REFRACTIVE EWAP JUNE 2022 21 currently, he added, and an eÝtended depth of focus I could create a bridge for these patients until they want to have cataract surgery. Even for patients who have had dated corneal refractive surgery, Dr. Wiley said some newer technologies in the works could be useful, including the I -8. A small aperture IO is a great option for patients with previous RK, he said, especially because current technology doesn’t do a good job of giving multifocality or EDO to these patients. Dr. Wiley also mentioned other technology on the horizon, like the Gemini Refractive apsule (Omega Ophthalmics), which he said is designed to go into the capsular bag to hold it open to allow for lens eÝchangeability. He also noted the option of phakic IO s, particularly the E6O (-TAAR -urgical). It allows for a non-corneal altering procedure and keeps all options open for the long term, Dr. Wiley said. “As implantable contact lens technology evolves and doctors become more comfortable with that, we’ll see wider use for even medium to moderate prescriptions, we’ll see alternatives going forward for phakic IO s, which are less invasive to the eye, and we’ll see that those truly do keep the broadest options open for the patient,” he said. Dr. Wiley also mentioned the use of presbyopia drops in the future as more eÝperience is gained with 61IT9 and as similar products are brought to market. It gives us some ability to consider that presbyopia myope who wants distance vision or monovision, he said. “With presbyopic drops, it gives more options for spectacle independence,” Dr. Wiley said. These options could give some longevity to corneal refractive surgery, Dr. Wiley said. ºIn the past, once a patient had corneal refractive surgery then lens surgery, it was so permanent that you had to be so careful about what lens you chose because they would be married to it for their lifetime.” Now, Dr. Wiley said there is the understanding that there are some eÝchangeable options on the horizon. EWAP Editors’ note: Dr. Lee practices at Altos Eye Physicians, Los Altos, California, and has interests with AcuFocus. Dr. Rebenitsch is Medical Director, ClearSight LASIK/43 Vision, Oklahoma City, Oklahoma, and has interests with Carl Zeiss Meditec and STAAR Surgical. Dr. Wiley practices at Cleveland Eye Clinic, Cleveland, Ohio, and has interests with Alcon, Allergan, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson Vision, Omega Ophthalmics, RxSight, and STAAR Surgical. Sheetal Brar, MD Senior Consultant, Nethradhama Superspeciality Eye Hospital 256/14, Kanakapura Main Road, J ayanagar 7th lock, angalore, arnataka, India brar_sheetal@yahoo.co.in ASIA-PACIFIC PERSPECTIVES IO planning in a patient with a previous history of corneal refractive surgery can be tricky due to known challenges of unreliable biometry as well as dilemmas related to the choice of the IO , especially when the patient desires to maintain glasses-free vision which he enjoyed after his refractive surgery. Regarding hyperopic corrections, I too agree that there may be concerns about the postoperative µuality of vision achieved after IO surgery, rendering these patients unsuitable for a multifocal implant. Fortunately, now we have access to tools such as Pentacam Holladay EKR maps that provide useful information about the quality of ablation pattern (centered/decentered), distribution of keratometry (regular/ irregular), and corneal higher-order aberrations ( OAs), thus helping us evaluate eligible candidates better. Generally, if the EKR map shows a single, well-defined spike, denoting a gaussian distribution of keratometry, and OAs are 0.È microns, patients may be adeµuately counseled for a premium trifocal lens. This also applies to high myopic ablations, wherein a good µuality E R spike and aberrations profile may not preclude a post- A-I patient from having a multifocal lens in his eye. Additionally, with the advent of improved formulas based on the concept of total keratometry (TK) such as the Barrett TK true-K, enabling true measurements of the posterior cornea, the accuracy of results in post- A-I eyes appears to have improved significantly. I also second the thoughts of the surgeons about the advantage that -MI E may have over A-I in this scenario, as the aspheric lenticule eÝtraction in -MI E leaves the cornea more prolate with less induced aberrations compared to A-I for a similar amount of ablation. We recently published a case report of a post myopic -MI E patient who had a successful trifocal IO implantation in both eyes using the above discussed concepts.1 In post PRE- 9O D A-I patients, however, I like to do a minimonovision and maintain the depth of focus achieved by modified corneal aberrations with the procedure, and thus prefer using an aberration-free monofocal IO . Patient’s age and type of refractive error is not a matter of significant concern for me due to the availability of advanced biometric techniµues and newer IO s (enhanced monofocal, EDO s and ight Adjustable Lenses (LALs)) on the horizon, enabling us to achieve fairly accurate results and good patient satisfaction in a vast majority of these cases. Preoperative counseling to set the right eÝpectations, remains the key to success and avoid unhappy patients. Reference: 1. anesh -, et al. Post-small incision lenticule eÝtraction phacoemulsification with multifocal IO implantation\ A case report. Indian J Ophthalmol. 201ÆÈ7(8)\1353-135È. doi\10.{103Éio.I OÚ20ÈÚ18. Editors’ note: Dr. Sheetal Brar is a consultant for Carl Zeiss Meditec.
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