Keratimileusis Study Group (KMSG)

Antecedentes: el KMSG estableció un correo, denominado “HOT LINE DEL KMSG” que distribuye entre sus afiliados interesados en recibirlo. El correo consiste plantear casos problema o de dificil manejo y el autor en la mayoría de las oportunidades, hace  una serie de preguntas sobre el caso a colegas  que reciben el correo, para que den sus opiniones libres sobre que determinación o conducta tomar ante el caso clínico. Se hace en forma gratuita. Con el propósito de difundir aún más el HOT LINE del KMSG en la República de Colombia, las instituciones firmantes se comprometen a colaborar en el presente acuerdo y en los futuros para difundir información relacionada con el HOT LINE que tiene como objetivos, difundir información sobre casos de difícil decisión médica o quirúrgica, y al mismo tiempo asesorar y educar al oftalmólogo, además de promover por este medio los lazos de colegaje internacional.

Acrysoft Toric

Raul Suarez, MD (Mexico)
Ashok Grover, MD (India)
Francisco Sanchez, MD (Mexico)

Gabriel Quesada, MD (EL Salvador)
Gabriel Oliveros, MD (Colombia)
Robert Kauffer, MD (USA)
Mark A Jank, MD (USA)
Alfredo Amigo, MD (Spain)
Luis Lu, MD (USA)
Hideharu Fukasaku, MD (Japan)


We would appreciate your reply if you have any comments about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Roberto Velazquez Montoya, MD
robvelazquez07@yahoo.com
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 


The question read as follow:


Dear KMSG,

What would you do?

36 years old female, with a hyperopic astigmatism in both eyes and a cerulean cataract on the left eye.

OD 20/60 (.) 20/20 +7.50= -4.00 x 175º
AL= 20.39 mm
K1 39.1 x 8º // K2 45.1 x 98º
ACD 2.17
cornea 545um

OI 20/70 (.) 20/20 +7.75= -4.00 x 175º
AL=20.44 mm
K1 39.7 x 170.8 // k2 44. x 80.8º
ACD 2.34
cornea 553um

Would you perform a cataract surgery first and then 1 one month later a hyperopic astigmatism with lasik performing the flap before the phaco surgery, or you would try to achive a good correction with an acrysoft toric iol T5?

I have perform a pentacam for the k readings and the the axial length with inmersion techique.

Roberto Velazquez Montoya, MD
Costa Rica
Centro oftalmologico Dra. Olga Montoya

 

Last answers:


DEAR FRIEND ROBERTO

I will suggest to implant a toric IOL with out a previous flap, considering the dominant eye for emetropia and leaving the non dominant with refraction between -1.25 and -1.75 we have experience with the acrysoft toric lens even in abortive keratoconus with very accurate results, I will calculated the power of the lens with the trough power function from Pentacam and SRK II formula.
This hyperopic patients are very Happy with mono vision.
Multifocal lens in this particular patient a believe will give you some problems because the high astigmatism, so if your optical laser center do not coincide with your optical IOL center you will be in trouble.
I will not suggested a previous flap because I'm sure you residual astigmatism with the toric lens will be less than 1.25 D so a PRK will gave you the final correction again very important to have a good centration in both procedures IOL and Laser

Muchos saludos Roberto

Raul Suarez, MD
Mexico

 

Dear Dr. Roberto Velazquez Montoya

It is important to assess the patients expectation of the surgery . If she wants emmetropia then it is necessary to explain to the patient that probably she may require two surgeries. I would prefer doing phacoemulsification with multifocal IOL implantation along with Limbal Relaxing Incisions OU. I would assess the patient's residual refractive error and if her uncorrected vision is acceptable no furhter surgery is required. If needed to correct residual cylinder LASIK can be performed after a month.

Dr. A.K. Grover
New Delhi, India

 

Dear Dr. Roberto Velazquez Montoya:
For a case of cataract and Mix Astigmatism, I will procede as follows
First, I will make a corneal flap either IntraLase or Microkeratome, followed by cataract phacoemulsificationthe same day.
Calculate a Restor Multifocal and perform phaco surgery
Lift the corneal flap and perform the enhancement of the astigmatism 6 weeks later, with Excimer at your preference
I do not like to perform limbal relaxing incisions or other astigmatism keratotomy procedure in young patients like yours because poor predictability and stability, and in the long term incisions closes, scars and loses effect.
Acrysof Toric at present time only corrects cyl of -2.5, any way patient will need a other by-optic procedure.

Francisco Sanchez MD
Instituo Oftalmológico Novavision

 

Dear Dr. Velasquez Montoya:

At this moment a toric IOL in your patient may not be the best treatment election. I would perform a normal cataratact surgery (IQ IOL) and LASIK.

Gabriel Quesada MD
El Salvador

 

Dear Dr Roberto,
:
I don´t know if you have in your country the Acrilisa (MIOL) from Acritec/ Zeiss, because it just has been released the Acrilisa Toric in all ranges, and you can ask for it with the pentacam and the AL. In case you don´t have it , I think the best option would be Restor + lasik postop.

Gabriel Oliveros
Bogotá, Colombia

 

Dear Roberto,
If she is sufficiently motivated and has the means ($ ) I would consider a MFIOL and when stability is obtained LASIK to correct the remaining residual astigmatism. Carefull explanation of the expectations and timming is crucial. I have a couple of patents with similar caracteristics and they had excelent outcomes.
Big abrazo,

Robert Kaufer
USA

 

Dear Dr. Roberto Velazquez Montoya-

I would do phaco with multifocal IOL of choice combined with Limbal Relaxing Incisions OU. I would asses the patient's visual lifestyle and priorities to aid in MFIOL selection. If she is fortunate enough to have an exaggerated response to the LRIs, her uncorrected vision may be acceptable with just one surgery. If needed to clear up residual cylinder though, LASIK will work well, especially with the astigmatism already "debulked" by the LRIs.

Mark Jank, MD
Ocala Eye
Ocala, Florida. USA

 

Dear Roberto:

I have addressed cases like this (generally with no cataract) by implanting first a multifocal IOL (MIOL) bilaterally, targeting for emetropia (+2.0-4.0 x OU) and performing bilateral lasik one month later. In this case I would choose for a MIOL available with more than 30.0D like a Tecnis multifocal (+34.00 D OU). Mix and match is a way for a patient claiming because different vision in his eyes.
In these cases flap first is not needed. Retinal detachment is not an issue in these “thirty something”, high hyperopes and there is an excellent change for achieving a spectacle free outcome.
Note: by the way, while Pentacam keratometry can be closer to the real corneal value, actual third generation IOL formulas are not calculated for this real values but for those obtained with classical devices like Automatic keratometer or Javal.

Un cordial saludo

Alfredo Amigó MD
Spain

 

Dear Dr. Velazquez-Montoya,

You have this interesting 36 year-old female patient with a high hyperopic astigmatism, a congenital cerulean cataract in her left eye and a BCVA of 20/20 in both eyes. She has 5 D of corneal astigmatism as measured by the pentacam and 4 D in her left. The AL has been measured by immersion.
I would suggest the following:

- Explain to the patient up front that most probably two procedures will be required in each eye to achieve a fair visual results, the cataract surgery followed by a laser corneal refractive surgery.
If you are to perform a refractive lensectomy, I will try to make the corneal incision at the 90 degree-meridian (3.5-mm CCI will correct 0.5D), combined with a LRI, aiming for a final refraction of + 1.0 -2.00 x 180. Laser refractive treatment for this mixed astigmatism will require less tissue removal and result in a prolate cornea which can be performed about 8 weeks after. With the +1.0-2.0 x 180 the patient should be able to get about 20/40 of UCVA. I would probably aim for emmetropia in the dominant eye and for a -1.50 for the non-dominant eye (monovision).
Hyperopic patients are usually very happy with these results. Multifocal implantation will become extremely expensive for this elective surgery (MTF IOL + Lasik) and will require less than 0.5 D of final remaining astigmatism to provide a decent visual outcome.

- At present, the SN60T5 can correct up to 2.25 D of astigmatism (labeled as 3.0) and your patient will still required a second procedure. A pair of LRIs will add an additional 1.0-1.5 D at this age (600 microns and 5-mm incisions), which will be OK as she will have a remaining 1 diopter at this age.
The T6, T7 and T8 IOLs will not be available until later 2008 or perhaps 2009 if she is willing to wait for one more year. In this case I would suggest to measure her corneal astigmatism with a Tomey (instead of the pentacam), a calibrated manual keratometer and an automated K, and take the average. I would double check the immersion AL and compare with the IOLMaster and finally use the Holladay 2 or the Binkhorst II or the Hoffer-Collenbrander, and Haigis formulas for the IOL power calculation.

Respectfully,

Luis W. Lu
USA

 

Dear Dr. Roberto Velazquez Montoya;

If her left cataract is good for operation, I will use the multifocal IOL and choose the refractive type such as ReZoom IOL. Final target is from plano to -0.25D. One month or later post op., I will add LASIK to correct residual astigmatism and refractive error. The other right eye can be waiting.. However, if the patient wants another operation, I will choose the diffractive type IOL such as Technis Multi IOL. Also, we may need to add LASIK for the right eye of post-multifocal IOL implantation to correct the refractive error.
If you can plan both cataract operation at the same time. I will operate the dominant eye first with refractive ReZoom IOL and next another non-dominant eye with diffractive IOL, Technis Multi IOL.
Such mix type multifocal IOL and fine tuning by LASIK later will be good for this patient.

Hideharu Fukasaku, MD
Fukasaku Eye Institute,
Vitreo-Retinal department,
Cataract/Laser/Refractive surgery center,
Yokohama, Japan

 

This is an automatically-generated notice. If you'd like to be removed from the KMSG mailing list, please send an e-mail to the KMSG <kmsg2007@kmsg.org > If you wish to respond to this message, please send your reply to:

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Axis and Intracorneal Ring

Pedro Ivan Navarro, MD (Colombia)
 
Guillermo Avalos, MD (Mexico)
Alexander Hatsis, MD (USA)
Luis F Restrepo, MD (Colombia)
Roberto Enrique Velazquez Montoya, MD (Costa Rica)
Emilio Mendez, MD (Colombia)
L. Felipe Vejarano, MD (Colombia)
 
We would appreciate your reply if you have any comments  about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Alfredo Amigo, MD
< amigo66@arrakis.es>
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 
The question read as follow:
 
 
Intracorneal rings segments (IRS) can improve significantly UCVA and BCVA in selected queratoconus, PMD and secondary ectasies. The original advised incision site for Ferrara/Keraring IRS types has been the steepest topographic corneal meridian. Some other surgeons are nowadays advising/using the axis of the coma (comatic axis) obtained through the aberrometry measurements. However both axis are usually not coincident or even opposite.
 
My question to the colleagues is what axis do you select for IRS implantation, steepest meridian or comatic, and what is the rationale of your decision?
 
Alfredo Amigo PhD
Spain
amigo66@arrakis.es
 
Last answer:
 
 
Dear Dr Amigo:
 
In my opinion after 4 years implanting intacs, I really think that there are tres factors to have nice results on these surgery: 1. Adequate depth of implants (aa least 80% of the depth in corneal incision 2. Consistent nomogram to decide to choose symmetric or asymetric implant thickness accoding to eccentricity of the conus apex 3. Consistent depth and symmetry of tunnels to avoid irregular astigmatism induction.
I would prefer corneal incision and implant symmetry or asymetry thickness according to total mean power map on Orbscan; as comatic axis sometimes doesn't correlate at all with topographic axis, sometimes centration of the conus apex on posterior elevation map doesn't correlate either with the TMP map and we can miss the indicate thickness implant asymmetry required to treat a decentered keratoconus.
 
Regards,
 
Pedro I. Navarro MD
Bogotá, Colombia
 
Dear Alfredo:
 
My answer is not relative exactly with your question, but I wish to add my opinion. I have a short experience with intracorneal rings, is a long way for patients and Doctor to see improvement of vision, most of them complains "of something", most of them needs contacts of glasses and if the KC are progressing the final steps will be a graft.
I would like to hear other opinions, maybe I am wrong.
 
