Eyeworld

42 | EYEWORLD | FALL 2024 R EFRACTIVE by Karolinne Maia Rocha, MD, PhD Refractive Editor A patient presents with a history of myopic LASIK 15 years ago, and his chief complaint is blurry vision. On exam- ination, I see early changes of the lens, and the patient's visual acuity is 20/25- with a manifest refrac- tion of 0.5 D +0.75@165. Corneal topography shows central flattening with a small optical zone. What is our next step? Put another way, do we proceed with corneal or lens surgery? Today we have a number of advanced diagnostics that can help us in meeting patients' visual needs. This issue of EyeWorld is designed to provide tips and clinical pearls to help us do just that. Dive in as our colleagues divulge their practice pearls in the areas of epithelial map- ping, angle kappa influence on multifocal IOLs' refractive outcomes, and higher order aberra- tions (HOAs). Improvements in vision using epithelial mapping is covered by David Huang, MD, PhD, Dan Reinstein, MD, MA(Cantab), and George Waring IV, MD, in "Epithelial mapping: appli- cations for residual refractive error and current technology." With uses for keratoconus and cor- neal ectasia, post-LASIK, warpage, dry eye, and planning for refractive enhancement, epithelial mapping, as the article states, has aided in our understanding of keratometric normalization and refractive and visual stabilization. I specifically will utilize epithelial mapping in post-laser vision correction patients in order to understand variations in central thickness that correlates with higher ablation profiles and its impact in residual refractive error. The tech- nology is an asset in predicting and adjusting for variation in epithelial thickness in refractive enhancements. Avi Wallerstein, MD, Mathieu Gauvin, PhD, and their research partners evaluated more than 26,000 eyes from more than 13,000 patients across Canadian IOL surgery centers; they discussed the findings in "Angle kappa and its influence on multifocal IOL outcomes." While the piece presents multiple findings, the conclu- sion of the comprehensive study was that angle kappa should be considered as part of a com- prehensive preoperative assessment, along with axial length, corneal topography, corneal HOAs and astigmatism, retinal health, pupil size, and the patient's individual visual needs. I had the pleasure of being included, along with Brian Armstrong, MD, and Damien Gatinel, MD, PhD, in "The impact of HOAs on refractive options and outcomes." In it, we dis- cussed the causes of higher order aberrations, including dry eye, the aging lens, age-related cataract, and posterior capsular opacification, and how these may impact refractive surgery, IOL selection, visual acuity, and patient satisfac- tion. In addition, we reviewed the technologies that can measure the eye's aberration profile: Hartmann-Shack wavefront sensors, ray tracing, double-pass sciascopy, OCTs, and Scheimpflug tomography, specifically. Getting back to our patient at the begin- ning, we were able to demonstrate that the aberrations were happening mostly due to the aging lens and proceeded with lens surgery to address the patient's chief complaint. We did so by taking advantage of the data provided by corneal tomography and wavefront analysis and knocking down this patient challenge. Advanced diagnostics to help clinicians knock down challenges Today we have a number of advanced diagnostics that can help us in meeting patients' visual needs. This issue of EyeWorld is designed to provide tips and clinical pearls to help us do just that.

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