The Laser technique is relatively simple and with practice the surgeon can also operate the laser and verify settings. For the patient it is not traumatic and we do not sedate our patients. The discomfort is minimal and comes mainly from the use of the speculum which is why the choice of the first patient is being considered. Few patients seem to be aware of the suction from the Patient Interface (PI) and lying still for the less than two minutes of the procedure seems to be of no concern.
The ideal first patient should have a well-dilated pupil and a wide palpebral aperture.
Choose a patient who can hear and understand commands and is able to see the fixation light. Avoid significant head tremor, dementia and claustrophobia. As the procedure is relatively painless not many patients are excluded.
Language barriers do not seem to be an issue as the patient really only needs to lie still and look towards the PI lights.
The palpebral aperture should not be to not be too tight to allow for easy docking.
The nasal bridge should not be too prominent on first case to allow the patient interface (PI) to descend easily without abutting on the nose.
The eye should not be too deep or sunken in the first few patients as it is harder to judge the PI position when looking from the side.
Assess the preoperative pupil size with tropicamide in the clinic and note this down. The pupil will usually dilate more than this after the pre-operative drop regimen in theatre.
Keep a flash torch and pupil gauge in admitting room. Minimum pupil size is 5.0 mm. The laser can treat close to the pupil margin. The error of parallax is very small and with experience you will feel comfortable doing the laser through pupils as small as 4.4 mm
Also make at least a mental note of the following in the clinic during the pre=-operative assessment.
- The femtosecond laser will not cut through opaque structures, so dense arcus might impede perfect wound construction. However it would be reasonable to go ahead and be aware that a blade may be required to complete the incision.
- A prominent brow or nasal bridge makes docking under visual guidance bit more challenging for the first few operations.
- Cheek fat pads may ride up and cause the eyelashes to turn in under the speculum. This is not a real problem but may cause slight discomfort.