EDITORIAL URRENT C OPINION
Changing trends in keratorefractive surgery Jimmy K. Lee a,b and Roy S. Chuck a,b
There has been a seismic shift in the approach to guiding patients toward spectacle or contact lens independence. Traditional cornea-based laser refractive surgery has always delivered outstanding outcomes. However, intraocular lens (IOL)-based procedures are reaching levels of accuracy that is quickly approaching comparable postoperative visual acuity outcomes. Given the plethora of surgical options, there is something for almost everyone with a refractive error. Recent developments, in technology and techniques, are allowing us to make our recommendations based on the refractive error and age, in which presbyopia is of paramount concern. First is an update on indications or contraindications for corneal laser refractive surgery. Drs Kraig Bower and Fasika Woreta provide the latest US Food and Drug Administration (FDA) indications, contraindications, warnings, and precautions as well as providing the latest American Academy of Ophthalmology’s Guidelines for LASIK and PRK. Their review of the literature reveals that these procedures may be offered to a wider patient base, including those with well controlled glaucoma, diabetes, dermatologic conditions, or those with HIV on antiretroviral treatment. However, as corneal refractive surgery is becoming popularized, one has to be cautious of its ramifications. Much attention have been directed to how corneal curvature effects IOL power calculations; however, Drs Wen-Jeng Yao and Alessa Crossan bring to light how corneal refractive surgery may give inaccurate intraocular pressure readings when measured by the most popular current method, Goldman applanation tonometry. In their review, the authors suggest that dynamic contour tonometry or Tonopen may have greater utility in accurately measuring IOP after laser ablative surgery. In their review of one of the most important concerns in patients undergoing LASIK or PRK, Drs Debora Garcia-Zalisnak, David Nash, and Elizabeth Yeu Lin expound on the importance of addressing the ocular surface, highlighting the role of metalloproteinase, especially MMP-9, and inhibiting them to ameliorate ocular surface disease. The same authors profile a novel secretagogue, diquafosol tetrasodium solution for the treatment of postLASIK dry eye disease.
Drs Marcony R. Santhiago, Newton Kara-Junior, and George Waring IV revisit the age old debate of microkeratome versus femtosecond flaps. Their review concludes that the latter provides greater precision in flap diameter and thickness and also responds to critics of the femtosecond platform that blame complications derived from the higher inflammatory response from the laser. In their review, the authors highlight recent studies that reveal that the newer generation of femtosecond laser platforms allow for much lower energy settings that reduce the risk for diffuse lamellar keratitis or transient light-sensitivity syndrome. Another major advantage of femtosecond laser, as Dr Neeti Parikh points out, is the ability to make flap side cuts, recuts, and mini flaps for retreatments, which is not common, but certainly a possibility after laser refractive surgery. Along the theme of troubleshooting or managing residual refractive error, Dr Bryan Lee discusses accuracy and stability of hyperopic treatments, both from a corneal and intraocular surgical approach. Highlighted by both authors is the emerging role of corneal cross-linking in stabilizing hyperopic regression or stabilizing postrefractive surgery ectasia. The fact that there are numerous options of addressing the same refractive error is illustrated by Dr Jimmy Lee’s update on astigmatism management. Whereby in a prepresbyope, corneal laser refractive surgery is highly reliable, for a patient with cataracts, lens extraction with a toric implant or a presbyopia-correcting IOL with peripheral corneal relaxing incisions are viable options. In fact, one of the growing trends is offering intraocular surgery as the first option for correction of refractive error. Refractive lens exchanges, however controversial, are not uncommon, and the popularization of femtosecond laser for cataract surgery has pushed not only the surgeons but also
a Albert Einstein College of Medicine and bMontefiore Medical Centre, Bronx, New York, USA
Correspondence to Jimmy K. Lee, Department of Ophthalmology and Visual Sciences, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA. E-mail: [email protected] Curr Opin Ophthalmol 2014, 25:249–250 DOI:10.1097/ICU.0000000000000078
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Refractive surgery
the patients to demand lens-based procedures to standards and expectations of LASIK or PRK. Although advancements in preoperative measurements, intraoperative confirmation of refractive error, and improvements in IOL technologies have allowed surgeons to live up to the expectations of patients, residual refractive error is still a reality. Drs Jorge Alio, Ahmed Abdelghany, and Roberto Fernandez-Buenaga review the latest in managing residual refractive error after cataract surgery. As found by other reviewers, these authors also conclude that LASIK or PRK is the most accurate procedure to correct residual refractive error after cataract surgery. However, in situations where the cornea is not suitable for additional surgery, or if the laser platform is not available, the authors report that exchanging or piggybacking IOLs are also viable options, with the latter being safer and more accurate.
250
www.co-ophthalmology.com
This issue of Current Opinion in Ophthalmology highlights a paradigm shift in relying more on IOLbased surgery as a primary option for correcting refractive errors. The melding of diagnostics and surgical tools from traditional refractive surgery, such as topography, tomography, aberrometry, and femtosecond laser platforms into the realm of cataract surgery, are equipping surgeons with various combination approaches to tackling refractive errors. The rate at which these new technologies are entering the market is an indication that the best days of being able to meet patients’ expectations are ahead of us. Acknowledgements Research to Prevent Blindness, unrestricted departmental grant award. Conflicts of interest There are no conflicts of interest.
