EyeWorld India March 2021 Issue

REFRACTIVE EWAP MAR C H 2021 35 How much residual astigmatism is impactful enough to correct? Dr. Wiley’s comment about patient perception comes into play here, but Dr. Berdahl said he and his team recently analyzed their data as they corrected low amounts of residual astigmatism (0.5–0.75 D) with LASIK and found it had a meaningful impact on patients’ visual acuity. Dr. Swan emphasized the importance of following the entire optical path through the eye before taking corrective action, making sure that things like dryness, lens positioning, early PCO, or low-grade CME aren’t the cause of refractive error. “Rule out all treatable causes and also rule out the potential untreatable causes that might be the real reason and don’t try to blame the astigmatism,” Dr. Wiley said. EWAP Editors’ note: Dr. Berdahl is in practice with Vance Thompson Vision, Sioux Falls, South Dakota, and has interests with Alcon, Bausch + Lomb, Johnson & Johnson Vision, and RxSight. Dr. Lee is in practice with Altos Eye Physicians, Los Altos, California, and has interests with Carl Zeiss Meditec. Dr. Ristvedt is in practice with Vance Thompson Vision, Alexandria, Minnesota, and declared no relevant financial interests. Dr. Swan is in practice with Vance Thompson Vision, Bozeman, Montana, and declared no relevant financial interests. Dr. Wiley practices at Cleveland Eye Clinic, Division of Midwest Vision Partners, and has financial interests with Alcon, Johnson & Johnson Vision, RxSight, and Carl Zeiss Meditec. a lot of skill.” Physicians have to go through training and get certified before the companies will allow them to buy an implant and use it. There are a number of training courses at the annual meetings of ASCRS, AAO, and ESCRS that can help surgeons become familiar with these devices. Dr. Srinivasan mentioned several contraindications. An artificial iris is not for patients who have a natural lens inside the eye. It would need to be combined with a phacoemulsification procedure or used in patients who are already pseudophakic. Dr. Miller said the devices are not implanted in congenital aniridics who have clear lenses. Dr. Miller said artificial irises can be used for anyone who has a large iris defect that can’t be fixed with sutures. This is a good option for these patients with large defects because very few patients can tolerate other options for the problem, which include closing the eye, patching the eye, wearing tinted glasses, or wearing a thick contact lens. From a cosmetic standpoint, Dr. Miller favors the HumanOptics product. To make the iris, you take a picture of the patient’s good eye, which the company then uses to hand paint the artificial iris. Dr. Miller noted that this FDA- approved device does not have a lens implant at this point, but devices from other companies do have a built-in optic in the pupil. He said this would be a nice advancement in the future. At this point, Dr. Miller said the primary limitation for artificial irises is the price. Another limitation is the process for matching the color of the eye. Because the iris is created from a picture sent to the company, lighting is critical. If the eye has major scarring, Dr. Miller said you may be able to notice the difference once the artificial iris is in, but for the most part, it’s hard to tell at a conversational distance. If there’s residual iris tissue in the eye, that may be darker than the implant as well. Dr. Miller said centration is another factor to be concerned about. When you’re suturing, especially with an open sky configuration, you don’t know for sure if it will be centered when the cornea is back on. If it’s not centered, it will be too late at that point, Dr. Miller said. This would be most noticeable in people with blue irises. In terms of pearls for placing the device, Dr. Miller said that every patient is unique, and there’s no cookie-cutter approach. “There’s so much pathology in these patients that surgeons who do this have to have a lot of tricks in their toolbox,” he said. Dr. Miller said that patients who receive these devices are often very happy with the outcome. “The vision is one thing, but there’s a huge psychological component when you lose a part of your facial anatomy that’s important for self-esteem and cosmesis,” he said. Reimbursement With FDA approval still being relatively new, Dr. Miller said reimbursement is difficult in that it’s inconsistent. Medicare will cover the artificial iris, but the device has to be ordered prior to surgery and paid for first. It’s then covered after the surgery is complete. Being around $8,100 out of pocket ahead of time, this can be a challenge for patients. Dr. Miller noted that there are three CPT codes associated with artificial irises: one for the artificial iris going in, one for the artificial iris plus cataract surgery, and one for an iris/ lens exchange. Almost all of these patients are getting other surgeries as well, he said, and those can be billed in addition to the base CPT code. Dr. Srinivasan also mentioned the cost factor in the U.S.; in the U.K., the artificial iris is covered. “We have to go through special permissions,” he said. This involves filling out extra paperwork to justify its use, but he said that the price of the device has been covered for all of his patients. EWAP Editors’ note: Dr. Miller is Kolokotrones Chair in Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California. Dr. Srinivasan practices at University Hospital Ayr, Ayr, UK. Neither declared any relevant financial interests. Current options in artificial irises - from page 44