Eyeworld

SUMMER 2024 | EYEWORLD | 49 R the changes they're noticing in low-light image quality, you can do a brightness acuity test, and if they glare down to a visually significant number, they may actually qualify for cataract surgery. With surgeons being more aware of the visual issues with early cataracts, a lot of what you would think of as refractive lens exchange becomes early cataract surgery. Dr. Thompson said the "sweet spot" of LASIK has come down over the years. Some people would say 7 or 8 D of myopia is the cutoff. "If I was a 30-year-old patient, and I was more than a 3 D myope, in addition to corneal refractive surgery, I'd be considering a phakic IOL," he said, adding that he talks to patients about that. If a patient is a good candidate for LASIK or a phakic IOL, many choose LASIK for cost and familiarity with the procedure, but more people are choosing phakic implants in the moder- ate range. Dr. Thompson said that he would consider a phakic implant if he was in that scenario because of his experience doing LASIK and phakic IOLs for 30 years. A lot of patients are coming in for cataract surgery that he did LASIK and phakic IOLs on a long time ago, and now that we can quantify HOAs and look at topography and epithelial thickness, some old LASIK cases can't have all the implant options that modern day technology has brought us, he said. "With phakic IOL patients, as long as they took care of their eyes, didn't rub their eyes, I monitored them over the years, their corneas are pristine, at the time of cataract surgery, I just take out the phakic IOL and put in whatever implant they want like they never had refractive surgery," he said. "It's a pretty powerful value proposition in the long run for an implant." As a result of the sweet spot of LASIK coming down and the comfort of phakic IOLs and refractive lens exchange going up, refrac- tive surgery is alive and well, Dr. Thompson said. Sometimes, refractive surgery volumes get equated with the name LASIK, but refrac- tive surgery is a lot more than that and is a lot healthier because it's PRK, LASIK, SMILE, pha- kic IOLs, refractive lens exchange, AK, allogenic corneal inlays, etc., he said. Dr. Thompson thinks all of the options in refractive surgery now fit together well because you have the safest and most efficacious ap- proach to doing the best procedure that fits the patient's situation. He also said that mod- ern-day diagnostics are teaching us a lot. Patient outcomes and satisfaction are showing us which groups of patients are best for corneal refrac- tive, etc., but diagnostics are telling us why, he said, and oftentimes it has to do with measuring optical scatter in the cornea with too high of a corneal refractive procedure. We've also learned the image quality enhancing power of the tear film, Dr. Thompson added. We're more aggres- sive with tear film management and tear film health for therapeutic and optical reasons than we were 20 years ago. Blake Williamson, MD "We were down with LASIK 4%, but when we looked at our other procedures like custom lens replacement and ICLs, we were way up. We made massive gains on those two segments," Dr. Williamson said. He thinks this is partly because his practice has been aggressively marketing custom lens exchange and ICL. "That 45-year- old patient who's a little myopic, who may have gotten LASIK before, is coming in and saying, 'I continued on page 50 Dr. Thompson performs LASIK. Source: Vance Thompson, MD

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