Eyeworld

EW FEATURE 55 Determining the best approach to get the patient spot on W hile all practitioners strive to hit LASIK refractions on the money, this is not al- ways possible. En- hancements are unfortunately a fact of life in the industry. Richard L. Lindstrom, M.D., adjunct professor emeritus, ophthalmology depart- ment, University of Minnesota, Minneapolis, and founder, Minnesota Eye Consultants, Minneapolis, finds that the initial enhancement rate at TLC Vision, where he's chief medical officer, is on the low side at about 2.6%. "I would say that the rate is about 5% nationwide," Dr. Lindstrom said. Daniel S. Durrie, M.D., clinical professor of ophthalmology, Univer- sity of Kansas, Overland Park, puts the enhancement rate in the 3-5% range with a couple of caveats. "Some people may have a higher en- hancement rate or some may have a lower enhancement rate depending upon their tolerance for doing an enhancement," Dr. Durrie said. He pointed out that he just scheduled a patient who is 20/15 for an en- hancement who has a little bit of residual higher-order aberration. "If you're willing to do those it might increase your enhancement rate, maybe to the 7-8% range," Dr. Durrie said. In addition, he pointed out that for practitioners who perform monovision or blended vision, their enhancement rates are much higher. "You have to hit both eyes exactly on the mark, so it's more in the 15% range if you're taking people for whom you're trying to do monovi- sion or blended vision," he said. Early and late retreatments There are actually two groups of LASIK enhancement patients—early and late. Determining when to bring a patient back for an enhancement depends on in which group the case falls, Dr. Lindstrom finds. "The first enhancement is one that would occur within the first year," he said. "That's usually related to an under- or overcorrection." Then there is a second group where the enhancement can be called for 5, 10, or even 15 years later, well after the eye has stabi- lized. "We sometimes call that a late vision adjustment or enhancement," Dr. Lindstrom said. These may be patients whose vision has changed over time due to presbyopia. For those in the initial group, Dr. Lindstrom typically waits about 3 months in myopes for eyes to sta- bilize and a little bit longer for hy- peropes. "In hyperopic patients I'll often encourage them to wait 6 months," he said. The exception here is the patient who for some un- expected reason is way off, which fortunately Dr. Lindstrom finds is a rare occurrence. "I've done a few en- hancements even within a week or two of surgery," Dr. Lindstrom said. "I've done this not just on my own patients but sometimes on patients referred in when lasers were pro- gramed improperly and they ended up with an outcome that they couldn't tolerate and they were un- able to wear contact lenses or get temporary glasses." But given his druthers, Dr. Lindstrom would prefer to wait for a stable outcome. "Then we'll be more likely to hit it dead on with the second procedure and not have to go to a third," he said. Dr. Durrie agreed that the 3- month visit is optimal for myopic procedures and the 6-month one for hyperopic or PRK retreatments. For the majority of cases he strongly cautioned against extremely early re- treatment. "We analyzed our data at one point in time and found that if we used the 1-month visit as a time to analyze whether the patient needed an enhancement or not, 50% of the people we would have done an enhancement on wouldn't have needed it if we had waited for the 3-month mark," Dr. Durrie said. "I find that when I quote that to pa- tients, saying that it's almost a 50/50 chance that if we tried to decide at 1 month whether someone needs an enhancement we'd be wrong, and tell them we might as well wait, they always wait." Post-IOL enhancements Likewise, if a patient needs an en- hancement after having an IOL implanted, it is important to wait for the eye to stabilize. David A. Goldman, M.D., assistant professor of clinical ophthalmology, Bascom Palmer Eye Institute, University of Miami, finds that many of these IOL patients who need retreatments have undergone previous refractive surgery. "A larger majority of pa- tients that we're seeing referred in now are those who have had previ- ous LASIK who then have cataract surgery and have refractive surprises because the Ks were so hard to meas- ure," Dr. Goldman said. If the error is large Dr. Goldman may consider piggybacking a lens or doing an exchange, but frequently will use laser retreatment instead. "Oftentimes there's astigmatism in- volved as well, which is corrected with a sulcus intraocular lens and so we'll move to laser vision correc- tion," he said. "Typically once they're a few months out of surgery, and they've had a YAG capsulotomy and it looks like their refractive error is stabilized, I'm comfortable offer- ing them laser vision correction to sharpen their vision." In cases where IOL patients have had previous LASIK Dr. Goldman will typically do PRK re- treatment. It's important in such cases to make it clear that the results will not be instantaneous, he stressed. With a case involving an IOL retreatment, Dr. Lindstrom typically February 2011 October 2011 Challenging refractive cases EyeWorld 10/1/11 Which type of vision is most important to you? For your patients who want to see it all, the choice is IQ ReSTOR ® IOL +3. The AcrySof ® IQ ReSTOR ® IOL +3.0 D delivers true performance at all distances. 1 For important safety information, please see adjacent page. Reference: 1. AcrySof ® IQ ReSTOR® IOL Directions For Use © 2011 Novartis 8/11 RE11067JAD AlconSurgical.com 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 secondary to removal of a cataractous lens in adult patients with and without presbyopia, who desire near, intermediate and distance vision with increased spectacle independence. The lens is intended to be placed in the capsular bag. 76264 RES11067JAD EW.indd 1 8/30/11 2:11 PM by Maxine Lipner Senior EyeWorld Contributing Editor Up to the challenge: Dealing with enhancement techniques AT A GLANCE • Early LASIK enhancements are typically done at the 3-month mark for myopes and at 6 months for hyperopes • If a retreatment is done based on outcomes from the 1-month visit, Dr. Durrie finds that there's a 50% chance that this will be unneces- sary • Thanks to self-sealing incisions, practitioners can perform retreat- ments relatively soon after IOL implantation—typically at the 2- to 3-month mark • Using the IntraLase to recut a flap is a boon for some and a bane of existence for others In the case of large refractive errors, physicians may consider piggybacking a lens Source: Richard S. Hoffman, M.D. continued on page 56 52-67 Feature_EW October 2011-DL33_Layout 1 9/29/11 4:51 PM Page 55

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