Guillermo Avalos MD
Mexico
 
 
Alfredo,
 
Over 400 keratoconus cases with 7 years follow-up I use the steepest axis.
 
Best,
Alexander Hatsis, MD
USA
 
Dear Dr. Amigo:
 
I have been waiting for more answers to your enquire, as I have had the hope somebody would have the answer to it. The comatic axis to be used would be the corneal comatic axis(CCA), obtained with the topographer, not from the complete eye aberrometry. I have been implanting  INTACS for 4 years and from my learning and experience, I would say that the best resuts are obtained when the CCA coincides (al least roughly) with the steepest meridian. A third item would be objective and subjective refraction, which also could not coincide with the steepest axis. Sometimes, when the CCA and the steepest axis don't coincide, to improve visual results, INTACS must be rotated to a position somewhere between both axis. I would like to stress that the main objective is to improve the corneal geometry to a point that a more conventional form of correction (glasses, soft toric contact lenses or even an ICL) can provide better visual acuity and quality. But going back to your question, I think that currently there is not an answer to your question. I would say that intracorneal ring segment surgery still depends more on the "art" of surgery than of the "technique o nomogram" al least regarding to the incision site. Most available nomograms are based on the steepest. Each case teach us something about this subject and I keep the hope that soon will find in wich cases wich option to use.
 
Regards,
 
Luis F. Restrepo
Pereira, Colombia
 
Dear Amigo,
 
In my experience I have seen that the steepest meridian works better for my patients. I implant kerarings in KK 2-3 based on the pentacam, and I go for 85% of the stroma.
I have over 100 implants and I can tell you that I have very happy patients. I explain to them that this is for the arquitecture of the cornea not for better vision, but after the surgery they find out that the quality of the vision is better, they get really happy about it. Stability of the vision is until 3 month, but with vitamin C 2 grams a day I seem better result, you should try it.
 
Hope it works for you too.
 
Dr. Roberto Enrique Velázquez Montoya
Córnea, Catarata y Cirugía Refractiva
Centro Oftalmológico " Dra. Olga Montoya"
San Jose, Costa Rica
 
Dear Alfredo
 
I always do my incision on the steepest axis of the PENTACAM and depending on the case implant one or two segments. The exception is in totally eccentric ectasias (Type 3 Keratoconus) where all the conus are in one hemimeridian of the cornea. In these cases I enter through the flat axis an implant one 160 or 210 degrees segment depending on the size of the ectatic area. The variables to take into account are: conus location, manifest refraction and keratometry.
 
I think superior incisions are more desirable because they are cover by the upper lid with minimum risk of infection and wound problems and risk of extrusion after chronic rubbing.
 
Emilio Mendez
Bogota,Colombia
 
Dr. Amigo, right now I had implanted almost 300 segments and the best result is with the steepest meridian based on the queratometry comparing with the topography, and based on the topographic pattern you design the position of your incision and the nomogram depending of the shape of the cone.
 
L. Felipe Vejarano, MD
FUNDACION OFTALMOLOGICA VEJARANO
Popayán - Colombia
South America
 
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Contraindication or not

Ana Luisa Höfling-Lima, MD (Brasil)

Peter J Polack, MD FACS (USA)

Arun Gulani, MD (USA)
Jorge Cazal, MD (Spain)
Juan Manuel Garcia Gil, MD (Mexico)
George Rozakis, MD (USA)
Luis F. Restrepo, MD (Colombia)
Amar Agarwal, MD (India)
Ignacio Manzitti, MD (Argentina)
Jairo Hoyos-Chacon, MD (Spain)
Soriana Rodriguez, MD (Cuba)
Gabriel Quesada, MD (El Salvador)
Emilio Mendez, MD (Colombia)
Luis F Restrepo, MD (Colombia)
Ivan Ossma, MD (Colombia)
Guillermo Avalos, MD (Mexico)
Pablo Suarez, MD (Ecuador)

We would appreciate your reply if you have any comments about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Antonio Rouras, MD
arouras@hes.scs.es
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 

The question read as follow:


Dear fellows,

I want to share with you an interesting case.

A 23 years old lady came to my office looking for refractive surgery, she can not wear contact lenses and her refraction is stable since 3 years ago. She has been asking for surgery in another two refractive surgery centers, in the first one the ophthalmologist advised her to wait until 35-40 years old to be operated, and in the second one they wanted to do surgery one week later. The patient preferred to ask for another opinion.

RE = -14.00 -3.00 x 180º = 20/80
LE = -5.00 -1.00 x 180 = 20/20
Near vision with correction = 20/20

Pachimetry = RE 550 / LE 540
TCC= RE = 46.50 x 43.25 x 90º // LE = 44.50 x 43.50 x 90º
Anterior chamber and retina are normal

Surgery option, seems clear:
RE = Phakic lens + LASIK for astigmatism
LE = LASIK

Our opinion is not to do surgery in this patient, as we consider the left eye like a monocular eye due to the RE’s low vision.

In which situations do you think that one eye contraindicates the refractive surgery of the fellow eye?. Do you think that it’s a contraindication?

Thank you for your opinons.

Antonio Rouras, MD
Barcelona - Spain

 

The results that we have with personalized PRK and mitomycin for this degree are very good, so for a situation like this
I would choose this option instead Lasik

Ana Luisa, MD
Brasil

 

Dr. Rouras
I agree with you. I would not perform an elective intraocular procedure in a 23 year-old with amblyopia.

Peter J Polack MD FACS
Ocala FL USA

 

Hi Dr. Rouras,

All the diagnostic exams and choices mentioned are what you would anyways do as a responsible surgeon for any case.

This is a straight forward case, the only difference being you shall do one eye at a time (right eye first till full vision is retrieved including lines gained which may include two steps as you have designated- Lens -Laser combination) followed by the left eye (Laser only).

She shall do very well

Arun C. Gulani, M.D.
Director: Gulani Vision Institute
Florida, USA

 

Dr. Rouras

In this particular case, the patient is out of range for amblyopia traditional treatment, however, we have reasonable experience to suggest after an superb clinical eye examination, ruling out the posibility of a Sub clinical KC:

OD Phakic IOL
OS Lasik or Phakic IOL

Traditional therapy for anisometropic amblyopia often fails when severe anisometropia is present. Recent advances in refractive surgery for anisometropic amblyopia suggest that surgical treatment may be a viable alternative in certain situations.

The potential indications for refractive surgery for anisometropia, the different refractive procedures available, and the risks and benefits of each procedure needs to be analyzed.

Randomized clinical trails are needed in order to optimally evaluate the long-term safety and efficacy of these treatments.

BEST

JORGE CAZAL,MD
BARCELONA ,SPAIN

 

1- Anisometropic Amblyopia: The Potential Role of Keratorefractive Surgery

Amer. Orthoptic Jrnl. 2007 57(1):25-29; DOI:10.3368/aoj.57.1.25

2- Saxena R, van Minderhout HM, Luyten GP.
Anterior chamber iris-fixated phakic intraocular lens for anisometropic
amblyopia.
J Cataract Refract Surg. 2003 Apr;29(4):835-8.
PMID: 12686258 [PubMed - indexed for MEDLINE]

3- Chipont EM, García-Hermosa P, Alió JL.
Reversal of myopic anisometropic amblyopia with phakic intraocular lens
implantation.
J Refract Surg. 2001 Jul-Aug;17(4):460-2.
PMID: 11472004 [PubMed - indexed for MEDLINE]


Everibody is thinking that there arean enough anterior chamber depth. I agree with RE Phakic Toric Lens (I don't think we need Bioptics), and LE Lasik, IF Topography is all right. But what if this is a swallow antherior chamber, even as miopic as she is?

Juan Manuel García Gil, MD
Mexico

 

I would do a phakic lens in the right eye and lasik. Surgeons choice on which phakic to use, Artisan, ICL, or PRL. Surgeon choice on OS after conservative screening for forme fruste etc. Her right eye will pick up 4 lines or so of vision which is always exciting.

George Rozakis, MD
USA

 

Dear Dr. Rouras:

I keep considering ICL in both eyes, as doing ICL in one eye and Lasik in the other will seriuosly jeopardize binocular corneal Q-factor balance, while ICL will keep the original balance (already adapted).

Regards,

Luis F. Restrepo
Pereira, Colombia

 

Dear Rouras,

This case is an example of the entity which I have termed as- ABERROPIA in the right eye.

We have done many cases like this. In such cases the vision can improve to 6/12 to 6/6 also when you implant a Toric ICL (Staar) in the right eye. The left eye can be done lasik by intralase or blade microkeratome.

We will be presenting this in the ASCRs also on Aberropia and Phakic IOL's. These patients are so happy at the end.

Prof.Amar Agarwal
India

 

Dear Dr. Rouras:

I would implant an artisan lens in her OD with a LRI, that would probably correct 2 diopters of astigmatism. If she is happy with the result, I would do Lasek with Mitomycin 0.02% in her OS to avoid flap complications.

Ignacio Manzitti, MD
Argentina

 

Dear Dr. Rouras,

This is a very interesting question. In our country (Spain) seems that every time is easiest to denounce doctors for any reason, that is why every time that we have a patient like this we go very carefully.

In this patient that has become contact lens intolerant, the surgery planning for her RE will be Phakic lens + laser for the astigmatism, and LASIK for her LE, as long as all the preop exams were OK with a cautious retinal exam.

The problem arrive when we have a very young patient (23 years old) like this and we do not have the perfect Phakic lens, our experience with Phakic lens is limited to PRL and ICARE lens, and with both we have had problems and we have had to explant some of them. Anyway and almost with all the possibilities, the Phakic lens implant will improve 1 or 2 lines the patient’s vision

I think in this patient I will do first the RE surgery (ICL or Artisan) and when everything will be OK I will do LASIK in her LE.

In my opinion I consider contraindicated the surgery when one eye has a vision of 20/200 or less.

Saludos

Jairo Hoyos-Chacon, MD
Spain

 

Dr Rouras

I will give you my personal opinion:

I think that this patient with 23 years old ( very, very young) is not a good candidate for Phakic lens in RE ( 20 / 80 ) , and the situation of ¨monocular eye¨ in a young patient can be considered as an important contraindication of refractive surgery, besides in many cases this patients could develop retinal complications after Phakic lens implant. Another point to analyze in this case with this anisometropy is that the binocular vision and the fusion of the image can be very difficult after the refractive surgery. I suggest the use of contact lens, and explain the reason to her.

Sorania Rodriguez Sachez MD.
CUBA.

 

I do not think that is a contraindication, but I would recomend doing the RE first for a phakic IOL, and if the patient is satisfied then
LASIK can be done on the LE.

Gabriel Quesada MD
Centro Panamericano de Ojos
El Salvador

 

Dear Antonio,

I will recommend implanting an Artisan phakic iol in the RE which I think will improve vision to near the 20/40 range because she has a "refractive amblyopia" that can recuperate after correcting the high ametropia. The LE I will recommend an SBK with Intralase with a 100 microns flap. If you do not have access to the Intralase a Lasek procedure with 15 seconds of Mitomycin 0.02% is a good alternative to reduce possibility of flap complication .

Emilio Mendez, MD
Bogota,Colombia

 

Dear Dr. Rouras:

In my opinion this is not a case for Lasik. I will consider ICL in both eyes, toric in the OD. It is not unusual that for an eye like the OD to gain 2 or 3 lines of vision even in cases wich such a high defect. If pachimetries are thick enough and there is not a suspected FFKC, I would consider making the flap before placing the ICLs to be able to refine results with Lasik on top of the ICLs although it is barely needed, if calculation is properly done. PRK could also be an option, of course. I have done that in cases of hyperopic astigmatisms when the ICL is not available.

