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The Art of LASIK.
  1. JOEL A SILBERT, Director
  1. Cornea and Specialty Contact Lens Service, The Eye Institute, Philadelphia, PA, USA

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    The Art of LASIK. JJ Machat, SG Slade, LE Probst, eds. 2nd ed. Pp 544; £155. Thorofare, NJ: Slack Inc, 1998. ISBN 1-55642-386-1.

    The Art of LASIK is the second edition of the well known Excimer Refractive Surgery: Practice and Principles, by Jeffrey Machat, Stephen Slade, and Louis Probst. It is an outstanding reference, not only for the ophthalmic refractive surgeon but also for anyone managing or co-managing patients who have had or plan to have laser refractive surgery. With the successes of refractive surgery for myopes, hyperopes, and astigmats being on everyone's lips, it is easy to become complacent as the number of successful cases and satisfied patients continues to mount. While the first edition placed great emphasis on procedures and techniques, there have been numerous advances in both instrumentation and in refinements of surgical technique in the intervening years to warrant a second edition. However, as one reads this volume, which has the contributions and clinical expertise of 45 clinicians worldwide, one cannot help but be impressed with its comprehensive scope, but more importantly, with the authors' concerns for avoidance of preventable conditions and their detailed management plans when postoperative complications do occur.The Art of LASIK also provides the reader with innovative chapters on the use of LASIK in patients with previous ocular surgery, as well as topography assisted laser ablation, and management of complex LASIK cases.

    As one would expect, section one's introductory chapter deals with refractive surgery options and with the historical evolution of today's LASIK procedures from keratomileusis, PRK, keratophakia, epikeratoplasty, and automated lamellar keratoplasty, as well as newer peripheral mass addition techniques (such as intracorneal rings and gel injection adjustable keratoplasty). Dr Machat presents an excellent chapter on the fundamental principles of excimer lasers and excimer laser surgical ablation, including discussion of the need for continual maintenance and the continual calibration of such lasers. He rightfully points out that despite the phenomenal precision in tissue ablation by the excimer laser, PRK's limitations revolve around the much less predictable effects of wound healing, thus paving the way for LASIK's embrace by refractive surgeons worldwide. A useful section dealing with Munnerlyn's formula for ablation depth and mathematical considerations involved in microkeratome produced flap thickness, maintenance of adequate residual stromal thickness, and diameter of ablation zone is provided, along with specific highlighted “pearls” showing the maximal correction possible using various LASIK techniques. These highlighted clinical pearls are present throughout the book, which serve to nicely emphasise major points and clinical observations.

    LASIK surgeons will find the chapter on predictive formulas for LASIK most valuable, with nomograms provided for various levels of refractive correction and for different lasers. The discussion of adjustment factors, based on altitude of the treatment centre, age of patient, and even dryness of the climate, is most interesting, as well as the discussion of LASIK nomogram refinement from postoperative results.

    Section two deals with the instrumentation involved in the LASIK procedure, including speculums, corneal markers, tonometry, forceps and spatulas, as well as irrigation cannulas and antidesiccation chambers (in the rare event of a free flap). A very useful chapter devoted to in-depth discussion of various traditional microkeratomes and their comparative data is presented, along with excellent photographs. A specific chapter devoted to the operation of the Chiron Hansatome and the “down-up” LASIK technique for production of a superior based hinge will be welcomed by both experienced and novice LASIK surgeons alike. This section also has the individual chapters devoted to disposable keratomes including the FLAPmaker (used on a monitored basis as numerous sites worldwide, including the Center for Sight at the Queen Victoria Hospital) and the Hydroblade waterjet microkeratome.

    Section three is devoted to the preoperative evaluation of the patient. This is an extremely important topic, which should be read by anyone involved in the care of the LASIK patient. To quote Dr Machat, “Managing patient expectations is the pivotal element to creating happy refractive patients”. Additionally, he writes “A surgeon who never has a complication is one who never performs surgery”. Candidate selection, careful screening for pre-existing conditions and anatomical limitations, as well as contraindications for LASIK are thoroughly explored, as is the topic of LASIK as the procedure of choice of patients over the age of 40 is given, but the reality is that few refractive surgeons wish to retreat patients, and as such bilateral LASIK treatment is commonly recommended. This is unfortunate as most presbyopic patients wish to shed their glasses or their presbyopic contact lenses (monovision or bifocal variety) and now must use glasses to read.

    Section four includes seven chapters devoted to detailed descriptions and superb photographic and diagrammatic illustrations of personal LASIK surgical techniques of some of the world's outstanding LASIK surgeons. This will surely be one of the most valuable sections of this text for surgeons beginning their LASIK practices. Section Five is devoted to the topic of LASIK enhancements, whether for refractive undercorrection or regression, or for complications such as central islands, epithelial ingrowth, flap striae, or flap melt.

    Section six deals with another critical issue for both the refractive surgeon as well as the co-managing optometrist—namely, the postoperative care of the LASIK patient. Here we have an excellent chapter detailing the specific normal and potentially abnormal responses occurring in the intermediate postoperative period, as well as in weeks and months after surgery. A wonderful section on corneal topography evaluation is presented, along with an excellent chapter written by co-managing optometrist (Dennis Kennedy, OD), illustrating how effectively the healthcare team can work in the best interest of the patient.

    The next section presents details of surgical outcomes for LASIK, including studies done at the Emory Vision Correction Center, TLC (The London [Ontario] Laser Center) outcome studies, and the CRS LASIK study. Two chapters follow, devoted to hyperopic LASIK. Another two deal with LASIK following penetrating keratoplasty, RK, and intraocular surgery such as phakic IOLs.

    Section nine is another “must read” for the refractive surgeon, as it includes several chapters with specific treatment techniques for LASIK complications. The photographs and diagrams in these chapters are invaluable and every conceivable complication is dealt with thoroughly, including chapters on epithelial ingrowth, flap striae, and overcorrection. My one criticism of this section comes only from an editorial viewpoint, in that there is considerable overlap in the topics discussed by the several chapter authors in this section, which could have been streamlined by the editors. However, as with most ocular complications of surgical procedures and/or ocular diseases, there is a variation in clinical treatment detail, even though the basic management principles are likely to be the same. Thus the reader may appreciate these treatment variances when reading this section.

    The final section deals with topography assisted LASIK techniques that can be helpful in cases of decentred ablation zones after PRK, irregular astigmatism after PK and RK, and asymmetric corneal astigmatism. In addition, the reader will appreciate the last chapter which contains 15 clinical cases involving complex LASIK management

    The Art of LASIK is an outstanding collaborative effort. The editors and contributors are highly experienced, and have greatly expanded our knowledge of this increasingly popular surgical treatment of refractive conditions. Its major strengths lie in its emphasis on careful patient selection and counselling, meticulous preoperative, surgical, and postoperative examination techniques, and in effective management of complications.The Art of LASIK should be read not only by refractive surgeons, but by all ophthalmic clinicians involved in the care of the refractive surgery patient.

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