Table 4.
Intraoperative complications observed during small incision lenticule extraction
| Complication | Pathophysiology | Prevention | Management | Outcomes |
|---|---|---|---|---|
| Suction loss | Low-suction VisuMax system with soft docking | Surgeon experience Avoid difficult orbital anatomy | Depends on stage of suction loss – re-dock to complete procedure or convert to excimer laser ablation (PRK/LASIK) | Satisfactory visual outcomes in majority |
| Black spots | Debris/air bubbles entrapped between contact lens and cornea | Clean contact lens/ocular surface | Satisfactory visual outcomes Increased adhesions during dissection | |
| OBL | Accumulation and transient opacification of cavitation bubbles in intrastromal interface | Wait for OBL to disappear/gently massage out from interface | Delayed visual recovery – eventual satisfactory visual outcomes Increased higher order aberrations and decreased contrast sensitivity | |
| Cap lenticular adhesions | Lenticule mis-dissection – posterior plane dissected before anterior plane | Intraoperative signs – meniscus sign, shimmer sign, and white ring sign | ASOCT to identify dissection plane. Sinskey hook-assisted dissection. Modified strippers and Y-shaped tip instruments | Increased likelihood of irregular interface, cap and side-cut tears, retained lenticule, epithelial defects |
| Retained lenticule | Difficult lenticule dissection/forceful extraction | Surgeon experience | Retreat – surface ablation/LASIK/circle pattern of VisuMax laser | Partially retained lenticule fragments – irregular astigmatism Completely retained lenticule – satisfactory visual outcomes after retreatment |
| Cap tears Side cut tears |
Excessive surgical manipulation, forceful lenticule dissection, and extraction | Avoid rough dissection and bulky instruments | Frequent instillation of artificial tears Bandage contact lens in cap tears and extensive side-cut tears till re-epithelialization | Delayed visual recovery Satisfactory visual outcomes in majority Cap tears may lead to stromal scarring and irregular astigmatism |
| Epithelial defects | Surgical trauma Frequent instillation of topical anesthesia |
Avoid frequent instillation of topical anesthesia Surgeon experience |
Frequent instillation of topical artificial tears Bandage contact lens in large defects |
Satisfactory visual outcomes in majority Interface haze may occur with central defects |
Abbreviations: ASOCT, anterior segment optical coherence tomography; LASIK, laser-assisted in situ keratomileusis; OBL, opaque bubble layer; PRK, photorefractive keratectomy.