Eyeworld

76 | EYEWORLD | APRIL 2022 R EFRACTIVE continued on page 78 W hen choosing a refractive pro- cedure, there is a lot of infor- mation for surgeons to go over with patients, and the possibility of needing implant surgery in the future is one point for discussion. Bryan Lee, MD, JD, Luke Rebenitsch, MD, and William Wiley, MD, shared how they counsel patients, specific considerations, and how changing tech- nology has had an impact on this and may open more options in the future. Technology is changing so quickly, Dr. Rebenitsch said, and the procedures of today are not the procedures of 20 years ago. For example, LASIK is very different today than it was 15–20 years ago. "We have better ablation patterns and larger optical zones, which do not necessarily preclude a patient from having a multifocal or advanced technology IOL in the future," he said. Dr. Rebenitsch said that all patients under 40 are counseled that their crystalline lens is going to change, and there are options for when they develop presbyopia. Setting expectations is a win for patients and practices, he said. In cases of hyperopic ablations, Dr. Rebenitsch advised caution and said that he might be more likely to recommend a refractive lens exchange earlier because even with modern technology, hyperopic ablations are more likely to prevent patients from having certain ad- vanced technology IOLs. "What's changed over time is we're doing lenses earlier, especially for hyperopic patients," he said Dr. Rebenitsch added that treatment for a –6 to –8 myope is usually when higher order aberrations increase with modern ablation pro- files, so he may be more likely to place a phakic IOL, like the STAAR Surgical ICL, to allow them to have better vision now as well as more op- tions in the future. Additionally, he highlighted the benefits of the SMILE procedure in these cases because it leaves more of the surface of the cornea un- touched. Any time you do a refractive proce- dure, it does make calculations more difficult for enhancement/lenses in the future, Dr. Rebenitsch added. But he noted that you can How refractive procedures impact future implant choices While there is no direct sign on examination that a patient is an eye rubber, Dr. Baartman said there has been postulation that without eye rubbing, or some form of repetitive mechanical strain placed on the cornea, progressive ectasia would not naturally occur. "For this reason, any patient with either post-LASIK or naturally occurring keratoconus is assumed to be an eye rubber, and even if they deny it, they are thoroughly educated on the dangers of eye rubbing and avoidance of planting their face into the pillow at night," Dr. Baartman said. Dr. Greenwood said he thinks the possible hazards of eye rubbing should be discussed more with the general public. Dr. Baartman thinks eye rubbing has become less frequent in the keratoconus population with continued em- powerment of optometric network and general ophthalmologist colleagues. A final tip to help educate patients about eye rubbing, especially when it's subconscious, is to explain that there is a threat of needing a full-thickness corneal transplant (possibly mul- tiple) if they have keratoconus and continue eye rubbing, Dr. Baartman said. continued from page 75 by Ellen Stodola Editorial Co-Director About the physicians Bryan Lee, MD, JD Altos Eye Physicians Los Altos, California Luke Rebenitsch, MD Medical Director ClearSight LASIK/43 Vision Oklahoma City, Oklahoma William Wiley, MD Cleveland Eye Clinic Cleveland, Ohio Contact Baartman: brandon.baartman @vancethompsonvision.com Greenwood: michael.greenwood @vancethompsonvision.com

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