoperative Care • Examine at slitlamp • Check flap position and adherence • Check for folds • Check for debris

  32. LASIKPostoperative Care • Place clear shield, no patch • Use antibiotic/steroid QID X 1 week

  33. LASIKPostoperative Course • Rapid visual recovery • Pain is minimal

  34. LASIKPostoperative Care • Postoperative visits • 1 day • 1-2 weeks • 2-3 months • 6 months • 1 year

  35. 雷射近視手術病人品質安全指引 • 一、施術醫師品質管控 • 二、雷射儀器每月定期維護保養及較正 • 三、手術耗材品質管控： 如手術用刀片必須更新 • 眼科醫學會監控 • 公告於醫學會網站：wwwophorgtw

  36. 高價雷射醫療器材之管控 • 健康商品化與醫病關係： （Commodification of Health and the Doctor-Patient Relationship: An Economic Sociological Critique）(成大 許甘霖 助理教授) • 健康商品化趨勢下醫 病關係中醫師自主性的弱化； • ＜轉虛弱的病人為有力的消費者？健康商品化與公民權初探＞（From Weak Patient to Powerful Consumer? Preliminary Remarks on Commodification of Health and citizenship），「公民權/統治術工作 坊」（東海大學） • 主要探討健康商品化 趨勢下的病患權益的弱化。

  37. 併發症機率 • 輕症 眼症乾燥，敏感 … < 5/100 • 重症 < 1~2/1000 (醫療爭議個案比白內障手術少)

  38. Lasik Complications

  39. Types of Complications • Intraoperative • Postoperative

  40. Intraoperative Complications • Partial Flap (部份層狀角膜瓣) • Motor Failure • Obstacle • Assembly

  41. Intraoperative Complications • Irregular Flap / Bed • Manual Keratomes • Gears • Blade Quality • Dirty Rings / Head

  42. Intraoperative Complications • Epithelial Abrasions • Excessive Dye / Anesthetic • Dehydrated Epithelium • Blade Quality • Dirty Head

  43. Intraoperative Complications • Intraoperative Bleeding • Flap Diameter Too Large • Contact Lens Users

  44. Intraoperative Complications • Suction Loss • Pump Failure • Defective Ring • Ring / Eye Compatibility • Rough Handling

  45. Intraoperative Complications • Free Cap (層狀角膜瓣斷落) • Suction Loss • Very Flat K’s • Ring / Eye Compatibility • De-centered Ring

  46. Intraoperative Complications • Button Hole

  47. Intraoperative Complications • Button Hole

  48. Intraoperative Complications • Button Hole

  49. Intraoperative Complications • Button Hole

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