Best regards,

Luis F. Restrepo, MD
Pereira, Colombia

 

Antonio

In addition to the Pentacam (as ruling out ectasia is a must in this patient) it would be important to have best corrected vision with a rgp contact lens measured as part of the "amblyopia" can be due to vertex distance in the phoropter You do not mention any pathological changes in the macula for this right eye, and notorious anisometropic amblyopia is much more common in hyperopes than myopes. If this patient does not have ectasia and rgp lens bcva is around 20/60 or better I would not hesitate in Artisan Toric Phakic IOL for the right eye and LASIK in the left eye. Given all safety criteria for both procedures is met. The toric option would eliminate the need to add bioptics and in my experience toric artisan's yield stable astigmatic corrections (since the axis is held by the fixation on the iris disallowing rotation in the long term), my first artisan toric has 6 years of followup and the behavior is as good as the normal artisan.

Best of luck

Ivan Ossma, MD MPH
Ophthalmologist
Anterior Segment and Cornea Specialist
Fundacion Clinica Valle del Lili
Cali Colombia

 

Dear Dr. Rouras:

A relative contraidication in a "monocular" eye, is the risk of a Lasik complication surgery.
This patient`s brain uses the monocular vision, the fellow eye helps in pseudo-stereopsis and visual field.

I don't think in an absolute contraindication.

Guillermo Avalos, MD
Mexico

 

Dear Dr. Rouras

First of all I would like to have more information about the topographic study. Maybe a Pentacam to see back curvatures of the cornea and also a keratoconic curvature to see if there is small component of ectasia. If this exam is normal, I will like to have both eyes visual acuity and how the patient tolerate this anisomethropy.

I think this information is very important.

Pablo Suarez MD
Fundacion Vista para Ciegos
Quito - Ecuador.

 

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KMSG Hot Line coordinator
kmsg2007@kmsg.org

Crosslinking

Luis Izquierdo, MD (Peru)

Ana Luisa Höfling-Lima, MD (Brazil)
Klaus Ditzen, MD (Germany)
Eduardo Arenas, MD (Colombia)
Francisco Sanchez L, MD (Mexico)
Luis F Restrepo, MD (Colombia)
Salvador García-Delpech, MD (Spain)


We would appreciate your reply if you have any comments about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Alexander Hatsis, MD
<Hatsis@aol.com>
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 
The question read as follow:


Dear Colleagues,

I would like to learn about keratoconus treatment using collagen crosslinking with riboflavin. Are any of the KMSG fellows doing this procedure? I would like to come and observe some cases.

Thanks much in advance,

Alexander Hatsis, MD
USA
 
Last answers:


Hello my friends,

Well our experience with crosslinking is almost 2 years.

Some tips:
- Limited to cases of mild keratoconus and Lasik Ectasia,
- Our results around 1 or 2 DT of central power reduction, and average of 1 to 2 lines of VA improvement after 3 to six months .
- Respect the 450 microns using if is avalaible a complete paquymetry map (Visate or Pentacam)
- Avoid bilateral simultaneous procedures wait at least 3 days for the second eye, the epitelization is fast
- We did not found endothelial cells we perform in every procedure
- Avoid in patients with history of AK or RK, any deep incision in the cornea develope more severe haze after crosslinking
- Tell to the patients that this is a procedure for stops the progression of the keratoconus not for improve the vision (only the 65 % does)
And of course every one is invite to Lima (Peru)
Abrazos

Luis Izquierdo MD
Peru

 
Dear Colleagues,
We started last Wednesday the protocol for cross link after Intrastromal corneal rings, ate Federal University of São Paulo, Brazil.

At the same time we will begin on ceratoconus and bullous keratopaty without rings.

A visit to São Paulo can also be included if you wish

ANA LUISA

Profa. Dra. Ana Luisa Höfling-Lima

Titular e Chefe do Depto de Oftalmologia

Universidade Federal de São Paulo - UNIFESP/EPM

 
Dr Dr.Hatsis,

I have done three cases .the results are not so convincing
Best regards

Klaus Ditzen,M.D
Germany
 
Dear Dr Hatsis:

Here in Colombia Dr. Luis Antonio Ruiz has been using the technique for m
ore tan one year. My experience is short, I can contact Dr.Ruiz and I sure
that he will be glad to share with you his results.

Eduardo Arenas, MD (Colombia)

 
Alexander Hatsis:
Today modern corneoplastics treatment of keratoconus includes ICR and cross-linking.
We have a great experience (over 1000 cases implanted) using keraring and IntraLase and we are so please with corneal and refractive results
Cross-linking in our experience is limited to cases of mild keratoconus and Lasik Ectasia, some studies from Caparossi and others have shown 1 or 2 DT of central power reduction, and average of 1 to 2 lines of VA improvement after the second year of treatment.
We have used cross-linking used after ICR implantation also.
Patients need to have clear central cornea, at least 400 microns thickness
There is a minimal central endothelial cell loss in thin corneas
The procedure bilaterally takesmore than 2 hs
Corneal epithelium needs to be removed
We used isotonic Riboflavin after corneal abrasion, 15 drops every 2 min
We need to check if Riboflavin has penetrated into the anterior chamber at the slit lamp with the cobalt blue light, because same Riboflavin initiates the photochemical change for the cross-linking but also protects intraocular structures from UV light damage (lens and retina)
UV light is applied for 30 min and we continuing dropping the corneal surface one drop every 2 minutes.
Wet weck cell material ring for limbus protection is used in order to avoid UV light stem cells damage
Finally, moxifloxacin, prednisolone acetate, voltaren, and bandage CL.
Patient need a strong pain killer because it really hurts.
You are welcome to come to our clinic in Mexico city when ever you want.
I sent a slide showing the procedure, attached file
Francisco Sánchez L.
Instituto Oftalmologico Novavision
Cd México, Acapuclo.
 
Dear Dr. Hatsis:

I have been doing UV Riboflavin corneal collagen crosslinking for 3 years. I have done crosslinking for FFKC, KC, "on-top" of INTACS, unstable post-lasik results, and ectasias.

In general:

Results are not predictable, although in most cases you will see at least some effect.
In almost all cases progression will slow down and in most cases will stop (depend on the indication and actual case).
In good cases, expect up to 2 K diopters of flattening.
Results last at least 3 years ( my experience up to today) .
Best results in early ectasias (complete regression and stabilization).
Poorer results in advanced KC.
Improves INTACS results.
Can be repeated without problems.
Repeated crosslinkings don't improve initial results too much.
No complications up to date.
Rivoflavin can be used without Dextran (my personal technique), in my opinion, safer approach. .
In some cases clinical results better than topo results.
Expect at least 8 weeks to see changes.

You or any other KMSG colleague will be very welcomed in Pereira, Colombia, anytime. Don't trust the news, Colombia is a very paceful and enjoyable country, and very beatiful. Colombia is the second country in biodiversity, only second to Brazil wich is six times bigger; we have more orchids, palms and frog species that any other country on the world and over 50.000 different flowers.

Come and discover a very well kept secret: Colombia is a paradise!

Best regards,

Luis F. Restrepo
Pereira, Colombia
 
Dear Hatis

We are using crosslinking with and without intracorneal rings (keraring) with good results (or at least without problems). I'm working in Valencia (Spain), if you want to come and see some cases there's not problem.

Salvador García-Delpech
Valencia. Spain.
 
Cross linking
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Enhancement in Irregular Topography Case

A NEW message,"Re: The question posted by, George Rozakis, MD<gwr@rozakis.com>,USA, was sent by:
- Gabriel Oliveros, MD (Colombia)
- Mariano Fernandez, MD (Guatemala)
- Raul Suarez, MD (Mexico)
- Jorge Cazal, MD (Spain)
- Gabriel Quesada, MD (El Salvador)
Wewould appreciate your reply if you have any comments about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

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KMSG Hot Line coordinator

George Rozakis, MD
gwr@rozakis.com
CC:kmsg2007@kmsg.org

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The question read as follow:
Dear Group,
This patient had Lasik for -2.00 -6.75 x 90
Uncorrected 20/40
His refraction is now +.25 -1.00 x 90 20/20 (good endpoint)
Take a look at his topography.
Will the ablation help him?
Best Regards,

George W. Rozakis, MD
USA
 
George:
Ive seen a couple of cases similar to this one. Before doing anything, why dont you tell us how is the patiet seeing right now without correction? how unconfortable is she or he?? with the actual vision?
Mariano Fernandez, MD
Guatemala
 
Dear Jorge

Your patient has less astigmatism than preop but now he (she)has an irregular astigmatism as I can see on the post op topography (something happens when the ablation went trough) your refraction showsthe axis on 90` and the topography show it at 51` so if you do conventional laser it willgave you a not accurate correction regarding the difference on the axis cylinder.

I will suggest a cicloplegic refraction to verify the positive sphere especially if the patient is young an will make a PRK withcustom ablation. I will not lift the original flap because probable the irregular astigmatism isdoto it.

Saludos

Raul Suarez, MD (Mexico)

 

Dear George:
With these pieces of the puzzle, I am not confident that this case was a previously myopic Regular Against The Rule Astigmatism,either I wouldnt treat him/her without a Ocular Tomography Scheimpflug Based + Ocular Response Analyzer Screening, beside a very goodhistory of refractive stability.
Right now of course this patient has probably ghost images (highly comatic anterior corneal surface -see Zernike Mapor Elevation Map)
Depending on elevation data this should fit for a Topography guide ablation Vs WF guided Ablation dependig of Pancorneal Pachymetry (limbus -limbus)
We can not disregard that this cases also respond very well to ICRS or CK to reduces corneal astigmatism in cases where Substractive Refractive Surgery are contraindicated.
Best
Jorge Cazal,MD
Barcelona
1: Pokroy R, Levinger S, Hirsh A.
Single Intacs segment for post-laser in situ keratomileusis keratectasia.
J Cataract Refract Surg. 2004 Aug;30(8):1685-95.

2: Knorz MC, Jendritza B.
Topographically-guided laser in situ keratomileusis to treat corneal
irregularities.
Ophthalmology. 2000 Jun;107(6):1138-43
3: Hersh PS, Fry KL, Chandrashekhar R, Fikaris DS.
Conductive keratoplasty to treat complications of LASIK and photorefractive
keratectomy.
Ophthalmology. 2005 Nov;112(11):1941-7. Epub 2005 Sep 12

In this case in particular, the pachymetry and posterior corneal
topography are very important before doing anything.

With that vision I probably wouldnt do any more surgery

Gabriel Quesada MD
Centro Panamericano de Ojos
El Salvador

 
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Enhancement in Irregular Topography Case

Epi-LASIK after LASIK

A NEW message,"Re: The question posted by, Ashley Behrens <abehren2@jhmi.edu>, MD, USA, was sent by:


Klaus Ditzen, MD (Germany)
Luis Felipe Vejarano, MD (Colombia)

Luis F Restrepo, MD (Colombia)
George O. Waring III, MD, FACS, FRCOphth (USA)
Guillermo Rocha, MD, FRCSC (Canada)
Enrique Suarez, MD (Venezuela)
George Rozakis, MD (USA)
Peter J Polack, MD FACS (USA)
Pedro Ivan-Navarro, MD (Colombia)
Fernando L Soler-Ferrandez, MD (Spain)
Jacqueline CO, MD (USA)
Gabriel Quesada, MD (El Salvador)
Mariano Fernandez, MD (Guatemala)
Emilio Mendez, MD (Colombia)


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Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

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Ashley Behrens, MD
<abehren2@jhmi.edu>
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 
The question read as follow:


Dear Colleagues,

I have been receiving e-mails from this list for a while (I really don't know who signed me in, but thanks!) and also have read interesting threads of challenging cases. Also have seen many names of good old friends participating in the discussions. Therefore I would like to post a question on this distinguished panel: A patient came to my office asking for LASIK enhancement 12 years after his initial procedure. His present correction is -1.50 OD and -2.25 +0.50 x 030 OS. As a general rule, I prefer not to lift flaps that I have not performed myself to avoid surprises. At the same time, due to the long time elapsed from his initial refractive procedure, I presume that the flap lifting per se may not be an easy one.

