EyeWorld Asia-Pacific September 2012 Issue

16 EWAP FEAturE September 2012 stressed what is possible. “You’ve got to be realistic,” he said. “You’ve got to look at them and say, ‘I can see you need to get 50% better or I can make you 60% better, but I’m not going to make you like you were before.” One option for such patients, he finds, may be the use of a specialty contact lens like SynergEyes (Carlsbad, Calif., USA). “If I see a disaster that I can’t fix, I say, ‘Let me get you to see first and spend $600 to do that, and then let’s see where we can go from there,’” Dr. Stonecipher said. “It will convince them that you’re good and that you’re not just looking after getting more money out of them, but it’s also going to get them to see and make them functional again.” With time, patients can also develop cataracts. “Sometimes patients are coming in for an enhancement when really what they need is cataract surgery,” Dr. Lindstrom said. “We need to explain, ‘It’s not your nearsightedness coming back, it’s actually that you’ve developed a cataract, and the good news is that we have a good treatment for that.’” He also stressed, however, that the power calculation accuracy is somewhat reduced in those who have had previous refractive surgery and that use of advanced technology IOLs may or may not be possible depending upon the style of LASIK or PRK that was used. For some unhappy patients for whom Dr. Lindstrom cannot provide ready answers, he will instead take a neurological approach with RevitalVision technology (Lawrence, Kan., USA), a cognitive training program that enhances central perception and capability. “I’ve used it in select dissatisfied patients after premium IOLs, and I’ve used it in select patients with symptoms and mild residual refractive error that was less than I wanted to do an enhancement for and for which there was no other good treatment,” Dr. Lindstrom said. He has found that the treatment can bump up Snellen acuity by one to two lines. He generally offers this to patients free of charge. “In my case, most of the time I’m buying the treatment and giving it to them—certainly if it’s a dissatisfied patient that is one of my own,” Dr. Lindstrom said. He finds that such patients appreciate his leaving no stone unturned. Overall, in even the most difficult cases, Dr. Lindstrom stressed that he will continue to strive for answers. “They want to know that you will never give up and that you’ll never abandon them,” he said. “That’s not just as an individual doctor but also as a representative of the medical profession as a whole.” He lets patients know that continuing research is being done. “[I say], ‘I might not have a perfect treatment today, but there’s a good chance that we’ll develop improved treatments to help you; as soon as those are available I will let you know,’” he said. “‘We’re going to follow you and take care of you the rest of your life to do everything we can to help you.’” EWAP Editors’ note: Dr. Lindstrom has financial interests with Bausch + Lomb (Rochester, NY, USA), Abbott Medical Optics (AMO, Santa Ana, Calif., USA), Alcon (Fort Worth, Texas, USA/ Hünenberg, Switzerland), TLC Vision, and RevitalVision. Dr. Stonecipher has financial interests with Alcon, Allergan (Irvine, Calif., USA), Nidek (Fremont, Calif., USA), Merck (Whitehouse Station, NJ, USA), AMO, Bausch + Lomb, Endure Medical (Cumming, Ga., USA), Oasis Medical (Glendora, Calif., USA), and TLC Vision. Contact information Lindstrom: +1-952-567-6051, rllindstrom@mneye.com Stonecipher: +1-336-288 8523, stonenc@aol.com than do a clear lens exchange,” he said. “I think the optics with a steeper cornea are better for these patients.” Dr. Vukich will try to leave patients in spectacles if they have a minimal correction and functional vision; otherwise he prefers to perform refractive lens exchange (presuming no irregular astigmatism/higher order aberrations). “I’ll aim to leave them a little myopic—maybe a –1 or so— because they’ll continue to have a slow hyperopic shift toward emmetropia,” he said. “They’ll need glasses for distance, but patients appreciate the improved near vision.” Likewise, he’s “hesitant” to correct astigmatism with a toric IOL, saying results are less predictable. “We have to tell these patients that ‘perfect’ isn’t possible. We can try to improve their vision, but they’re not going to have the vision they did in their 20s,” he said. Most RK patients have been living with variable vision and advancing hyperopia “for at least a decade,” so while they may not be happy about the situation, “they’ve learned to cope with their vision,” he said. Dr. Donnenfeld “highly recommends” intraoperative aberrometry in clear lens exchange patients, especially in cases of high hyperopia, because predicting IOL powers is “next to impossible” after the keratometry changes. Dr. Vukich also recommended using a scleral tunnel incision to minimize induced corneal astigmatism. “You want to tread as lightly as possible to avoid stretching,” Dr. Donnenfeld said. Following cataract surgery, it’s not uncommon to have an immediate hyperopic shift of up to 2 D, “but don’t be dissuaded by that,” since the patient can go plano after 2 months or so, Dr. Donnenfeld said. Because of the significant higher order aberrations associated with these patients, he recommended using a negative or zero aberration lens. CXL? Dr. Majmudar said a newer, but somewhat controversial, potential treatment for these patients might be corneal collagen crosslinking (CXL), which “may improve the biomechanical stability of the cornea like we see in keratoconus.” Early results seem to indicate CXL may help alleviate the diurnal fluctuations in vision for these patients. No studies have shown CXL can change the hyperopic shift— yet, Dr. Donnenfeld said. “I’ve done CXL on about 20 patients with previous RK and found in patients with fewer incisions it’s eliminated the diurnal fluctuations, but not so in those who had eight or 16 incisions. In that latter group, however, CXL did reduce the magnitude of the fluctuation.” More importantly, no one’s vision was adversely impacted after undergoing CXL, he added. For Dr. Vukich, the early anecdotal results are promising, but “it’s too early for any projections forward.” “If you’ve done PRK, done cataract surgery, tried CXL, and the patient is still having issues, the only remaining option may be transplant,” Dr. Majmudar said. EWAP Editors’ note: The physicians have no financial interests related to this article. Dr. Majmudar is an investigator for the CXL Group. Cont act info rmation Donnenfeld: +1-516-446-3525, eddoph@aol.com Majmudar: +1-847-275-6174, pamajmudar@yahoo.com Vukich: +1-608-282-2000, javukich@gmail.com Addressing - from page 10 When - from page 14