EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/176967
Refractive challenges and innovations September 2013 LASIK continued from page 49 DUOVISC® Viscoelastic System is designed to give two viscoelastic materials with different physico-chemical properties that can be used differently and/or sequentially to perform specific tasks during a cataract procedure. DUOVISC® Viscoelastic System consists of VISCOAT® Ophthalmic Viscosurgical Device and PROVISC® Ophthalmic Viscosurgical Device. CAUTION: Federal law restricts this device to sale by or on the order of a physician. VISCOAT® OVD (Sodium Chondroitin Sulfate – Sodium Hyaluronate) Ophthalmic Viscosurgical Device INDICATIONS: VISCOAT® OVD is indicated for use as an ophthalmic surgical aid in anterior segment procedures including cataract extraction and intraocular lens (IOL) implantation. Viscoat maintains a deep anterior chamber during anterior segment surgeries, enhances visualization during the surgical procedure, and protects the corneal endothelium and other ocular tissues. The viscoelasticity of the solution maintains the normal position of the vitreous face and prevents formation of a flat chamber during surgery. WARNINGS: Failure to follow assembly instructions or use of an alternate cannula may result in cannula detachment and potential patient injury. PRECAUTIONS: Precautions are limited to those normally associated with the surgical procedure being performed. Although sodium hyaluronate and sodium chondroitin sulfate are highly purified biological polymers, the physician should be aware of the potential allergic risks inherent in the use of any biological material. ADVERSE REACTIONS: VISCOAT® OVD has been extremely well tolerated in human and animal studies. A transient rise in intraocular pressure in the early postoperative period may be expected due to the presence of sodium hyaluronate, which has been shown to effect such a rise. It is therefore recommended that Viscoat be removed from the anterior chamber by thorough irrigation and/or aspiration at the end of surgery to minimize postoperative IOP increases. Do not overfill anterior chamber. ATTENTION: Reference the Physician Labeling/Directions for Use for a complete listing of indications, warnings and precautions. PROVISC® OVD (Sodium Hyaluronate) Ophthalmic Viscosurgical Device INDICATIONS: ProVisc® OVD is indicated for use as an ophthalmic surgical aid in the anterior segment during cataract extraction and intraocular lens (IOL) implantation. Ophthalmic viscoelastics serve to maintain a deep anterior chamber during anterior segment surgery allowing reduced trauma to the corneal endothelium and surrounding ocular tissues. They help push back the vitreous face and prevent formation of a flat chamber during surgery. PRECAUTIONS: Postoperative increases in intraocular pressure have been reported with sodium hyaluronate products. The IOP should be carefully monitored and appropriate therapy instituted if significant increases should occur. It is recommended that PROVISC® OVD be removed by irrigation and/or aspiration at the close of surgery. Do not overfill anterior chamber. Although sodium hyaluronate is a highly purified biological polymer, the physician should be aware of the potential allergic risks inherent in the use of any biological material; care should be used in patients with hypersensitivity to any components in this material. Cannula assembly instructions should be followed to prevent patient injury. ADVERSE REACTIONS: Postoperative inflammatory reactions such as hypopyon and iritis have been reported with the use of ophthalmic viscoelastics, as well as incidents of corneal edema, corneal decompensation, and a transient rise in intraocular pressure. ATTENTION: Reference the Physician Labeling/Directions for Use for a complete listing of indications, warnings and precautions. © 2013 Novartis 1/13 VIS13003JAD-PI "The refractive goals of this patient are challenging," Dr. Probst said. "She expressed an interest in monovision and has successfully used monovision in the past, however, we do not know the time period or duration of the monovision trial." He said the patient's age also comes into play because she would just be beginning to see the full effect of presbyopia, which means that a complete monovision experience could still be a few years away. "Monovision for refractive surgery in general is challenging as it is permanent rather than adjustable as when done with contact lenses, results in a loss of depth perception and night glare, and does not give the same quality or quantity of vision of bilateral distance refraction correction with reading glasses for near vision," Dr. Probst said. Because of this, he said he would attempt to convince the patient to choose an option other than monovision. "If the patient has used monovision contacts for years, I would consider monovision correction but cautiously," he said. Dr. Probst said that he does not see using a monovision contact in the left eye as an attractive option. "I do not believe that any patient that embarks on the refractive surgery course is ever truly interested in using contact lenses again," he said. Dr. Desai's reaction and solution to the complication Reacting to the free cap complication in his LASIK procedure, Dr. Desai chose to do a CLE. "Ultimately, we performed a CLE with bimanual microincisional techniques for monovision targeting assisted by ORA [WaveTec Vision, Aliso Viejo, Calif.], the intraoperative wavefront aberrometer," Dr. Desai said. On postoperative day one, the patient was 20/20 OD, and J1+ OS with a –2.25 refraction as targeted. "In retrospect, I think it would have been to this patient's advantage to consider CLE with presbyopia-correcting lenses from the start, as we originally suggested and as more and more patients are realizing the benefits of the high precision outcomes attainable with one surgery," he said. However, because the patient elected to have LASIK due to her familiarity with it, she elected to avoid an intraocular procedure. Dr. Desai said he has since stopped offering patients the option to have microkeratome-assisted LASIK and promotes the benefits in safety and precision with femtosec- ond-assisted procedures. "From a patient safety, patient counseling, and a practice management point of view, it doesn't make sense to maintain the microkeratome and even offer this as an option anymore," Dr. Desai said. Comments on the solution Dr. Salz said he agrees with the way the complication was handled. "I agree that I would not do another LASIK procedure, especially with another microkeratome, perhaps creating a double flap and having a lot of trouble," he said. However, he would have approached the problem by doing PRK over that LASIK flap with mitomycin-C and avoided lensbased surgery. He thinks this would have turned out fine for the patient as well. "I've done several PRKs over aborted LASIK flaps," Dr. Salz said. "With mitomycin-C, they do quite well." He said that it is very important to help the patient understand that there are a few choices in this case. The patient could do nothing and wear contact lenses, have PRK, or have a lens-based surgery, as was the case for this patient. The surgery turned out fine, Dr. Salz said, with the patient regaining her monovision. Dr. Probst said with the free cap complication, he would not consider another lamellar surgery procedure. "A repeat cut with a microkeratome, even if done with a deeper cut, could result in intersecting wedges of tissue that would cause irregular astigmatism and a loss of best corrected vision," he said. "A femtosecond flap at a deeper level could result in vertical gas break through and another flap complication." Because these would all be bad outcomes, he said the possibilities would be either PRK or CLE. "While both options are reasonable, I would have chosen custom PRK because of the age of the patient, the clear lenses, and the relative simplicity of the PRK procedure," he said. EW Editors' note: The physicians have no financial interests related to this article. Contact information Desai: desaivision@hotmail.com Probst: leprobst@gmail.com Salz: drjjsalz@gmail.com