Eyeworld

EW REFRACTIVE SURGERY 68 March 2016 Placing the inlay Where to place the inlay is critical, Dr. Cummings said. With the KAMRA or Raindrop, bringing the flap back into place may dislodge or displace the inlay, so flap manip- ulation is crucial. He recommends placing a mark on the cornea before lifting the flap to determine where it should be positioned. The AcuTarget device (AcuFocus) will confirm the ideal location; a slit lamp can confirm the Raindrop. "You can see its edges and if it's well positioned," he said. Not all pockets are created equal, Dr. Cummings said; he prefers to use the WaveLight laser (Alcon, Fort Worth, Texas) as its pocket options are unsurpassed, he said. He makes a 4-mm wide tunnel and a 6-mm wide central optical zone "to give us enough space to move around." Manipulating the KAMRA inside the pocket "is a little tricky," Dr. Cummings said, adding it has to be placed inside the delivery forceps with about one-third protruding from the leading edge. Going "a fraction beyond your perfect posi- tion" is ideal, as it moves slightly back once the forceps is removed. Post-incision considerations The KAMRA is "easy to manipulate" under the flap, and "the moment it sits on the cornea it becomes very stable but difficult to move," Dr. Cummings said. The Raindrop needs to be "somewhere in the vicinity" of ideal with the initial placement and can then be manipulated afterward into the ideal position, Dr. Cummings said. While there's still moisture inside that pocket, surgeons can ma- nipulate the inlay from the ocular surface, "like you're pushing around something under a tablecloth," he said. Bear in mind these are not short-term follow-up patients, Dr. Hovanesian noted. "Patients may have issues that may not be per- ceivable until several months later. Physicians who are interested in this technology will need to invest the time to properly monitor patients over the longer term." EW Editors' note: Dr. Cummings has financial interests with Alcon. Dr. Hovanesian has financial interests with ReVision Optics. Dr. McDonald has no financial interests related to this article. Contact information Cummings: abc@wellingtoneyeclinic.com Hovanesian: jhovanesian@harvardeye.com McDonald: margueritemcdonaldmd@aol.com the KAMRA placed." In his limited experience (n=2), outcomes seem to be better than simLASIK; colleagues are "definitely happier" with the approach, he said. Flaps present potential issues— if it's thick it will behave differently than a traditional LASIK flap, being "far more inclined" to flip closed, Dr. Cummings said. Centration of the incision—flap or pocket—is secondary to centra- tion of the inlay, Dr. Hovanesian said. The Raindrop is centered on a patient's pupil while he/she views an illumination target coaxially. Consider the refraction Dr. Cummings advises surgeons to consider the presenting refraction— if patients are slightly hyperopic, he prefers the Raindrop, but if slightly myopic, he prefers the KAMRA. If mild enough, he may opt to create a pocket only and not perform laser surgery. Consider the ocular surface health, Dr. McDonald said. Even mild dry eye will benefit from treatment before inlay implantation, she said. "Patients' ability to appre- ciate these inlays is vastly enhanced by first diagnosing and treating the dry eye component." Visit us at ASCRS in booth 2645 Pocket continued from page 66

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