The Case
A 23-year-old white female patient presented for routine LASIK surgery. I
chose to use a Hansatome microkeratome (Bausch & Lomb Surgical;
Claremont, CA) to perform the procedure. Unfortunately, the
microkeratome failed to reverse after completing the forward pass. After
I made several attempts to advance and reverse, it was clear that the
microkeratome would not reverse.
Course of Action
I remained calm. I controlled the tone of my voice and calmly alerted my staff
to the situation. I asked the technician to remove the suction, who, after
doing so, stated that he had experienced this situation once before, and
recommended that we dissemble the microkeratome and manually reverse the
blade. He unscrewed the motor
housing while I held the vacuum plate. Fortunately, the patient was
compliant and able to hold still. After I removed the motor, I turned the axle
of the pinion gear, bringing the blade back along the curved rack gear on the
suction plate, which allowed me to extract the microkeratome.
Surgical Outcome
The patient's flap was folded and edematous, and there were some chatter marks
distant from the visual axis. In addition, the inferior gutter was quite
pronounced, but symmetric. I placed a contact lens over the first eye; I
decided to proceed with the other eye using a different microkeratome.
Both eyes looked clear the next day. Following are the accounts of a few
surgeons who have encountered a similar problem.
COLLEAGUES OFFER SOLUTIONS
Gently Slide Off
If the HansatomeT keratome does not reverse after the forward pass or stops at
any point, you can stop suction and gently slide the keratome and suction ring
as a single unit inferiorly towards the lower lid. Since the HansatomeT
produces a superior hinge, the flap should lay back in position as you move
the keratome inferiorly off the cornea. Do not try to disengage the
keratome from the suction ring or lift the unit too high off the eye until the
flap is completely free as this may tear the flap. There is no reason to
disassemble the keratome.
Some surgeons after the forward pass, routinely perform this maneuver instead
of the reverse pass in order to reduce suction time. Outcome is the
corneal flaps look great.
-Srini Mutyala, MD, Weston Laser & Vision Institute,
Fort Lauderdale, Florida.
If this happens for any reason with any keratome, you can release the suction and slowly move the entire keratome/suction ring unit opposite the direction of the cut. It really just emulates what the keratome would do in reverse.
J. Charles Casebeer, MD, President of CRS Clinical Research & Statistics of Divide, Montana.
Check the Connection
I have found that the motor will not reverse if the gray cord that connects to
the top of the keratome hand piece is too tight. I have had instances where the keratome moves forward to the end of its excursion, and then nothing happens when I press the reverse pedal.
I have been able to "loosen" that gray cord attachment on the keratome hand piece (not completely detached, just loosened a bit), and attempt to
press the reverse pedal, and it has worked. Also, if the keratome is truly
jammed, you can break suction, ask the patient to look up slightly and slide
the keratome off, without having to disassemble the entire keratome on the
eye.
-Parag A. Majmudar, MD, Assistant Professor of Ophthalmology Cornea
Service, Rush Medical College, Chicago Cornea Consultants, Ltd.,
Chicago, Illinois.
Robert I. Tibolt, MD, practices at the Medical Center Eye Clinic in Salem, Oregon. Dr. Tibolt may be reached at rtibolt@bst.mvipa.org
http://www.crstoday.com/03_archive/1001/archive_1_1001_13.html
Posted by Admin at September 13, 2003 10:09 PM