CASE PRESENTATION
A 36-year-old man has never been able to wear contact
lenses despite numerous attempts. His manifest refraction is
-14.5 +4.5 X 92 OD and -13 +3.5 X 100 OS. Pachymetry
measures 579 μm OD and 578 μm OS. The slit-lamp and
fundus examinations are normal, as is the patient’s intraocular
anatomy. He would like to discuss his refractive surgical
options (Figure 1).
JAY BANSAL, MD
In my opinion, this patient has three viable
options, all requiring an extensive discussion of
their risks and benefits:
- Visian ICL or TICL (both from STAAR
Surgical Company, Monrovia, CA; TICL not available
in the United States) followed by LASIK - refractive lens exchange with a toric IOL,
probably followed by LASIK - wavefront-optimized LASIK with femtosecond
laser-created flap
Given his age, the patient has to decide
between an intraocular (IOL or ICL) and an
extraocular (LASIK) procedure. Optically, the former
will yield better results but at a greater risk
(eg, cataract, presbyopia, retinal detachment,
infection) compared with LASIK.
After an extensive discussion, I am comfortable
treating this type of patient with wavefrontoptimized
LASIK using a thin flap (100 μm) created
with a femtosecond laser. If the patient had
6-mm pupils, I would perform the ablation with a
6-mm optical zone instead of 6.5 mm to save stromal
tissue. Prior to LASIK, I would counsel this patient
about alternative options for treatment (ICL
and IOLs) available now and what I believe will be
available in the near future. I would further advise
him regarding the unlikelihood of any future enhancements
after the LASIK procedure. It would
also be important to counsel him regarding his
increased risk of dry eyes, decreased contrast sensitivity,
and halos/glare. Finally, he would need to
be aware that he might still require a small prescription
for spectacles/contacts for optimal visual
acuity postoperatively.
The majority of patients in my practice elect to
proceed with wavefront-optimized LASIK and
achieve good results. Thus far, my younger
patients have shown little interest in an intraocular
procedure, but this may change in the near
future.
KEITH LIANG, MD
Assuming the patient has an appropriate anterior chamber
depth (> 3.5 mm with the IOLMaster [Carl Zeiss
Meditec, Inc., Dublin, CA]) and a white-to-white measurement
greater than 11.5, I would recommend a Visian ICL
and laser vision correction as a two-staged procedure. His
topography looks normal, with some of his astigmatism
located within the lens. It is the amount of astigmatism that
necessitates laser vision correction.
The first stage of the procedure would include meticulous
measurements for the ICL. I would measure the white
to white under a microscope and use calipers, since this
information is critical to the lens’ sizing. I would try to place
an ICL of -10.00 D or lower. This would allow the ICL’s optic
to be 5.8 mm, giving the patient the largest corneal effective
optical zone of 7.30 mm. Since he will require laser vision
correction, any residual myopia can be addressed along with
his astigmatism. I would perform a YAG peripheral iridotomy
1 to 2 weeks preoperatively and offer same-day sequential
ICL surgery.
The second stage would occur 6 to 8 weeks after the ICL’s
implantation. The choice of wavefront-optimized or wavefront-
guided LASIK/PRK would depend on the patient’s
optical aberrations after ICL surgery. In my experience, the
Allegretto Wave Eye-Q excimer laser system (Alcon
Laboratories, Inc., Fort Worth, TX) has no problem tracking
eyes that have ICLs. The patient’s steep keratometry readings
are optimal for myopic laser correction. This second
stage would allow me to correct any myopic surprises from
the ICL calculations, which is why I would create the largest
effective optical zone with the ICL and maintain that zone
with a correction for low myopic astigmatism.
The patient’s expectations would have to be addressed,
because a two-staged procedure will require some patience.
I would discuss his risks and benefits and allow a retinal surgeon
to examine him prior to surgery. Even with the Visian
TICL, this patient might require a two-staged procedure due
to his high astigmatism.
DAVID A. WALLACE, MD
If the topography and pachymetry are as stated, and if in
all other respects this patient would be a good candidate for
the Visian ICL (endothelial cell count, anterior chamber
depth, etc.), then I would be enthusiastic about two possible
options. First would be bioptics with the ICL followed by
LASIK, an approach I have used with modest frequency for
patients exactly like this one. The second alternative, in principle,
would be the Visian TICL. I now create the LASIK flap
before implanting the ICL (sometimes on the day of the
laser peripheral iridotomy). Two to 4 weeks after placing the
ICL, I lift the flap and treat the patient’s residual refractive
error.
