EyeWorld Asia-Pacific June 2017 Issue

June 2017 48 EWAP cornea microns to remove the corneal epithelium, immediately followed by topography-guided PRK. Ice is applied to the cornea immediately after the laser application for 30 seconds, which enhances post- op comfort. Mitomycin C is then applied on a sponge for 1 minute. This is followed by CXL using riboflavin drops for 10 minutes and ultraviolet A light for 12 minutes on pulse mode with an energy of 15 mw/cm2. A bandage soft contact lens is then inserted, and typically removed at 5 days post-op. “My preference is to wait for 6 months for corneal stability before performing cataract surgery either with a monofocal or toric implant,” Dr. Stein said. Pre-op Intacs or CXL Dr. Stein prefers to perform topography-guided PRK instead of using Intacs (Addition Technology, Lombard, Illinois) in corneas that are 450 microns or thicker. Topography-guided PRK is a more customized approach that allows the surgeon to flatten steep areas and steepen flat areas to reduce irregular astigmatism. In corneas that are less than 450 microns centrally, Intacs can be used to reduce the irregular astigmatism. “My preference is not to use Intacs in patients under 60 years of age because of long-term risks of corneal haze, neovascularization, and extrusion,” said Dr. Stein, who was involved in an Intacs study for myopia in the late 1990s, during which many patients developed complications after 10 years post-op. Dr. Holland sees little pre-op role for Intacs or CXL because he has found good results from topography-guided PRK with CXL after cataract surgery with a monofocal IOL. “A short CXL is done as usually older patients have less change of progression, and a shorter CXL is less likely to induce hyperopia,” Dr. Holland said. Dr. Stein performs topography- guided PRK prior to cataract surgery in patients who either wear RGP lenses or who have a longstanding history of reduced BSCVA secondary to irregular astigmatism. “In patients that were seeing well with glasses or soft contact lenses prior to the onset of their cataract, then straightforward cataract surgery is all that is required,” Dr. Stein said. Monofocal lenses If a cataract patient is prepared to undergo post-op topography- guided PRK, then Dr. Holland would use a monofocal rather than a toric IOL. When refractive laser surgery is required after placing a toric IOL, such patients need a standard PRK instead of topography-guided PRK, which is less likely to reduce aberrations from an irregular cornea. Following topography-guided PRK, if the cornea has less than 1 D of net astigmatism, Dr. Stein would use a monofocal implant. In patients with a net astigmatism of 1 D or more, he would use a toric implant. “It is important to determine the net astigmatism and axis, which factors in both the anterior cornea and posterior cornea,” Dr. Stein said. EWAP Editors’ note: Drs. Stein and Holland had no financial relationships related to their comments. Contact information Holland: simon_holland@telus.net Stein: rstein@bochner.com medications or drops in order to get the best imaging possible so I can help you achieve the quality of vision you’re looking for,’” she said. If at the 4-week checkup the patient still hasn’t responded to treatment for adequate measurements, Dr. Yeu said they can push back surgery for the first eye to the 8-week mark, which was already on the schedule for the second eye. This, Dr. Yeu said, allows her patients to feel like they are moving forward with a date already on the calendar. Dr. Kieval said his typical surgery schedule runs 2 to 3 months out, a timeframe that usually allows for the addressing of most ocular surface issues. However, 5% of his patients need more treatment and thus require a delay in surgery. This conversation usually goes well, he said. “Individualizing their care often makes the patients understand our commitment to a great outcome,” he added. When it comes to candidacy for multifocal or extended depth of focus IOLs, Dr. Zavodni said he would tell mild dry eye patients his recommendation will depend on their response to treatment. For those with moderate to severe dry eye, however, Dr. Zavodni said he’ll usually recommend against these advanced optics because they are more likely to be frustrated by the quality of their postoperative vision. “Obviously, I may tailor Prepping – from page 46 Preop – from page 47 my discussion based upon the response to dry eye therapy seen at subsequent visits,” he added. In patients who are receiving advanced IOLs after responding well to dry eye treatment, Dr. Yeu makes sure to tell them they might need to maintain some sort of dry eye regimen—drops or a longer-term office-based thermal procedure—to ensure their vision continues to perform at the highest level. Dr. Zavodni said he will tell his dry eye patients that they might have more postoperative irritation in the weeks following surgery and it also might take them longer than average to reach their best visual acuity. EWAP Editors’ note: Dr. Yeu has financial interests with TearLab (San Diego), Rapid Pathogen Screening (Sarasota, Florida), TearScience, Bio-Tissue, Shire (Lexington, Massachusetts), and Allergan (Dublin). Dr. Kieval has financial interests with Abbott Medical Optics (Abbott Park, Illinois), Allergan, Shire, and Sun Pharmaceutical (Mumbai, India). Dr. Zavodni does not have any financial interests related to his comments. Reference 1. Epitropoulos A, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672–7. Contact information Kieval: jkieval@gmail.com Yeu: eyeulin@gmail.com Zavodni: zacharyzavodni@gmail.com