Volume 25 Number 4 July 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Changing trends in keratorefractive surgery Jimmy K. Lee a,b and Roy S. Chuck a,b
There has been a seismic shift in the approach to guiding patients toward spectacle or contact lens independence. Traditional cornea-based laser refractive surgery has always delivered outstanding outcomes. However, intraocular lens (IOL)-based procedures are reaching levels of accuracy that is quickly approaching comparable postoperative visual acuity outcomes. Given the plethora of surgical options, there is something for almost everyone with a refractive error. Recent developments, in technology and techniques, are allowing us to make our recommendations based on the refractive error and age, in which presbyopia is of paramount concern. First is an update on indications or contraindications for corneal laser refractive surgery. Drs Kraig Bower and Fasika Woreta provide the latest US Food and Drug Administration (FDA) indications, contraindications, warnings, and precautions as well as providing the latest American Academy of Ophthalmology’s Guidelines for LASIK and PRK. Their review of the literature reveals that these procedures may be offered to a wider patient base, including those with well controlled glaucoma, diabetes, dermatologic conditions, or those with HIV on antiretroviral treatment. However, as corneal refractive surgery is becoming popularized, one has to be cautious of its ramifications. Much attention have been directed to how corneal curvature effects IOL power calculations; however, Drs Wen-Jeng Yao and Alessa Crossan bring to light how corneal refractive surgery may give inaccurate intraocular pressure readings when measured by the most popular current method, Goldman applanation tonometry. In their review, the authors suggest that dynamic contour tonometry or Tonopen may have greater utility in accurately measuring IOP after laser ablative surgery. In their review of one of the most important concerns in patients undergoing LASIK or PRK, Drs Debora Garcia-Zalisnak, David Nash, and Elizabeth Yeu Lin expound on the importance of addressing the ocular surface, highlighting the role of metalloproteinase, especially MMP-9, and inhibiting them to ameliorate ocular surface disease. The same authors profile a novel secretagogue, diquafosol tetrasodium solution for the treatment of postLASIK dry eye disease.
Drs Marcony R. Santhiago, Newton Kara-Junior, and George Waring IV revisit the age old debate of microkeratome versus femtosecond flaps. Their review concludes that the latter provides greater precision in flap diameter and thickness and also responds to critics of the femtosecond platform that blame complications derived from the higher inflammatory response from the laser. In their review, the authors highlight recent studies that reveal that the newer generation of femtosecond laser platforms allow for much lower energy settings that reduce the risk for diffuse lamellar keratitis or transient light-sensitivity syndrome. Another major advantage of femtosecond laser, as Dr Neeti Parikh points out, is the ability to make flap side cuts, recuts, and mini flaps for retreatments, which is not common, but certainly a possibility after laser refractive surgery. Along the theme of troubleshooting or managing residual refractive error, Dr Bryan Lee discusses accuracy and stability of hyperopic treatments, both from a corneal and intraocular surgical approach. Highlighted by both authors is the emerging role of corneal cross-linking in stabilizing hyperopic regression or stabilizing postrefractive surgery ectasia. The fact that there are numerous options of addressing the same refractive error is illustrated by Dr Jimmy Lee’s update on astigmatism management. Whereby in a prepresbyope, corneal laser refractive surgery is highly reliable, for a patient with cataracts, lens extraction with a toric implant or a presbyopia-correcting IOL with peripheral corneal relaxing incisions are viable options. In fact, one of the growing trends is offering intraocular surgery as the first option for correction of refractive error. Refractive lens exchanges, however controversial, are not uncommon, and the popularization of femtosecond laser for cataract surgery has pushed not only the surgeons but also
a Albert Einstein College of Medicine and bMontefiore Medical Centre, Bronx, New York, USA
Correspondence to Jimmy K. Lee, Department of Ophthalmology and Visual Sciences, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA. E-mail: [email protected] Curr Opin Ophthalmol 2014, 25:249–250 DOI:10.1097/ICU.0000000000000078
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Refractive surgery
the patients to demand lens-based procedures to standards and expectations of LASIK or PRK. Although advancements in preoperative measurements, intraoperative confirmation of refractive error, and improvements in IOL technologies have allowed surgeons to live up to the expectations of patients, residual refractive error is still a reality. Drs Jorge Alio, Ahmed Abdelghany, and Roberto Fernandez-Buenaga review the latest in managing residual refractive error after cataract surgery. As found by other reviewers, these authors also conclude that LASIK or PRK is the most accurate procedure to correct residual refractive error after cataract surgery. However, in situations where the cornea is not suitable for additional surgery, or if the laser platform is not available, the authors report that exchanging or piggybacking IOLs are also viable options, with the latter being safer and more accurate.
250
www.co-ophthalmology.com
This issue of Current Opinion in Ophthalmology highlights a paradigm shift in relying more on IOLbased surgery as a primary option for correcting refractive errors. The melding of diagnostics and surgical tools from traditional refractive surgery, such as topography, tomography, aberrometry, and femtosecond laser platforms into the realm of cataract surgery, are equipping surgeons with various combination approaches to tackling refractive errors. The rate at which these new technologies are entering the market is an indication that the best days of being able to meet patients’ expectations are ahead of us. Acknowledgements Research to Prevent Blindness, unrestricted departmental grant award. Conflicts of interest There are no conflicts of interest.
Volume 25 Number 4 July 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
