EyeWorld Asia-Pacific June 2018 issue

63 EWAP DEVICES June 2018 Technologies that improve refractive surgery What’s helped surgeons improve refractive outcomes S everal technologies have revolutionized refractive surgery and have improved patient outcomes. They allow surgeons to prepare the ocular surface for surgery and achieve results that are better than 20/20. Tear film analysis Both TearLab Osmolarity Test (TearLab, San Diego) and LipiS- can (Johnson & Johnson Vision, Santa Ana, California) are used for tear film analysis. According to John Hovanesian, MD, today’s refractive surgery patients are baby boomers, who are older. “Dry eye, and addressing it before surgery, can mean everything to their out- come. Many of these eyes are in a marginally compensated state. In other words, they aren’t sympto- matic, but their eyes are somewhat dry. If a doctor doesn’t educate a patient about his or her dry eye before surgery, then the doctor owns that problem after surgery. It’s important that the patient understands that he or she has two problems: one that requires correcting refraction and one that by Michelle Stephenson EyeWorld Contributing Writer requires correcting and treating dry eye,” he said. Dr. Hovanesian uses this technology in older patients and in those who have symptoms only. George Waring, MD, uses this technology on every lens refrac- tive surgery patient and selectively for laser vision correction patients. “We take a holistic approach to eye care, and we have found that objectively, dry eye can result in fluctuation of vision as a result of increased light scatter. If we are going through the efforts of helping a patient relieve his or her dependence on glasses and contact lenses and improve overall vision, we think that we may be able to improve it even further if we address any underlying ocu- lar surface issues and the overall health and wellness of the ocular surface,” he said. He has found that even young patients can have meibomian gland dysfunction and blepharitis that may be due to computer vi- sion syndrome. Alan Carlson, MD, said that LipiScan, LipiView, and LipiFlow (Johnson & Johnson Vision) have been a huge asset in managing dryness. “These have also given us a lot more comfort perform- ing LASIK procedures. Previously, we have been so worried that we would make dry patients even dri- er that our options were limited. Now, diagnostically evaluating these patients and therapeutically treating them has allowed us to take a lot of patients who are bet- ter suited for LASIK or SMILE and proceed with that rather than giv- ing them PRK for a high correction that will have a much slower and unpredictable recovery,” he said. Daniel Durrie, MD, uses the TearLab test in select cases, and he uses LipiScan or LipiView on every patient. “As a screening on all of our refractive surgery patients, we want to make sure that their meibomian glands are functioning well,” he said. “In short, LipiFlow works. It treats the most common type of dry eye that we see in young and old patients. When we see an ab- normal tear film, we need to treat it. It’s a valid and valuable tool,” Dr. Hovanesian said. Dr. Durrie agreed. He uses LipiFlow in patients who do not respond to lid hygiene. Topography for corneal analysis Topography provides thousands of points of data, in terms of curvature. “Not only does it help us identify the degree of corneal astigmatism, but it also provides a sense of surface irregularity, so it’s a poor man’s dry eye test as well,” Dr. Hovanesian said. “It’s standard of care to do some type of topogra- phy imaging.” Dr. Waring agreed. “Topogra- phy and tomography are requisites for any form of refractive surgery. It’s the hallmark and foundation of refractive surgery, both cornea and lens-based refractive surgery. All patients should have topogra- phy and/or tomography. You can- not and should not be addressing astigmatism and managing astig- matism without topography or to- mography. This would prevent you from participating in presbyopia- correcting IOLs. Additionally, you would not be able to do toric IOLs because you can’t properly meas- ure the magnitude or orientation of your astigmatism, and you can’t adequately screen for risk factors for the development of ectasia in laser vision correction unless you use topography. Lastly, you’re go- ing to miss pathology that can af- fect your outcomes, such as kerato- conus and/or epithelial basement membrane dystrophy, or even dry eye, in many cases,” he said. continued on page 64