EyeWorld Asia-Pacific September 2014 Issue

11 September 2014 EWAP FEAturE Experts: PRK effective refractive surgery option for cataract surgeons If a surgeon lacks refractive training, many experts suggest using PRK over LASIK N ot every cataract surgeon has experience with surface laser vision correction procedures to correct residual refractive errors. Whether choosing PRK or LASIK, cataract surgeons can experience varied learning curves. Experts weigh in on their recommendations and uses of both refractive procedures in these cases. Overcoming learning curves It is fairly common for surgeons “who are not laser vision correction surgeons by trade” to do surface laser vision correction at TLC, said Karl G. Stonecipher, MD , director of refractive surgery at TLC, Greensboro, NC, U.S. “But as more surgeons begin using a docking process with cataract surgery, we’re seeing more surgeons This patient had a nicely performed cataract surgery with a well-centered multifocal IOL, but had residual myopia and astigmatism that limited visual quality. A small treatment with PRK enabled the patient to achieve a near-plano outcome with excellent distance and near vision. Source: Uday Devgan, MD AT A GLANCE • Cataract surgeons can learn to perform refractive surgery for the correction of residual refractive errors with a minimal learning curve, experts say. • Experts interviewed suggested choosing PRK over LASIK for novice keratorefractive surgeons. • Wait until the initial cataract wound is secure (approximately 3 months) before performing LASIK enhancement surgery. by Michelle Dalton EyeWorld Contributing Writer considering moving some of those patients based on their refractive error to LASIK.” Dr. Stonecipher typically performs transepithelial PRK for residual myopia or residual myopic astigmatism, and LASIK for residual hyperopia, hyperopic astigmatism or mixed astigmatism on his own patients, but added that he has started performing laser astigmatic incisions on either the IFS (Abbott Medical Optics, Santa Ana, Calif., U.S.) or the LenSx (Alcon, Fort Worth, Texas, U.S.) for mixed astigmatism. For Richard S. Hoffman, MD , clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, and in private practice at Drs. Fine, Hoffman & Sims, Eugene, Ore., U.S., there is no question about which procedure he prefers and recommends for novices. “PRK for residual myopia,” he said, especially in premium patients, as they are already unhappy they did not have “perfect” vision and “want it fixed quickly.” He does recommend waiting until the initial cataract wound is secure, about 3 months, before performing any LASIK enhancement surgery. “By about 2 weeks or so, the refraction will be stable, but the longer you can wait before resolving the residual errors, the better for the wound,” he said. Additionally, healing time is continued on page 12 One surgeon’s pearls For the novice keratorefractive surgeon, Dr. Devgan suggests: When performing PRK in pseudophakes with residual refractive error: 1. Let the patient fully heal after the cataract surgery. This means waiting 2 to 3 months. 2. Ensure the tear film is healthy and there is no active dry eye issue. 3. Check topography to see that all is regular and symmetric (no epithelial basement membrane dystrophy, no irregularities, etc.). 4. Put the desired correction prescription into trial frames and have the patient try it around the office. In particular, be careful of patients who want you to make their far vision sharper by treating their residual myopia. They may not realize that they’re using the residual myopia in order to see their cellphone. “If the patient is –1.00 or so, I may put a contact lens in the eye for a day so that they can see what the results of PRK would be,” he said. For the PRK procedure itself, this is a simplified technique: 1. Use a small circular sponge soaked in alcohol on the cornea for 45 seconds. Then simply wipe off the epithelium with a dry Weck-Cel sponge. 2. Do the PRK treatment. You do not need large optical zones since these older patients have small pupils and your laser treatment is very low. 3. Mitomycin-C is not typically needed, but can be used if desired. 4. Place a bandage contact lens and use topical nonsteroidals until the corneal epithelium is sealed/closed, then remove the contact lens and switch to low dose topical steroids for at least a month.