Due to the low correction required, I am planning to schedule this patient for a custom surface ablation with our Visx S4/Wavescan combination. Although PRK/MMC is perhaps the logical option, I would like to hear if anyone has attempted Epi-LASIK enhancement on a previous LASIK treated cornea. I would prefer Epi-LASIK over standard PRK because of the faster recovery, less associated pain and shorter postoperative steroids. However, I have spoken with the manufacturer of the epi-lasitome (Gebauer) and they do not recommend this approach due to a bad experience with one case in Germany (actually they list this option as a contraindication). At least hypothetically, it should be possible to inadvertently lift and damage a previously cut LASIK flap during the pass of the epi-lasitome. Any thoughts?

Thanks much in advance,

Ashley Behrens, MD
Baltimore, Maryland, USA.
 
Last Answers:


Do not use the epitom,the flap would be destroyed.

You can open the flap also after 5 years to do an enhancement.

Regards

Klaus Ditzen,M.D
Germany
 
Dear Colleague, depends on the paquimetry why don’t you try Lasik because the Visx with Custom treatment you can change the optical zone decreasing the Microns of ablation without change the whole ablation zone (8 mm) that gives the patient better quality of vision and treat the previous aberrations and because the small amount of correction, for sure I’ll try Lasik trying to make a bigger and thinner flap.

Luis Felipe Vejarano, MD
Colombia
 
Dear Dr. Behrens:

Lifting an 11 years-old flap is as easy as lifting a 6 month old flap. I have lifted flaps up to 12 years old without any problem. The most dificult are those that have peripheral scarring but once you "break" thru the scarring, lifting is easy. Also surprises could be ruled out with a carefully inspection with the slit lamp. I agree that PRK over the flap is a good option for small "touch-up". I just scrape the epithelium, if you scrap from the hinge toward the periphery you won't lift the flap; scrapping is easier, safer and even more comfortable for the patient that alcohol.

Good luck,

Luis F. Restrepo
Pereira, Colombia
 
Lifting a flap years after lasik is almost as easy as lifting 6 months after – that is ok and if you can see some particles in the interface to insure a decent flap thickness and your correction is small so you do not overthin the bed and your total corneal thickness now is acceptable – lift and shoot.
Do not do epikeratome – it may disrupt the flap.
Prk /mmc is an option.

Best

George O. Waring III, MD, FACS, FRCOphth
USA
 
Dr Behrens:

I have gone away from relifting a flap like you describe. In particular, I have seen a couple of patients with epi ingrowth with a particular type of microkeratome, after long term relift.

I would manage this patient by performing a "flap-off LASEK". I would apply the 20% alcohol and start a laseEk dissection at the hinge, taking care of not disturbing the flap's edge. Then discard the epithelium you dissected as you won't need it to cover the area again, apply the laser ablation, apply MMC 0.02% for 12 seconds, and treat as a PRK, with a contact lens and your usual regime. The rationale for this is that you would not disturb the flap with epilasik, or with a PRK brush, and by remaining within the flap's edge, you prevent epithelial ingrowth and ensure quick healing.

Regards,


Guillermo Rocha, MD, FRCSC
Canada
 
Dear Ashley:

I stongly suggest you not perform Epi LASIK or PRK over a LASIK surgery.
Lifting the flap is not a problem. I have lifted flaps even after 12 to 13 years (not for hyperopic ablations).
My tip, use the microkeratome suction ring to hold the eye firmly, with a Merocel sponge pressure the mid periphery and you will notice the edge. With a Suarez Spreader I lift the border for a couple of millimeters then, with an atraumatic Fechtner ring forceps, following a Capsulorhexis-like movement, I lift the rest of the disc. With this manouver you do not seed epithelial cells in the interface.

The most important thing is to determine the stromal reserve you have for the reoperation. With the OCT Visante, find out not only the quality of the flap but the depth of the stromal bed to see if it is suitable the enhancement.

Good luck.

Kindes regards.

Enrique Suarez, MD
Venezuela
 
Assuming corneal topography regular and no cataract, I would lift the flap and treat. 2 years or 12 years, no difference. At the slit lamp you can see the flap's basic outline, your only surprise might be a thin bed but odds are you will still be fine if you breach the 250 limit we created years ago.

George W. Rozakis, MD
USA
 
Dr. Behrens

While I have performed LASIK after Epi-LASIK, I have not done the reverse. I would have concerns for two reasons:

First, I have found Epi-LASIK to be more effective by pitching the epithelial flap. The concern there would be the potential risk of melt of a flap which has been insulted from both sides. I am not sure that the epithelial flap is anything more than a temporary scab.

Second, as you point out, is the concern that the Epi-LASIK microkeratome, while not a sharp blade, may disrupt and possibly lift the previous LASIK flap.

I have lifted lASIK flaps as far out as 6 years but understand your reluctance to lift another surgeon's flap and get a 'surprise.'

Peter J Polack MD FACS
Ocala FL, USA

 
Dear Dr Behrens:

I really would recommend to think on lift the flap as the first procedure on this patient, prior its evaluation with Visante OCT to confirm its features. We have had the chance to lift flaps for myopia (not hyperopia) correction after long post-op time (8-10 years) without any complication.

To perform a epilasik over a flap increases highly the risk for complications as dislodging, improper or irregular epi flap, lose of suction due to flat corneas, etc. If Visante reports an irregular lasik flap or a thin stromal bed, standard or advanced surface ablation would probably be the procedures to elect or reject the patient for an enhancement.

Sincerely yours,
Pedro Navarro MD
Bogota, Colombia

 
Dear Ashley:

Epi-lasik over a lasik flap is the best and faster way to be in troubles.

Go with standard PRK alcohol assisted, scraping the epithelium centrifugally to the previous hinge. Forget also, with a previous flap, the Amoils brush.

Best regards

Fernando L. Soler-Ferrandez
Elche - Spain

 
Hello
I have lift one out 11 year, if you be able to see the edge of the flap, tried to used an angle Mcpherson to indent, break the edge and open the edge about 5 mm then do rest when patient lied down. I can be reach at 214-923-4315, if you have any question, as a matter of fact I have one patient today that need a small enhencement that had LASIK 10 yrs ago, we will see....

Best regards,

Jacqueline Co MD
USA
 
Ashley

Personaly I don´t like to do a new flap in a LASIK, I would always try to lift the previous flap, measure the remanent stroma, and then if posible do the laser tx. With the Pentacam you can measure the thikness of your previous flap and decide better your aproach.

Best regards

Gabriel Quesada, MD
El Salvador

 
Dear Doctor Behrens.

If the manufacturer of the epilasitome, don`t recommend this aproach, I think you should go with the PRK.

Several months ago I had the same feeling about the pain, and bad time that each patiet had with this procedure. But one of the greatest ophthalmologist in Spain help me using the right steps, and thereafter, my PRK patients are as happy as the lasik Ones.

A Couple of tips will be:
- Use Alcohol to remove the ephithelium, try to avoid any debridement with a blunt spatula or sharp blade . Try to be gentle with it.
- Use a proper CL ( I am using the O2 Optix from CIBA)
- Drops of sodium Hyaluronate every 2 horas the firs 3 days as a moisturing drop.

Regards

Mariano Fernandez, MD
Guatemala

 
Dear Ashley

I think surface ablation in any of its versions: PRK, LASEK, EPILASIK, SBK WITH INTRALASE, are all wonderful options for enhancement after previous lasik. First you have good amount of tissue to work on without thinning the posterior layers and in the vast mayority of cases you only have to correct a couple of diopters to the most. Regarding Epik enhancement I will assure to run the keratome in the same sense as the previous lasik flap in order not to risk lifting the previous one.

Good luck

Emilio Mendez
Colombia
 
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Free cap losted

A NEW message,"Re: The question posted by, Mariano Fernandez, MD,< marianofrnndz@yahoo.com > Guatemala, was sent by:


Fernando Rodriguez-Mier, MD (Spain)

Arun Gulani, MD (USA)
Pablo Suarez Saona, MD (Ecuador)
Klaus Ditzen, MD (Germany)
George Rozakis, MD (USA)
Robert Dotson, MD (USA)
Fernando Rodriguez-Mier, MD (Spain)
Guillermo Avalos, MD (Mexico)
Paris Royo, MD (USA)
Alexander Hatsis, MD (USA)
José Miguel Varas-Prieto, MD (Ecuador)

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The question read as follow:


Dear Collegues:

I would like your suggestions in reference to the following case:

Male
29 year old

OD -1.50 -0.50 65
OI -1.75 -0.75 145

Pachimetry OD 544 OI 563

K: OD 42.56 x 43.95 80
OI 42.40 X 43.81 105

July 21st 2007

Bilateral Lasik was performed. On the left eye I had a complication a " free cap", after the ablation was completed I relocated the flap according to the marks. Contact Lens was not recommended.

After one hour the patient was revaluated and the flap was in place. The eye was closed and I asked him to return that afternoon to the clinic. The patient was on time but the flap was gone (disappear).

Today October 16th the cornea has an epithelium formed and the present data of the patient is:

OD 0.00
OI -3.25 -1.75 74

Pachimetry OI 460
K OI 43.37 X 44.00 167

I am sending picture of the recent status of the interface and the recent topography.

We will appreciate your recommendations on this specfic case since the patient requests a second surgery to elminate the residual ametropy.

Regards,

Mariano Fernandez, MD
Guatemala
marianofrnndz@yahoo.com

 
Last answers:


Dear Fellow!!!


I think that your patient is doing corneal ectasia. Please repeat you the pachymetry and corneal topography using a pentacam -if is possible for you.
Very interesting bibliography:
1.Randleman j, Russell B, Ward M et alls. Factors and Prognosis for corneal ectasy after lasik. Ophthalmology 2003, 110:267-275.
2. Kymionis g, siganos c, Pallikaris I et als. Management of post lasik corneal ectasia with intacs insert. Ophthalmology 2003; 121:322-326.
In this moment wait, I recommend soft contact lens use.

Best regards,

Fernando Rodriguez Mier
Figueres- spain

 
Dear Dr Fernandez,

Yo have more myopia due to collagen deposit and epithelial hyperplasia (haze) on the ablated area also irrgular astigmatism as show in the topography.
Its posible that if the total amount of removed cornea (flap + ablation) it's under 100 microns the haze will be grade + to ++ and will not decrase V.A. significantly.
If total resection it's over 100 microns, haze will more severe.

I suggest : Pleace a C.L with E.E refraction and wait untill stabilization occurs (refractive and topography).

Depending on the haze degree you will need to do PRK with mytomicin, if irregular astigmatism perisit it will be a serius problem because custom ablation takes a lot of tissue and conventional ablation will not corrected the irregular astigmatism so it's posible that you will be able just to treat the sphere E.E. If haze it's severe you would need a new flap from a corneal donor, this will control the haze but VA in the postop it's not going to be very good do to impredictable postoperative refraction.

I beliave that the cornea in the preop was normal, topgraphy and pachimetry so I would not consider ectasia as a posibility. Never the less if serious instabillity occurs along the time ectasia must be considerated

Saludos

Raul Suarez S, MD
Instituto de Oftalmologia Conde de la Valenciana
Mexico
 
Dear Mariano

I wuold recomend to repeat the topography, and a maped pachymetry, because it looks like a ectasia and probably to fit a contact lens could
help.

Gabriel Quesada MD
Centro Panamericano de Ojos
El Salvador

 
I agree with Dr. Avalos. Time is a very good fiend in this cases. Will you check the patient data between July and the las visit and you will see that your patinet is getting better. At last, when the cornea has stabilized, re-evaluate. I think that you will have enough cornea to perform a PRK. Good luck.

