EyeWorld India September 2018 Issue

18 EWAP FEATURE September 2017 need vital staining, a detailed slit lamp exam, a retinoscope, and a phoropter, he said. “It doesn’t take huge capital expenditures … to identify some of these problems ahead of time,” Dr. Desai said. “What it does take is not technology but an interest in finding those things, a will- ingness to look for them and a willingness to treat them.” The patient who can’t see well with glasses or contact lenses and could need a corneal transplant Dr. Donnenfeld said to him, today’s challenging refractive sur- gery cases are the ones in which he is rehabilitating a person’s vision. “Someone who is having visual disturbances that are af- fecting their quality of life that can’t be fixed with glasses or even contact lenses, and what I’m offer- ing patients is an opportunity to improve their vision and eliminate the need for corneal transplanta- tion,” Dr. Donnenfeld said. Many of these cases are only now possible due to recent ad- vances in technology. One exam- ple is the ability to rehabilitate the vision of a young person with keratoconus. Dr. Donnenfeld said he first evaluates if the cornea is stable; if not, he will perform cor- neal crosslinking. Once progres- sion of the disease is prevented with crosslinking, the patient could be a candidate for topo- graphic or wavefront-guided laser refractive surgery. “None of these treatments were in the United States a couple of years ago,” Dr. Donnenfeld said, noting FDA approval of crosslinking in 2016 and approval of the first topographic laser in 2013 and wavefront lasers start- ing in 2003. “Now I can take these irregular corneas, smooth them out, improve quality of vi- sion, and many times take these patients out of gas permeable con- tact lenses and put them in soft contact lenses, very commonly glasses, or sometimes they can see without glasses completely. “This takes refractive surgery to the next generation. Before we were doing refractive surgery to remove the need for glasses, but now we can do refractive surgery to remove the need for corneal transplantation or gas permeable contact lenses,” he said. Another example is patients who have irregular corneas from scars, which might be due to trauma or viral infection. In some cases, these scars can be removed with a laser through photothera- peutic keratectomy (PTK) 2 or a lamellar flap, created with a fem- tosecond laser. From there, the refractive error could be treated. There are also cases of corneal dystrophies, Dr. Donnenfeld said, that can be treated with PTK 3 or lamellar keratectomies. “Not only are we doing re- habilitation with excimer lasers, we’re doing rehabilitation with femtosecond lasers as well,” Dr. Donnenfeld said. On the horizon is the ability to do stromal ablations to remove stromal scars using the SMILE technique; registration systems to more accurately map the cornea and treat irregularities; lamellar inlays with human corneal tissue that won’t be rejected; use of cor- neal inlays, such as KAMRA (Cor- neaGen, Seattle), to treat higher order aberrations in irregular corneas; and using lasers to treat irregular corneas prior to cataract surgery or, conversely, IOLs to improve the contour of the lenses to suit an irregular cornea to improve refractive outcomes, Dr. Donnenfeld said. “The goal of refractive sur- gery is to be able to rehabilitate patients with normal corneas and abnormal corneas as well,” Dr. Donnenfeld said. “There are many new technologies on the horizon.” EWAP References 1. Eydelman M, et al. Symptoms and satisfaction of patients in the Patient- Reported Outcomes With Laser In Situ Keratomileusis (PROWL) studies. JAMA Ophthalmol . 2017;135:13–22. 2. Alevi D, et al. Photorefractive keratectomy with mitomycin-C for the combined treatment of myopia and subepithelial infiltrates after epidemic keratoconjunctivitis. J Cataract Refract Surg. 2012;38:1028–33. 3. Miller A, et al. Prevention of recurrent Reis- Bucklers dystrophy following excimer laser phototherapeutic keratectomy with topical mitomycin C. Cornea. 2004;23:732–5. Editors’ note: Dr. Desai has financial interests with Johnson & Johnson Vision, Alcon (Fort Worth, Texas), Novartis (Basel, Switzerland), and Bio-Tissue. Dr. Donnenfeld has financial interests with Johnson & Johnson Vision, Alcon, Bausch + Lomb (Bridgewater, New Jersey), TLC Laser Eye Centers (Mississauga, Canada), and Carl Zeiss Meditec (Jena, Germany). Dr. Durrie has financial interests with Johnson & Johnson Vision and Alcon. Contact information Desai: desaivision@hotmail.com Donnenfeld: ericdonnenfeld@gmail.com Durrie: ddurrie@durrievision.com Challenging...refractive surgery – from page 17 8