EyeWorld Asia-Pacific September 2018 Issue

September 2018 14 EWAP FEATURE Challenging cases in refractive surgery by Liz Hillman EyeWorld Senior Staff Writer AT A GLANCE • Challenges in refractive surgery include the rare intraoperative and postoperative complications that can arise, but experts say the modern challenge is matching the right procedure to the patient. • Other challenging cases involve patients with amblyopia or ocular surface disease. • While many think of refractive surgery as an elective procedure to reduce a patient’s dependence on glasses or contact lenses, it also provides methods for functional vision restoration in some complicated cases. Experts discuss the chal- lenge of dysfunctional lens syndrome, amblyopia, ocular surface disease, and vision restoration O ver the last three decades, modern re- fractive surgery has grown to seven pro- cedures (eight including refractive cataract surgery). The stalwarts of corneal refractive surgery—PRK and LASIK—have been refined in patient selection, risk mitigation, technology, and complication management to the point where patient satisfaction with vision after LASIK in the PROWL studies ranged from 96–99%, and patient satisfaction with surgery ranged from 98–99%. 1 Relative newcomers—small incision lenticule extraction (SMILE), intracorneal inlays, pha- kic IOLs, refractive lens exchange, and crosslinking—have expanded refractive options beyond corneal based procedures, made inroads into presbyopia correction, and are starting to find their place within the market. With so many options available, just selecting the right procedure for the patient is considered a challenge by to- day’s refractive surgeons. The ophthalmologists Eye- World spoke with about challenges in refractive surgery each cited the paradigm shift that has come about with the options available to patients seeking better vision. “The biggest challenge is figur- ing out which option matches the patient who is at a certain stage of life, at a certain stage of activities, hobbies, and work, and which one of these is going to suit the patient in terms of visual lifestyle but also be the best in terms of long-term stability and be the least risky,” said Neel Desai, MD , The Eye Institute of West Florida, Largo, Florida. In addition to this challenge, Dr. Desai, Daniel Durrie, MD , clinical professor and director of refractive surgery, University of Kansas Medical Center, Overland Park, Kansas, and Eric Donnen- feld, MD , Ophthalmic Consult- ants of Long Island, Garden City, New York, and EyeWorld chief medical editor, shared specific ex- amples of what they consider chal- lenging refractive surgery cases. A range of overarching themes were addressed, including the impor- tance of patient education, ocular surface disease, and visual reha- bilitation. The middle-age patient requesting LASIK A patient 48–60 years old comes in seeking LASIK, but a corneal- based procedure might not be the best option, Dr. Durrie said. While LASIK, PRK, or SMILE might all be possible for these patients, Dr. Durrie said, this age group has an underlying problem beginning in their crystalline lens that they probably don’t understand, and it might cause them to be unhappy with laser vision correction. “The important thing right up front is to spend the time to educate them on what’s going on in their eye,” Dr. Durrie said, explaining that he will describe to patients the three stages of dys- functional lens syndrome, what it’s doing to their lens, and how that will impact their vision now and in the future. After helping patients under- stand the changes that are causing them to develop presbyopia and eventually a cataract, then you can discuss refractive options with them. Dr. Durrie said candidacy for laser vision correction can be discussed in the context that the patient’s lens will change and impact the visual outcomes of this procedure. The other option, he tells these patients, is refractive lens exchange, which can not only correct their refractive error but prevent cataract formation in the future as well. Dr. Durrie said some patients still want a corneal-based proce- dure, even after the discussion of lens-based. He said the educa- tion about the changes in their lens “helps them not blame their