EyeWorld India September 2017 Issue

September 2017 3 EWAP EDITORIAL ERRATUM In “MIGS: Understanding the options” ( EyeWorld Asia-Pacific June 2017, Vol. 13, No. 2, pp. 58, 60, 63), the caption for the photo on p. 58 should read as follows: “The iStent is placed in the angle intraoperatively as an adjunct to cataract surgery.” The photo was provided by Jason Bacharach, MD. We apologize for any inconvenience caused by this error. LASIK advances I n the September issue of EyeWorld Asia- Pacific, we revisit laser vision correction. LASIK volumes have declined in recent years but recent surveys suggest an upward trend in the last 12 months. This probably relates to improving economic circumstances, particularly in the U.S., but also a renewed focus on new technology. Although the LASIK procedure is essentially unchanged, diagnostic equipment has been refined and topography-guided laser treatments are an alternative to wavefront-guided ablations. Although the former has been available for some time and has proved useful in treating irregular corneas, there does appear to be merit in utilizing this approach in regular LASIK treatments. Intrastromal femtosecond laser correction of refractive errors or SMILE is now considered an attractive alternative to LASIK. The outcomes with this approach appear to be more predictable with higher myopic corrections than LASIK and the procedure is thought to better preserve corneal strength by limiting the breach of Bowman’s membrane to a few millimeters rather than the 8.5-mm diameter flap required by LASIK. Nevertheless, there have been cases reported of ectasia with SMILE and caution suggests that the normal precautions that we have observed with LASIK are still relevant. There does appear to be better preservation of corneal sensation and perhaps fewer dry issues by avoiding flap creation. In addition, the requirement for a single laser instead of both a femto and excimer platform is attractive. Although avoiding the need for a flap suggests a safer procedure, complications during lenticule extraction can occur. Complications, however, like any procedure, diminish with experience. Surface ablation remains relevant as this procedure remains the least likely to be associated with ectasia. Indeed, the combination of crosslinking and surface ablation has proved to be useful for early keratoconus. Transepithelial PRK where the epithelial removal and treatment are performed in a single non-touch treatment is an attractive option. In my experience, epithelial healing time and visual recovery is quicker than regular PRK or LASEK and the use of low-dose mitomycin has proved to be safe after many years of widespread clinical use. Although the instant “wow” factor associated with LASIK and SMILE is missing, by 4 to 6 weeks the predictability and unaided acuity has matched that of LASIK in recent publications. Looking to the future, the prospect of a synthetic on-lay that could be applied to the cornea and sustain an intact epithelium remains an intriguing concept as this would be a truly reversible refractive procedure. The concept remains attractive with continued research, but whether this will prove to be a viable alternative to laser correction in the future has yet to be determined. Lens-based procedures have increasingly replaced laser correction in the treatment of hyperopia in the presbyopic age group but I believe laser-based keratorefractive procedures will remain the mainstay in the correction of myopia in younger patients. It is almost 30 years since I performed my first laser correction (PRK) in 1991 and it is amazing to see how keratorefractive surgery has become increasingly sophisticated. The early microkeratomes have been replaced by femtosecond creation of flaps and lenticular removal and the topographic and wavefront-guided treatments are now commonplace. We are very fortunate to have experienced the birth of this subspecialty which has developed into one of the most common ophthalmic procedures performed today. The renewed interest in laser correction reflects the many advances in this field and ensures that laser correction will remain an integral part of ophthalmic practice in the 21st century. I am certain that you will find this issue and the description of recent advances of great interest and relevant to your practice. EWAP I t gives me immense pleasure to present to you the new issue of the scientifically enriched EyeWorld Asia-Pacific . Our September 2017 issue highlights laser vision correction. New techniques such as topography-guided laser ablations, corneal crosslinking and phototherapeutic keratectomy with the excimer laser are some techniques which are giving new hopes to patients with irregular corneas. Post LASIK patients suffering from temporary, neurotrophic dry eye and superficial punctate keratitis can benefit from plugs at the time of surgery. Femtosecond corneal laser platforms which can offer better vision and better flap predictability than microkeratomes are also described in an article. In this issue, there is also guidance on how to start performing refractive surgery. Attending a training course, finding a mentor, and knowing how to choose the right patient are some good ways for comprehensive ophthalmologists to learn new refractive procedures. This informative issue also gives the reader tips and techniques for optimizing approved microinvasive glaucoma surgery (MIGS). The XEN Gel Stent (Allergan, Dublin, Ireland), a “hybrid” MIGS device which has been launched in U.S. market, is discussed at length. It is suggested that to ensure high patient visual satisfaction post IOL implantation, carefully constructed questionnaires can help surgeons connect clinical options to patient’s requirements and desires. New toric IOL and trifocal IOL studies are also highlighted. The role of nepafenac in CME is discussed. In our daily practice, NSAIDs are used as blanket treatment for postoperative CME with visible benefits; however, its benefit has been clearly demonstrated only in patients with risk factors. We should always strive for new knowledge that ultimately benefits the patient. When we choose what is right for the patient, our existence becomes worth living. As always I would like to end with a few lines from the Tirukkural : Volume 2, Chapter 95 (Quote 950) : For patient, leech, and remedies, and him who waits by patient’s side, The art of medicine must fourfold code of laws provide. EWAP S. Natarajan, MD Regional Managing Editor EyeWorld Asia-Pacific Graham Barrett Chief Medical Editorial EyeWorld Asia-Pacific