Eyeworld

EW FEATURE 64 Refractive corrections • March 2019 by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor AT A GLANCE • Topography can be a key diagnostic tool. Knowing the spherical aberra- tion and the ablation areas are also important. • There are some indications that a patient is not a good candidate for a premium IOL. If there is any evidence of decentered ablation or presence of significant total corneal higher order aberrations, these are red flags. • It's important to consider treating the ocular surface to maximize the chance of success. Discuss- ing a plan for addressing residual refractive error with patients is also important. Choosing which implant is best for these patients W ith many lenses available for those with different visual demands, surgeons have more and more options for patients who want to be less dependent on glasses. However, patients who have had prior cor- neal refractive surgery may require special considerations when choos- ing which option is best. Brandon Baartman, MD, Vance Thompson Vision, Omaha, Nebraska, and Kevin Waltz, MD, Indianapolis, discussed diagnostics, lens options, and potential postoperative issues. Goal of being glasses-free EyeWorld asked Dr. Baartman and Dr. Waltz to weigh in on how to ap- proach patients who want distance, intermediate, and near vision with- out glasses after cataract surgery. This is an important issue in refractive cataract surgery, Dr. Baart- man said. "Patients who underwent refractive surgery in the 1990s and early 2000s are now aging into the cataract demographic, and many are still very active both in the work- force and their personal lives," he said. "The desire for clear and func- tional vision independent of glasses doesn't go away." These patients can require a lot from a visual freedom perspective but can also be some of the most challenging due to the prior corneal surgery, he added. Dr. Baartman said that he ap- proaches cataract surgery the same way with all patients, regardless of refractive surgical history: How much do they want to be able to do without glasses after surgery? "Some of these patients are used to wear- ing reading glasses and don't mind using them but want that LASIK-like visual outcome at distance after surgery," he said. "Others have con- verted to monovision after the onset of presbyopia and plan to continue using this for spectacle freedom af- ter cataract surgery." He added that even though both patient groups generally wind up with a monofo- cal optic, the outcome is critical for their happiness, and it's important to nail the refractive target. Patients who are more visually demanding at intermediate and near may benefit from a multifocal or extended depth of focus optic, Dr. Baartman said. "Historically, optics that split light were not good op- tions in the post-refractive cornea, but that has changed," he said, add- ing that many surgeons have report- ed impressive outcomes with newer technology diffractive optics in the post-refractive eye, including LASIK, PRK, and even certain patients with radial keratotomy. "There's a lot that goes into these patient evaluations in terms of discussion and testing, but nothing is as important as clear communication and a mutual understanding of patient goals and possible limitations of the surgery," Dr. Baartman said. Dr. Waltz said that he does a lot of refractive surgery and personally has multifocal lenses. The main point to understand with a post-re- fractive patient is they've already set themselves apart from the average patient. Since these patients paid ex- tra for a certain refractive outcome, Dr. Waltz said they likely would be interested in optimizing that outcome after refractive surgery. He added that the number one criterion in these cases is patient motivation. "If they want it easy and quick and don't mind wearing glasses, that's a perfectly good choice," he said. "But if someone says they love refractive surgery and was happy and want to get that back, that's a different choice, and you can make that per- son happy, too." Dr. Waltz noted that there are a number of technical details the physician has to be aware of for these patients. If the patient has had prior refractive surgery, the likelihood that you're going to get a good refractive outcome with the initial result is decreased. Part of what the surgeon has to understand is what the enhancement strategy will be, he said, adding that the sur- geon who operates initially doesn't necessarily have to be the one to do the enhancement, but it has to be available to fine-tune the outcome. Considerations for patients with prior corneal refractive surgery Topography and aberrometry obtained from the OPD-Scan III on a patient with an interest in spectacle independence after cataract surgery. She had a history of prior PRK with a moderate amount of corneal higher order aberrations, circled in bottom right box. This was the patient's dominant eye, which did well with an extended depth of focus IOL with no plans for enhancement at this time. Source: Brandon Baartman, MD

• Blank Page
• Blank Page (1)