Eyeworld

96 | EYEWORLD | JULY 2021 R EFRACTIVE by Ellen Stodola Editorial Co-Director About the physicians Kathryn Hatch, MD Assistant Professor of Ophthalmology Harvard Medical School Boston, Massachusetts Allison Jarstad, DO SoCal Eye Long Beach, California William Trattler, MD Center for Excellence in Eye Care Miami, Florida W hen choosing the best refrac- tive surgery option, there are a variety of factors that surgeons consider, including patient age, overall goals, and expectations. Three surgeons discussed which procedures they use and some of the specifics of laser refractive surgery, phakic IOLs, and lens replace- ment surgery. William Trattler, MD, said that over the last decade, surgeons have come to use LASIK for a variety of patients, from high myopes to hyper- opes, in a wide range of ages. Now there are other options as well, he said, noting refractive lens exchange and the option to offer phakic IOLs to patients with lower refractive errors. When potential refractive surgery patients come in for a consultation, Dr. Trattler said it's important to be prepared with all the options. "Every patient is going to need a unique strat- egy to figure out how to make them happiest," he said. "These are patients that you'll probably see years after surgery, so you want to give them something to make them happy in the long term as well as short term." Dr. Trattler said procedure decisions may be easier for the younger patient. For those young- er than 40, typically if they're myopic and under –9 or –10 D, he'll offer them laser vision cor- rection, which could be PRK, LASIK, or SMILE. That decision depends on surgeon preference, Dr. Trattler said, but these are all good proce- dures. If the patient has more than –9 or –10 D, that's when you start thinking ICL. Laser vision correction can be used for high myopes, but its risk profile increases, he said. A newer version of the ICL is approaching FDA approval and will make the procedure easier, he added. The new version has a small hole in the lens optic that allows for aqueous flow. This eliminates the need for placement of peripheral iridectomies. International surgeons who have been using the technology have com- mented that this update improves the safety of the ICL, he said. When considering patients of presbyopic age, choices become more nuanced. For those patients who are hyperopic in their 20s to 30s, Dr. Trattler said they're typically able to accom- modate through their hyperopia, except when the hyperopia is severe. But once patients reach their 40s, hyperopia starts to impact vision, and patients will request refractive surgery consul- tations. Hyperopic patients in their 40s and 50s may be good candidates for a refractive lens exchange. Dr. Trattler added that with improved technology, patients are usually happy with this option. He said a lens like PanOptix (Alcon), Vivity (Alcon), Symfony (Johnson & Johnson Vision), or Eyhance (Johnson & Johnson Vision) could be considered. Alternatively, a monovision or blended vision strategy with monofocal or monofocal toric IOLs can be considered. LASIK can still be an option for patients in their 40s and 50s, he said, while ICLs are usually not the procedure of choice except with a high level of myopia. "I try to create an individualized, custom approach for each patient," Dr. Trattler said. He noted that many patients associate the word "LASIK" with improvement of vision to the point of not needing glasses. Many patients don't understand the different tools and tech- nologies in addition to LASIK that are available to accomplish this goal. Laser vision correction wouldn't necessarily be the right choice for a patient in their 60s. This patient might be a better candidate for a refractive lens exchange or could need cataract surgery. "If they're not going to be a good fit for a certain technology, it's OK to tell them that," he said. Comparing laser refractive surgery, phakic IOLs, and lens replacement continued on page 98 Removal of epithelium during a PRK procedure with the EBK device (Epi Clear, Orca Surgical) Source: Jennifer Loh, MD

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