LASIK Laser Eye Surgery Articles from
Jacksonville Vision Specialist Dr. Arun Gulani

New Flap Instruments are Created as LASIK Goes Mainstream
Eye World: An International Magazine by Ophthalmology for Ophthalmology
Arun C. Gulani, M.D., M.S.

There are spatulas, flippers, cannulas, forceps, and instruments too unusually shaped to put into a category ? all competing for the attention of the growing number of phthalmologists performing laser in-situ keratomileusis (LASIK).

LASIK is booming and so is the number of handheld instruments designed to manage the corneal flap.

One LASIK surgeon can name five instruments he uses to manage flaps. Louis E. Probst, MD, of London, Ontario, Canada, said he seeks instruments that minimize epithelial trauma. After the keratome cuts, Probst lifts the flap with a smooth LASIK Forceps or a Machat Retreatment Spatula (both from ASICO) for retreatment cases.

?When using the ACS [Auto-mated Corneal Shaper] microkeratome, I protect the flap with the Slade Flap Spatula (ASICO), which is angled to allow placement over the nasal hinge. When using the Hansatome with the superior hinge, I protect the flap with the Probst Hansatome Flap Spatula (Bausch & Lomb), which I designed to allow protection of the superior flap while maintaining my hands in the superior position.?

Probst also designed an irrigating cannula to replace the flap. The Probst Hansatome LASIK Cannula (Bausch & Lomb) is bent to allow the surgeon to maintain a 12 o?clock hand position. Probst is director of clinical care for TLC The Las Center and is its London Office?s medical director. He is also an assistant clinical professor at University of Western Ontario.

For Mastel Precision, Richard A. Erdey, MD, of CoIumbus, Ohio, designed a two instrument retreatment set (not yet named) that is due for release this spring. The first piece is a 9-mm optical marker, which is applied over the original keratectomy site. Its imprint will allow the flap to be relifted where it was originally cut, he explained. Other instruments permit the epithelium to tear in sheets, extending the tear beyond the original cut, he said. ?This device allows the epithelium over the edge of the flap to be more cleanly cut ? like tearing a piece of folded paper, ?Erdey said.

Another instrument due out this spring is the Johnston LASIK Flap Applanator (Rhein Medical).

?Everyone?s doing it differently and nothing's working well,? said Robert M. Johnston, MD, of Leesburg, Va., of dehydrating and realigning the flap. He said 5% to 10% of patients develop visual problems due to micro striae.

His device ?applies pressure on the flap, emanating from a central point and distributing it with diminishing force to the edges,? he said. ?It largely eliminates lines of stress.?

Since using the applanator, a ring of metal with a dear, convex bottom, ?I can?t remember
the last time I had to reposition the flap,? said Johnston, a clinical instructor at Howard University.

Ernest W. Kornmehl, MD, of Boston, has designed flap instruments for Atorn, including the LASIK Sweep. It is longer than a cannula, so its blunt side can reach the entire stromal bed, and its curvature matches the cornea, he explained. He uses it every 20 seconds during the procedure.

This LASIK Press is used postoperatively to remove excess fluid with its round, smooth head. On rare occasions, he uses it the day after surgery to remove extra hydration, which could render a patient?s vision only 20/50, for example. The patient usually will be restored to 20/20 or 20/25 immediately, said Kornmehl, medical director at Center for Laser Vision Correction and a professor at five universities.

ARUN C. GULANI, MD, of New York City, has designed 10 LASIK flap instruments, each for a specific purpose. He said the five-piece Gulani LASIK Revision Set (Bausch & Lomb) is ?for revising and fine-tuning previous LASIK surgery without the reuse of the intimidating microkeratome and its inherent complications?? This set comprises the Corneal Indentor, Flap Outliner, Periphery Dissector and Interface Spatula, and the Corneal Shovel designed to achieve ?resistance-guided uniplanar dissection.?

He designed the Triple Function Gulani LASIK Cannula (Eagle Labs) for simultaneous interface cleansing, flap opposition, and squeegee. Gulani also created the Gulani Edge Delineator and Liftor (Bausch & Lomb) for corneal flap lift at a slit-lamp; Gulani LASIK Globe Stabilizer and Flap Restrainer (ASICO), for use in nystagmoid apprehensive patients; Gulani LASIK Edge Marker for flap realignment (Bausch & Lomb); and Gulani Hyperopic Flap Liftor (Duckworth & Kent) for corneal flap lift with minimal erosion of the sculpted central stromal steepening.

Charles H. Williamson, MD, Baton Rouge, La., uses an irrigating cannula to replace a flap, with the "curved blunt portion [used like a squeegee [to get] some extra fluid out." Then he stretches the flap gently with a Wexel sponge.

Williamson, an associate professor at Louisiana State University Medical School, also designed a retreatment spatula for use at his own surgical center. The instrument, made for him by Diamatrix has a point that is used to break bonds in a can-opener style, not cut them.

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