Eyeworld

EW REFRACTIVE SURGERY 64 December 2016 Corneal surface and customized steroid regimens are required in an individualized manner. The confir- mation of proper inlay centration, adequate tear film, and reduction of postoperative light scatter with guided healing are required to manage the recipient to excellent healing and globally great vision at all distances. EW Editors' note: Dr. Fox is medical direc- tor of the Cornea and Refractive Surgery Practice of New York. He has no finan- cial interests related to his comments. Contact information Fox: foxmd@laserfox.com by Martin L. Fox, MD, FACS greater than –2.0 are best counseled toward a staged approach as these excimer ablations coincide with the path of light through the KAMRA aperture and can result in a lengthy delay in distance vision recovery in the implanted eye. Our experience with IntraLase iFS (Abbott Medical Optics, Abbott Park, Illinois) has been stellar as it creates excellent smooth pocket beds, and in my experience this has been the best option for smooth pocket creation essential in achiev- ing good outcomes. Patient management and expectations Our results suggest that KAMRA works well and that the technology is here to stay as a viable choice in the correction of presbyopia. Part of our success with KAMRA can be attributed to the appropriate management of patient expecta- tions. KAMRA surgery is in no way similar to LASIK, nor is its man- agement. We have noted that 25% of our candidates read well and see at all distances within 2 weeks but that 75% require 4 to 8 weeks and sometimes longer to reach the therapeutic finish line. Most in this group notice impressive near vision improvement within several days but can lag in distance acuity clarity. with pinhole disk superimposi- tion (Lorgnette or other) over the non-dominant eye, they are likely to do well with KAMRA. Ocular light scatter determination with AcuTarget HD (AcuFocus) technol- ogy will usually confirm a low level of scatter in such individuals (below an OSI grade of 2 on a scale of 1–10). In the preliminary evaluation, it is important to establish and confirm the pattern of eye dominancy with standard Miles, Porta, or visual blurring techniques as those who indicate an ambivalent pattern of dominancy may be masking muscle balance disorders that can create ocular confusion after surgery. Candidates for surgery should be evaluated for tear film stability by tear break-up time, vital dye tear film observation, as well as by means of low mean OSI tear film over a 20-second testing period on the AcuTarget HD. Those who test suboptimally will need treatment to improve the pre-corneal tear film before surgery can be anticipated to ensure good outcomes. The small aperture optics of KAMRA require a robust tear film in order to provide for the best near vision outcomes. The seminal work of Pablo Artal has indicated that small aper- ture optics work best when the eye is very slightly myopic with low levels of astigmatism and higher order ab- erration. Not only do these patients do better in response to KAMRA, but they are also much less sensi- tive to inlay decentration issues. Ideally one must strive to place the inlay aperture to coincide with the center of vision as indicated by the first Purkinje reflection, however, decentrations of up to 300 microns are well tolerated in mildly myopic individuals, especially if the decen- tration is nasal or inferior. Therefore, prospective patients who are outside the ideal refractive range are best counseled to consid- er adjunct laser vision correction (LASIK or PRK) to bring them into the appropriate status of plano to –0.5. This can be offered as a staged procedure or simultaneously with KAMRA implantation. We have ob- served that patients presenting with hyperopic refractive errors do very well with simultaneous LASIK and KAMRA surgery, whereas myopes of Dr. Fox reflects on his experiences after using this corneal inlay for a year M ore than a year has passed since we added the KAMRA corneal inlay (AcuFocus, Irvine, California) to our menu of offered refractive proce- dures. KAMRA was the first U.S. FDA-approved entry into the field of corneal inlay surgery aimed at the correction of presbyopia. It consists of a 3.8 mm microscopically thin disk of biocompatible material with a 1.6 mm central aperture. KAMRA achieves its effect by making use of the long-standing principle of small aperture optics, allowing for the re- establishment of an enhanced depth of focus. The KAMRA corneal inlay is placed in a femtosecond laser-cre- ated corneal pocket at mid-corneal depth on the line of sight in the non-dominant eye. It restores the full range of near function while having only mild effects on distance acuity, a far cry from prior standards of presbyopia treatment including multifocal lenses or monovision contacts, and laser vision correction. In my refractive surgery prac- tice, I have now placed more than 70 inlays over the past year and have had the chance to look back on my experience to make important observations on the effectiveness of this new technology. Although the data is being continually updated, I can now identify the essential requisite elements to achieve great KAMRA outcomes. I can say without qualifica- tion that when KAMRA surgery is performed properly on a good candidate, it produces gratifying visual outcomes with a high degree of safety. In fact, when our KAMRA recipients are asked to report their satisfaction level, 98% of them report they are very satisfied with their vision, and they would do the surgery again and advise it for friends or family. What makes a good KAMRA candidate? Our experience indicates that when individuals demonstrate a positive response of improved reading acuity The KAMRA corneal inlay experience: One-year observations Watch a video of this procedure at EyeWorld Clinical rePlay clinical.ewreplay.org KAMRA inlay in situ Source: Martin L. Fox, MD, FACS

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