Eyeworld

SEPTEMBER 2023 | EYEWORLD | 39 R COMPLICATED CASES by Liz Hillman Editorial Co-Director About the physicians Steven Greenstein, MD Medical Director Cornea and Laser Eye Institute Teaneck, New Jersey William Trattler, MD Center for Excellence in Eye Care Miami, Florida Blake Williamson, MD Williamson Eye Center Baton Rouge, Louisiana A patient who elected years ago to have refractive surgery is no longer seeing as well and learns they have ectasia. In many cases their vision can be preserved and/or improved. EyeWorld spoke with Steven Greenstein, MD, William Trattler, MD, and Blake Williamson, MD, about how they address corneal and refrac- tive issues for these patients. Dr. Trattler said the biggest determiner for these patients still being able to see well is catching their ectatic condition early. "The ear- lier you catch these patients, the better because they will have less vision loss when diagnosed, and treatments can stabilize and often improve vision," he said. Dr. Trattler said he recently saw a patient with post-LASIK ectasia who was 20/60 un- corrected in their better eye when ectasia was diagnosed in 2020. This patient, now 3 years after undergoing crosslinking, had improved to 20/25 without glasses. "Crosslinking improves the corneal shape in the majority of patients," Dr. Trattler said. "If ec- tasia is not identified until it is quite advanced, even after crosslinking and other procedures, patients likely will need to use advanced contact lenses to achieve their best vision." If a patient's uncorrected or best corrected vision with spectacles is not satisfactory after crosslinking, Dr. Trattler said scleral contact lenses are often the first line of visual correc- tion. He said scleral contact lenses are a "very reliable and highly successful method for improving vision in patients with irregular corneal shape due to ectasia." Dr. Greenstein said the approach for the pa- tient with ectasia after refractive surgery is sim- ilar to that for a patient with keratoconus. "It starts with establishing corneal stability through crosslinking, addressing corneal curvature, then visual improvement," he said. "We try to address all three of those things, set a plan for the patient moving forward, and create the realistic expectations about what we can do for their vision," Dr. Greenstein said. He said that depending on the thickness of their cornea and severity of the disease, topography-guided PRK could be an option. A literature review published in 2019 described studies that found crosslinking combined with or followed by topography-guided PRK or transepithelial PRK were effective at "providing corneal stability as well as significantly improv- ing functional visual acuity." 1 At the time, the authors wrote that more data was needed on the long-term stability of the combined tech- nique, as well as long-term studies on endothe- lial cell counts. Other methods to regularize the cornea include Intacs (CorneaGen) and corneal tissue addition keratoplasty (CTAK, CorneaGen). Dr. Greenstein said he primarily does the latter. It uses sterilized corneal tissue that is shaped and placed into a laser channel to reshape the cornea. If the patient's disease is too severe or if Management and options for patients with post-refractive ectasia continued on page 40 These are axial topography maps before and 1 year after CTAK in a patient with ectasia after LASIK. Preop uncorrected Snellen visual acuity and best spectacle corrected Snellen visual acuity was 20/200 and 20/30, respectively. Postop, uncorrected Snellen visual acuity was 20/30, and best spectacle corrected Snellen visual acuity was 20/25 at 1 year. Source: Steven Greenstein, MD

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