Juan Manuel Garcia Gil
Clínica Mayer
Sonora - Ciudad Obrego - Mexico

Dear Dr. Fernandez,
 
You may explain to the patient that you wish to wait for complete healing. Contact lens to be used if not completely epithelialized. This will help in two ways:
1. Put a powered CL on this eye (so patient is seeing and less unhappy while he waits)
2. The CL will allow smooth epithelial remodelling (while you wait)

Re-eval monthly for 3 more months before making any final conclusions

"Epithelial remodelling is the Giant of Corneal healing compared to more commonly discussed pygmies like Wavefront, Custom laser, topographies etc"

PRK with MMC after all the healing will help him refractively after documenting absence of any induced pathology

Best Regards

Arun C. Gulani, M.D.
Director: Gulani Vision Institute
Jacksonville, Florida

 
Dear Dr. Fernandez:

First of all what kind of microkeratome did you use in this surgery? I analized the picture you sent in the email and the new epithelium is in the nasal periphery of the cornea. Maybe it is in the place of the hinge of the flap. Sometimes depending on the reason of the free cap we could have some irregularities in the hinge's place. I will wait at least two months: analize the new epithelium an may be a PRK with PTK will be the solution. I agree on the use of ciclosporine drops three times per day. Good Luck with the case and let us know the outcome.

Pablo Suarez Saona, MD
Ecuador

 
Dear Dr.Fernadez,

Wait about half a year. In this time the patient ca wear a soft contact lens. Possibly you can measure topography,wavewfront aberrations,pachymetry and also the development of keratectasia.
If all datas are comparables after about 2 months I would prefer either a topography-guided or wafefront guided transepithelial PRK.

Klaus Ditzen,M.D.
Germany
 
Dear Doctor Fernandez,

I am very sorry to hear about your complication. First of all, I too would not have used a contact lens. You did what you needed to do which was repositioned the disc and you followed the patient properly afterwards. You are now three months after the procedure. The eye is myopic with astigmatism. The corneal topography is irregular with steepening below and nasal. The slit lamp photo shows clarity centrally and some scarring temporally.

If the patient is able to wear a rigid contact lens that would certainly be a logical first step to restore vision.

At this point I would allow another three months to elapse to see what the final topography looks like. It is too early to do anything.

If in six months the topography has not changed it may be difficult to plan a surface procedure because of the epithelium. If we assume that the epithelium will not play a role in the final outcome then obviously we would need to remove the epithelium and deliver a customized ablation. Probably the best way to do that is with topography guidance.

If you did want to go ahead and provide the patient a new disc you will need a microkeratome that allows for the ability to cut the right donor disc size preferably from another patient who has a normal cornea but a useless eye. I have done this. It is called a live lamellar homograft procedure. You would need to remove the epithelium and simply lay the donor disc and proceed as usual. No sutures would be necessary.

After healing you could then lift the donor disc and apply another laser treatment to correct any residual irregular astigmatism. I have done this with success but must admit it is frustrating.

Let's hope that the eye heals on its own over the next few months. Dr. Hatsis makes an interesting comment that there may be ectasia based upon the myopia. It is interesting thought. Hopefully careful observation will allow you to make such a determination.

George W. Rozakis, MD

USA

 
Dr. Fernandez... Nearly ten years ago I had a patient similar to this who lost a flap when struck in the eye by a tree branch (he was about 2-3 months post-op LASIK with parameters much like your patient). After much soul searching, I decided to simply treat him as a PRK patient - he healed well. After letting him alone for about 3-4 months and after he was stable (with low residual error of about -1.50), I cut a new flap (had enough cornea to do this) and he did great... He returned to 20/20 after that and stayed there for many years after. He did manifest an unusual doughnut shaped ring of haze along the diameter of the flap... That, too, faded away over a couple of years... Good luck. I would expect the patient to do well with tincture of time...

Robert S. Dotson, M.D.
Oak Ridge, Tennessee
USA
 
Dear fellow

I have some questions. You had an irregular or normal "free cap"? and In this momment the refraction is minus or plus 3.25 ?. The corneal topography is similar to decentered steep ablation, as hyperopic treatment.

Best regards,

Fernando Rodríguez Mier
Figueres - Spain

 
Dear Dr. Fernandez:

Wait, wait,wait...Epithelial Hiperplasia after several months will diminish the induced myopia. Prescribe a Soft Contact Lens. Drops of Ciclosporine helps to prevent haze.

Guillermo Avalos MD
Mexico
 
Dear Dr. Fernandez: A loose cap is always a dreaded complication of lasik. The loss of the cap is usually prevented by a bandage lens placement after realigning the prelasik marks. Unfortunately, there was no contact lens and the cap was lost. Approximately, 15 years ago I was working with Dr. Guillermo Avalos in the early days of microkeratome lenticule correction of myopia. I cut a very thin flap (ie. 80 microns) and was worried abot the accuracy of the microkeratome for the second cut. At this point Dr. Avalos said to just throw away my cap, which I finally did after some debate. To my surprise and elation after the cornea had reepithelialized the patient had a perfect correction and to this day still sees 20/20 with that eye. You still have 200 microns of safe cornea and I would vote for PRK within this margin.

Buena Suerte,

Paris Royo M.D.
Sacramento, California U.S.A.
 
Dr. Fernandez,

The problem seems to be that after you flattened the cornea with Excimer it is steeper and there is a consecutive myopia. He is infact more myopic than pre-LASIK. I'm afraid there is an ectasia here and that it will progress. What is the pachymetry and the IOP? Intacs with X-linking may be helpful if the pachymetry is enough. In the meantime not much to do except lower the IOP, try a NSAID, UV block sunglasses and use a contact lens.

Alexander Hatsis, MD
USA
 
Dear Dr. Fernández:

The easiest way to correct this problem is to replace the lost cap with a new one, same thickness, same diameter (or slightly smaller). Nylon 10-0 sutures are not mandatory, however it would be prudent to use some.

Good luck,

JM Varas-Prieto, MD
Ecuador

 
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Free cap losted
   
Free cap losted Corneal Topography System

Hyperopic and low esteem case

Raul Suarez, MD (Mexico)
Emilio Mendez, MD (Colombia)
Eduardo Viteri, MD (Ecuador)
 
Jorge Cazal, MD (Spain)
Francisco Sanchez, MD (Mexico)
Gabriel Quesada, MD (El Salvador)
Pedro Ivan-Naarro, MD (Colombia)
Klaus Ditzen, MD (Germany)
Mariano Fernandez, MD (Guatemala)
Felipe Vejarano, MD (Colombia)
 
We would appreciate your reply if you have any comments  about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Pablo Suarez Saona, MD
< pablo_ticha@hotmail.com >
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org
The question read as follow:

Dear KMSG members:

A 17 years old teenager came to my office a couple weeks ago She came with her parents looking for an opinion about getting corrective eye surgery. Her driver license was denied and she is experiencing low self esteem because she wares big glasses.
 
Examination:
 
UCVA OD: Counting Fingers,  OS: Counting fingers.
BCVA OD: 20/40  OS: 20/40
 
Refraction without ciclo.
OD: +12.25 -0.75 x 120
OS:  +13.25 -0.50 x 70
IOP 16 mmHg OU
Biomicroscopy: Normal, narrow anterior chamber in the gonioscopy.
Fundoscopy: Normal changes for  hyperopic eyes.
 
Topography: (Keratron)
Sim K OD: K1 49.92 @ 148° K2. 50.73 @58°
            OS: K1 49.95 @   48° K2. 50.87 @ 138°
Sph Ab. Normal in both eyes.
Coma. Normal in both eyes
PPK: Normal.
 
IOL Master:
AL: OD: 16.26mm  OS: 16.00mm
ACD: OD: 2.87  OS: 2.83
 
Please send me your opinion about this case.
 
Thank you all

Pablo Suarez Saona, MD
 
Fundación Ecuatoriana Vista para Ciegos
Sight for the Blind Foundation

Quito - Ecuador
Last answers:
 
 
Dear Dr Suarez,
 
Contact lens will be the best option. The anterior chamber  is narrow ( 2.87 and 2.83)  in a very short AL  so I will not recomend any phakic IOL  beacause high risk of glaucoma, even the piggy back will narrow the anteriror chamber.
 
I will avoid any intraocular surgery because the high risk of acute angule closure glaucoma
 
Best regards
 
Raul Suarez S, MD
Jefe del Dept de Córnea y Cirugía Refractiva
Instituto de Oftalmología Conde de la Valenciana
Dear Dr Suarez,
 
This patient is too young for any refractive surgery.  Besides her corneas are too steep for lasik, her anterior chamber too flat for phakic iol and not a good candidate for CLE. I would recommend a soft contact lens in both eyes and in the future a Clear Lens Exchange with miniphaco and phakic IOL  or piggy back combined.
 
Good luck
 
EMILIO MENDEZ, MD
COLOMBIA
Dear Pablo:

I agree with the diagnosis of Nanophthalmos.  I have treated some cases like yours.  They are a challenge from many aspects and there is not a perfect solution for them.

You can not consider any corneal surgery because it is very steep.  Also the corneal diameter is usually small and there is not enough space for a phakic IOL.

If you decide to proceed with clear lens exchange, then you have the problem of the calculation of the IOL power, as you will find a great deal of variation among the different formulas.  I have found that the Haigis formula is more approximate, but far from perfect for these cases.  You can not use multifocal IOLs as they don’t come in the power that this case will require, even in the assumption that you have an adequate calculation.

If you are looking for the best possible correction, then you could go for a piggy-back approach, implanting a +30 Aspheric IOL in the bag during the primary procedure and later on an IOL in the sulcus, depending on the post op refraction.  At least you should do a peripheral iridectomy.

You will always have to deal with the risks of Glaucoma, trans operative complications and flat anterior chamber even after an uneventful surgery.  I have cases where the IOL haptics have eroded the iris and the post operative refraction usually was significantly far from emmetropia.

Good luck and keep us informed!

Eduardo Viteri, MD - Guayaquil (Ecuador)
By definition we are facing a case of Nanophthalmo wich  refers to a bilateral inherited condition consisting of short axial length, normal-sized crystalline lens, and thick sclera. Nanophthalmos is usually autosomal recessive, but dominant cases have been reported.
 
The axial length in nanophthalmos measures 14-20 mm. Frequently, the visual acuity is good in youth, but the patients are very hyperopic (+10-+20D) and have been described as phakic patients who wear cataract glasses. The abnormally thick sclera contains large collagen bundles and increased glycosaminoglycans.
 
Nanophthalmos has been reported in association with the mucopolysaccharidoses, fetal alcohol syndrome, myotonic dystrophy, and achondroplasia that we have to rule out.
 
Normally this eyes are complicated by Acute Angle Closure Glaucoma .
These eyes have a high propensity for angle-closure glaucoma and hence periodic gonioscopy at intervals of 3 to 4 months is suggested with careful documentation of the gonioscopic findings. PENTACAM is a valuable tool for objective assesment of the anterior segment biometry in this cases. The frequency of angle-closure glaucoma in such eyes is highest in 40 to 70 year age group.  In such eyes medical and laser management of the glaucoma is indicated and intraocular surgery is performed only when absolutely necessary
 
Jin and Anderson  have reported uncomplicated cataract surgeries following unsutured sclerotomies.
 
Besides all this information we did not encourage any intraocula procedure on this patient and we will recommend as a first choice a Customized Contact Lens correction.
 
