Eyeworld

6 6 The impact of refractive error on outcomes and patient satisfaction Figure 3. A large capsulorhexis may make IOL removal for exchange easier. Figure 4. This "stubby" limbal relaxing incision knife has a short length that makes it easier to use at the slit lamp. continued from page 5 whether we use wavefront-op- timized, wavefront-guided, or topography-guided systems. Most surgeons use the system with which they are most comfortable. In my experience, the fem- tosecond laser is advantageous in creating LASIK flaps. The incidence of flap complications is greater with a mechanical microkeratome com- pared with a femtosecond laser. 1,2 Arcuate incisions created with a femtosecond laser are exquisitely accurate and controlled, but they rely on a coupling effect and the patient's tissue response. Therefore, there is still variability in those nomograms. Bladed arcuate incisions are very low tech and low cost, and surgeons do not need to pay dis- posable or interface costs. Both techniques and technol- ogies work well. It is up to surgeons to choose what works best in their hands. Before the enhancement Before a touchup with LVC or a lens exchange in presbyopic " I want to use my best procedure to satisfy the patient as efficiently as possible, with the lowest risk of complications. " –Richard Tipperman, MD patients, a contact lens trial is ben- eficial, simulating the final result. Patients can see that they will give up some near focus if we treat my- opic residual refractive error, and they can decide whether additional surgery would be worthwhile. Additionally, it is important to wait until the patient's refraction is stable before performing a touch- up. If there is any sign of capsular opacification, we treat that and wait for the refraction to stabilize before performing the enhance- ment. Going the distance Because patients are already disap- pointed if a refractive surprise oc- curs, I prefer to perform LASIK with a femtosecond laser, if possible. I want to use my best procedure to satisfy the patient as efficiently as possible, with the lowest risk of complications. Although I absorb that cost, I think it is in their best interest. They achieve good results and are usually extremely appreciative, knowing that we have gone the extra distance to achieve a good result. References 1. Montés-Micó R, et al. Femtosecond laser versus mechanical keratome LASIK for myo- pia. Ophthalmology. 2007;114:62–68. 2. Pajic B, et al. Femtosecond laser versus mechanical microkeratome-assisted flap creation for LASIK: a prospective, random- ized, paired-eye study. Clin Ophthalmol. 2014;8:1883–1889. Dr. Tipperman practices with Wills Eye Hospital in Philadelphia. He can be contacted at rtipperman@mind- spring.com.

• Cover