 | | Clinical News Live from the 4th Annual Regional Meeting of the International Society of Refractive Surgery of the American Academy of Ophthalmology (ISRS/AAO) in Cancun, Mexico
FRIDAY, MAY 30, 2008 |
Editor-in-Chief: H.Dunbar Hoskins Jr., MD | Managing Editor: Susanne Medeiros
Advisory Panel: Andrew Iwach, MD, Terry L. Forrest, MD, Jean E. Ramsey, MD,
Franco M. Recchia, MD, James C. Tsai, MD and Helen K. Wu, MD
ISRS/AAO’s fourth Annual Regional Meeting attracted physicians from 24 countries, from Sudan and Turkey to Taiwan and the Philippines. This year’s meeting in Cancún, México, is held in partnership with the Asociación Latina de Cirugia de Catarata Refractiva y Segmento Anterior (ALCRS) and the Centro Mexicano de Cornea y Cirugia Refractiva (CMCCR).
Laser-created multifocal cornea is a viable option for treating presbyopia “I love controversy,” said Gustavo E. Tamayo, MD, as he began his talk here on using presby-LASIK to produce a multifocal cornea to correct presbyopia plus any refractive defect. “Yes, we can create a multifocal cornea with a specially designed excimer laser ablation shape, and it is another option for inducing multifocality.” Dr. Tamayo, director of the Bogota Laser Refractive Institute, said that creating a multifocal cornea is a better option than multifocal lenses in younger patients because it is a non-invasive procedure. It’s also easier to reverse because the multifocality of the cornea can be erased with a wavefront laser treatment. He believes lens-exchange surgery in patients under 55 or 60 is inadvisable. Presby-LASIK is a group of LASIK techniques that aim to increase depth of field in presbyopic eyes by creating multifocality in both eyes through a central, peripheral or transitional multifocal excimer laser ablation. Dr. Tamayo presented his results using a treatment that consisted of the correction of the refractive error with the Visx Star S4 CustomVue with iris registration (AMO), plus the addition of multifocal ablation. The myopia/presbyopia group included 48 patients with a mean age of 54.9 years and a mean spherical equivalent of -3.75. At follow-up, mean 36.4 months, 93 percent of eyes could see J3 or better uncorrected for near, and 95 percent could see 20/25 or better uncorrected for distance. No patients lost lines of BCVA.
The hyperopia/presbyopia group included 30 patients with a mean age of 52 years. At follow-up, mean six months, 85 percent of eyes could see 20/20 uncorrected for distance, and all patients could see 20/40 or better. For near, 85 percent could see J1 uncorrected and 96 percent J5 or better. No eye lost more than two lines of BCVA. Dr. Tamayo said patient acceptance of this technique is good, with a 93 percent satisfaction rate. Still, patients experience some visual symptoms similar to multifocal IOLs, such as decreased contrast sensitivity, glare and halos at night. But these symptoms begin to disappear at three to six months. Despite the complaints, he said most patients are very happy because they can see well at distance and do not need glasses for near. In another presentation; however, Ricardo Trigo, MD, professor of ophthalmology at the Universidad Popular Autonoma del Estado de Puebla, said he was skeptical about the duration of the treatment effect, since most studies don’t have a published follow-up of more than six months. “I don’t know how long it will last,” he said. Dr. Tamayo is a consultant to AMO and Moria Back to Top
Vast majority of complications from refractive surgery can be fixed Today, most complications from refractive surgery can be managed easily, said Marguerite B. McDonald, MD, and president of ISRS/AAO, who provided an overview of how to treat complications of refractive surgery. Dry eye remains the single most common post-LASIK complication. In addition to cyclosporine emulsion, artificial tears and nutritional supplements, there are several new therapies now available, or will be available soon: - Diquafosol tetrasodium, which should be available soon, is a potent and selective agonist at P2Y2 receptor that promotes secretion of ions, fluid, mucin, and surfactant on the mucosal surface
- Form Fit plugs from OASIS Medical. These are one-size-fits-all dehydrated hydrogel punctual plugs that swell to 20 times their original size after insertion
- Lacriserts (Aton Pharma), small pellets of hydroxypropyl methylcellulose that are tucked inside the lower lid. They dissolve slowly over 24 hours to form artificial tears
- Tears Again Liposome Spray (OcuSoft). A phospholipid-containing liposome spray to decrease evaporation of the tears
For lenticular procedures, complications such as residual and induced astigmatism, as well as significant IOL power errors can all be treated with laser vision correction, especially surface ablation. Dr. McDonald recommends: - Wavefront-based PRK for conventional and diffractive IOLs
- Conventional PRK for refractive IOLs
- When in doubt, use conventional PRK
Though less critical with conventional IOLs, decentration must be fixed in patients with premium IOLs. Dr. McDonald described a nifty trick from her colleague Erik Donnenfeld, MD, that can be helpful in fixing a decentered IOL – argon laser iridoplasty. He uses four, 500 milliwatt, 500 micron diameter spots of 0.5 second duration, placed in the mid-periphery of the iris from 12 o’clock to 3 o’clock. The indications for using argon laser iridoplasty: - IOL not centered on pupil and patient has glare and halo unresponsive to treatment
- Patient with IOL not centered on pupil and patient having excimer laser enhancement
- Poor near vision in patient with ReZoom IOL and small pupil.
