EyeWorld India September 2018 Issue

EWAP REFRACTIVE 47 September 2018 When to consider an enhancement According to Dr. Chang, patients dictate when an enhancement is necessary. “I let patient satisfac- tion drive things. If patients are happy with their refractive state after surgery, I call it good. Even with all of the technology we have for preoperative and intraopera- tive measurements, there are still variables that can prevent us from hitting our refractive target, but patient happiness is always my primary goal,” he said. Dr. Chang doesn’t have a numerical threshold for enhance- ments; it is mostly determined by patient satisfaction and their appreciation of the potential im- provement with a refractive correc- tion. “If a patient’s uncorrected vi- sion is 20/40 and I do a refraction to 20/20, patients typically notice the difference. If it’s a smaller improvement, I’ll sometimes give them a prescription for glasses to wear temporarily to see if they like that improvement. I occasion- ally even do a contact lens fit to demonstrate whether a refractive correction will make a difference. I use this approach in subtler cases where I’m not sure the refractive error is the entire problem because there may be other issues involved. Most commonly, I choose laser vision correction as my enhance- ment technique,” he said. Dr. Chang said his enhance- ment rate is in the single digits. “I have not needed to perform many enhancements. If you counsel patients thoroughly, if you set expectations correctly, if you are meticulous about your preopera- tive measurements, and if you do good surgery, most patients do well and won’t need an enhancement. However, everyone has a differ- ent threshold for enhancement. I typically wait at least 3 months to make sure I have a stable refraction before considering an enhance- ment,” he said. Dr. Koch said it is impor- tant to explain to patients when they initially present for cataract evaluation that they may need an enhancement postoperatively. “However, we also need to explain that there are some small adjustments that could make things worse. If a patient is off by 0.5 D or more, you may or may not want to do something, particu- larly if it’s on the hyperopic side, because the predictability of the procedure might not be as good as you want, and you could make the patient’s vision worse. You need to set expectations for the original outcome and for the indications for doing additional steps,” he said. Enhancement strategies Dr. Schallhorn’s enhancement strategy depends on the patient’s refractive error. “If the patient has a significant deviation in his or her refractive error, some type of intraocular procedure might be the best option. For example, if the patient has a toric IOL that is not well aligned and there is visually disturbing astigmatism, rotating the toric lens might be the most appropriate procedure. Or if there is a considerable deviation in the sphere (postop surprise), either exchanging that IOL or a piggy- back IOL may be the best option. The best enhancement procedure depends on the residual refractive error,” he said. Dr. Koch will use relaxing inci- sions in patients with astigmatism and spherical equivalent within 0.25 D of plano. “Otherwise, I do PRK. LASIK is also great, and patients love the fact that they get their vision back early, but you have be wary of inducing a dry eye,” he said. Another option is IOL exchange. “In my premium patients, I have always been able to address prob- lematic residual refractive errors with corneal procedures, but an IOL exchange may be the best op- tion for anything outside the range of +1 on the hyperopic side and –2 on the myopic side. I will also con- sider a lens exchange if the patient feels like the wrong lens is in his or her eye. Sometimes it’s a psycho- logical issue,” Dr. Koch said. EWAP Editors’ note: Dr. Koch has financial interests with Alcon (Fort Worth, Texas), Carl Zeiss Meditec (Jena, Germany), Johnson & Johnson Vision (Santa Ana, California), and Perfect Lens (Irvine, California). Dr. Schall- horn and Dr. Chang have financial interests with Carl Zeiss Meditec. Contact information Chang: dchang@empireeyeandlaser.com Koch: dkoch@bcm.edu Schallhorn: steve.schallhorn@zeiss.com