Eyeworld

38 | EYEWORLD | SEPTEMBER 2023 R EFRACTIVE by Karolinne Maia Rocha, MD, PhD Refractive Editor I had a post-RK patient recently, following a long recovery in the first eye post-keratoplasty. At this point in his care, the 16-cut RK contralateral eye needed cataract surgery and possible keratoplasty for corneal ectasia, a fate that was avoided for the second eye with a small aperture intraocular lens. At this patient's 1-week postop visit, he presented with 20/30 vision. In "Incorporating the IC-8 Apthera into practice," Blake Williamson, MD, shares a sim- ilar story: a case with extreme myopia preop- eratively in which the physician was expecting a myopic surprise using this lens, considering the lens only goes down to 10 D at the moment. However, the patient came back with excellent visual acuity several days postop. In this article, Shamik Bafna, MD, Arthur Cummings, MD, and Karl Stonecipher, MD, also share their experi- ences with the IC-8 Apthera (Bausch + Lomb). This lens, an FDA-approved extended depth of focus lens for use in the non-dominant eye, is not only a lens I consider in my cornea and refractive practice but also a topic of my research in identifying optimum pupil diame- ter for presbyopes. While its on-label uses are helping normal eyes to see at varying distances, therapeutically this lens can be used off label to achieve positive visual outcomes for patients with aberrated corneas. From the research that I've been working on with my colleagues, the answer as to how small aperture optics work therapeutically is two-fold: The pinhole effect provides extended depth of focus and correction of aberrations leading to improved visual outcomes. Small aperture can optimize vision at several distances, but impor- tantly, the ideal pupil size is also affected by variables like retinal illuminance, diffraction, grating detection, as well as lower and higher order aberrations. Correction for any of these issues can lead to improved visual outcomes for a variety of patients. Prior to this article, in "Management and options for patients with post-refractive ectasia," Steven Greenstein, MD, and Dr. Williamson provide details on their use of small aperture technology as an option in patients who have ectasia following cornea stabilization. The physicians, including William Trattler, MD, also detail procedures and technologies that can be used to stabilize corneal ectasia, for example crosslinking and intracorneal ring segments. While not the standard for practice, I applaud their efforts to treat the disease and ensure the best possible visual outcomes for their patients. In "Using presbyopia drops in practice and products in development," Steven Dell, MD, Jennifer Loh, MD, and Luke Rebenitsch, MD, describe their experiences with Vuity (pilo- carpine ophthalmic solution, Allergan). The physicians discuss the practical visual outcomes experienced by their patients, which are that they will not always have the ideal vision for each task they come across in the day. Multiple variables are at play to achieve the appropriate percentage constriction of natural pupil size, including light levels and whether the task calls for near, distance, or intermediate vision. The physicians also describe specific patient popula- tions for which they've found the therapy to be useful, such as in those who we are screening for future small aperture interventions or in early presbyopes. As new technologies become available, it's an opportunity to learn more about the function and adaptability of the eye as well as to identify ways in which they can be used to achieve the best visual outcomes for our patients. Seeking the best visual outcomes for our patients As new technologies become available, it's an opportunity … to identify ways in which they can be used to achieve the best visual outcomes for our patients.

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