Warmest Regards
 
Jorge Cazal,MD
Barcelona (Spain)
Dear Dr. Suarez:
• This is not a good candidate for Lasik surgery
• Phakic IOL either ICL or Artisan, are not the best options because we don't have enough space (anterior or posterior chamber) to place them
• I will go for a phaco refractive procedure (clear lens extraction), we don't have the risk of retinal detachment like in myopes.
• The IOL calculation  will be in between 48 to 50 Dt, so you can either ask an IOL company to produce it, or to make a piggyback implantation, using to IOL splitting the power.
• I am agree with Dr . Bejarano, and I have experience in similar cases placing a Restor in the bag and you can decide either to place the second monofocal IOL in the same bag or in the sulcus, as you feel comfortable.
Dr. Francisco Sánchez León
Instituto Oftalmológico Novavision
Cd. de México.
In that case I would think in clear lens exchange with multifocal IOL

Gabriel Quesada MD
Centro Panamericano de Ojos
El Salvador
Dear Dr Suarez:
 
This is a really interesting and uncommon case due to presence of steep corneal curvatures (keratoconus) with high hyperopia. Due to this combination my first choice would be rigid gas permeable contact lenses because there is no surgical options on the cornea ( as segments) or in the lens ( young patient) to fix these two problems.
 
My best regards,
 
Pedro Iván Navarro MD
Bogotá, Colombia
Dear Pablo Suarez Saona,
 
The ACD would just let implant an Artesan/Verysize IOL:.For piggy-back lenses the patient would be too young.
 
Klaus Ditzen,M.D.
Germay
Dear Pablo:
 
Obviosly she is not a case for laser surgery, and its kind of hard think in IOL, before that, I would like to heard if you´ve tried a  contact lens??
 
Best Regards.
 
Mariano Fernandez, MD
Guatemala
Dear Dr.Suarez, what a CASE, even the anterior chamber is shallow (I assume that the ACD is from epithelium), so may be doing a UBM and see the depth of the posterior chamber thinking in ICL.
 
The other idea that I have is make a Clear lens extraction (biaxial or Micro biaxial) with piggy back one aspheric IOL in the bag and one multifocal in sulcus, this is a very risky idea but talking a lot with the patient and parents may be is the only solution for me, If not then just a contact lens.
 
L. Felipe Vejarano
FUNDACION OFTALMOLOGICA VEJARANO
Popayán - Colombia
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LASIK or PRK by Pentacam

 
Pedro Ivan-Navarro, MD (Colombia)
 
We would appreciate your reply if you have any comments  about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

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KMSG Hot Line coordinator

John Belardo, MD
lzrsurgeon@hotmail.com
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 
The question read as follow:
 
Dear Collegues,
 
What are the parameters for the pentacam which people use to determine eligibilty for LASIK or PRK or not to do surgery...Also how much distance from the center is being taken into consideration to make that decision????
 
Thanks....
 
John Belardo MD
USA
 
Last answers:
 
Dear Dr Belardo:
 
Anterior surface elevation normal limit is 12 microns to me, same as Orbscan map, for posterior corneal elevation we always use 17 microns as a cutoff point to rule in or rule out a candidate for refractive surgery.
My parameters are the same for any type of substraction technique, lasik or surface ablation.
 
Sincerely yours,
 

Pedro Ivàn Navarro Naranjo, MD
Colombia

 
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Lasik patients with undercorrections

A NEW message,"Re:  The question  posted by, Guillermo Avalos, MD,< guavalos@infosel.net.mx > Mexico, was sent by:
Robert Dotson, MD (USA)
Gabriel Quesada, MD (El Salvador)
Alfredo Amigo, MD (Spain)
Francisco Sanchez, MD (Mexico)

We would appreciate your reply if you have any comments  about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Guillermo Avalos, MD
< guavalos@infosel.net.mx  >
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org
 
The question read as follow:

Dear Fellows:
 
I started doing Lasik in 1995 . At this time I have seen patients with undercorrections, even in low myops or astigmatics.
 
Do we expect latter to see many patients to complain of their vision and ask for a "re-touch" ?
 
What is your sincere opinion? Are you having the same patients?. How to prevent it?
 
Guillermo Avalos MD.
Mexico
 
Last answers:
 
 
Dr. Avalos...
 
I am seeing a few "late" myopic shifts in my patients (in the -0.50 to -1.50 D range) - some done as far back as 1995, too. Almost always, though, something else is responsible for this change: early cataracts (higher rate of early nuclear sclerosis - especially in the original high myopes); significant keratoconjunctivitis sicca (simply due to age-related changes - it seems like everybody 40 and up has dry eyes); systemic health issues (diabetes, use of statins, etc.). I really try to persuade presbyopic age patients to leave low amounts of minus alone.
 
All the best...
 
Robert S. Dotson, M.D.
Oak Ridge, Tennessee
 
We have had experience first with PRK (Summit), during early 90s, the we changed to LASIK (using Chiron + Summit), in 2001 we changed to Schwind (ESIRIS + Pendular), also we change from doing anterior topography (Tomey) to the Pentacam this years, and we are doing ORK treatments.

In our practice we have reduced te "reop's" doing a better refractive calculation, and knowing better our equipments and the physiology of the refractive surgery as well, but in general I wuold say that those patients that after one month post op still have a refractive error, probably with age that accomodation is reduced, will need a reop in the future.

Gabriel Quesada MD
Centro Panmericano de Ojos
El Salvador
 
Dear Guillermo:
 
It seems to me that you are meaning that after having lasik you are seeing low myops that being originally "officially stabile" and emetrope after surgery, some years later they come in with some amount of myopia. If so, after 10 years performing lasik I see the same, not infrequently, in my patients. I have observed that it is especially significant when first surgery was performed in patients below thirty years old even though at the moment of the surgery they were apparently stabile (1 year with no significant change in refraction). Usually when they come back in they do not present significant topographical changes respect postop but an apparent "regression" of -0.50 to -1.5 D. In my opinion the term stabile refraction we are using, even in low myops, is actually incorrect and we are not assisting to a real regression of the ablation effect but to an "unexpected" formal slow natural progression of their myopia. This is clear to me and nowadays I’m overcorrecting patients according to their amount of pre-operative myopia, targeting for up to +1.5 sph. when they are round 23-25 y.o. and up to +0.75 when they are closer to the thirties.
 
Un cordial saludo
 
Alfredo Amigo, MD
Spain
 
Dear Guillermo:
 
During last presentations at ASCRS and ESCRS John Marshall PHD from London talked about LASIK with blade long term regression. (slide included)
 
As we know regression would be explain by three causes:
1. Epithelial hyperplasia (described by Chayet )
2. Axial length increase
3. Biomechanical changes (ectasia in the worst case)
• Today ORA has demonstrated changes in the corneal hysteresis and long term biomechanical stability is compromised in patients who underwent to LASIK with blade
• These new findings are pushing to go back to either PRK, LASEK or LASIK IntraLase
• After these new information,  I only perform either PRK or LASIK IntraLase 90 microns flaps (sub-bowman safety area) in most of my procedures in order to prevent long term corneal stability changes.
Francisco Sanchez Leon MD
Instituto Oftalmológico Novavision
Cd. de México
 
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Multifocal lens in Monocular

Raul Suarez, MD (Mexico)
Juan Guillermo Ortega, MD (Colombia)
Robert Kaufer, MD (Argentina)
Lucas Andrioli, MD (Argentina)
Luis Lu, MD (USA)
Gabriel Oliveros, MD (Colombia)
Ernesto Otero, MD (Colombia)
Luis Escaff, MD (Colombia)
Kevin Waltz (USA)
Francisco Sanchez (Mexico)

We would appreciate your reply if you have any comments about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Jairo Hoyos-Chacon, MD
<hoyoschacon@iohoyos.com>
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 

The question read as follow:


Dear Friends,

I have one patient looking for refractive surgery because she does not want wear glasses, she is 61 years old and she works at home.

She has her left eye with a deep amblyopia (BCVA = 20/200) and her right eye is OD = +2,00-0,50 X 180º = 20/25.

She has an incipient Cortical and subcapsular cataratact in both eyes.

I am planning to do a multifocal implant in her right eye (MONOCULAR) and in her left eye I will implant a monofocal lens.

Do you have experience implanting a multifocal lens in monocular patients.

Jairo Hoyos-Chacon, MD
hoyoschacon@iohoyos.com

 

UPDATE:

Dear friends

Thank you for your opinions. I can say to you that now may patient is really very happy. I has operated her 3 weeks ago, first her left eye with a Restor lens and a week later her right eye with a Monofocal lens (SN60AT - Alcon).

In the last control her vision was:
RE = 20/25 LE = 20/200
Near = 20/20
No complains

She is really happy, just like me.

Jairo Hoyos-Chacon, MD
Spain

 

Last Answers:

Dear Jairo

This is a good indication for monocular Restor IOL implantation

beacause the ambliopia on the other eye. You should not have any problem

with the binocular VA in this type of patient

Saludos

Raul Suarez, MD
Mexico
Dear Doctor Hoyos:

 

I have 4 monocular patients with ReSTOR intraocular implantation.
One of them is a girl 12 years old, with a microftalmic eye, and the fellow eye with a developmental cataract, she was to a phacoemulsiphication with a successful IOL implantation, and by this time, after 12 months she is 20/25 J1, and she feels very happy, with no complains.

My opinion is that ReSTOR is the multifocal IOL of choice in monocular patients.

Yours truly,

JUAN G. ORTEGA, MD
Medellin, Colombia

 

Dear Jairo,

You should have no problem at all with any kind of m,ultifocal as long as the patient understands the expectations. I have had no problems at all with this kind of patient.

Kind regards,

Robert Kaufer, MD
Argentina

 

Dear Jairo:
I have implanted a multifocal IOL (Restor) in a 18 year old patient with a traumatic cataract in his left eye. I did that thinking in recover his lost of accommodation after the surgery. And it worked acceptable. The near vision was not perfect but we had explained it before and was accept.

Lucas Andrioli, MD
Argentina

 

Dear Jairo,

Your patient should be a candidate for multifocal IOL implantation as she is hyperope with a very low amount of astigmatism.

If requested by the patient, my indications for Monocular Multifocal Implantation are:
- Dense amblyopia in the contralateral eye
- Dense and long standing corneal scar in the contralateral eye
- Macular scar in the other eye i.e. Toxo scar
- Traumatic monocular cataract in the non-dominant eye
- Previous Pseudophakia in the opposite eye with poor visual outcome
- Previous Monofocal IOL with a -1.00 of refractive error . A MTF IOL should provide then the distance and near vision as the patient has the intermediate distance vision

Unilateral MTF IOL implantation in one eye and Monofocal in the other works only in certain very cooperative patients, but requires certain rules to be followed.

Respectfully,

Luis W. Lu, MD
USA

 

Dear Jairo:
I have a patient like yours, same age , with amblyopia and multifocal IOL in the good eye, with about 2 years since the surgery was done and she is happy. I´m using now the Acrilisa fron Acritec because intermediate vision is better than Restor, and less night vision symptoms too, that are more evident when you implant only in one eye. I have more patients with monocular multifocal IOL(Acrilisa), second eye of previous monofocal IOL in the other eye and it works very well . With Restor in monocular vision you don´t get 100% in far and near vision and this last is very close wich is bothersome for most people.

Gabriel Oliveros

Bogotá, Colombia

 

They work really well if the expectations of the patients are realistic. I have implanted single multifocal IOL's in patients with unilateral cataract and to my surprise, they see very well both at a distance and near. I am obviously very obsessive spending "chair time" with them to keep their expectations realistically low.

Ernesto Otero, MD
Colombia

 

Dear Jairo

I have had the opportunity to implant a monofocal IOL in one eye and a multifocal IOL in the other eye and works well, better when in the monofocal eye you leave a miopía between -1.5 to -2.00. Also I have implant Multifocal IOL’s in monocular patients.

Luis Escaff, MD
Barranquilla, Colombia

 

Dear Jairo,

I have implanted multifocal IOLs in many patients who have one best eye, like your patient.
They do well with the surgery. Of coursem they don't do quite as well as a patient with two eyes.
The only real problem is what to do if they need a refractive enhancement with a laser or an IOL exchange for power. Then you have to decide is the extra surgery worth it in this case?

Kevin Waltz
USA

 

Dear Jairo Hoyos

I have had experience doing a case like your, and works well
I will prefer a Restor aspheric lens for a case like this, on the right eye, and a monofocal acrysof IQ for the left.
Besides in a presbyiopic with hyperopia patitient Restor aspheric works beautiful, patient are very please with result.

