Avoiding Problems With the Microkeratome
Miles H. Friedlander, MD, FACS
Avoiding Problems: Pre Op
•	Know your machine thoroughly
•	Own your microkeratome or share it with a trusted friend
•	Pachymeter before surgery
•	Avoid thin corneas
•	High or low K readings, may have to modify hinge or rings
Avoiding Problems: Pre Op
•	Use aximeter to mark line of sight
•	Make eccentric mark
Avoiding Problems   At the Time of Surgery
•	Have pre incision check list and go through it personally
•	Test motor,vacuum, rings, etc
•	“Trial run” before each case
Avoid Problems   At the Time of Surgery ( Cont.)
•	Be sure suction ring is correctly centered before applying suction
•	Once vacuum is applied, the ring will always center over the same area
•	Check IOP before microkeratome cut
•	Check dry   meniscus for IOP and diameter of cut
Difficulty Fitting Suction Ring to Eye
•	Check lid speculum (have variety handy)
•	Spread the speculum and “shoehorn” in
•	If above fails, do a lateral canthotomy
IOP Too Low
•	Double  check  vacuum - if possible adjust
•	Inject 4 cc anesthetic as a retrobulbar injection immediately before  microkeratome pass
Epithelial Problems
•	Disturbance of epithelium occurs in 10% of patients
•	Use bandage contact lens post operatively 
Avoiding Problems Time of Surgery
•	Microkeratome stops halfway
•	Replace flap over bed and stop operation
•	Repeat after 3 months
No Hinge
•	Replace cap
•	Single suture loosely tied
•	Remove suture next day
Hinge Too Large: Not Extending into Laser Optical Zone
•	Carefully hand dissect to reduce the size of the hinge
Perforation (Donut Shaped Cap)
•	More common with steep corneas and then caps
•	Place cap back on eye.
•	Approximate carefully
•	Bandage soft CL
•	Re-operate 2 + months
Replace Cap  After Laser
•	Handle as little as possible
•	Irrigate under the flap
•	I like to aspirate
•	Be sure to align exactly.  If not exact life up and reposition
Handling Cap (Cont.)
•	Not too much moisture or manipulation of the anterior surface
•	Keep epithelium on cap moist
•	Gently stroke from hinge nasal to temporal to avoids folds in Bowman’s
Cap Movement and Edema Next Day
•	Place anti-toric suture
•	Remove in one week
Anti-toric Suture

Irrigation and Aspiration
Thank You