For glare and haloes after premium IOLs, Dr. McDonald suggested using Alphagan P (brimonidine) used tid prn, which can be helpful during the neuroadaptation period because is makes the pupil ¼ to ½ mm smaller during the day, and prevents dilation at night. For poor near and intermediate uncorrected visual acuity in a patient implanted with a premium IOL, Dr. McDonald suggests going conservative. Conductive keratoplasty will provide the best near UCVA with least loss of distance UCVA. In refractive surgery today, serious complications are rare, and the vast majority of complications are either fixable or soon will be, said Dr. McDonald. Dr. McDonald’s financial disclosures include: AMO, Alergan, Bausch & Lomb, Inspire Pharmaceuticals, Essilor, OASIS Medical and Santen Back to Top
Patient with keratoconus has good outcome following toric IOL implantation Alejandro Navas Perez, MD, of Mexico City, Mexico, described a 55-year-old man whose topography and Scheimpflug images were consistent with forme fruste keratoconus. Because his vision (UCVA 20/400 and 20/800, respectively) was stable and he had non-progressive forme fruste keratoconus, Dr. Navas and his colleagues decided to perform phacoemulsification implanting a toric IOL in his right eye and an aspheric IOL in his left eye. Two months after surgery, UCVA in the left eye was 20/25. Two weeks after the right eye was implanted with the toric lens, UCVA was 20/20 with a refraction of plano. Dr. Navas said that although further follow-up is required to evaluate the possibility of rotation, the patient reports being very satisfied with his vision in both eyes. Back to Top
Femtosecond laser has made surgery fun – again In a discussion here about the nonrefractive applications of femtosecond laser technology, Ramon Naranjo-Tackman, MD, professor of ophthalmology at the Universidad Nacional Autonoma de Mexico, explained how it has evolved from making incisions for LASIK and channels for intracorneal segments to become a very precise instrument with an increasing number or applications in corneal surgery. But more than that, he said “It has given me something – a chance to play.” He also believes it will allow surgeons to go much deeper into the eye, as deep as the lens. Ronald R. Krueger, MD, medical director of refractive surgery at the Cole Eye Institute Cleveland Clinic, who was moderating the discussion, agreed, saying “It is a revolution in ophthalmology and its being unveiled in front of us.” Dr. Krueger suggested that in the future the femtosecond laser may also have a place in vitreoretinal surgery. Dr. Naranjo’s financial disclosures include: AcuFocus, Alcon and IntraLase Back to Top
Best Paper Award winners Section I: Phakic IOLs
Alejandro Navas Perez, MD, Toric IOL in Patient
with Keratoconus Section II: Presbyopia
Ricardo Trigo, MD: Can We Really Recommend
Corneal Photoblation to Treat Presbyopia? Section III: Accomodating IOLs
Jose M. Vargas, MD: Accomodative IOLs Update Section IV: Surgical Complications - Cataract
Daniel A. Badoza, MD: Anterior Capsular Tear Extending to the Posterior Capsule in Intumescent Cataract Section V: Femtosecond Lasers
Steven E. Wilson, MD: LASIK-Induced Dry Eye With the Microkertome vs. Femtosecond LASIK Section VI: Surgical Complications - Refractive
Marguerite B. McDonald, MD: Treating the Complications of Refractive Surgery Section VII: Caring for the Complicated, Post-Refractive Patient
Thomas E. Clinch, MD: Intacs Intracorneal Ring Segments for Treatment of Post-LASIK Ectasia Section VIII: What Now, How to Deal with the Future
Carlos Buznego, MD: A New Approach to Combined Cataract and Glaucoma: An Ab Interno Approach Section IX: Hot, Hotter, Hottest: Late Breaking News
Renato Ambrosio Jr., MD: Corneal Tomography and Biomechanics: New Concepts for Screening for Ectasia and Its Susceptibility Back to Top
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