I am in the habit of imaging the anterior and posterior
surfaces of all laser refractive candidates. I would therefore
obtain a study with either the Orbscan topographer
(Bausch + Lomb, Rochester, NY) or the Pentacam
Comprehensive Eye Scanner (Oculus, Inc., Lynnwood, WA)
to complete his workup. For surgical planning, I would
prefer to use a high-frequency ultrasonic instrument to
determine a sulcus-to-sulcus measurement for ICL sizing.
Sizing based on any white-to-white measurement does not
always correlate perfectly with the sulcus-to-sulcus measurement.
MING WANG, MD, PHD
The patient has normal corneal thickness and
corneal topography. Assuming good ocular health, a
stable refraction, and good BCVA, the patient has two
options if he is motivated and understands their risks
and potential complications. The first is refractive lens
exchange with a limbal relaxing incision (LRI) and the
placement of a toric IOL. The second is implantation
of the Visian ICL, with or without an LRI, followed by
a planned LASIK/PRK procedure.
Typically, a small number of my patients choose
refractive lens exchange. I would discuss with this
patient the risks, including a slightly increased
chance of retinal detachment due to his high
myopia. If he elected to proceed, I would ensure that
the patient understood that he might subsequently
require a keratorefractive procedure to address his
astigmatism. I would also explain that the best surgical
endpoint would be plano for the dominant eye
and -1.25 D for the nondominant eye, and I would
conduct a contact lens monovision trial if needed. In
terms of surgery, I would extract the crystalline lens,
create an LRI, and implant a toric IOL.
If the patient chose instead to receive a phakic IOL,
I would explain that the Visian TICL may become
available late this year or next year and suggest that
waiting would be an excellent option. If he wished to
proceed immediately with surgery and he were
strongly motivated to undergo ICL surgery now, I
would determine his candidacy for the lens (in terms
of anterior chamber depth, etc.). I would also discuss
with him the risks of ICL surgery, which include the
need for subsequent keratorefractive surgery to correct
residual spherical error and astigmatism in addition
to the routine risks of endophthalmitis, cataract,
glaucoma, etc.
The astigmatic treatment plan and ICL power calculation
depend on whether or not the surgeon performs
an LRI at the time of the ICL’s implantation. I
generally do, which reduces the amount of tism requiring subsequent correction by LASIK/PRK
and thus increases the laser procedure’s precision
and accuracy.
In this case, I would perform an LRI to debulk the
cylinder during the ICL surgery and target a postoperative
spherical equivalence that was either equal to
zero (eg, -2.25 +4.50 cylinder and -1.75 +3.50 cylinder)
or a bit more minus (eg, -4.50 +4.50 cylinder and -3.50
+3.50 cylinder). The reason is that spherical values of
opposite signs tend to cover up the cylinder. The efficacy
of refractive surgery for such eyes (where the
magnitude of the sphere is at least equal to that of the
cylinder) is much better than for mixed astigmatism,
where the magnitude of the cylinder is much larger
than that of the sphere. It is important to keep in
mind that the LRI does not change spherical equivalence.
Section Editor Stephen Coleman, MD, is the director of
Coleman Vision in Albuquerque, New Mexico. Parag A.
Majmudar, MD, is an associate professor, Cornea Service,
Rush University Medical Center, Chicago Cornea
Consultants, Ltd. Karl G. Stonecipher, MD, is the director
of refractive surgery at TLC in Greensboro, North
Carolina. Dr. Stonecipher may be reached at (336) 288-
8523; stonenc@aol.com.
Jay Bansal, MD, is the medical director of
LaserVue Eye Center in Santa Rosa,
California. He acknowledged no financial
interest in the products or company he mentioned.
Dr. Bansal may be reached at (707)
522-6200; bansal@laservue.com.
Keith Liang, MD, is the medical director at
Center for Sight in Sacramento, California.
He acknowledged no financial interest in the
products or companies he mentioned.
Dr. Liang may be reached at (916) 446-2020;
kliang@liangvision.com.
David A. Wallace, MD, has acknowledged no financial interest in the
products or companies he mentioned.
Ming Wang, MD, PhD, is the international
president of Shanghai Aier Eye Hospital, a
clinical associate professor of ophthalmology
at the University of Tennessee, and the director
of the Wang Vision Cataract and LASIK
Center in Nashville, Tennessee. He acknowledged no
financial interest in the products or companies he mentioned.
Dr. Wang may be reached at (615) 321-8881.
