EyeWorld Asia-Pacific June 2011 Issue

June 2011 14 EW FEATURE LASIK Surgery 025,$ 6 $ UXH *HRUJHV %HVVH $QWRQ\ )5$1&( 3KRQH )D[ PRULD#PRULD LQW FRP ZZZ PRULD VXUJLFDO FRP • Thin, 100-micron, planar flaps • Accuracy and predictability equivalent to Femto-SBK • Smoother stromal bed • No femto-complications • … At a fraction of the cost Think Thin SBK without compromise Nikica Gabrić, MD (Zagreb, Croatia) Board member of the ESCRS *DEULF 1 %RKDF 0 0RULD 2QH 8VH 3OXV 6%. YV /'9 IHPWRODVHU FOLQLFDO HYDOXDWLRQ WK (6&56 PHHWLQJ 6HSW 3DULV )UDQFH 3URI *DEULF KDV QR ÀQDQFLDO LQWHUHVW DQG LV QRW D SDLG FRQVXOWDQW IRU 0RULD © %RWK PHWKRGV KDYH H[FHOOHQW UHVXOWV LQ P\RSLF FDVHV 2QH 8VH 3OXV 6%. VKRZHG EHWWHU UHVXOWV ‡ LQ ÁDS DQG VWURPDO EHG TXDOLW\ ‡ SURYLGHV HDVLHU KDQGOLQJ ‡ SURYLGHV OHVV SDWLHQWV GLVFRPIRUW GXULQJ WKH VXUJHU\ ª Keratome One Use- Plus SBK (Moria) LDV (Da Vinci) (Ziemer)* 1E RI SDWLHQWV )LUVW /DVW )ODS WKLFNQHVV “ EODGH ÁDSV “ )ODS DQG EHG TXDOLW\ YHU\ VPRRWK PDUNV 3DWLHQW H[SHULHQFH YHU\ JRRG LQWUDRS GLVFRPIRUW 3URFHGXUH WLPH ² PLQ ² PLQ 9LVXDO DFXLW\ HTXLYDOHQW DW 'D\ )HPWR /'9 70 LV D UHJLVWHUHG WUDGHPDUN RI =LHPHU *URXS $* 3RUW 6ZLW]HUODQG 'RZQORDG ORQJ YHUVLRQ WHVWLPRQLDOV RQ ZZZ PRULD VXUJLFDO FRP 5RXQGWDEOH ZLWK LQWHUQDWLRQDO 6%. H[SHUWV $ $VN IRU D GHPR PRULD#PRULD LQW FRP 6%. QHZVOHWWHUV QRZ RQ OLQH that the surgeon requested was somewhere between 160 and 180 microns,” Dr. Holland said. “We started noticing a few years ago that with the thinner EK tissue, the patients saw better.” With the thin EK technique, outcomes have been better for Dr. Holland. In an article that appeared in the October 2010 issue of Cornea, Dr. Holland and fellow investigators reported that patients who received the thin EK tissue showed a statistically significant improvement in BSCVA. “We found that 100% of thin EK eyes were 20/25 [6/7.5] and 71% were 20/20 [6/6],” he said. “With the standard EK eyes with tissue over 130 microns, only 50% were 20/25 and 19% were 20/20.” Dr. Francis Price likewise favors the use of thin tissue. He dubs his thin approach Descemet’s membrane endothelial keratoplasty (DMEK). “For most patients after DSEK, the average vision is 20/30 [6/9] to 20/40 [6/12] best corrected, whereas after DMEK most patients are 20/20 to 20/25 and they have better vision,” Dr. Price said. He acknowledged that there are some downsides since patients need more reinjections of air to push the thin stem donor tissue up in the first 2-3 weeks after surgery. But ultimately they do attain better vision with the thin approach. While Dr. Price does perform combined phaco/DMEK surgery, in some cases he prefers to do the procedures in stages. “We do some of these as combined cases, especially if the patient came from far away or has a very dense cataract with a bad cornea,” he said. “However, for a lot of these we’re shifting to doing the cataract 1 month ahead of time.” He finds that it’s easier to constrict the pupil during the unfolding of the DMEK graft. “If you do a cataract at the same time, even if you use constricting agents like miochol or miostat, the pupil doesn’t go down as small as it does if you have not done a cataract,” he said. Going forward, Dr. Price sees the use of thinner tissues as becoming more of the norm with the combination approach. “What I think is going to happen is that we’re going to go to thinner and thinner grafts,” he said. “As we’ve done more data analysis with the 1-year results, we’re doing a lot more DMEKs, where it’s just Descemet’s and endothelium.” Given the improved outcomes, Dr. Price thinks that the next big push will likely be working on predictabiltiy. “Our next big area of interest is to figure out if we can predict preoperatively in the DMEK patients how much of a hyperopic shift they are going to get so that we can have more accurate IOL calculations,” he said. “What we find will determine whether or not we want to do the cataract before or after the DMEK surgery. As we can give people better vision, there may be an ability to give them premium IOLs, which we don’t do now.” Meanwhile, Dr. Holland thinks that the improved results will lead to earlier intervention. “Five or 6 years ago when DSEK started to become popular we would put off patients,” he said. “As we got better results, we’ve become more aggressive, and we are certainly operating earlier in the Fuchs’ part of the story.” He pointed to the patient with 20/25 to 20/30 vision who was experiencing glare and haze and difficulty driving at night. “We would now consider a phaco DSEK, whereas 5 years ago we wouldn’t do that,” Dr. Holland said. “We’re getting better results, so we can recommend surgery earlier for these patients.” EW Editors’ note: The physicians interviewed have no financial interests related to their comments. Contact information Holland: 859-331-9000, eholland@holvision.com Francis Price: 317-844-5530, wendymickler@pricevisiongroup.net Marianne Price: 317-814-2823, mprice@cornea.org Winning continued from page 13