Eyeworld

44 | EYEWORLD | FALL 2025 R EFRACTIVE Relevant disclosures Hersh: CorneaGen Meghpara: Glaukos Contact Hersh: phersh@vision-institute.com Meghpara: bmeghpara@willseye.org prescription and reduce it as much as possible but not necessarily eliminate it." This goes back to the whole refraction dis- cussion, Dr. Meghpara said. It's important to get an accurate refraction but also know when add- ing refractive error into the refraction is worth it or not. It's easy to overcorrect and put too much. "You want to correct as much as possible but not overcorrect, and you have to learn when you're at a happy medium," he said. "When I'm talking to a patient, I tell them there are three things we need to discuss in the treatment," Dr. Hersh said. The first is that kera- toconus is a progressive disease, and aberrations will change over time, so refractions can change over time. "Because it's a progressive disease and we now have a treatment for progression that is corneal crosslinking, that is first and fore- most what's on our mind when we're seeing a keratoconus patient. If they're progressive, they should have crosslinking." The second thing is getting the best optical vision, Dr. Hersh said. We're trying to get the best spectacle correction, but they're always go- ing to get their best vision with a rigid or scleral contact lens. In those cases, the fitting is entirely different from the refraction because these lenses cover the cornea and give a new optical surface, so they negate the lower and higher order aberrations. The last thing to discuss is surgery, he said. Many patients are diagnosed with keratoconus when they come in seeking refractive surgery, and he agreed that procedures like LASIK or PRK are contraindicated in keratoconus because you don't want to thin the cornea and further weaken it in what is a progressive disease caused by weak cornea biomechanics. However, there are some interventions that can be helpful for patients surgically. Some are candidates for topography-guided PRK, which takes the corne- al topography map and feeds these aberrations into the laser to correct some of the topography irregularities. "This will not prevent progression and should be done with crosslinking, and we limit the amount of tissue removed," he said. Another option is CTAK, first originated by Dr. Hersh in 2015, which uses a custom femtosec- ond laser-cut inlay of corneal preserved tissue, using various topography and tomography inputs that are specific to the patient. CTAK can improve corneal topography and, most impor- tantly, patients' visual function in many cases. Dr. Meghpara also mentioned CAIRS or CTAK as options, which involve the addition of corneal segments into the patient's cornea to try to thicken it and make it more regular. By doing those, you're also reducing refractive error. You may not be eliminating contacts but are reducing the prescription or making it easier to correct. "As corneal surgeons, we'd offer crosslink- ing, which is great and it's revolutionized the treatment of keratoconus, but all crosslinking does is stabilize the disease," Dr. Meghpara said. It doesn't make the patient better, but it hope- fully prevents corneal transplant in the future. "We're doing more and learning more," he said, adding that he thinks there will be a shift in the next 5–10 years to focus on trying to get these patients to see better. continued from page 42 CTAK inlay immediately postoperatively; note flattening of approximately 14 diopters; uncorrected distance visual acuity improved from count fingers to 20/60, and corrected distance visual acuity improved from 20/70 to 20/30+ Source: Peter Hersh, MD Preop 3-month CTAK Difference

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