EyeWorld India March 2017 Issue

48 EWAP refractive March 2017 Five refractive - from page 47 Views from Asia-Pacific Mohamad ROSMAN, MD Head of Refractive Surgery Department, Singapore National Eye Centre 11 Third Hospital Avenue, Singapore Tel. no. +65-63228893 rosman_sg@yahoo.com A ge is one of the key factors that I look at when a patient comes to me for refractive surgery. At the Singapore National Eye Centre, we use 21 years old as the lower age limit for refractive surgery. This is because the younger the patient, the higher the likelihood there is of refractive instability and risk of regression. However, on a case by case basis, we do consider performing refractive surgery for patients between the ages of 18 to 21 years. These patients must have evidence of refractive stability for at least 2 years. Even when these young patients are deemed suitable for corneal refractive surgery, I would emphasize to the patients the risk of regression and the possibility of retreatment in the future. Because of that, I would ensure that the residual stroma will be sufficient for future retreatment. At the other end of the spectrum are those patients who are older. I find that patients above 40 years old will require longer chair time. Many of them, especially low myopes, simply do not understand what presbyopia is. They must be educated on the effects of presbyopia. I have had a number of myopic patients who decided not to undergo LASIK after being advised that they may require spectacles to read after LASIK. These are usually individuals who spend a significant proportion of time with near work and tend to take off their myopic glasses for near work. Options for presbyopia correction, such as monovision, must be discussed. Ideally, a trial of monovision contact lenses is necessary in order for the patient to make a decision about whether to undergo monovision LASIK. For patients who are above 40 years old and complain of increasing myopia, a detailed examination to exclude early nuclear sclerosis cataracts must be performed. In some cases, the cataract may not be evident during the time of assessment. I would advise surgeons to review the patients again at a later date, usually a year later, to determine whether the patient is indeed developing early cataracts. I have had a number of patients whose cataracts became more evident over the next 1 to 2 years. These patients developed index myopia and eventually required cataract surgery. There is a need to spend sufficient time with refractive surgery patients to understand their needs and expectations. This is critical to avoid making “false promises”. Some patients expect better vision than what they are seeing with their current spectacles or contacts lenses after refractive surgery, and when they do not achieve these results, they become very unhappy. I usually counsel my patients that not every patient will achieve 20/20 vision even though the success rate with current technology is very high. I also make it clear to them that the aim of refractive surgery is to achieve spectacle independence for daily activities. Being able to see better than what they are seeing with contact lenses or spectacles is a bonus. The key principle is to under-promise and over-deliver. SMILE surgery is a novel approach to corneal refractive surgery. It provides the advantages of a flapless surgery and much smaller incision. However, I agree with Prof. Kohnen that we will need long-term studies to compare its results and safety with respect to LASIK. While the refractive outcomes of SMILE at SNEC have been encouraging, we will require more time to determine whether SMILE will live up to its expectations of preserving corneal biomechanics. Editors’ note: Dr. Rosman declared no relevant financial interests. WANG Zheng, MD Aier Eye Hospital (Guangzhou) 191 Huanshi Zhong Road, Guangzhou, China Tel. no. +86-13903002594 gzstwang@gmail.com I deally, we should wait until the patient is at least 18 years old and has stable refraction for more than 2 years. However, sometimes we need to compromise a little bit. For example, here in China, many young myopic patients ask for re- fractive surgery in order to have more competitive advantages in getting a good job or going to a better school. Some of them are under the age of 18. Also, many don’t have a complete refraction record in the past 2 years. We discuss with the patient and the parents about the possibility of regression, which is the major risk. Many think that considering the importance of the chance to get a good job the compromise is worth it. Under such circumstances, I think it is okay to proceed. The same is true for the limits of refractive correction. We’re not living in a “black or white” world. There are often less ideal situations. We need to discuss with the patient and make the decision together. I agree with Dr. Kohnen that we should not overpromise to our patients. In fact, the “under-sell and over-deliver” strategy can raise the patient’s level of satis-faction. In clinical practice, however, for each individual patient, it is sometimes not easy to judge if the promise is over or not, because the outcome of this spe-cific patient is not always predictable. For example, severe postop glare and driving difficulties occur in some patients, but we don’t know who will have this problem until the surgery is done. Again, we need to communicate with our pa-tients and give them enough information to make the decision. Refractive surgery is one of the fastest growing fields in ophthalmology and new technologies emerge rapidly. A common misconception among our pa-tients is “the newer is better”. As a matter of fact, quite a few of these technolo-gies are later proved to be either not safe or not effective. Surgeons should re-spect the principles of scientific research and also take the responsibility to ed-ucate our patients to avoid misunderstandings. An important way to prevent surgeons from blundering into these mistakes is to spend adequate time preoperatively to evaluate the patient comprehensively and to discuss his/her situation with the patient in detail. We should keep in mind that the ultimate goal of refractive surgery is to improve patients’ quality of life. The patient should take part in the decision making for this elective surgery. Editors’ note: Dr. Wang declared no relevant financial interests.