Francisco Sánchez León
Instituto Oftalmologico Novavision
México

 

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New Restore

Carlos Vergés, MD (Spain)
Ivan Ossma, MD (Colombia)
 
 
We would appreciate your reply if you have any comments  about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Mariano Fernandez, MD
marianofrnndz@yahoo.com
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 

The question read as follow:
 
Dear Group:
As an answer to the +4.00 power of the restore IOL.claims as you know, Alcon is introducing its new +3.00 Restore.
Who is going to " mix and match" with the two powers at this point?
Who its going to keep using the same power for both eyes in order to achive more deep percepcion, and quality near vision?
Best Regards
Mariano Fernandez, MD (Guatemala)

 

Last answers:
 
Dear friends,
 
I don´t believe that this new addition,  +3,  could help to achieve something similar to “Mix and Match”. This concept rice up on the principle to combine two lenses, one for distance an intermediate vision and other for distance and near vision. The focus for the first one, for intermediate vision, is provided with an addition of 1.5 D and the focus for the second lens, for near vision, is provided with an addition of 3.5 D.
 
The Restor lens has an addition of +4, to high, to reduce halloos avoiding  retinal images  superimposition, the problem is a close near focus, less than 20 cm, that explain way is necessary to read close to the eye and way these people has bad intermediate vision. To resolve this problem appear the new lens with an addition of +3. This lens will be better to improve near vision, to fell more comfortable ours patients but insufficient to resolve intermediate vision.
 
Carlos Vergés, MD
Spain

 

Unfortunately the "new" Restor 3.0 add will yield more halos as the two foci will be closer together. I grant you that you will get better intermediate vision with this lens but I don't think addressing intermediate vision in this fashion will necessarily render happier patients. 

I Custom Match the vast majority of patients with combinations spanning from TecnisMF-TecnisMF, Restor-Rezoom, TecnisMF-Rezoom, Restor-Restor and Rezoom-Rezoom in an approach that I think makes more sense...
A smaller percentage of patients receive pseudophakic monovision with Aspheric IOLs or Toric IOLs as the case applies.

I think that the Industry has attempted to "force" us into using only one specific brand of IOL for every patient and this approach is as wrong as it is solely driven by a marketing strategy to sell more.
 
Just my humble opinion...
 
Ivan Ossma, MD, PhD
Colombia

 

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Pentacam

Guillermo Ortega, MD, FRCSC (Canada)
Juan Guillermo Ortega, MD (Colombia)
Luis Izquierdo, MD (Peru)
L Felipe Vejarano, MD (Colombia)
Pedro Ivan-Navarro, MD (Colombia)

We would appreciate your reply if you have any comments about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Rodrigo Quesada, MD
rquesadaeyemd@yahoo.com
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 

The question read as follow:

Dear Fellows,

For those who are using pentacam topography, what are the parameters do you use for normal or abnormal posterior corneal elevation?

Rodrigo Quesada, MD
El Salvador

 

Last answers:

For anterior elevation: maximum of 11-15
For posterior elevation: maximum of 16-21

Also, I look at the pachymetry apex and thinnest pachymetry, and hope to get, ideally, less than 1 mm, preferable less than 0.50 mm.

I always run the keratoconus software as well.

Regards,

Guillermo Rocha, MD, FRCSC
Canada

 

My feeling is that no perfect answer for that question. Everybody is talking about 20 as a magical number to determine if you have to confront an “ abnormal” cornea. I thinh that the posterior aspect of the cornea is more sensible to alert about keratoconus. For me more than + 20 in the anterior aspect of ther cornea is abnormal. More than + 15 in the posterior one is abnormal indeed. But I am very curious about the panel’s opinion.

Best regards

Juan Guillermo Ortega, MD
Colombia

 

Dear Friends

We use the pentacam, and we have the visante and just arrive the galilei
with the pentacam a central posterior elevation of 15 is high suspect for central ectasia.

Saludos

Luis Izquierdo Jr., MD
Lima Peru

 

I had been using Pentacam since July 2006, the best way is using manually at 9.0 mm in the Best Fit Sphere, and the data is at the anterior surface more than 15 Microns and at the Posterior more than 20 Microns.

And the decentration of the thinnest part more than 1 mm from the apex.

L. Felipe Vejarano, MD
Colombia

 

Dear Dr Quesada:

Although Orbscan IIz is my gold standard to screen candidates for refractive surgery, normal pentacam anterior and posterior surface normal values to me are 12 microns and 17 microns. respectiveley.

Sincerely yours,

Pedro Ivàn Navarro Naranjo, MD
Colombia

 

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Presbyopia

 
Alfredo Amigo, MD (Spain)
Luis Escaff, MD (Colombia)
 
Jérôme Bovet, MD (Switzerland) 
Raul Suarez, MD (Mexico)
Felipe Vejarano, MD (Colombia)
Soriana Rodriguez, MD (Cuba)
Luis F Restrepo, MD (Colombia)
Jorge Cazal, MD (Spain)
Mariano Fernandez, MD (Guatemala)
Francisco Sanches, MD (Mexico)
Guillermo Avalos, MD (Mexico)
Enrique Suarez, MD (Venezuela)
Gabriel Quesada, MD (El Salvador)
 
We would appreciate your reply if you have any comments  about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Melania Cigales, MD
mcigales@teleline.es
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 
The question read as follow:
 
 
Dear fellows,
 
Do you use any techique for the correction of presbyopia? What technique do you practice an why? What about your results?
Thank you

Melania Cigales
Barcelona - Spain

 
Last answers:
 
 
Dear Dr Suarez,
 
Contact lens will be the best option. The anterior chamber  is narrow ( 2.87 and 2.83)  in a very short AL  so I will not recomend any phakic IOL  beacause high risk of glaucoma, even the piggy back will narrow the anteriror chamber.
 
I will avoid any intraocular surgery because the high risk of acute angule closure glaucoma
 
Best regards
 
Raul Suarez S, MD
Jefe del Dept de Córnea y Cirugía Refractiva
Instituto de Oftalmología Conde de la Valenciana
 
Last answers:
 
Dear Melania:
 
Summarizing actual trends, presbyopia treatment can be divided in two techniques:
1. - A  mini-monovision (MMV) approach, this is, targeting for aprox. -0.25/-0.75 in patients (pt) < 50 y.o.
2. - MIOL for patients > 50 y.o.
 
Now, to have success when using MMV there are two absolutely important aspects:
a. - Which eye is going to be chosen for near vision and
b. - What amount of addition can each pt tolerate.
 
In order to get an answer for this it is essential to use a proper test (ContacL test performed at the office is frequently not trustable). The best test I ever used to guarantee preoperatively this purpose is the SCORE TEST (Cummings A. Monovision with Lasik. In. Agarwal A. Presbyopia. Slack Inc . 2002; 18: 155.) and thus I believe it is convenient to explain it:
 
SCORE TEST steps:
1. - Asking the patient (pt) to call (TO SCORE) his binocular BCVA for distance as a 100%. This will be the reference point for the rest of the test.
2. - Adding +0.75 D on any of his eyes, we ask the pt to score the new image respect the 100% distance VA. Then repeating the same procedure on his other eye.
 
SCORE TEST result:
If a patient scores his VA on any of his eyes as being 90% or more we have a 100% chance of achieving successful MMV by adding that amount on that eye. A score < 80% in both eyes, is very likely that amount of adding will not be accepted postoperatively for the patient. In this case we can try again by adding a lesser amount like +0.50 or even +0.25 if necessary until getting a >90% answer.  80-85% is a grey area
 
Presbyopia, below 50 y.o., can be treated successfully in 80% lasik pts by using the score test method. Above 50 y.o., MIOL (not mix and match) is there after the adequate technique
 
Un cordial saludo
 
Alfredo Amigó MD
Spain
 
Clear Lensectomy with ReSTOR Aspheric implant .
 
Luis Escaff, MD
Colombia
 
Dear Melania, 
 
A really Pretty good question to do the point on  this. first of all I will increase the police and bold , that everyone can read the mail...
 
1-first of all I think that everybody still use monovision or a sort of monovision because we can test the patient before to do the procedure before or after the cataract.
They are not a dominant eye versus a non dominant eye like males, dogs, etc etc but you have an eye for far and an eye for near and sometimes you have people absolutely binocular ,which support only the same correction (Bovet's monovision test)
 
That's why so many surgeon still use this technique because you can test it before to do the surgery. We don't loose some contrast visual acuity like with multifocal
 
2-for lasik after 45 y o we use monovision procedure
 
3- for catarefractive surgery  beetween 60-65 Hypermetropia and emmetropia we use multifocal acrylysa from acritec and we have a contract with the patient to change the lenses if he doesn't support (IOLXchange ASCRS film festival 2008) 
 
4-for catarefractive surgery beetween 60-65 light myopia we use monovision 
 
5- for catarefractive surgery beetween 60-65 high myopia the patient stay sligthly myopique both eye 
 
6- for hard cataract we use monofocal lens and we correct after 3 monthes with a lasik allegretto monovision.
 
The problem is: we still have for multifocal lenses and presbyopia lasik procedure  no test to have an idea if the patient will support or not this doubble vision on his fovea    and the young Papyboomer want pay but for a good results
 
Best regards
 
Jérôme Bovet, MD
Switzerland
 
DEAR MELANIA
 
IN RESUME I DO LASIK FOR MONOVISION
 
I GO WITH RESTORE IF THE PATIENTS HAVE CHANGES IN THE CRYSTALLINE LENS
 
IN A FEW CASES I GO WITH CK MONOVISION BUT SOME  PATIENT HAVE REGRESSION
 
SALUDOS MELANIA
 
Raul Suarez, MD
Mexico
 
Dear Melania,
 
All depends of the age and the refractive error.
 
Older than 65 always Multifocal IOL.
 
Younger than 65.
Emetropic I use Inlays the Invue lens with amazing results as showed Francisco Sanchez.
 
Hiperopic between +1.5 to +4.00 diops. I use the Presbiopic software of AMO-VISX
 
Miopic and Astigmatic I’ll use the next release software for Presbiopic patients from AMO-VISX
 
L. Felipe Vejarano, MD
Colombia
 
Dear Dra Cigales:

In ours Institute we are doing LASIK surgery as monovision procedure.
Is very important in this treatment the patient's expectatives, and the patient has to be adapted to monovision before the surgery.

Indications: 40 or more years of age.The hyperopes are the best patient for this treatment.

Results:
-stability of the refraction.
-good predictability.
-very good vision for near and distance .
-good satisfaction of the patients.

Sorania Rodriguez Sanchez MD
Cuba.

 
Dear Melania:
 
Your question is a very wide one. Before describing my technique, I would like to make a statement: Binocularity is the key for Presbyopia treatment. Most approachs just take no account of binocularity, that’s why many patients are not satisfied, just “get used” after many months. Intraocular techniques like “Mix and Match” are a good example of this. I don’t understand why so many clever colleagues approach Presbyopia as a monocular problem, not only not taking advantage of binocularity but in some way jeopardizing it.
 
I developed a Lasik  technique that I called Panvision. It is designed with binocularity in mind, so rivalry between the images from both eyes is minimized and the brain can take full advantage of binocular functions. Also thru Q-factor binocular adjustment (not inducing or actually decreasing spherical aberration), we look for an improvement in PSF (Point spread function), MTF (Modular transfer function) and as a result the best possible CSF (Contrast sensitivity function). Also, due to careful binocular Q-factor adjustment, Panvision increases DOF (depth of focus/field) and also the not well known subject called Binocular Summation (excellent papers on this subject from the Sevilla University Laboratory of Optics). As a rule, I always take into account Kappa angle to center the ablation and consider it of paramount importance (discussion could be too long)..
 
