NEWS & OPINION 42 EWAP DECEMBER 2022 enhancement via flap relifting can be safe years after primary LASIK treatment. It may have fewer complications compared to alternatives like surface ablation or recutting. Clinically significant EI is rare and does not cause vision changes after it was removed. The authors also showed that previously suggested risk factors for EI like pre-enhancement time interval, flap creation tool, sex, and age were unsupported. This is the largest retrospective study to date that examines LASIK flap relifting and describes a specific surgical technique with low complication rates. The authors present a compelling argument for flap relifting to become the preferred method for LASIK enhancement many years after primary treatment. EWAP References 1. Moshirfar M, et al. LASIK enhancement: clinical and surgical management. J Refract Surg. 2017;33:116–127. 2. Cagil N, et al. Effectiveness of laser- assisted subepithelial keratectomy to treat residual refractive errors after laser in situ keratomileusis. J Cataract Refract Surg. 2007;33:642–647. 3. Carones F, et al. Evaluation of photorefractive keratectomy retreatments after regressed myopic laser in situ keratomileusis. Ophthalmology. 2001;108:1732–1737. 4. de Rojas V, et al. Infectious keratitis in 18,651 laser surface ablation procedures. J Cataract Refract Surg. 2011;37:1822–1831. 5. Schallhorn SC, et al. Flap lift and photorefractive keratectomy enhancements after primary laser in situ keratomileusis using a wavefrontguided ablation profile: Refractive and visual outcomes. J Cataract Refract Surg. 2015;41:2501–2512. 6. Caster AI. Flap-lift LASIK 10 or more years after primary LASIK. J Refract Surg. 2018;34:604–609. 7. Davis EA, et al. Lasik enhancements: a comparison of lifting to recutting the flap. Ophthalmology. 2002;109:2308–2314. 8. Rubinfeld RS, et al. To lift or recut: changing trends in LASIK enhancement. J Cataract Refract Surg. 2003;29:2306–2317. 9. Vaddavalli PK, et al. Complications of femtosecond laser-assisted re-treatment for residual refractive errors after LASIK. J Refract Surg. 2013;29:577–580. 10. Domniz Y, et al. Recutting the cornea versus lifting the flap: comparison of two enhancement techniques following laser in situ keratomileusis. J Refract Surg. 2001;17:505–510. 11. Alió Del Barrio JL, et al. Laser flap enhancement 5 to 9 years and 10 or more years after laser in situ keratomileusis: Safety and efficacy. J Cataract Refract Surg. 2019;45:1463–1469. 12. Santhiago MR, et al. Flap relift for retreatment after femtosecond laser-assisted LASIK. J Refract Surg. 2012;28:482–487. 13. Randleman JB, Shah RD. LASIK interface complications: etiology, management, and outcomes. J Refract Surg. 2012;28:575–586. 14. Wang MY, Maloney RK. Epithelial ingrowth after laser in situ keratomileusis. Am J Ophthalmol. 2000;129:746–751. 15. Letko E, et al. Influence of original flap creation method on incidence of epithelial ingrowth after LASIK retreatment. J Refract Surg. 2009;25:1039–1041. 16. Caster AI, et al. Incidence of epithelial ingrowth in primary and retreatment laser in situ keratomileusis. J Cataract Refract Surg. 2010;36:97–101. 17. Henry CR, et al. Epithelial ingrowth after LASIK: clinical characteristics, risk factors, and visual outcomes in patients requiring flap lift. J Refract Surg. 2012;28:488–492. 18. Ting DSJ, et al. Epithelial ingrowth following laser in situ keratomileusis (LASIK): prevalence, risk factors, management and visual outcomes. BMJ Open Ophthalmol. 2018;3:e000133. 19. Durrie DS, Aziz AA. Lift-flap retreatment after laser in situ keratomileusis. J Refract Surg. 1999;15:150–153. 20. Walker MB, Wilson SE. Incidence and prevention of epithelial growth within the interface after laser in situ keratomileusis. Cornea. 2000;19:170–173. 21. Chan CCK, Boxer Wachler BS. Comparison of the effects of LASIK retreatment techniques on epithelial ingrowth rates. Ophthalmology. 2007;114:640–642. Editors’ note: Dr. Mai and Dr. Murri are residents, Dr. Pettey Residency Program Director at Moran Eye Center, University of Utah, Salt Lake City, Utah. IOP elevation - from page 39 During the Journal Club discussion, the strengths and limitations of this work were weighed. Regarding the limitations, it was discussed that many, if not all, of the posited weaknesses should apply equally to both groups (i.e., AcrySof and TECNIS). These suggested weaknesses therefore should not detract from the validity of the study, unless there is an inherent difference in the type of surgeon (e.g., experience or skill level) who implants the AcrySof lens as compared to the TECNIS lens, which we agreed was unlikely. A potential weakness that was not mentioned by the authors but was raised by our panelists was the potential for conflict of interest given the financial relationship between Alcon and the study’s authorship. Regarding younger age as a risk factor for realignment, our panelists hypothesized that perhaps surgeons have a lower threshold to take younger patients back to the operating room given that they are, on average, a healthier population better able to withstand anesthesia and a second surgery. Finally, in terms of future directions, given that the TECNIS lens in the study had already been redesigned at the close of the study, our group was particularly interested in future studies comparing the newly modified TECNIS II lens with the AcrySof lens. The new generation of TECNIS toric lenses are designed to enhance rotational stability to address the very issue discussed herein. Conclusions Proper astigmatic axis alignment is critical for the visual outcomes of patients implanted with toric IOLs. The rate of surgical realignment of monofocal toric IOLs was compared using the real-world data of the IRIS Registry, confirming prior reports of greater frequency of realignment associated with the TECNIS monofocal toric IOL as compared to the AcrySof monofocal toric IOL. EWAP References 1. Anderson DF, et al. Global prevalence and economic and humanistic burden of astigmatism in cataract patients: a systematic literature review. Clin Ophthalmol. 2018;12:439–452. 2. Kessel L, et al. Toric intraocular lenses in the correction of astigmatism during cataract surgery: a systematic review and meta-analysis. Ophthalmology. 2016;123:275–286. 3. Visser N, et al. Toric intraocular lenses: historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes, and complications. J Cataract Refract Surg. 2013;39:624–637. 4. Dang S, et al. Estimating patient demand for ophthalmologists in the United States using Google Trends. Invest Ophthalmol Vis Sci. 2021;62:1724. 5. Oshika T, et al. Comparison of incidence of repositioning surgery to correct misalignment with three toric intraocular lenses. Eur J Ophthalmol. 2020;30:680–684. 6. Lee BS, Chang DF. Comparison of the rotational stability of two toric intraocular lenses in 1273 consecutive eyes. Ophthalmology. 2018;125:1325–1331. Editors’ note: Dr. Sun is Residency Program Director, Dr. Koenig a resident Weill Cornell Medicine, New York, New York.
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