Eyeworld

SEP 2023

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

Issue link: https://digital.eyeworld.org/i/1504856

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40 | EYEWORLD | SEPTEMBER 2023 R EFRACTIVE Contact Greenstein: sgreenstein@vision-institute.com Trattler: wtrattler@gmail.com Williamson: blakewilliamson@weceye.com Reference 1. Al-Mohaimeed MM. Combined corneal CXL and photorefractive keratectomy for treatment of keratoconus: a review. Int J Oph- thalmol. 2019;12:1929–1938. Relevant disclosures Greenstein: CorneaGen, Glaukos Trattler: CXLO, Glaukos, Oculus Williamson: Glaukos they have too much scarring, a corneal trans- plant (hopefully lamellar) is an option, he said. If the patient is eligible for cataract surgery, there are lens-based options that could improve their vision (again after crosslinking and stabili- zation). Dr. Greenstein said he has had success with reshaping the cornea (with CTAK or topog- raphy-guided PRK) prior to cataract surgery. He sees a role for monofocal and toric lenses and blended vision and monovision options. Drs. Greenstein and Williamson mentioned the utili- ty of an adjustable IOL, like the Light Adjustable Lens (LAL, RxSight), due to the ability to fine tune vision postop. They all mentioned the util- ity of the IC-8 Apthera IOL (Bausch + Lomb). Dr. Greenstein and Dr. Williamson advised caution when it comes to multifocal lenses with these patients, though Dr. Williamson said some patients might be eligible for Eyhance (Johnson & Johnson Vision) or Vivity (Alcon). Dr. Williamson said he thinks the LAL in both eyes or the IC-8 Apthera in the non-domi- nant eye and LAL in the dominant eye are good for patients who have 2–2.5 D of cylinder. If there is more cylinder, like 3–4 D of irregular cylinder, Dr. Williamson said he might use bilat- eral IC-8 Apthera off-label. "It can clean up coma and some of the high- er order aberrations that you typically see in those post-refractive ectasia patients," he said. In addition to selective choice, Dr. William- son said factors for achieving on-target cataract surgery still apply. These include making sure you have a good informed consent that "gives you plenty of runway to achieve a reasonable result," using the right tools (accurate measure- ments with multiple devices confirming degree and power of astigmatism, updated formulas), and appropriate lens offerings. Monitoring for progression is especially important for patients with keratoconus or post-refractive ectasia. Dr. Trattler said while crosslinking is highly effective at strengthening the cornea, a small percentage of patients can still progress. Known risk factors for progression include continued eye rubbing and advanced ec- tasia. "The good news is that most patients with ectasia will not progress after a single crosslink- ing procedure. However, patients need to be seen every year after crosslinking to ensure that their corneal shape is stable or improving," he said. "In our experience, when progression is identified after a previous crosslinking proce- dure, a second crosslinking procedure is quite effective at preventing further progression." Dr. Greenstein presented 10-year results of crosslinking with patients who had topogra- phy-altering surgery (PRK or Intacs) compared to those who didn't at the 2023 ASCRS Annual Meeting. Overall, there was stability 10 years after crosslinking (76.7% of eyes were stable) with no significant differences in eyes that had subsequent topography-altering surgery. However, eyes with keratoconus that received crosslinking were less likely to progress later compared to eyes that had crosslinking for post-refractive surgery ectasia; 86.7% of eyes with keratoconus that had crosslinking re- mained stable at 10 years postop compared to 66.6% of eyes that had crosslinking for post-re- fractive ectasia. "This is why it's important to tell those patients: 1) They need crosslinking done to stabilize their cornea now, and 2) they need to be monitored for the rest of their lives to make sure they don't need repeat crosslinking down the road," Dr. Greenstein said. continued from page 39 These are axial topography maps before and 1 year after topography-guided PRK in a patient with ectasia after LASIK. Preop uncorrected Snellen visual acuity and best spectacle corrected Snellen visual acuity was 20/200 and 20/50, respectively. Postop, uncorrected Snellen visual acuity was 20/25 with no additional improvement in best spectacle corrected visual acuity at 1 year. Source: Steven Greenstein, MD

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