Eyeworld

EW FEATURE 44 Challenging cases • July 2018 A month later her ocular surface was pristine with no keratitis and her topography revealed no astig- matism. "It occurred to me that if someone had done LASIK, her dry eye and ocular surface disease state would have been far worse off, and I may have been treating off a refraction that was so erroneous she would have been way off target," Dr. Desai said. Discussing all of the different refractive options that were avail- able to her, the patient opted for clear lens extraction with Tecnis Symfony extended depth of focus IOLs (Johnson & Johnson Vision, Santa Ana, California). Postop she was 20/20, J2+, and "wildly happy," he said. From a technological stand- point, Dr. Desai said this case shows that you don't necessarily need some of the more advanced bio- metric devices to diagnose a pa- tient with ocular surface disease or corneal irregularities. You need vital staining, a detailed slit lamp exam, a retinoscope, and a phoropter, he said. "It doesn't take huge capital expenditures … to identify some of these problems ahead of time," Dr. Desai said. "What it does take is not technology but an interest in finding those things, a willingness to look for them and a willingness to treat them." The patient who can't see well with glasses or contact lenses and could need a corneal transplant Dr. Donnenfeld said to him, today's challenging refractive surgery cases are the ones in which he is rehabili- tating a person's vision. "Someone who is having visual disturbances that are affecting their quality of life that can't be fixed with glasses or even contact lenses, and what I'm offering patients is an opportunity to improve their vision and eliminate the need for corneal transplantation," Dr. Donnenfeld said. Many of these cases are only now possible due to recent advances in technology. One example is the ability to rehabilitate the vision of a young person with keratoconus. Dr. Donnenfeld said he first evaluates if the cornea is stable; if not, he will perform corneal crosslinking. Once progression of the disease is prevent- ed with crosslinking, the patient could be a candidate for topograph- The patient with disguised ocular surface disease When a woman in her 40s came to Dr. Desai's office seeking LASIK, she didn't complain of dry eye symp- toms. Careful examination, how- ever, revealed not only dry eye but more serious ocular surface disease. This patient was a moderate myope but only corrected to 20/30 with glasses, which Dr. Desai said was a red flag when she wasn't correctable to 20/20. With some manipulation, he was able to refract her to 20/20 but it fluctuated. Her cycloplegic refraction didn't match her manifest refraction in terms of magnitude and axis of astigmatism. Preopera- tive topography revealed 3.5–5 D of corneal astigmatism. With these indicators, Dr. Desai examined her further, find- ing chronic underlying keratitis, dry eye, and a little bit of epithelial basement membrane dystrophy. Dr. Desai told the patient that he thought LASIK, at this time, was a bad idea due to her ocular surface disease and inconsistency of her preoperative measurements. "I told her that I'd rather do this the right way, regardless of what option we might choose, rather than do it the fast way," he said. Establishing this trust with the patient, Dr. Desai moved forward with a superficial keratectomy with a PROKERA (Bio-Tissue, Doral, Flor- ida) graft placed for 3 days. By the time the graft was removed, 100% reepithelialization was achieved. In the month following, Dr. Desai put the patient on a tapering dose of steroids and lifitegrast (Xiidra, Shire, Lexington, Massachusetts). After that month, the patient told him for the first time she could feel that her eyes were dry. This, Dr. Desai said, was actually a good sign because it indicated corneal nerve regen- eration. The ocular surface disease was being treated and she was on her way toward candidacy for some possible refractive procedure. cational process because they're not going to get a lot of benefit out of surgery," Dr. Durrie said. While their myopia, hyperopia, and astigmatism can be corrected, they're still likely to be no better after surgery. "It's a real disappointment to them … but it's important to help them understand that they've gotten along well and functioning to this stage; it's something they've adapted to," Dr. Durrie said. If they really want refractive surgery in their good, dominant eye, Dr. Durrie said this presents a dilem- ma because they only have one eye for functional vision. He proceeds with extreme caution in these cases and might even perform surgery on the amblyopic eye as a trial run, discounted or free of charge, before proceeding with the other eye. Finally, there are patients with strabismus with a lazy eye. Dr. Durrie said these patients' strabis- mus can often get better with re- fractive surgery due to better vision getting them to hold their eye in a more regular position, but he'll have them consult with an adult strabismus specialist before surgery because some patients can have an increase in their deviation. Dr. Durrie has this same edu- cational conversation with patients in their 20s and 30s, just so they're aware of the changes that will happen decades down the road. It doesn't keep them from choosing to have surgery, he said. The amblyopic patient who wants refractive surgery Another challenging case is the pa- tient with amblyopia who comes in seeking refractive surgery. Dr. Durrie said he sees about one of these pa- tients a week. "People who have had poor vision throughout their life are more likely to come in, so we see patients with amblyopia at a higher percent- age than the general ophthalmolo- gist or optometrist would," he said. Patients who are 20/15 or better in their dominant eye and have mild amblyopia of 20/25 or 20/30 best corrected in their nondominant eye can benefit tremendously from surgery, Dr. Durrie said. With these patients, he explains what a lazy eye is—how their brain learned to favor the good eye—and that refractive surgery will not fix that aspect of their vision. It's expectation setting, he said. "You're telling them they can have a surgery, but we can't change the brain," he said, adding that he'll see these patients twice before sur- gery to make sure their prescription is stable. Another category is the patients whose amblyopia was missed or untreated in childhood and they are 20/200–20/400 best corrected. "They've been hoping all their life that someone could fix their lazy eye. This is a more important edu- Challenging continued from page 43 " The goal of refractive surgery is to be able to rehabilitate patients with normal corneas and abnormal corneas as well. " —Eric Donnenfeld, MD Managing dry eyes in cataract and refractive surgery Hungwon Tchah, MD, discusses the need for aggressive management of dry eye in cataract and keratorefractive patients. EWrePlay.org

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