29 EyeWorld Asia-Pacific | March 2025 REFRACTIVE SURGERY The myopes are a different breed from hyperopes. They come in because they’re taking glasses off to read for the first time, Dr. Hamilton said. “If someone in their late 30s or early 40s comes in with a –7 and I do LASIK on them, it changes corneal optics in a negative way. I’m going to create too much positive spherical aberration. Now in 5–6 years, they’ll come back and say the LASIK wore off, but I’m going to say that we talked about LASIK not being the final solution. I won’t have as many options for that patient because we did LASIK and created optics not compatible with some options, like the multifocal lens. This is another reason why I’m not doing LASIK in patients with high myopic corrections in their late 30s and early 40s.” For these patients Dr. Hamilton prefers to use the EVO. “I can put the EVO in, I haven’t altered the corneal optics, and when they come back in 5–10 years for RLE, we have more options available,” he said. Dr. Rebenitsch said the best education happens even before patients come through the door. “It’s important to have this information on your website and in marketing materials that there are solutions beyond LASIK,” he said. In terms of RLE candidacy, Dr. Rebenitsch said it’s the same evaluation for cataract surgery for candidacy for multifocals. The technology, he continued, is even more important in RLE because this is elective surgery. “The expectations are higher with RLE than with refractive cataract surgery, so it’s important to not only have the conversation about what it’s going to take to adapt, … but it’s also important to talk about what happens if they need a touchup or what it will look like in the future. “Two of the newest players are the TECNIS Odyssey and the Lenstec ClearView 3 segmented bifocal,” Dr. Rebenitsch said. “We found that for those who are concerned about glare and halo, they tend to be less.” He’s finding success with these lenses in virgin corneas and postrefractive eyes. Preop Testing And Evaluation In terms of preoperative testing and evaluation, it’s similar to refractive cataract surgery. “You want a good topography, you want to look at the mires, you want to look for dry eyes,” Dr. Rebenitsch said. Dr. Rebenitsch likes to use the OPD-Scan III (Marco). He also noted tests for tear osmolarity and looking at overall higher order aberrations (HOAs). “Just like cataract surgery, it’s important to look at the macula for signs of ERM, PVD (if there’s not one yet, there’s a decent chance it could induce PVD),” he said. Dr. Hamilton said there are several considerations. On the myopic side, we want to have a good retina exam, he said. We also want to have a discussion with the patient about the risk of retinal tears and detachments. “I would insist that myopic patients get plugged in with a retina specialist and go for dilated exams periodically for a few years after RLE.” The PVD is critical because the presence of a complete PVD drastically reduces the risk of retinal tear and detachment. Unfortunately, we don’t have great imaging for PVDs, he said. “We can see if the vitreous is still attached in most situations; it’s hard to know if it’s totally detached, so that’s an area where we need better imaging.” Enhancement Plan Dr. Hamilton said that in virgin eyes, modern formulas are remarkably accurate. He added that if you’re going to do a lot of RLE, you have to be comfortable with IOL exchange. “For the post-refractive patient, we’re using the LAL primarily, and it’s essentially a non-issue because you can adjust the power after if there’s a miss.” Dr. Rebenitsch has found the typical RLE patient rate of enhancement is about two times the rate of traditional refractive cataract surgery. It’s about setting expectations, he said, adding that he brings patients back after 3–4 months. “We run all the tests again and see if there’s anything we need to do to enhance vision further; 20/ happy is what we’re going for, but it’s harder to get that with RLE.” Especially for post-LASIK patients, Dr. Farid strongly recommends the LAL because she doesn’t want to do another LASIK or PRK enhancement on a cornea that’s already been touched. If they haven’t had LASIK, she said it depends on the type of patient and lens you go with. “If we go forward with a multifocal lens, we do talk about possibly enhancing. If it’s a virgin cornea, I’m more comfortable doing laser vision enhancement if needed.” The Ocular Surface The ocular surface is going to be a key player for any patient having refractive surgery, Dr. Farid said. Preoperatively, she will put these patients on a treatment regimen based on how dry they were before. “Sometimes I’ll be really aggressive for those who have significant dry eyes before surgery, but even if they don’t have symptoms, I still talk about dry eyes,” she said. “I talk about starting basic things like hot compresses, so the patient understands that this is something we’re going to be treating after surgery as well.”
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