37 EyeWorld Asia-Pacific | September 2024 REFRACTIVE SURGERY Vance Thompson, MD Dr. Thompson agreed that LASIK volumes are down across the country, including in his practice. He does around 1,000 LASIK cases per year and in addition does a fair amount of refractive lens exchange and phakic IOLs. “It amazes me how many people come in for refractive surgery consultation, especially in their 50s–60s, who are still correctable at 20/20, so that’s one criteria of LASIK, and they think that’s what they want,” he said. “But when you start talking with them about LASIK, one reason they’re interested is they think it’s going to help them with the reduction in low-light image quality that they’re experiencing and/or presbyopia.” He continued that when you educate them, they shift from wanting LASIK to wanting a lens replacement procedure. When they talk about the changes they’re noticing in lowlight image quality, you can do a brightness acuity test, and if they glare down to a visually significant number, they may actually qualify for cataract surgery. With surgeons being more aware of the visual issues with early cataracts, a lot of what you would think of as refractive lens exchange becomes early cataract surgery. Dr. Thompson said the “sweet spot” of LASIK has come down over the years. Some people would say 7 or 8 D of myopia is the cutoff. “If I was a 30-year-old patient, and I was more than a 3 D myope, in addition to corneal refractive surgery, I’d be considering a phakic IOL,” he said, adding that he talks to patients about that. If a patient is a good candidate for LASIK or a phakic IOL, many choose LASIK for cost and familiarity with the procedure, but more people are choosing phakic implants in the moderate range. Dr. Thompson said that he would consider a phakic implant if he was in that scenario because of his experience with performing LASIK and phakic IOLs for 30 years. A lot of patients are coming in for cataract surgery, being former patients that he did LASIK and phakic IOLs on a long time ago, “and now that we can quantify HOAs and look at topography and epithelial thickness, some old LASIK cases can’t have all the implant options that modern day technology has brought us,” he said. “With phakic IOL patients, as long as they took care of their eyes, didn’t rub their eyes, I monitored them over the years, their corneas are pristine, at the time of cataract surgery, I just take out the phakic IOL and put in whatever implant they want like they never had refractive surgery,” he said. “It’s a pretty powerful value proposition in the long run for an implant.” As a result of the sweet spot of LASIK coming down and the comfort of phakic IOLs and refractive lens exchange going up, refractive surgery is alive and well, Dr. Thompson said. “Sometimes, refractive surgery volumes get equated with the name LASIK, but refractive surgery is a lot more than that and is a lot healthier because it’s PRK, LASIK, SMILE, phakic IOLs, refractive lens exchange, AK, allogenic corneal inlays, etc.,” he said. Dr. Thompson thinks all of the options in refractive surgery now fit together well because you have the safest and most efficacious approach to doing the best procedure that fits the patient’s situation. He also said that modern-day diagnostics are teaching us a lot. Patient outcomes and satisfaction are showing us which groups of patients are best for corneal refractive, etc., but diagnostics are telling us why, he said, and oftentimes it has to do with measuring optical scatter in the cornea with too high of a corneal Above: Dr. Thompson performs LASIK. Source: Vance Thompson, MD Left: Dr. Rebenitsch performs RLE in his office-based surgery center. Source: Luke Rebenitsch, MD
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