Eyeworld

EW REFRACTIVE 68 January 2018 by Arun Gulani, MD provement was not the goal at this stage (preparatory for next stage). He was now at the desired optical plat- form and ready to be corrected to full emmetropia with a clear cornea (with myopic laser ablation profile). The next stage was myopic astigmatism laser ASA. This brief and topical procedure (after confirming refractive stability over 6 weeks) improved the uncorrected vision of the patient in the right eye to 20/25, along with the desired flattening of the cornea and removal of anterior scars. We made his own lens implant work, honored his prior surgeon's desire, and maintained their rela- tionship and trust in each other. This patient emailed me a few weeks later telling me he recertified his fly- ing license, and his unaided vision in this eye is 20/15. EW Editors' note: Dr. Gulani has no finan- cial interests related to his comments. Contact information Gulani: gulanivision@aol.com hyperopic refraction? So I focused on first making him myopic. Given his open capsule (YAG capsulotomy by his past surgeon), IOL exchange to induce myopia would be rela- tively invasive and possibly induce vitreo-maculopathy, all of which would result in a poorer final visual outcome. Additionally, we would still need to clear his central cornea with some procedure and aim for refractive correction simultaneously. Among the 14 keratoconus surgical options, I did not want to use Intacs (Addition Technology, Lombard, Illi- nois) since that would not accurate- ly address the refractive error or the corneal scar. To turn him hyperopic, I first performed a piggyback IOL sur- gery. This was a brief, topical, and minimally invasive procedure that was successful in inducing myopic astigmatism in the eye. The deep anterior chamber in this originally myopic eye was in my favor. At this stage, the patient's vision actually deteriorated, and he and I were fine with that since vision im- matism with intolerance to contact lenses. On application of my 5S evalua- tion system, I found sight potential, but it would be necessary to tackle the shape (keratoconus/astigmatism) and central corneal scar. My goal was to achieve a clear cornea with flatter keratometry with the best vision possible, keeping in mind the principles of Corneoplastique, i.e., minimum, brief, aesthetic, topical, least interventional, and visually promising procedures. Additionally, his refraction over the last 5 years had been stable. The best option to achieve all the goals would be a corneal surgery, however, a hyperopic laser treat- ment would increase the curvature of the cornea in this already high keratometry cornea and not remove the central corneal scar. I then nar- rowed down my goal to be a myopic laser advanced surface ablation procedure to address the corneal scars, keratometry, and best vision potential. The only question was, how do I do a myopic laser ablation on a Dr. Gulani shares his approach to a patient with keratoconus who had cataract surgery and could no longer tolerate contact lenses A 60-year-old CEO with ker- atoconus had undergone cataract surgery previous- ly with another surgeon. He wore RGP contact lenses even after surgery but stated that he could not tolerate contact lenses anymore. On presentation, he had a well-placed monofocal lens implant, deep AC, open PC with healthy endothelium and keratoconus with hyperopia and astigmatism along with steep keratometry and ante- rior corneal scarring. His unaided vision was found to be 20/100 in his right eye, which improved to 20/40 on pinhole. OPD-Scan III (Nidek, Gamagori, Japan) and manual refrac- tion revealed a mixed astigmatism of +1.75 DS, –2.50 DC x 80 with BCVA of 20/50 OD. The right eye was dominant, and the cornea showed a thin ectatic contour with high keratometry along with anterior corneal scars. Monofocal pseudopha- kia was present, and the rest of the anterior and posterior segment was normal. He had undergone a YAG capsulotomy. On investigation, corneal topography showed evidence of keratoconus and irregular astigma- tism OD. Pachymetry (thinnest) was 528 microns OD and 536 microns OS. Keratometry showed K1 = 48.1 D and K2 = 49.6 D, with the steep axis at 164 degrees. From the vision exam, we noticed that the right eye had a visual potential better than that corrected by refraction. It was a pseudophakic eye with keratoconus (with high keratometry) and corneal scars with hypermetropia and astig- Making a lens work Patient referred with pseudophakia keratoconus corneal scar and hypertrophic astigmatism with vision of 20/200 corrected to 20/20 Source: Arun Gulani, MD Arun Gulani, MD

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