Eyeworld

89 EW FEATURE March 2017 • Advances in corneal inlays AT A GLANCE • Inlays provide another option for presbyopic patients, who must increasingly use their near vision in everyday tasks, including for smartphone use. • Inlays are reversible; they also can be used after cataract surgery. • Inlays have some drawbacks, including possible dry eye, haze, and intolerability. • Better patient selection can help minimize the number of patients who need an inlay removed. • Refractive surgeons are usually adept at managing certain complications caused by inlays. by Vanessa Caceres EyeWorld Contributing Writer from the preoperative refraction, he added. "The safety record for both the KAMRA and Raindrop [ReVision Optics, Lake Forest, California] in- lays were very favorable in preser- vation of good best-corrected vision in patients where the inlays were removed," Dr. Pepose said. If exu- berant wound healing occurs or a patient has an immune response to an inlay associated with central haze formation around a hydrogel inlay or an amorphous deposit around a small-aperture inlay linked to a hy- peropic shift, the patient should be treated with strong steroid therapy, he advised. "If they don't respond, then early removal of the inlay generally leads to more rapid return of uncorrected and best-corrected vision," he said. One inlay advantage ophthal- mologists may not always consider is its role as a practice builder, Dr. Vukich said. Offering inlays will bring in patients who may not oth- erwise come to a practice, and even those who are not candidates may be interested in other options to relieve their presbyopic symptoms, he said. Inlays and cataract surgery Surgeons with inlay experience also note that inlays can still function well after cataract surgery. "I have performed some cataract surgeries in "Couple that with individuals working longer and enjoying a full life into their 60s, 70s, and beyond, and this is a need that is real," Dr. Vukich said. Inlays offer a conve- nience for patients in the presbyopic age who may want to avoid read- ing glasses, said Dr. Vukich, who gained experience with inlays early on as part of the original U.S. Food and Drug Administration trial for the KAMRA lens (AcuFocus, Irvine, California). Inlays also provide a gap proce- dure for patients between the ages of 45 and 60 who may not be ready to assume the risks of an intraocular procedure, said Jay Pepose, MD, PhD, director, Pepose Vision Insti- tute, St. Louis, and professor, clinical ophthalmology and visual sciences, Washington University School of Medicine, St. Louis. Inlays also can be adjusted if needed, said Damien Gatinel, MD, PhD, Rothschild Foundation, Paris, France. "Adjustability refers to the possibility of recentering the inlay postoperatively and, in some cases, fine tune refraction after inlay implantation with additive corneal surgery," Dr. Gatinel said. "Inlays are usually implanted in one eye, but optimal refraction for distance vision of the contralateral eye may sometimes require a bilateral refrac- tive procedure," he said. Reversibility as an advantage Another advantage is that inlays are reversible in a way that LASIK is not, said Robert Maloney, MD, Malo- ney Vision Institute, Los Angeles. "Generally, if the patient is unhappy 3 months after inlay insertion, more time won't make him or her happy. That is a good time to remove the inlay," he said. An inlay should be removed if both local medical and surgical ad- junct postoperative therapies do not provide the patient with satisfacto- ry results, Dr. Gatinel said. "Local complications such as inflammation or severe dry eye cause a decrease in vision. In my experience, this may happen in a small percentage of cas- es and should always be explained to the patient preoperatively," he said. Surgeons should let patients know that the post-explantation refraction may be slightly different On the pro side One major advantage of inlays is that they provide a near vision solu- tion for a universal vision problem, said John Vukich, MD, adjunct associate clinical professor, Univer- sity of Wisconsin Madison School of Medicine. Although the need for better near vision has always been important, that need has increased substantially with today's ubiquitous smartphone and computer screens. They provide another option for presbyopic patients, but careful patient selection is crucial I nlays offer another option to patients of presbyopic age. As surgeons garner more experi- ence with this technology, they get a better sense of the pros and cons of inlays. Weighing the pros and cons of inlays Schematic depiction of the KAMRA inlay optical principle: narrowing the entrance pupil aperture results in a reduction of the defocus blur for near targets and increase depth of focus. continued on page 90 Slit lamp picture of a KAMRA inlay 1 year after implantation. Source (all): Damien Gatinel, MD, PhD

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