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Say Anything | Sept 2020

Say Anything: CRST Readers Share Their Strategies for Getting Refractive Surgery Patients to 20/10

Karl G. Stonecipher, MD <br/> Clinical Associate Professor of Ophthalmology, University of North Carolina, Chapel Hill

Karl G. Stonecipher, MD
Clinical Associate Professor of Ophthalmology, University of North Carolina, Chapel Hill

I always say you must start with the basics because what goes into the laser is what comes out of the laser. In my clinic, we always repeat the refraction and the diagnostics on the day of surgery. We have only two refractionists who do these measurements, and we do them in only two rooms that are FDA-calibrated lanes. We are also aggressive when treating ocular surface disease, which we see in roughly 38% of patients in our practice. Remember, many patients come to us because they cannot wear their contact lenses successfully anymore.

We also keep meticulous records of our outcomes data. If you do not analyze your outcomes, you can never improve. The human cornea is not a piece of plastic, and the environments we operate in are not static.

Our current preferred treatment involves using the WaveLight FS200 (Alcon) femtosecond platform combined with the WaveLight EX500 (Alcon) excimer laser system. For more than 8 years, we have combined these systems (or earlier editions) to perform LASIK and have published several articles attempting to develop a strategy to produce better than 20/20 outcomes.1-5

Our center participated in the original FDA trial for the approval of topography-guided custom ablation (TCAT). In that trial, 20/10 and 20/12 UCVAs were achieved in 15.7% and 34.4% of patients, respectively, at 1 year. However, these were patients with normal corneas, and, when TCAT launched commercially, many users found that they were not attaining these same levels of UCVA in their patient populations. In a more normal patient population, Stulting et al showed that, with TCAT LASIK, roughly 7% of patients achieved 20/10 vision at 3 months, increasing to 16% at 1 year.6

Two recent multicenter studies showed that, using a new topography-guided analytic engine, we could obtain TCAT-like LASIK results in a standard laser vision correction population.7-9

In my opinion, with topography-guided analysis and aggressive data collection to reach deep learning in terms of numbers, we can slowly move our patients to levels of vision never expected before.

I now have three patients with 20/8 vision using the aforementioned methods."

Edward Manche, MD <br/>Director of Cornea and Refractive Surgery, <br />Stanford Laser Eye Center, Stanford, California

Edward Manche, MD
Director of Cornea and Refractive Surgery,
Stanford Laser Eye Center, Stanford, California

Several factors contribute to excellent visual acuity after refractive surgery. It is important to screen and select appropriate candidates preoperatively. The ocular surface should be in pristine condition to obtain high-quality, reproducible measurements.

I always perform custom keratorefractive surgery using both wavefront- and topography-guided ablations. It is crucial to have accurate measurements preoperatively to achieve the most accurate refractive outcomes. My preferred method of either PRK or LASIK is wavefront-guided surgery using the high-resolution iDesign aberrometer (Johnson & Johnson Vision). The beauty of the high-resolution aberrometer is that the refractive error is determined objectively, unlike the subjective phoropter-based refractive error measurement used in conventional or wavefront-optimized surgery. I also use topography-guided ablations in a smaller subgroup of patients. The topographic measurements are automated, but you still need to use the subjective manifest refraction.

In my hands, I achieve the best UCVA outcomes using these two technologies. Both have the potential of providing 20/10 outcomes for patients undergoing LASIK and PRK."

Asim R. Piracha, MD <br/> Medical Director, <br />John-Kenyon Eye Center, Louisville, Kentucky

Asim R. Piracha, MD
Medical Director,
John-Kenyon Eye Center, Louisville, Kentucky

We obsess over exact refractions and flawless workups to achieve more perfect outcomes since our treatments are based on this data. We measure the angle kappa and treat the visual axis or line of sight rather than the pupil center with laser vision correction; this is especially important in hyperopic treatments. We also measure the angle alpha and avoid premium IOLs if the chord µ is high to improve uncorrected near vision and to reduce the risk of night vision disturbances. If patients have reduced BCVA, we identify the cause and choose surgical solutions to improve their postoperative BCVA and UCVA. For instance, if a patient has dysfunctional lenses, we choose refractive lens exchange to correct their refractive error; if they have irregular astigmatism or significant corneal higher-order aberrations, we choose topographic laser vision correction to achieve better outcomes.

It’s important to offer more than just LASIK, too. The ability to offer the best procedure for each patient can help optimize outcomes by staying within the sweet spot for each procedure offered. We offer PRK, LASIK, SMILE, refractive lens exchange, and phakic IOLs so that we can choose the best procedure for each patient. To achieve the best outcomes consistently, we standardize the surgical technique and use the best equipment available. We also track all our data and continuously optimize our nomograms.

Of course, patient selection is key, as is the management of any preexisting pathology such as ocular surface disease that may reduce potential vision. We do not always achieve 20/10 vision, but our workup examination, surgical procedure and technique, and postoperative management are performed with this ultimate goal."

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