EyeWorld Asia-Pacific September 2018 Issue

16 EWAP FEATURE September 2018 Views from Asia-Paci c LEE Mun Wai, MD Consultant Ophthalmologist & Retinal Surgeon Medical Director, Lee Eye Centre 44-46 Persiaran Greenhill, Ipoh, Perak, Malaysia 30450 Tel. no. +605-2540095 Fax no. +605-2540273 munwai_lee@lec.com.my C ataract surgery has entered the realm of refractive surgery now and many ophthalmologists view refractive lens exchange (RLE) as a viable option for their patients who are not suitable for a cornea-base refractive procedure. The RLE debate has been ongoing for a long time and brings forth many clinical and ethical issues. A population study of retinal detachment (RD) risk after phacoemulsification 1 looked at over 65,000 eyes which underwent cataract surgery and the following was found: Younger age and male sex were significant risk factors for RD Patients younger than 60 years have 4 fold risk of RD compared to those over 60 years Men are twice as likely to get RD compared to women Eyes with axial length greater than 25 mm have 6 times the risk of RD compared to shorter eyes If anterior vitrectomy was done, risk of RD was 30 times higher These findings should raise significant concerns for the refractive cataract surgeon as patients who present for refractive surgery are often younger than 60 years and myopic. Informed consent is key and the implications of RLE surgery should be explained to the patient. Patients need to understand that the risk profile for RLE is different from cornea-based procedures. They should be educated about the symptoms of retinal detachment such as floaters, flashes and peripheral vision loss and be informed about the risk of endophthalmitis and the dysphotopsias associated with the use of multifocal intraocular lens implants (MFIOL). Other clinical considerations when offering RLE include the accuracy of biometry calculation in the more extreme eyes, astigmatism management, and the range of MFIOL available. Monofocal monovision may also be an option if a MFIOL is not available but the risk of anisometropia and loss of stereopsis has to be explained to the patient. With the recent advancements in cataract surgery, RLE has become a relatively common practice. However, we should be mindful of the potential complications associated with this and the importance of communication with the patient cannot be overstated. Candidacy for RLE should be restricted to a select group of individuals and we should try to avoid RLE in the highly myopic young male patient. Reference 1. Clark, et al. Risk of retinal detachment after cataract surgery. Arch Ophthalmol. July 2012:130(7);882-888 Editors’ note: Dr. Lee declared no relevant nancial interests. Myoung Joon KIM, MD Asan Medical Center 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea Tel. no. +82-2-3010-3975 Fax no. +82-2-470-6440 mjmjkim@gmail.com T hree refractive surgery experts (Dr. Desai, Dr. Durrie, and Dr. Donnenfeld) discussed four challenging cases. 1. Middle-aged patient requesting LASIK 2. Amblyopic patient who wants refractive surgery 3. Patient with disguised ocular surface disease 4. Patient who can’t see well with glasses or contact lenses and could need a corneal transplant I like Dr. Desai’s “matching concept”. In one side of doctor’s mind, there is a full line-up of treatment options. In another side, patient’s needs are identified. I believe best matching between treatments and patient’s needs will maximize clinical outcome and patient’s satisfaction. For this concept, doctors should understand various treatment methods and be willing to discuss visual lifestyle with patients. In middle-aged patients, lenticular astigmatism is common even without significant cataractous change in the crystalline lens. If laser vision correction were done, corneal astigmatism would have been induced to correct lenticular astigmatism. When cataract develops in the future, IOL should be selected to compensate corneal astigmatism. Also, asphericity of current IOLs cannot fully compensate spherical aberration of post-laser refractive surgery corneas. For these reasons, I don’t prefer laser vision correction in older patients. If a patient wants to wear glasses or a contact lens for the correction of vision in a mildly amblyopic eye, I would think about refractive surgery especially when the eye is myopic. Of course, doctors have to verify that the patient understands his/ her postoperative vision will be poorer than their dominant eye’s. In myopic eyes, a refractive procedure can have some magnification effect and increase postop BCVA. The importance of the ocular surface cannot be overemphasized not only in laser refractive surgery but also in multifocal IOL implantation. If ocular surface disease exists, lens-based surgery is preferable. However, the ocular surface should be managed properly pre- and postoperatively. If not, any surgery should be delayed or re-considered. Laser refractive surgery is often considered to be an elective or cosmetic procedure. However, it is an option for the treatment of diseases such as keratoconus or other irregular corneas. We now have crosslinking, topography-guided ablation, and other methods. I prefer topo-guided rather than wavefront-guided when the optics of the cornea is highly aberrated because wavefront sensors are not accurate in those eyes due to their limited dynamic range. Treatment of corneal irregularities with a femtosecond laser is a new application of the laser. There are many new technologies on the horizon. That’s why we have to keep our eyes on the horizon. Editors’ note: Dr. Kim declared no relevant nancial interests. Challenging...refractive surgery – from page 15