JAN 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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34 34 EW REFRACTIVE SURGERY January 2012 Is LASIK an option for older patients? by Vanessa Caceres EyeWorld Contributing Editor Surgeons debate LASIK advantages, discuss other possible approaches I t's no secret that LASIK is typi- cally associated with younger patients. However, is LASIK a viable option for patients over the age of 60? "In our current society, a lot of patients in their 60s are 'young' 60s," said Louis E. Probst, M.D., na- tional medical director, TLC Laser Eye Centers, Ann Arbor, Mich. "I'm amazed by patients in their 60s and late 50s who are physically active, still working, have healthy eyes, and have no signs of significant cataract. In that group of patients, refractive surgery is reasonable." On a weekly basis, Dr. Probst, who focuses exclusively on refractive surgery, does indeed have patients age 60 and older who will inquire about LASIK and sometimes go on to have the procedure done. If the pa- tient appears to be a possible candi- date—no cataracts are seen and there is no contraindicated ocular pathology—he will discuss the bene- fits and risks, pointing out that the patient will likely develop cataracts one day. "However, LASIK will not make that happen any slower or faster," he said. Dr. Probst will add a handwritten note to the patient con- sent form to indicate that the pros and cons of the procedure were dis- cussed. Then, he lets the patients make the decision. "It's not our decision [as sur- geons] to decide if they deserve LASIK. It's our job to inform them," he said. Despite the risk for cataract growth, some patients are more con- cerned about the short-term quality- of-life benefits that LASIK can deliver to them, Dr. Probst said. Even with the possible advan- tages of LASIK in some older pa- tients, Uday Devgan, M.D., chief of ophthalmology, Olive View–Univer- sity of California, Los Angeles Med- ical Center, believes the procedure should be approached with caution. "In any patient, particularly those over age 60, it is imperative to check for early signs of cataract. Even with mild nuclear sclerosis, where the pa- tients are still correctable to 20/20 vision, corneal refractive surgery may not be the best choice," Dr. Devgan said. "A refractive error in- duced or influenced by cataractous changes will tend to progress with time, and the patient will perceive that the benefit from LASIK is 'wear- ing off.'" LASIK for residual refractive error? LASIK might be a better option to correct residual refractive error after cataract surgery and multifocal or accommodative IOL implantation, some surgeons said. "LASIK can be an appropriate procedure for senior patients to de- liver a specific refractive outcome and minimize the use of spectacles," Dr. Devgan said. He recommended a YAG laser capsulotomy in patients with posterior capsule opacities or contraction and in patients with ac- commodating IOLs because the ef- fective lens position—and hence the refraction—can change afterward. Richard L. Lindstrom, M.D., adjunct professor emeritus, ophthal- mology department, University of Minnesota, Minneapolis, and founder, Minnesota Eye Consult- ants, Minneapolis, will perform PRK or LASIK in older patients with a post-op residual refractive error. He prefers this because the laser is more precise and predictable than other options. Although post-op dry eye is a concern in this patient group, he typically prepares the ocular surface pre-operatively, prescribing a dual antibiotic/steroid four times a day for a week. Perhaps because of this, he has not seen any meaningful problems with post-op dry eye in these patients. Dr. Lindstrom said that while side effects such as wound healing and infection are always possible, the chance of these occurring is low, which is why he prefers to correct residual errors with the laser versus other methods. However, he does add that these corrections come with a cost to use the laser, and surgeons often have to absorb that cost. An incision approach: A LASIK alternative in older patients Some surgeons select a non-laser ap- proach to correct residual refractive error in premium IOL patients. This alternative involves two small radial incisions made with a diamond blade, can be performed under the slit lamp, and does not involve addi- tional costs. J.E. "Jay" McDonald II, M.D., Fayetteville, Ark., refers to this particular technique as an "inci- sional enhancement" or "mini- touchup" when speaking with patients, although he will call it "two-incision radial keratotomy" (RK) or "mini-RK" when speaking with other surgeons. However, Dr. McDonald is quick to say that an- other term for this procedure may be more appropriate, as what he is per- forming is not actually RK at all. The use of the term "RK" might initially scare away potential users of this ap- proach, he said. "I have been doing these mini- touchups for several years. I believe the reason I am successful in my pre- mium channel is that I know how to correct these leftover refractions and do it without all the time, money, and corneal issues surrounding laser vision correction in those 55 and older," Dr. McDonald said. He has used his laser only once in the past 5 years to correct residual refractive error; he performs mini-RK or astigmatic keratotomy in 15% of his premium IOL patients. John Sonntag, M.D., Boise, Idaho, also believes that an inci- sional approach is more appropriate than laser use to treat mild myopic residual refractive errors. "LASIK works, of course, but it is like using a fire department hook-and-ladder truck for a fire that is only as big as a small trash can," Dr. Sonntag said. "I make one or two 3-mm radial inci- sions, both of them under the upper lid." This contrasts with some sur- geons' understanding that the inci- sions have to be 180 degrees opposite of each other, Dr. Sonntag said. A Thornton-Fine fixation ring with a guide going down the middle that the surgeon rests his diamond blade up against so that his incision is perfectly radial Source: Mastel Image shows two incisions in the cornea from the 5- to 8-mm optical zones. One incision is at about the 10 o'clock position, and the other is at about the 2 o'clock posi- tion. This demonstrates an alternative tech- nique to use for residual refractive errors Source: Mastel Like Dr. McDonald, Dr. Sonntag pointed out that calling this proce- dure RK is misleading. The only thing that the procedures have in common is their instrumentation. He instead calls the procedure "micro-incisional advanced technol-

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