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LASIK Complications: Prevention and Management
  1. J A SCOTT

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    LASIK Complications: Prevention and Management. Howard V Gimbel, Ellen E Anderson Penno. £79.95. New Jersey: Slack Incorporated, 2000. ISBN 1556424736.

    LASIK requires meticulous planning and rigorous attention to detail in preparation as the technology is very precise and there is little room for improvisation within the practice of the procedure. To learn such a technique can be challenging, especially when it is to be performed upon a group of patients demanding perfection, and also under the pressure of a time limit. It is, therefore, most gratifying to see a book published by authors who have a strong track record in LASIK and refractive surgery, and who have published their own learning curves in peer reviewed journals.

    The book is presented in two sections. The first deals with the machinery, patient selection, performance of the surgery, and perioperative management. The second is the authors' selection of case reports of patients who were less than straightforward and provides an instant practical experience.

    Section 1 begins with a brief history of excimer lasers and microkeratome technology, including the individual foibles of each instrument. Patient selection (who is suitable and, importantly, who is not), examination, and documentation are well covered, and examples of appropriate data collection forms, to permit the essential audit of one's own data, are presented.

    The individual parts of the LASIK procedure are well documented with clear and helpful colour photographic illustrations. Advice is presented in a style that is direct and reasoned. You, the reader, are in the hands of an experienced supervisor keen to impart knowledge. There are subtle tips on, for example, positioning of the hands or drape, which will be invaluable. Chapters describing complications from the microkeratome, excimer laser, errors in refractive result, and individual patient's biological response are all classified and dealt with logically. The conditions “sands of the Sahara” is dealt with twice, if slightly differently, by “guest” contributors and highlighted in special boxes. While the information was most interesting, their pasted position within the main text was distracting and I had to flick back a number of pages to find what I had been interrupted reading about in the first place!

    Another team of guest contributors discusses the photoablative treatment of LASIK complications, which will be of more interest to the advanced LASIK surgeon. Topics include techniques to deal with ablation microirregularities, errors caused by patient head movement, and narrow transition zone. The penultimate chapter of section 1 discusses LASIK retreatment and special clinical scenarios—for example, after penetrating keratoplasty (PK), photorefractive keratectomy (PRK), and radial keratotomy (RK). While the experience presented is not vast, useful information is provided for anyone contemplating these newer indications. The last chapter draws it all together with a run through of a typical procedure, perhaps acting as a “dress rehearsal” for the reader.

    Section 2 comprises 31 cases in which there were complicating factors or unusual patient characteristics—for example, the effects of pupil size, occult preoperative keratoconus, and other unmasked corneal topographical anomalies. The authors advise on other modalities of refractive surgery which may be more appropriate. Surgical complications such as free caps, thin flaps, incomplete passes of the microkeratome, etc are included. Individual case reports of LASIK in patients who previously underwent epikeratophakia and penetrating keratoplasty are included as worked examples. I felt the cases were most helpful, but the layout of the refractive/visual data might have been more readable if tabulated—there is plenty of space.

    In summary, I think this is a most valuable book for both the aspiring and experienced LASIK surgeon, and will help in the early learning curve and “getting up to speed”. Advice is well directed so that the reader may make correct patient selection, counsel patients realistically, acquire a slick technique, and deliver thoughtful aftercare. It is the intention to put the surgeon and, thus, the patient at ease.

    The text addresses the surgical minutiae that are most important to success. The techniques and tips are apposite, and expectations realistic given the limitations of the technique in its current form. The avoidance of potential difficulties is particularly strongly stressed but, in the event, the management is dealt with simply and without embarrassment—after all every one has a learning curve. The book therefore acts as a reliable tutor during this period. Nevertheless, there is no true substitute for hands-on experience, although it can be reassuring that the book provides support and knowledge that someone has been there before and can provide sensible, accessible, and evidence based advice in adversity.

    I did not think that this book was especially directed at the advanced surgeon, although they will find useful material and techniques within, particularly addressing the more complex conditions and retreatment options.

    It is clearly presented and readable with plenty of relevant information without being too dry. There are good illustrations and references. The extended characters set proofing errors (“£” for “<” substitutions) within the guest contributor section are not too confusing. I would recommend this book to those wishing to take up LASIK, and for the general reader who wants to know what this surgery involves. Would it, however, be a substitute for a supervisor/trainer during your first few cases? I am not sure. Anyway, for your own confidence, read it before you start and you will not go far wrong.

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