On rare occasions, one will encounter a patient with extreme anxiety, if not an outright phobia, with his eye examination. Not only will he refuse all drops, citing agitation and fear, but also there is absolute defiance toward any tonometry or touching of the eyelids. Contact lenses? Not a chance. LASIK surgery? No way. Well, maybe.
We have performed LASIK eye surgery on these types of patients utilizing general anaesthesia or, in the more recent past, with a Diprivan (propofol, AstraZeneca) drip. With the advent of Diprivan, surgery lasik can quickly and easily be performed even in the most highly anxious patients.
Our pediatric colleagues perform exams under anaesthesia routinely and without hesitation. One wouldn’t hesitate to use Diprivan to achieve a lower eyelid blepharoplasty. There is an entire subspecialty within dentistry that utilizes conscious sedation. Furthermore, literature on LASIK surgery in the pediatric population utilizing general anaesthesia is abundant. However, I have yet to read anything in the literature on using Diprivan in adults for performing LASIK.
Ironically, we all have had patients who became agitated or completely uncooperative after we had already started their LASIK. During these complex cases, the surgeon, whose pulse is racing as fast as the excimer fires, often thinks, “I wish I had an anesthesiologist right now to sedate this patient!” These markedly uncooperative patients can have suboptimal results secondary to movement during flap creation and poor fixation during the ablation. I recommend a much safer way of treating such patients if the surgeon can identify them before surgery.
Once carefully consented, these patients can be the most ecstatic and gratifying people in one’s practice. It’s almost as if they had given up hope of discarding their glasses. In the past 14 years of having a practice specializing in LASIK and cataract surgery, I have performed LASIK using Diprivan anaesthesia on two patients. Both were in their early 30s. Neither tried contact lenses because of the “fear of something getting near their eyes.” Just getting close to their eyelids would lead to panic. They infrequently scheduled examinations because of anxiety. Both were moderate-to-high myopes who had never even considered the surgery until I offered them the option of performing it with an anesthesiologist.
Your surgeon will conduct routine testing. After that, he will use Pentacam and Orbscan to quickly obtain the thickness of your cornea without applanation pachymetry. Schirmer’s testing may not be possible, so the customary tear film, meibomian gland and external exam are even more critical. Your surgeon should also document the size of your pupil even with a penlight if the patient is intolerant of formal pupillometry.
These patients certainly do not want to hear any details of the procedure. However, they need to have the risks of infection, complications and even blindness explained carefully, as with any LASIK patient. Furthermore, they need to explain the risks of anaesthetic-related complications.
These cases should be done in a laser centre adjacent to a surgery centre so that the patient can receive appropriate care if there is an anaesthetic-related complication. The patient fasts for 6 hours before the procedure, before a board-certified anesthesiologist uses some medication on the eyes. Your optometrist should explain the case details to the anesthesiologist ahead of time. Ideally, the anesthesiologist can watch an earlier case to become familiar with what he will do. All appropriate equipment, medication and monitoring devices should be available.
The surgeon will start an intravenous line and administer verse to relax your nerves. He will then administer oxygen through a nasal cannula, obtain pulse oximetry and place EKG leads. The eye care provider will also help with Vitals, blood pressure, respiration and record pulse, as with any similar intraocular or extraocular surgical procedure. Gas anaesthesia is a poor choice because of reports of nitrous oxide interfering with the argon fluorine excimer laser. A Diprivan drip is a perfect sedative because of its rapid induction time and effortless ability to titrate the dose. Once he turns off the “drip”, the patient rapidly returns to normal.
He continues to do the usual prep. Draping the lashes and placing the lid speculum are best done after the patient is unresponsive. Using an IntraLase femtosecond laser (Abbott Medical Optics) must be in the same room as the excimer laser because the patient will be immobile for the entire procedure.
The trickiest part of the procedure is tracking. It is impossible to place limbal marks for astigmatism alignment preoperatively. Thus, preoperatively noting iris or limbal landmarks can be helpful. I used the Visx laser (AMO) on both patients with outstanding results, but there may be some advantages to using a laser with an activity tracker.
Using toothed forceps or globe fixation devices can be critical for fixation. One of my two patients became a bit “lighter” as I began the excimer portion of the surgery on the second eye. She was very cooperative with fixating on the fixation light.
Checking the flap for alignment, fibres, and debris is critical before completion because it will be challenging to do anything postoperatively without subjecting the patient to another round of anaesthesia. Your surgeon will place the goggles before stopping the Diprivan drip and exiting the laser suite.
As with any ophthalmic procedure, the anesthesiologist or recovery room nurse monitors the vital signs, gives the patient something to drink, removes the IV and discharges the patient when ready. Carefully explaining instructions to family or friends is essential. These patients will struggle with their postoperative drops. I have explained preoperatively to the patient, family, and friends the best way to administer eye drops. I like to have the patients lie down supine with their eyes closed.
The drops are placed in the medial canthal area while their eyes are closed. Your ophthalmologist will instruct you to open your eyes after he might have put the drops in the medial canthal “trough.” After opening their eyes, if you don’t feel any drop getting into the eye, the surgeon needs to repeat that procedure until you feel something.
I hope this article will encourage my colleagues to try this procedure. Countless people are terrified of having their eyes examined, let alone having LASIK. Offering an anesthesiologist to such patients can make LASIK as life-changing an event as it has been for the rest of us.