EyeWorld Asia-Pacific September 2012 Issue

14 EWAP FEAturE September 2012 TrEATmENT TrEE sNApshoT t o resolve complaints in the unhappy refractive patient, Dr. Stonecipher recommended using a “tree branch” approach. The first branch he considers to be the residual refractive error tree branch. If a complaint appears to be totally refractive, such as glare, he suggested offering a temporary pair of glasses or contact lenses. “If they can see with that and they’re happy with that then you can target them—it’s that simple.” If the patient has three-quarters of a diopter or more of cylinder, he treats that. For tree branch number two, dry eye disease, Dr. Stonecipher recommended a 90-second workup using the ocular surface disease index. “It gives this number and I can look at it and say, ‘You’re a 20 and that tells me that you’re a moderate dry eye disease person,” he said. He puts in fluorescein and lissamine green to determine the true extent of the disease and then pulls out the appropriate treatment stops. When it comes to tree branch number three, leftover higher order aberration, Dr. Stonecipher urged using a cutoff of 0.4 or 0.45 RMFH when deciding on retreatment. “Your laser system and your diagnostic system can come together and predict an outcome that is reliable,” he said. Patients with small optical zones or decentrations are those who have had a highly myopic treatment. If enough cornea remains, Dr. Stonecipher recommended a wavefront-guided surface treatment such as transepithelial PRK or alcohol-assisted PRK. He applies MMC for 12 seconds on the table and then treats like a typical PRK. The last tree branch involves refractive cataract surgery. One of the items on this tree branch is double residual refractive error associated with cylinder, ocular surface disease, or retinal disease such as epiretinal membrane. “It’s not the standard of care that people get OCT preoperatively, but if there is any issue preoperatively by your retinal exam then have a low threshold to get an OCT,” Dr. Stonecipher said. If there is a retinal abnormality, he steers clear of multifocal or accommodating lenses. “One thing that the refractive cataract surgery cannot defend is if [physicians] put one of these lenses in and the patient has an epiretinal membrane or retinal disease before surgery and then afterward they’ll take the lens out,” Dr. Stonecipher said. For those who are referred such a patient, he suggested trying to improve the vision as much as possible with a contact lens. If the patient is happy with that, you can let him know that there’s always going to be something new coming down the pike that may help. “I’m a believer in technology,” Dr. Stonecipher said. “Technology has always rescued us in some way, shape, or form.” a complication related to healing that’s beyond the surgeon’s control or whether it is something simple like they are just not as happy as they think they should be, you’ve got to treat those patients with respect and listen to what their problem is,” Dr. Stonecipher said. He builds on this and has developed his own technique for eliciting the problem from patients that he finds often come in with a list of complaints. “I like to start the conversation with, ‘I’m a one fix-it doctor, and I’m going to fix one thing in you today,’” He said. “I say, ‘You know I’m only good at fixing one thing, and you’re going to tell me what it is, but you’re not going to tell me that you have blurred vision.’” Usually he finds he is able to drill down on the major complaint such as the patient needs to read better, wants to enhance poor intermediate vision, or reduce glare at night. With the complex patients who have been referred, he stressed practitioners have to tell them what they’re going to do better or different from what the other doctor did. He will outline for the patient steps that he will take such as treating the ocular surface disease, higher order aberrations, or topographic abnormality. Often the timing of the patient’s return can have an impact. Dr. Lindstrom finds that early problems such as DLK, flap slips, striae, microstriae, abnormal flaps, epithelial defects, and epithelial ingrowth can be straightforward to treat. “For DLK it’s steroids and irrigation if it progresses, and for flap slips, striae, and epithelial ingrowth, we fix them,” he said. Epithelial defects he finds are often related to missed cases of epithelial membrane dystrophy. Dr. Lindstrom usually treats this with superficial keratectomy or sometimes PTK. Dr. Lindstrom is always careful in these cases to write in the patient’s chart that risks, benefits, and alternatives have been discussed, as well as making sure that the proper informed consent documents are filled out. Late focus For the long late post-op cases, Dr. Lindstrom finds that patients are unhappy about one of a small number of things. Many patients have complaints of residual or recurrent refractive error. “Now they’ve become worried because they’ve developed myopia again, hyperopia, astigmatism, or in some cases they’ve become presbyopic,” Dr. Lindstrom said. “Those patients are fairly straightforward, except for the presbyopia patients, because we can easily treat those problems.” For the presbyopia patients, Dr. Lindstrom carefully explains the condition and offers them the option of monovision. In the U.S., he pointed out, there are limited choices. “We don’t have advanced technology that is becoming available elsewhere in the world to treat those patients in the U.S.,” he said. With age, Dr. Lindstrom pointed out, patients are more apt to develop ocular surface disease. “Both aqueous deficient and evaporative dry eye becomes more prevalent, and sometimes patients who were well tolerating of the situation early on develop some dry eye symptoms,” Dr. Lindstrom said. “We explain dry eye to those patients, as we do for other patients, and treat the dry eye.” In some cases, those treated with smaller optical zones without the blend zones may have night vision complaints, which can be exacerbated by age. “Sometimes as they age and develop a little residual refractive error on top of their higher order aberrations, they start to have more and more trouble, particularly driving at night,” Dr. Lindstrom said. “Often we can help those patients with a surgical enhancement.” Much dicier patients are those with post-LASIK ectasia. “The bad one is the occasional patient, perhaps 1 in 2,000, who develops post-LASIK ectasia,” Dr. Lindstrom said. “That one is really hard for all of us.” After making the diagnosis, it’s important to explain what happened to the patient. “Without knowing whether or not [the patient] might have had an abnormal topography 10 years ago, I say, ‘You may have had a tendency toward this,’” Dr. Lindstrom said. “This may have developed even if you hadn’t had LASIK because about 1 in 2,000 people will develop keratoconus, which is more or less what you have, whether [the person has] surgery or not.” He treats this as he would keratoconus with a combination of glasses, contact lenses, and collagen crosslinking, as well as occasionally after that with Intacs (Addition Technology, Des Plaines, Ill., USA), PRK, PK, or lamellar keratoplasty. Likewise, for those who are coming back because they previously had RK, Dr. Stonecipher continued on page 16 When - from page 13