On comparing the right and left eyes, a markedly asymmetrical reflex was also observed on retinoscopy with significantly greater irregularity noted in the left eye. Case 1.
Corneal topography of both eyes. Although the overall powers of the central corneal curvatures are similar, the left eye shows greater irregularity, as represented by the elevated surface asymmetry index SAI.
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Although a relatively high degree of astigmatism was noted in the left eye, the spherical equivalent was calculated to be —1. Since the refraction in the right eye was —1. A large epithelial defect was created in the left eye, so the flap was repositioned without excimer laser ablation. A bandage contact lens was placed to promote epithelial healing. Approximately 2 months later, the patient returned to surgery. An epithelial defect was noted at the end of the procedure, and a bandage contact lens was kept in place for the next 3 days.
No significant epithelial ingrowth was noted. Two weeks later, the patient returned with the complaint of ocular discomfort in the left eye. Epithelial ingrowth was noted along the nasal hinge, with extension toward the entrance pupil.
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At that visit, the flap was lifted to remove the interface epithelium, and the epithelium overlying the flap was noted to be friable. On the basis of anticipated difficulties with recurrent epithelial ingrowth, the flap was amputated and a bandage contact lens was placed.
Ciprofloxacin and diclofenac solutions were prescribed 4 times daily. The ciprofloxacin solution was discontinued, and corticosteroid drops were prescribed for use 3 times daily. The corticosteroid therapy was reduced to 1 drop per day and then discontinued. The patient complained of poor vision and nighttime glare and halo and was referred to the University of California, San Francisco Refractive Surgery Service for consultation in May , approximately 18 months after LASIK and subsequent flap amputation of the left eye.
Slitlamp biomicroscopic examination of the right eye showed a well-positioned, nasally hinged corneal flap with mild central subepithelial opacification, whereas slitlamp examination of the left eye was remarkable for mild vertical linear elevation at the site of the transected hinge, a semicircle of subepithelial haze reminiscent of surface photorefractive keratectomy PRK —associated scarring that appeared to outline the perimeter of the flap, and a relatively lucent central cornea overlying the entrance pupil.
Figure 2 The surface of the central cornea appeared to be relatively smooth, but upon instillation of fluorescein sodium solution, inspection of the tear film pattern indicated an irregular surface. Case 2.
Slitlamp photograph of the left eye. Note within the slit beam a band of scarring that outlines the perimeter of the flap, but relative clearing of the central cornea overlying the entrance pupil. The irregularity of the left eye's corneal surface was confirmed by computerized corneal mapping Figure 3. A topographic map of the right eye produced a simulated keratometry reading of However, a topographic map of the left eye showed a simulated keratometry reading of On comparing the right and left eyes, a markedly asymmetrical reflex was also observed on retinoscopy, with markedly greater irregularity noted in the left eye.
The left eye shows significant astigmatism with the rule and elevated irregularity compared with the right eye, as represented by elevated surface regularity SRI and surface asymmetry indices SAI. Other abbreviations are explained in the legend to Figure 1. Rigid contact lenses were also suggested, but the patient elected to forgo fitting. The findings from large reported series of complications seen in consecutive cases of patients who have undergone LASIK suggest that most complications can be attributed to abnormalities of the corneal flap that translate to irregularity or opacification of the anterior cornea.
Unfortunately, few reports in the literature provide a guide to the clinical course that can be expected after flap amputation in the uninfected cornea. Patel and colleagues 3 recently reported a case of traumatic flap dislocation that was followed by loss of the flap. However, as our 2 cases demonstrate, it cannot be assumed that a regular surface will result after removal of the flap.
The irregular myopic astigmatism we observed implies that the curvature of the stromal bed might not precisely reflect that of the anterior surface of the overlying flap. This finding suggests that the flap might vary in thickness from one region to another, leading to variability in the curvature of the stromal bed created. Patterns of variability in thickness may well differ from one microkeratome to another, and this variability is expected to contribute to the development of irregularity in the contour of the stromal bed, which results in irregular astigmatism that limits best spectacle-corrected vision.
Under normal circumstances, irregularity of the surface of the stromal bed is expected to be matched by corresponding irregularity of the undersurface of the flap, so that if an irregular flap is created and then replaced precisely with a "lock and key" effect, little change on the anterior corneal surface is expected. Sharp and rough edges of the bone are filed down, skin and muscle flaps are then transposed over the stump.
