EyeWorld India September 2021 Issue

REFRACTIVE EWAP SEPTEMBER 2021 33 great option in younger patients who are extremely myopic and are unable to undergo LASIK,” she said. “If their pachymetry is too thin for LASIK or PRK or if their treatment is outside the parameters of our laser, I will discuss a phakic IOL and refer these patients to a colleague who implants them.” For patients over age 50 who have no evidence of cataract and would like to have refractive surgery, Dr. Jarstad will consider LASIK with monovision, but she also counsels them on refractive lens exchange with either monovision or a multifocal or EDOF IOL. When considering LASIK vs. lens replacement, Dr. Jarstad said it’s important to look for narrow angles as this will impact the surgical plan. If the angles are narrow in an otherwise healthy eye, she prefers refractive lens exchange. “I explain to the patient that they can have bilateral PIs then LASIK (four procedures) vs. RLE (two procedures). If the anterior chamber is narrow and I can’t perform a dilated exam, I always obtain an Optos and do my best to evaluate the retina with a 90 D lens at the slit lamp to rule out retinal pathology,” she said. “I also like to get a macular OCT for my RLE patients prior to operating.” Kathryn Hatch, MD, said she uses all of these refractive surgical options for her patients, and she stressed that the decision among the three has a lot to do with a patient’s goals. For a younger phakic patient with good accommodation under the age of 45, she said lens replacement surgery is not typically used, though she noted there may be some occasional outliers. Dr. Hatch usually offers lens replacement surgery for patients age 55 and older, but it also depends on the prescription. “I have plenty of patients between age 50 and 65 who can have laser vision correction and do great with that,” she said. Once they’re over 65, most patients have some form of cataract, and it makes sense to do lens replacement at that age, she said. For patients with high degrees of hyperopia, Dr. Hatch said you have to be careful about doing laser vision correction because these patients can lose visual quality, and outcomes become less predictable. Older presbyopic hyperopes are good potential candidates for lens replacement, she said. “In my practice, with phakic IOLs, I’m typically offering those for extreme myopes or myopic astigmatism or people who aren’t good candidates for laser vision correction,” Dr. Hatch said. “I’ll mention it to a higher myope, but I’m not usually offering it for moderate myopia.” If she had a high myope with a slightly irregular cornea and didn’t want to do laser surgery, she thinks a phakic IOL is a great alternative. She stressed the role patient’s goals play in the decision- making process. Dr. Hatch added that there is a cost factor as well. Phakic IOLs and lens-based surgery are much more costly. Though she tries to focus on what the best option for the patient would be, if the patient is a candidate for multiple procedures, she tries to make a custom recommendation for each patient. Dr. Hatch said it’s also important to know which options will not work with certain conditions. A shallow anterior chamber, keratoconus, and nanophthalmic eyes, for example, can be contraindications for some procedures. Comparing the procedures, Dr. Hatch stressed that with lens surgery, there are presbyopia options. If you’re doing a phakic IOL or laser vision correction, you’re not treating presbyopia, so monovision can be explored. Phakic IOLs preserve the cornea, but you’re putting an implant in the eye that could increase the risk for cataracts or pressure issues related to sizing of the ICL. With the new ICL models on the horizon, this risk will be significantly reduced, she said. She added that IOL surgery is a one-time surgery, but if you do laser vision correction on someone, they’ll need IOL surgery in the future. “That probably doesn’t matter to patients under 40, but once you start talking about the pre-cataract group, that might be something to think about,” she said. “We have all these amazing technologies that give us great results,” Dr. Hatch said. “But I do think the patient wants you to tell them what they should have. They appreciate a recommendation. They know what they want the results to be, and it’s our job to pick the procedure that best aligns with their expectations and goals.” EWAP Editors’ note: Dr. Hatch is Assistant Professor of Ophthalmology, Harvard Medical School, Boston, Massachusetts, and has interests with Carl Zeiss Meditec and Johnson & Johnson Vision. Dr. Jarstad practices at SoCal Eye, Long Beach, California, and disclosed no relevant financial interests. Dr. Trattler practices at Center for Excellence in Eye Care, Miami, Florida, and has interests with Alcon, Bausch + Lomb, BVI, and Johnson & Johnson Vision.