Eyeworld

EW CORNEA 114 March 2018 by Liz Hillman EyeWorld Staff Writer of Jan. 30, 2018, Revision Optics went out of business and Raindrop is not being sold as of the time of publication. A third inlay still in trials—the Flexivue Microlens (Presbia, Irvine, California)—creates multifocality using variation in refractive index, much like an intraocular lens. The transparent implant has a central zone dedicated to distance vision and progressively gains refractive add power at greater distances from the center. Selecting a candidate Mark Lobanoff, MD, director of refractive surgery, North Suburban Eye Specialists, Minneapolis, said the ideal presbyopic inlay candidate two lines of distance vision. There are currently two inlays approved by the U.S. Food and Drug Administra- tion (FDA). The first approval went to KAMRA (AcuFocus, Irvine, Cali- fornia) in April 2015. The KAMRA inlay is made of an opaque material with a diameter of 3.8 mm and a central 1.6 mm aperture that creates a pinhole effect with an extended depth of focus. Raindrop (ReVision Optics, Lake Forest, California), which was cleared by the FDA in June 2016, is a transparent space-oc- cupying meniscus that reshapes the anterior curvature of the cornea. Near objects are viewed clearly through the central hyperprolate cornea, while intermediate and distance vision is preserved through paracentral light rays. However, as Intracorneal inlays for the young eye surgeon D istance, intermediate, and near—our aging patients want it all, however, we are still searching for the holy grail of restoring natural accommodation in our presbyopic patients. Over the past cou- ple of years, we have added FDA-approved corneal inlays to our armamentarium, and we have learned a lot. In this month's "YES connect" column, William Wiley, MD, Mark Lobanoff, MD, and Jeffrey Whitman, MD, share an abundance of pearls when it comes to selecting patients, performing surgery, and postoperative management. I would argue the biggest lesson learned has been that preop refraction makes a huge dif- ference in the success rate of these devices, which is why more and more surgeons are now combining excimer ablation with inlay placement. For the KAMRA inlay it is clear that a preop refraction of –0.75 sphere will lead to far better results than starting at plano. Starting with a touch of hyperopia (+0.75 sphere) with the Raindrop is equally as important. Another critical lesson has been that deeper placement leads to less haze, so KAMRA inlays are now being placed at 40% depth. With the Raindrop deeper placement is not an option due to its mechanism of action, so many surgeons have started to use mitomycin-C at the time of placement, myself included. In spite of improved results, surgeon adoption of these technologies has been slow. Persistent barriers to progression include: (1) successful inlay outcomes require extensive preop patient education, and patient expectations must be clearly defined, which requires time and resourc- es; (2) nighttime visual complaints remain common for all existing technologies, and this influences patient satisfaction rates; (3) inlays require a great deal of postoperative care, significantly more than other refractive surgeries. These factors and others have recently led to the closure of ReVision Optics and the discontinuation of the Raindrop inlay. This disappointing development will at least temporarily limit U.S. surgeon options for inlay technology, but will hopefully motivate us to continue to improve upon what we have already learned in our quest to satisfy our presbyopic patients. Zachary Zavodni, MD, YES connect co-editor The Flexivue Microlens Source: Ioannis Pallikaris, MD continued on page 116 A young eye surgeon might be interested in offer- ing the latest refractive options to his or her patients, and intracor- neal inlays would fit the bill, being among some of the newest proce- dures for surgical correction of pres- byopia. EyeWorld spoke with three ophthalmologists experienced with using intracorneal inlays. "If you're into refractive surgery, I think inlays are a great addition to a refractive surgery practice," said William Wiley, MD, medical direc- tor, Cleveland Eye Clinic. In general, inlay technology is reserved for use in the non-domi- nant eye and can offer the opportu- nity to gain multiple lines of near vision with the loss of only one or Some patients benefit from the use of oral steroids, which can help with the periocular inflammation. Physicians should ensure there are no contraindications to using either the oral nonsteroidals or steroids. Dr. Amescua uses compounded cyclosporine drops at 0.5% or 2% to control inflammation in such patients. "Cyclosporine is a drug that has antifungal properties, but also has strong anti-inflammatory proper- ties," Dr. Amescua said. "We use oral nonsteroidals if the inflammation is severe." Missed diagnoses To avoid missing a diagnosis of fungal keratitis, Dr. Amescua urged sending the tissue for culturing. However, he noted that not every- one has access to a lab, and most of the corneal infections respond to topical fluoroquinolones. "But if you have an ulcer that is suspicious for fungal keratitis, an ulcer that is not responding to treat- ment, the treatment that the patient is receiving should be stopped. Do a washout period and reculture and send it to a lab or academic hospital with the capability of doing that," Dr. Amescua said. Additionally, confocal microsco- py can be performed to see if there are fungal elements. In some chal- lenging cases, Dr. Amescua has used PCR diagnosis, which uses corneal cells from the patient to determine if there is a fungal keratitis diagnosis. "If there are small corneal infiltrates and it's not responding to standard treatment, we must study it and see why it is not," Dr. Amescua said. "It may not be fungal but it could be. If there are risk factors for fungal keratitis and it is not responding to standard medical care, it needs to be cultured. Even a corneal biopsy can be done." EW Editors' note: Dr. Mah has financial in- terests with Alcon (Fort Worth, Texas). Dr. Amescua has no financial interests related to his comments. Contact information Mah: Mah.Francis@Scrippshealth.org Amescua: GAmescua@med.miami.edu Latest continued from page 113 YES connect The KAMRA inlay Source: AcuFocus

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