Eyeworld

EW REFRACTIVE 76 March 2017 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer A retinal surgeon describes how refractive surgery won him over R efractive lasers used in cos- metic, elective procedures have weathered some criticism over the years for their use in procedures lacking a strictly medical indication. Still, when something is good, it should be recognized, according to Siegfried Priglinger, MD, director, Eye Clinic at Ludwig-Maximilians University, Munich, Germany, and clinical head of Smileeyes Eye Laser Center, Linz, Austria, who spoke on the subject at the 114th Congress of the German Ophthalmological Society, which took place September 29–October 2, 2016. "Certain aspects of refractive surgery have truly removed my early skepticism and any doubts I may have had early on of thinking that Refractive surgery turnaround refractive laser treatments were only used as cosmetic, 'lifestyle' medi- cine, to understanding that they are much more. I was forced to look at refractive surgery from a different point of view, as these so-called cosmetic lasers were being used for therapeutic purposes. Also, technical developments, reduced risks and complications, and long-term study outcomes deserved my closer atten- tion and recognition," he said. Therapeutic uses Dr. Priglinger thinks that refractive lasers have assumed an important role in refractive surgical therapeu- tics. Phototherapeutic keratectomy (PTK), for instance, refers to a surgi- cal procedure that uses the excimer laser to treat surface level corneal disease and its associated eyesight problems, not as a cosmetic appli- cation. It can be used to remove superficial scars, recurring corneal erosions, and anterior corneal dys- trophies like Reis-Buckler's corneal dystrophy. As an example from his practice, he described a patient with superficial scars due to map-dot-fin- gerprint dystrophy, whose visual acuity was 0.4. The patient's corneal topography revealed a strong astig- matism. A one-time excimer laser application was enough to better the astigmatism and improve vision to 0.8. Another case example was a patient suffering from uveitis who had a band-shaped keratopathy, with a visual acuity of 0.1. A single PTK treatment removed the scar and improved visual acuity to 0.4. Dr. Priglinger explained that PTK, when combined with photorefractive keratectomy (PRK), can take on both a medical and cosmetic role. Other lasers have become vital in therapeutics as well. Femtosec- ond laser, for instance, is applied in astigmatic keratotomy to reduce the steep axis of astigmatism, and it can also be used to correct astigmatism in the context of intracorneal ring segments. It is applied in penetrat- ing keratoplasty and in femtosecond laser-assisted cataract surgery, which might be the future norm. Surgeons implement femtosecond laser to improve outcomes in lamellar kera- toplastic procedures such as Descem- et's stripping automated endothelial keratoplasty and femtosecond deep anterior lamellar keratoplasty for both deep and superficial treat- ments, creating an excellent wound bed for easy corneal transplant implantation. "The credit needs to go to the ingenious improvements in laser technology. This continuous evo- lution now offers decided advan- tages that definitely outweigh any disadvantages to the surgeon," Dr. Priglinger said. (R)-evolution According to Dr. Priglinger, re- fractive surgery has undergone an (r)-evolution. "The (r)-evolution was/is ongoing with each new change, setting the stage for the next generation. Radial keratotomy was revolutionary but poorly tolerat- ed over time, caused hyperopization, and left scars that caused astigma- tism. With excimer laser surgery, we Presentation spotlight continued on page 78 refractive error. Unlike with previ- ous generations of lenses, today, most patients can be corrected to a point where they will be happy," he explained. According to Bryan Lee, MD, JD, Los Altos, California, "the rate of multifocal IOL implantation has been fairly stable for many years, in the 7% to 9% range (actual number is 5–6%). There are definite advan- tages in convenience, but these lens- es necessarily require some optical compromises. Of course, there are also some patients for whom the cost is a barrier." He noted that the future for presbyopia-correcting IOLs looks promising as the number of Baby Boomer patients needing cataract surgery increases. "The new catego- ry of extended depth of focus IOLs should also drive growth in this segment," he explained. He added that there is always a sacrifice of some quality of vision with multifocal IOLs. "Patients are trading some sharpness for conve- nience. Contrast sensitivity decreas- es because incoming light is being split between the distance and near images, and some of the light is lost because of the optics. I also tell all of my patients to expect halos and night symptoms, but I explain that most patients do not find them very bothersome," he said. "Ultimately, I think the key is to have a well-informed patient with realistic expectations. If the patient is unhappy, I have a low threshold for IOL exchange because unhappi- ness with a multifocal is a reversible condition," he added. EW Editors' note: Dr. Donnenfeld has fi- nancial interests with AMO, Alcon, and Bausch + Lomb (Bridgewater, New Jer- sey). Dr. Foster has financial interests with Alcon, Bausch + Lomb, AcuFocus (Irvine, California), and Ivantis (Irvine, California). Dr. Lee has no financial interests related to his comments. Contact information Donnenfeld: ericdonnenfeld@gmail.com Foster: gjlfos@gmail.com Lee: bryan@bryanlee.pro Era continued from page 75 These are corneal HD-OCT pictures of a patient suffering from granular corneal dystrophy. The first is before phototherapeutic keratectomy (top), and the other (bottom) is 3 months afterwards. The patient clinically presented with reduction of vision and glare. Clinical presentation of the cornea showed numerous irregular shaped discrete crumb-like subepithelial corneal opacities. The pre-treatment OCT scan showed dense hypofluorescent subepithelial material (arrow heads). After ablation of 25 microns, there was a reduction of symptoms (vision 20/20 and no glare). In the post-surgical OCT, there was a reduction in corneal subepithelial hypofluorescent material and a marginal thinning of the cornea. Source (all): Christian Wertheimer, MD

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