Eyeworld

scientifically proven that that's the best way to do it. [Patients] epithe- lialize at least 24 hours earlier, have faster vision recovery, less pain, and less chance of chronic epithelial de- fects, which can form late haze." Both Drs. Chynn and Durrie use chilled balanced salt solution during surgery, but Dr. Durrie uses a pre- made frozen Popsicle of sorts for 10 seconds on the eye before removing the epithelium and after lasering the patient. "Everyone who has tried that has found it makes patients more comfortable, and it also controls the wound healing," he said. In terms of a post-op regimen, Jason E. Stahl, M.D., Durrie Vision, Overland Park, recommended put- ting the patient on an antibiotic and steroid four times a day for a week. "There are some surface ablation gurus who have a very lengthy and complex list of medications that they use afterward, but we keep it pretty simple and similar to our LASIK patients," he said. "Patients can use a nonsteroidal for pain as needed for a couple of days. We en- courage cold compresses and chilled artificial tears, which help with dis- comfort. We recommend taking ibuprofen and then using acetamin- ophen and hydrocodone for any breakthrough discomfort." Dr. Chynn puts all of his pa- tients with high refractive errors on Pred Forte (prednisolone, Allergan) over a months-long taper, i.e., four times daily for a month, three times daily for a month, two times daily for a month, and so on. Dr. Chynn also stressed the importance of hav- ing the patient wear UV protection diligently for a few months after sur- gery. "If you don't give them mito- mycin C, oral steroids, Pred Forte, vitamin C, and UV protection all the time, they are going to scar," he ex- plained. "Before we laser these sky- high prescriptions, I have to put the fear of God into them. I have to say to them, 'You're going to go blind and scar if you're not compliant.'" Another key way to avoid haze is making sure the epithelial defect closes as quickly as possible. This re- quires following up with the patient frequently at 1 and 4 days post-op. If it turns out the patient isn't epithe- lializing properly, change some- thing. "Take that contact lens out and use a different one, take it out and patch the patient, or change the medication," said Dr. Durrie. "Your goal is to get the epithelial defect to close as rapidly as possible, and then it won't trigger the healing variabil- ity that we sometimes see if it takes longer than that to heal." If the patient does develop haze, Dr. Durrie recommended putting the patient back on steroids and doing a slow taper like the one described by Dr. Chynn. The haze will eventually clear up and go away and not need any further intervention. "Where we've gotten into trou- ble is a lot of times either patients or doctors are impatient, and doctors try to scrape the haze or retreat pa- tients with the laser when they are still in the active healing phase. Sometimes that turns the haze into a scar," Dr. Durrie said. "Sometimes it's hard to get doc- tors to do less. They want to help their patients and aid in recovery. It's about being patient and sitting on your hands for a little bit and fol- lowing the patient carefully." Should scarring occur, Dr. Durrie recommended performing a transepithelial removal of the ep- ithelium using a laser with pho- totherapeutic keratectomy (PTK) mode, such as the VISX (Abbott Medical Optics, AMO, Santa Ana, Calif.). Refer back to the patient's chart and see where the refraction was at 1-month post-op. "The thickness of that haze is equivalent to the refractive error be- cause the patient used to be plano before he or she grew that extra stuff on the cornea," he said. When you perform the PTK, watch for the fluorescence of the ep- ithelium. Each pulse of the laser re- moves a quarter micron of tissue, and eventually it will extend to the periphery. Then you program the re- fractive error into the laser, and use mitomycin C. "It's fascinating because as you're watching those pulses, you can actually see the last part of the haze go away because it fluoresces, too. It's a very elegant way to get through the haze and the residual refractive error," Dr. Durrie ex- plained. If the practice doesn't have a VISX laser, Dr. Chynn recommended putting the patient back on Pred Forte. It won't get rid of the scar entirely, but the patient should re- gain most of the visual acuity. When surgeons add surface ab- lation to their practice, the pain, haze, and scarring possibilities can seem daunting. But these complica- tions can be avoided if all appropri- ate steps are followed. "Each one of these pieces is giv- ing a little more oomph to your ar- mamentarium so the patient doesn't have scarring," Dr. Chynn said. EW Editors' note: Dr. Chynn has no finan- cial interests related to his comments. Dr. Durrie has financial interests with AMO and Alcon (Fort Worth, Texas). Dr. Stahl has financial interests with AMO, Alcon, and Bausch & Lomb (Rochester, N.Y.). Contact information Chynn: toplasikdoc@gmail.com Durrie: via Hattie McWhirt, hmcwhirt@durrievision.com Stahl: jstahl@durrievision.com February 2011 October 2011 Challenging refractive cases Surface ablation for the refractive surgeon © 2011 Novartis 8/11 RES11067JAD CAUTION: Federal (USA) law restricts this device to the sale by or on the order of a physician. INDICATIONS: The AcrySof ® IQ ReSTOR ® Posterior Chamber Intraocular Lens (IOL) is intended for primary implantation for the visual correction of aphakia second- ary to removal of a cataractous lens in adult patients with and without presby- opia, who desire near, intermediate and distance vision with increased spectacle independence. The lens is intended to be placed in the capsular bag. WARNING/PRECAUTION: Careful pre- operative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before im- planting a lens in a patient with any of the conditions described in the Directions for Use labeling. Physicians should target emmetropia, and ensure that IOL centra- tion is achieved. Care should be taken to remove viscoelastic from the eye at the close of surgery. Some patients may experience visual dis- turbances and/or discomfort due to mul- tifocality, especially under dim light con- ditions. Clinical studies with the AcrySof ® ReSTOR ® lens indicated that posterior capsule opacification (PCO), when pres- ent, developed earlier into clinically sig- nificant PCO. Prior to surgery, physicians should provide prospective patients with a copy of the Patient Information Bro- chure available from Alcon for this prod- uct informing them of possible risks and benefits associated with the AcrySof ® IQ ReSTOR ® IOLs. Studies have shown that color vision dis- crimination is not adversely affected in individuals with the AcrySof ® Natural IOL and normal color vision. The effect on vi- sion of the AcrySof ® Natural IOL in sub- jects with hereditary color vision defects and acquired color vision defects sec- ondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and other retinal or optic nerve diseases) has not been studied. Do not resterilize; do not store over 45° C; use only sterile ir- rigating solutions such as BSS ® or BSS PLUS ® Sterile Intraocular Irrigating Solu- tions. ATTENTION: Reference the Directions for Use labeling for a complete listing of indi- cations, warnings and precautions. www.AcrySofReSTOR.com 76264 RES11067JAD_PI EW.indd 1 8/30/11 2:07 PM EyeWorld factoid Although PRK was invented in the early 1980s, the FDA first approved a laser for the procedure in 1995 Source: All About Vision 52-67 Feature_EW October 2011-DL33_Layout 1 9/29/11 4:51 PM Page 53

• Cover