Distal stabilisation of the muscles is recommended, allowing for effective muscle contraction and reduced atrophy. This in turn allows for a greater functional use of the stump and maintains soft tissue coverage of the remnant bone. Muscles should be attached under similar tension to normal physiological conditions. Through the pelvis to warm the arteries contraindicated in patients with arterial insufficiency because the warmth leads to increased metabolism, causing a greater demand for nutrients, which are not available.
See here , for more detailed information on post-operative complications following an amputation. The content on or accessible through Physiopedia is for informational purposes only. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider.
The team may include members of the family and successfully treated amputees. Amputee self-help groups are further extensions of this approach . Restoration of the capability for gainful employment is an integral part of the patient's recovery. Kohl  notes that amputees may regard unemployment as a "denial of their 'right' to participate in the family's decision making processes.
Anticipating and dealing with the various issues that patients will face, even if these are not raised by the patients themselves, is of great help. Such issues include disposal of the limb, relationship with friends and family, degree of functional loss and return, work capability, costs of surgery and rehabilitation, sexual adjustment, and social impact . At this stage it is recommend that the surgeon paint a realistic picture of the immediate and long-term goals for the patient and his family. Labeling the amputation as a reconstructive prelude to an improved life is a much different matter from implying that it is a mutilation and a failure.
Furthermore, a hopeful attitude, detailed explanation of all aspects of the surgery and the rehabilitative process, and full response to all questions especially those that seem trivial appear to diminish anxiety, anger, and despair . The psychotherapy helps in accepting the body image thereby reducing the distress. This reinforces the need for psychological assessment and intervention after the amputation to prevent psychological abnormalities . Team management reduces hospital stays significantly and increases the long-term effectiveness of rehabilitation. The amputee rehabilitation team should include the surgeon, surgical nurses, prosthetist, physical therapist, occupational therapist, social worker, vocational counselor, and if indicated, a psychiatrist or psychologist.
Each member of the team is in a position to address one aspect or another of the patients needs . The involvement of members of the family at all of these stages can be of tremendous help. Perhaps the most valuable contribution of the team approach is the facilitation of a more rapid return to familiar surroundings and to independence . Treatment of psychiatric illness that precedes amputation can carry benefits for the rehabilitation process.
Failed suicide attempts with resultant amputation may present particular challenges for successful rehabilitation, and psychiatric hospitalization as well as intensive outpatient treatment may be indicated .
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No approach to amputation can be considered successful without some resolution of the issue presented by the loss of skill, job, and livelihood. Even in the absence of pressing financial need, the loss of earning capacity may entail a profound loss of self-esteem, which brings with it a variety of adverse psychological phenomena .
It is not essential that the person resume work, but it is essential that the person accept whatever new role and capacity that can now be enjoyed . The Barthel Index of activities of daily living reflects the general condition of the amputee and the fitness of his prosthesis and suggests its prognostic value for rehabilitation outcome .
Cognitive-behavioral therapy CBT is often used in the psychological management of pain. It utilizes many approaches such as goal setting and problem solving techniques which help amputees cope with their condition. It is essential that goals are realistic, attainable and provide an opportunity to succeed.
Goals may be whole tasks or smaller components of a single activity, broken down into smaller steps. Anxiety management strategies can be taught such as relaxation, breathing , distraction and cognitive techniques to facilitate this process of gradual exposure to the feared situation. Helping clients to challenge their negative thinking can also be an important part of psychological therapy.
The client should be encouraged to look at the effect the belief has on their mood and behavior and consider alternative ways of thinking. Problem-solving techniques can often be helpful in assisting the amputee to make the many decisions that may face them following an amputation in a more structured and clear way. This approach takes the client through a series of stages, starting with problem definition and option generation, and moving on to weighing up the pros and cons of the various possibilities, enabling an option to be selected, and action planned, carried out and reviewed.
By the end of psychological therapy, the client should feel equipped with coping strategies that they can apply to a range of situations that may help them to prevent problems developing in the future . Friends and family may go through many of the same feelings that the amputee experiences, and when communication is clear and open between the amputee and their social support networks, there may be no need for the psychological therapist to become involved.
Significant others may therefore benefit from a confidential place in which to share their concerns. Group discussion programs facilitate adjustment and cover a diverse range of topics such as fears of falling and failing, and changes in body weight and health issues. More recently, Delehanty and Trachsel  found that a preventive psycho-educational series of 2—3 groups aiming to provide information, anticipate and normalize future stress and build coping strategies, resulted in significantly lower levels of distress at 8 months following discharge.
In addition to utilizing cultural resilience involving the patient's ethnic and religious community , social support may come from national organizations such as Paralympics and the Amputee Coalition , each of which has support groups for patients and resources for care-givers to prevent feeling overwhelmed .
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