EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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August 2012 Refractive challenges and innovations February 2011 EW FEATURE 39 tients we can remove the hyperopia today, but in 6 months or a year that might change. If the cornea contin- ues to get more ectatic in the mid-periphery, the hyperopia will return." Surgeons basically have three options, he said: LASIK, PRK, or (if age appropriate) cataract surgery. Creating a LASIK flap after RK can result in irregular astigmatism be- cause of potential flap issues, so Dr. Majmudar doesn't recommend it. "RK and LASIK are incompati- ble," Dr. Vukich said. "The hyper- opic shift is a corneal problem, and placing horizontal transecting incisions into vertical incisions is a recipe for disaster." When he did perform LASIK on these eyes in the past, Dr. Donnenfeld said some patients had issues with the RK incisions split- ting, creating a "pizza pie-like appearance." If he can obtain wave- front aberrometry, he's comfortable performing PRK but offered a few pearls. First, he said, if there are epithe- lial inclusion assists within the inci- sions themselves, it indicates the incisions are spreading. He prefers to clean out the incisions with a Sinskey hook and suture them closed with non-biodegradable su- tures (such as 10-0 prolene). Sutur- ing will hold the incisions together and, by tightening, may result in re- versing some of the hyperopia and astigmatism that's been caused in the area. He also uses mitomycin-C for 30 seconds (0.02 mg/mL) instead of the typical 12 seconds in surface ablation. "I'd rather steepen the cornea than do a clear lens exchange," he said. "I think the optics with a steeper cornea are better for these patients." Dr. Vukich will try to leave pa- tients in spectacles if they have a minimal correction and functional vision; otherwise he prefers to per- form refractive lens exchange (pre- suming no irregular astigmatism/ higher order aberrations). "I'll aim to leave them a little myopic—maybe a –1 or so—because they'll continue to have a slow hy- peropic shift toward emmetropia," he said. "They'll need glasses for dis- tance, but patients appreciate the improved near vision." Likewise, he's "hesitant" to correct astigma- tism with a toric IOL, saying results are less predictable. "We have to tell these patients that 'perfect' isn't possible. We can try to improve their vision, but they're not going to have the vision they did in their 20s," he said. Most RK patients have been living with variable vision and advancing hy- peropia "for at least a decade," so while they may not be happy about the situation, "they've learned to cope with their vision," he said. Dr. Donnenfeld "highly recom- mends" intraoperative aberrometry continued on page 40 An ASCRS Membership For every stage of your career Whether you're just beginning or experienced in cataract and refractive surgery, ASCRS is the professional society that's right for every stage of your career. Established Anterior Segment Ophthalmologists Mid-career is perhaps the most challenging period for today's ophthalmologist. The clinical and technological changes have never come faster and the regulatory concerns have never been greater. ASCRS' Annual Sympo- sium and Winter Update offer the education and networking needed to help your practice excel, and our ASCRS MediaCenter provides targeted online content addressing the issues most pressing to you. ASCRS' monthly Journal of Cataract and Refractive Surgery reports on all aspects of anterior segment surgery, and our meetings are focused, well-organized, and highly interactive. eyeCONNECT, ASCRS' online clinical service, lets you share questions and answers with like-minded peers in a private and supportive environment. ASCRS' commitment to fostering excellence through collaborative exchange is unmatched by any other ophthalmic organization. Join ASCRS today! The Society for Surgeons AMERICAN SOCIETY OF CATARACT AND REFRACTIVE SURGERY 4000 Legato Road, Suite 700, Fairfax, VA 22033 • 703-591-2220 • www.ASCRS.org