Eyeworld

32 | EYEWORLD | MAY 2019 R EFRACTIVE Contact information Fox: martinlfox@me.com Augustine: draugustine@ clearchoicelaser.com Wiley: abrowning@ clevelandeyeclinic.com POINT/COUNTERPOINT by Martin L. Fox, MD, Jeffrey Augustine, OD, and William Wiley, MD requires a robust tear film in order to work well, and therefore, punctal occlusion and topical lubricants are required along with Restasis (cyclosporine, Allergan) or Xiidra (lifitegrast, Shire) as adjunct topical therapeutics. Frustrat- ed KAMRA inlay patients should be offered explantation, which could restore preoperative best corrected visual acuity. T he KAMRA corneal inlay (Cornea- Gen) has become well-established for the safe restoration of near vision through its mechanism of small aperture optics. By expanding depth of focus, the inlay surgically enhances reading vision from intermediate to near range while preserving distance acuity in presbyopic patients. When implanted in a deep femtosecond laser-created corneal pocket of the nondomi- nant eye, the KAMRA inlay produces predict- able outcomes with a high probability of patient acceptance and low rates of requested explanta- tion (2% MLF). Our clinical results indicate that with careful patient selection and preparation, meticulous surgery, and postoperative care, KAMRA inlay surgery produces considerable results. Preoperatively, patients do best when refractive error is in the –0.75 D range with no levels of astigmatism. We have learned that those with refractive errors outside of this range need to be adjusted with laser vision correction (PRK or LASIK), performed simul- taneously at the time of KAMRA inlay pocket implantation or prior to KAMRA inlay place- ment in a staged approach. Careful attention to tear film quality and levels of ocular light scatter as determined by the HD Analyzer (Visiomet- rics) will also ensure appropriate candidacy. Success with the KAMRA inlay requires patience both from the physician and patient as the majority of KAMRA inlay recipients can take up to 3 months to fully appreciate the ben- efits of the small aperture optics and extended depth of focus delivered with this surgery. Poor neuroadaptation, which seems to occur more frequently in patients who display indeterminant ocular dominance, is the most common cause of patient discontent. Testing for monovision with contact lenses is helpful in determining which eye should receive the KAMRA inlay. In many instances, patients can also benefit from neuroadaptive exercises. As with all forms of refractive surgery, maintenance of an excellent ocular surface is of utmost importance, but this is especially true for KAMRA inlay patients. The KAMRA inlay Successful use of the KAMRA corneal inlay after cataract surgery About the doctors Martin Fox, MD, FACS Medical director Cornea and Refractive Surgery Practice of New York Surgical Consultant Vision Group Holdings Jeffrey Augustine, OD Director of Clinical Operations ClearChoice LASIK Brecksville, Ohio William Wiley, MD Assistant clinical professor of ophthalmology University Hospitals/ Case Western University Medical director Cleveland Eye Clinic Financial interests Fox: CorneaGen Augustine: AcuFocus, CorneaGen Wiley: AcuFocus, CorneaGen Case 1 69-year-old male with past history of LASIK complains of inadequate reading acuity and poor quality of vision in the distance following bilateral cataract surgery with implantation of Tecnis +2.75 multifocal IOL (model ZKB00, Johnson & Johnson Vision) Preoperative findings (10/17/17) UCVA OD: 20/50+2 J7 c/o glare UCVA OS: 20/50+2 J5 c/o glare Ocular dominance: OS MR OD: +1.25-0.50 x 90 20/30+2 Add: +2.50 J2 MR OS: +0.75-1.00 x 70 20/25-2 Add: +2.50 J2 AcuTarget HD OD: OSI 1.5 OSI mean 1.75 Central corneal thickness: 550 µm Surgical planning (12/18/17) Simultaneous PRK and KAMRA implantation – OD Treatment: +2.00 D PRK with mitomycin-C and amniotic membrane Femtosecond laser pocket depth: 270 µm Postoperative findings 4/03/18 UCVA OD: 20/50 J1+ 9/05/18 UCVA OD: 20/30-2 J1+ HD OD (9/5/18): OSI 2.5, OSI mean 2.90 Patient comments: Delighted with reading acuity and reduction of visual halos continued on page 34

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