EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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42 EW FEATURE When continued from page 41 Treatment tree snapshot T o resolve complaints in the unhappy refractive patient, Dr. Stonecipher recommended using a "tree branch" approach. The first branch he considers to be the residual refractive error tree branch. If a complaint appears to be totally refractive, such as glare, he suggested offering a temporary pair of glasses or contact lenses. "If they can see with that and they're happy with that then you can target them—it's that simple." If patients have three-quarters of a diopter or more of cylinder, he treats that. For tree branch number two, dry eye disease, Dr. Stonecipher recom- mended a 90-second workup using the ocular surface disease index. "It gives a number and I can look at it and say, 'You're a 20 and that tells me that you're a moderate dry eye disease person," he said. He puts in fluorescein and lissamine green to determine the true extent of the disease and then pulls out the appropriate treatment stops. When it comes to tree branch number three, leftover higher order aber- ration, Dr. Stonecipher urged using a cutoff of .4 or .45 RMFH when deciding on retreatment. "Your laser system and your diagnostic system can come together and predict an outcome that is reliable," he said. Patients with small optical zones or decentrations are those who have had a highly myopic treat- ment. If enough cornea remains, Dr. Stonecipher recommended a wavefront- guided surface treatment such as transepithelial PRK or alcohol-assisted PRK. He applies MMC for 12 seconds on the table and then treats like a typi- cal PRK. The last tree branch involves refractive cataract surgery. One of the items on this tree branch is double residual refractive error associated with cylinder, ocular surface disease, or retinal disease such as epiretinal membrane. "It's not the standard of care that people get OCT pre-opera- tively, but if there is any issue pre-operatively by your retinal exam then have a low threshold to get an OCT," Dr. Stonecipher said. If there is a retinal abnormality, he steers clear of multifocal or accommodating lenses. "One thing that the refractive cataract surgery cannot defend is if [physi- cians] put one of these lenses in and the patient has an epiretinal membrane or retinal disease before surgery and then afterward they'll take the lens out," Dr. Stonecipher said. For those who are referred such a patient, he sug- gested trying to improve the vision as much as possible with a contact lens. If the patient is happy with that, you can let him know that there's always going to be something new coming down the pike that may help. "I'm a believer in technology," Dr. Stonecipher said. "Technology has always rescued us in some way, shape, or form." February 2011 Refractive challenges and innovations August 2012 An illustration of a visual aberration Source (all): Elizabeth A. Davis, M.D. fore." One option for such patients, he finds, may be the use of a spe- cialty contact lens like SynergEyes (Carlsbad, Calif.). "If I see a disaster that I can't fix, I say, 'Let me get you to see first and spend $600 to do that, and then let's see where we can go from there,'" Dr. Stonecipher said. "It will convince them that you're good and that you're not just looking to get more money out of them, but it's also going to get them to see and make them functional again." With time, patients can also de- In some cases, those treated with smaller optical zones without the blend zones may have night vi- sion complaints, which can be exac- erbated by age. "Sometimes as they age and develop a little residual re- fractive error on top of their higher order aberrations, they start to have more and more trouble, particularly driving at night," Dr. Lindstrom said. "Often we can help those pa- tients with a surgical enhancement." Much dicier patients are those with post-LASIK ectasia. "The bad one is the occasional patient, per- haps 1 in 2,000, who develops post- LASIK ectasia," Dr. Lindstrom said. "That one is really hard for all of us." After making the diagnosis, it's important to explain what hap- pened to the patient. "Without knowing whether or not [the pa- tient] might have had an abnormal topography 10 years ago, I say, 'You may have had a tendency toward this,'" Dr. Lindstrom said. "'This may have developed even if you hadn't had LASIK because about 1 in 2,000 people will develop kerato- conus, which is more or less what you have, whether [the person has] surgery or not.'" He treats this as he would keratoconus with a combina- tion of glasses, contact lenses, and collagen crosslinking, as well as occasionally after that with Intacs (Addition Technology, Des Plaines, Ill.), PRK, PK, or lamellar keratoplasty. Likewise, for those who are coming back because they previ- ously had RK, Dr. Stonecipher stressed what is possible. "You've got to be realistic," he said. "You've got to look at them and say, 'I can see you need to get 50% better or I can make you 60% better, but I'm not going to make you like you were be- velop cataracts. "Sometimes patients are coming in for an enhancement when really what they need is cataract surgery," Dr. Lindstrom said. "We need to explain, 'It's not your nearsightedness coming back, it's that you've developed a cataract, and the good news is that we have a good treatment for that.'" He also stressed, however, that the power calculation accuracy is somewhat re- duced in those who have had previ- ous refractive surgery and that use of advanced technology IOLs may or may not be possible depending upon the style of LASIK or PRK that was used. For some unhappy patients for whom Dr. Lindstrom cannot provide ready answers, he will instead take a neurological approach with RevitalVision technology (Lawrence, Kan.), a cognitive training program that enhances central perception and capability. "I've used it in select dissatisfied patients after premium IOLs, and I've used it in select patients with symptoms and mild residual refractive error that was less than I wanted to do an enhance- ment for and for which there was no other good treatment," Dr. Lindstrom said. He has found that the treatment can bump up Snellen acuity by one to two lines. He gener- ally offers this to patients free of charge. "In my case, most of the time I'm buying the treatment and giving it to them—certainly if it's a dissatisfied patient that is one of my own," Dr. Lindstrom said. He finds that such patients appreciate his leaving no stone unturned. Overall, in even the most diffi- cult cases, Dr. Lindstrom stressed that he will continue to strive for answers. "They want to know that you will never give up and that you'll never abandon them," he said. "That's not just as an individ- ual doctor but also as a representa- tive of the medical profession as a whole." He lets patients know that continuing research is being done. "[I say], 'I might not have a perfect treatment today, but there's a good chance that we'll develop improved treatments to help you; as soon as those are available I will let you know,'" he said. "'We're going to follow you and take care of you the rest of your life to do everything we can to help you.'" EW Editors' note: Dr. Lindstrom has finan- cial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.), Alcon (Fort Worth, Texas), Bausch + Lomb (Rochester, N.Y.), RevitalVision, and TLC Vision. Dr. Stonecipher has financial interests with AMO, Alcon, Allergan (Irvine, Calif.), Bausch + Lomb, Endure Medical (Cumming, Ga.), Merck (Whitehouse Station, N.J.), Nidek (Fremont, Calif.), Oasis Medical (Glendora, Calif.), and TLC Vision. Contact information Lindstrom: 952-567-6051, rllindstrom@mneye.com Stonecipher: 336-288-8523, stonenc@aol.com