REFRACTIVE 20 EWAP JUNE 2022 be better off with refractive lens eÝchange,» he said. ºI do not use specific age cutoffs because there is so much variability among patient needs and goals. owever, I am reluctant to do corneal refractive surgery in a hyperope with significant presbyopia and would usually recommend lens eÝchange.» When Dr. Lee performs cataract surgery on someone who had prior refractive surgery, he does not distinguish between A-I and surface ablation. ºI am more concerned about RK versus laser vision correction,” he said. ºI eÝpect that any corneal refractive surgery I perform will likely cause mild irregularity to the cornea but do not use that to help patients choose their procedure.” Dr. Wiley said he thinks that as implant technology gets better, it does guide discussions on refractive surgery. ºIn the past, when implant technology was in its infancy, the motivation to delay or choose IO options over corneal refractive options wasn’t there,” he said. “As IO technology has advanced, the corneal refractive surgery mindset has changed.” or eÝample, he said that he was using corneal inlays quite frequently in his practice for a while. KAMRA (AcuFocus) provided distance and near over time, but one issue was that for it to work well, for most patients you had to do A-I on both eyes and KAMRA on one. Now that trifocals are on the U.S. market, Dr. Wiley noted that the same patient considering A-I plus AMRA might be a good candidate for a trifocal clear lens because it gives distance, intermediate, and near. The eÝpense to the patient for a bilateral trifocal is similar to A-I and AMRA, he added, and it tends to be a better and easier approach with more longevity. Dr. Wiley noted that hyperopic A-I is being done less. A low hyperope or young hyperope tends to be able to accommodate and usually doesn’t come in until their 40s. Most hyperopes who come in are already eÝperiencing distance and near vision loss, he added. Almost all hyperopic patients should be evaluated for lens surgery, as opposed to just corneal refractive surgery, Dr. Wiley said. He cautioned that once you do hyperopic A-I , it may make the patient no longer a candidate for premium IO surgery in the future and may limit options. From an age standpoint, Dr. Wiley said, for eÝample, for a 30-year-old hyperope, by the time the patient needs lens surgery, the technology should have advanced enough where there might be an accommodating lens option. “You can be a little more aggressive with younger patients,” he said. Dr. Wiley has also found a benefit to -MI E vs. A-I in that it leaves more future advancement options open for the patient. If you do A-I in a 30-year-old, and 30 years later they need an IO , if you need to enhance after the IO surgery, your only option is PRK, he said. You can’t easily lift the yapÆ there is a risk of epithelial ingrowth or scarring. He also said PR after A-I is not µuite as predictable. “What’s nice with -MI E is you have the ability to convert -MI E to A-I years or decades after,” he said. This leaves the potential to have a A-I yap created in the future after an IO and thus have a more predictable adjustment procedure if the need arises. The future of implants In the time since he completed ophthalmology training, Dr. Rebenitsch said that he’s found it eÝciting the way the conversation with the patient has changed. It has become less of a question of if a patient is a candidate for an advanced technology IO and has shifted to what type of advanced technology IO is an option for them. With the advent of eÝtended depth of focus lenses, the LAL, and potentially with better accommodating lenses in the future, Dr. Rebenitsch said that every patient should qualify for something. One of the things he½s most eÝcited for is the I -8 (Acu ocus). ºOur practice placed more than 250 KAMRA inlays with a 5¯ satisfaction rate,” he said, adding that he thinks this pinhole technology is better in the sulcus or in an IO . “For patients with aberrated corneas who have historically not µualified for anything, they now will have something that will manage astigmatism, give eÝtended depth of focus, and give overall higher satisfaction and spectacle independence than we could have done in years past,” he said. Dr. Rebenitsch also spoke about other technology that he’s looking forward to implementing, specifically those for presbyopia. He mentioned drops for presbyopia and the approval of 61IT9 (pilocarpine HCl ophthalmic solution, Allergan), the first of these products, noting that it will “act as a bridge” for many patients. ºWhat I½m really looking forward to is there should be an eÝtended depth of focus I in the future,” Dr. Rebenitsch said. Presbyopic high myopes don’t have a lot of good options
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