To be short Panvision looks for a balanced binocular Q-factor as close as possible to -0.6 and a planned ammetropia not bigger than 0.75 (it means the non-dominant eye will be between 0 to -0.75) according to each case. I presented preliminary results at the Allegretto Users Meeting last year in Berlin: out of  115 patients seeing 20/20 for far, 95% of the cases (all type of defects) were 20/40 or better for near, 73% 20/20 or better for near. Grossly, for all type of defects, 40% needed some help with glasses ONLY for sustained small near work (fine print, sewing, nail cut and so) and in all cases no more than +1.50 (dominant eye). Only grossly 14% requested glasses for activities like cell phone usage, price tags at the supermarket, computer work and so.
 
I want to stress that:
A gross  60% never requested glasses help for even fine print
No complaints for night vision in over 85%
No one has requested reversal of the procedure
Over 95% never notice the slight ammetropia
No adaptation time for over 95%
Longest adaptation time 12 weeks (1 case)
Under 5% requested glasses for night road driving (not for city driving)
All very satisfied with intermediate vision  (intermediate vision is one of the most important complaints among presbyopic patients)
 
I agree that the cornea could be not the ideal place to correct Presbyopia, but also, I think that intraocular lenses are not either the right way. Since a physiological point of view, the cornea brings too much more advantages to correct Presbyopia than the lens replacement and currently is the way to go.
 
Regards,

 
Luis F. Restrepo
Pereira, Colombia

 
Hi Melania,
 
Always is a pleasure to hear from you, regarding yor question in our practice as you know there is two surgeons( Carlos Vergés and me)  we have many point in common however we approach presbyopia in some different manner.
 
First, he works mostly with Custom Match phylosophy-MICS Phacorefractive, and researching is doing on Motion Perception with some custom software that our visual & Psycology department are developing with this patients.
By the way we already started the protocol for FDA Syncrony IOL (dual optic) and ready to start with Accufocus Corneal Inlay.
 
We still are not convinced, at least with our current platform (Allegreto Wavelight 400 Hz Eye Q)  that its FCAT approach could give all our patients a safe, stable,accurate presbyopic treatment at the cornea plane, based in our pilot study (data on file 2006-07) however may be this overview  would change in the near future.
 
Otherwise, ophthalmologists who want to begin offering presbyopia-correcting lenses should select one model and become comfortable with it before branching out to other IOL designs.
I personally approach my presbyopic patient with in two different and pragmatic ways.
 
My practice is a combination of cornea; refractive surgery, including LASIK and Epi-Lasik/PRK; and cataract/IOL surgery. I perform probably 30% refractive lens exchange and 70% cataract surgery. I don´t use all of the presbyopia-correcting lenses that are available.
 
If my patient ask for Multifocal IOL
In general,I will implant the ReSTOR IOL bilaterally when the patient does well with the ReSTOR lens in his first eye.Of course if he/she fit to a very strict protocol for MIOLs candidate selection.
 
I also are very familiar with this platform since the conception of its antecessor monofocal SA60AT and I rely very well in my explantation technique if it should be requested. But this is not my favorite approach as you will read.
 
I think that all of us in our community already know and have experienced that monofocal IOL solution is one that cooperates with the  brain´s natural processes of fusion while maintaining the highest quality of the image.
 
MIOLs are designed to recapture the phenomenon of accommodation,yet these lenses produce lower contrast sensitivity, are associated with a higher rate of glare and halos and are highly sensitive to lens decentration. (see bibliography below 1-3)
 
According to Cloé and Parmar, patient loses 18% of light energy with MIOLs, which can be attributed to the conflicting and overlaping patterns produced by these lenses.
 
The degradation in the visual quality that occurs after the implantation of multifocal lenses cannot be reversed with spectacles. A successful monovision procedure , however, allows for  visual improvement with spectacles.
 
 
1:Chiam PJ, Chan JH, Aggarwal RK, Kasaby S.
ReSTOR intraocular lens implantation in cataract surgery: quality of vision.
J Cataract Refract Surg. 2006 Sep;32(9):1459-63. Erratum in: J Cataract Refract
Surg. 2006 Dec;32(12):1987.

2: Javitt JC, Steinert RF.
Cataract extraction with multifocal intraocular lens implantation: a
multinational clinical trial evaluating clinical, functional, and quality-of-life
outcomes.
Ophthalmology. 2000 Nov;107(11):2040-8.
 
3: Claoué C, Parmar D.
Multifocal intraocular lenses.
Dev Ophthalmol. 2002;34:217-37. Review. No abstract available.
Research in Neuroscience has facilitate development for us to understand different between multifocal and monofocal lenses. Multifocal IOLs rely on monoptic suppression.(4)  Each eye must supress certaing visual information to perceive a clear picture. Conversely, utilizing  monofocal IOLs for monovision induces binocular fusion when desired clinical outcomes are obtained. That is the reason I prefer monovision as my first choice in the world of MIOLs.
 
 4: Sengpiel F, Vorobyov V.
Intracortical origins of interocular suppression in the visual cortex.
J Neurosci. 2005 Jul 6;25(27):6394-400
 
Sorry to to much long but this is a very interesting field in refractive surgery.

Hope this help
 
Best
 
Jorge Cazal,MD
Barcelona,Spain

 
Dear Dra.Cigales.
 
In our center, we are doing mostly a MIOL with good results. Even for patients in the early 50´s. Almost always using a"Custom Match", analysis.(Restore-Rezoom),(Tecnis-Rezoom)
Besides that we have experience wtih CK. Good option for "young"  patients with presbyopia. It works quite good in Hyperopes, no side effects, but the patiet has to be adapted to monovision first. We use it also after a MIOL Surgery, in which we have a low hypermetropia remaining, avoiding a lasik surgery, for +0.50/+0.75.for example.
 
Best Regards.
 
Mariano Fernandez, MD
Guatemala
 
Melania:
 
Decision depends on patients needs, age, associated refraction, monovision tolerance, activities, profession.  
 
1. My best option is Phacoemulsification with Restor Aspheric.
Indications: patients over 50 years of age
Associated refraction: Hyperopes  seem to be the best patients.
We use in Myopes and Emmetropic patients a well, particularly in those who does not tolerate monovision technique.
Results: Excellent predictibility, good stability, some night side effects: 10% complains about halo and glare, good response to Bromonidine.
We do not recommend in patients who are involved in color selection, night drivers or artists like paintors.
 
2. LASIK surgery as monovision procedure.
Indications: 40 to 50 , tolerance to monovision, patients who refuses to have intraocular procedure.
Associated refraction: Myope or hyperopes, aspheric algortim preferable,  if we have enough cornea thickness.
 
3. Corneal Inlays for Presbyopia (Inveu Biovision Inlay)
I  have been consultant for a Presbyopic Inlay as a investigation protocol
We carve a channel with IntraLase and place a presbyopic inlay, we chose the non dominant eye
Indications: At the present time only for emmetrops
Results: It produces an intelligent monovision reading vision which work in relation to the pupil physiology. The system at distant when pupil dilates the system is emmetropic, and for reading vision when pupil constricts because accomodation we have seen a myopic system using WF Sciences aberrometry pupil reconstruction (for reading)
Reading vision results: UCVA 100%  20/30 or better, 75% 20/25, 50% 20/20
Distant vision:  1 to 2 lines of loss of UCVA in 70% of the cases, which is better comparing to leave a case with -1.50 Sph and 20/100 of distant UCVA
Advantages: You can remove it if patient does not get use to it (very easy), small percentage
 
4. Recently, we have been working in a protocol for Conductive Scleroplasty with Richard  Lindstrom for presbyopia
10 cases only
Indications: Emmetropic patients
One month results: All gain reading vision preop 20/100 av, postop 20/40 or better all.  
Advantages: Non loss of lines of UCVA
Good satisfaction
 
Francisco Sánchez Leon MD
Instituto Oftalmológico Novavision
Cd. de México.
 
Dear Melania:
 
In a "young patient" 47 to 55 Y/o I do my own Lasik Presbyopia surgery (PARM), with excellent results, is bilateral, next day patient achive very good vision for near an distance, is stable. At this age Corneal surgery is a good option. After 60 y/o MFIOL is the option.
 
Guillermo Avalos MD.
Mexico
 
Clear Lensectomy with ReSTOR Aspheric implant (better ReSTOR + 3) .
 
Enrique Suarez
Caracas - Venezuela
 
Dear Melania:

We use almost every technic we have:
Monovision either with LASIK or IOL
Multifocal IOL (ReStor)
LASIK (ORK) for presbyopia in some cases and the use of reading glasses

 
The results depends on the expectatives of the patients and his or her needs

Gabriel Quesada MD
Centro Panamericano de Ojos
El Salvador

RD after ReStor IOL

Luis Lu, MD (USA)
Hideharu Fukasaku, MD (Japan)
Soriana Rodriguez, MD (Cuba)
Ana Luisa Höfling-Lima, MD (Brasil)
Samuel Boyd, MD (Panama)
Arun Gulani, MD (USA)
Cyres K Mehta, MD (India)
 
We would appreciate your reply if you have any comments  about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Gabriel Quesada, MD
clique-gq@salnet.net
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 

The question read as follow:
 
 
Dear fellows,
 
I would like to hear any experience of Retinal Detachment after ReStor IOL

We have a patient, 65 years old, male; he had cataract surgery OU with a ReStor IOL on Sep 2006. Previous refraction RE -1.00 -1.00 x 165 20/50-;LE -2.75-0.50 x26 20/70.
IOL calculation RE +19.5; LE +20.0 ReStor
One month post op RE 20/20- (-0.50x157); LE 20/20 plano; No.1 OU.

One year later, on Oct 2007 He came for "flashes and shadow" RE, 2 days.
RE Retinal Detachment, macula on 20/60-. A Retinal Surgery with buckle + argon laser; was performed the next day.
2 month post op; RE -1.75 -3.50 x 156 20/30+

The questions
1. Would you do refractive surgery on the RE?
2. When? (3 months, 6 months...)
3. What tipe of Refractive Surgery? (PRK; LASIK; other)

Thanks in advance

Gabriel Quesada MD
Centro Panamericano de Ojos
El Salvador

 

Last answers:
 
 
Dear Dr. Quesada,
 
As the patient presented with a "macula on" RD and 20/60- BCVA, we must assume there was a macular involvement by the time he went to the OR for his surgical repair.
Full recovery for those cones with take up to 6-12 months, and it will take a while until you get the final stable prescripion, of course, with a serial OCT follow up.
I would suggest waiting up to 12 months for the Lasik or PRK.
Why is so much of a problem waiting for 12 months if he has 30 years to enjoy the results of a good outcome !
 
Respectfully,
 
Luis W. Lu, MD, FACS
Senior Partner, Pennsylvania Eye Consultants
Instructor, University of Pittsburgh School of Medicine

 

Dear Fellows:

Thanks for your comments, they have been very helpfull

Finally we decided to do a PRK treatment on this patient
Previous refraction RE -2.00 -3.00 x 156 20/30-
3 weeks post op RE 20/40+ (+0.50 -0.50 x 30 20/30+) No.5

The patient is very happy and that is the important fact in this case

Gabriel Quesada MD
Centro Panamericano de Ojos
El Salvador

 

Dear Dr. Quesada;
 
Essential problems are the changing the refraction and some problems of retina /vitreous body.
 
If the retina has been attached, you can remove the silicone buckling and refraction will be reversed.
 
I wonder, there is some macula problem. There may be ERM (Epi Retinal Membrane) or macula pucker.
Vitrectomy may be necessary to strip out ERM , ILM (Internal Limiting Membrane) and vitreous opacity.
 
Vitrectomy will be much better to treat the retinal detachment for the post multifocal IOL implantation case.
 
Additional another laser surgery may cause another problem.
 
Hideharu Fukasaku, MD
from the Fukasaku Eye Institute,
Vitreo-retinal department and
Cataract/Laser/Refractive surgery center 

 

Yes I would plan a refractive surgery,
 
After three months if the refraction is stable
 
Conventional PRK with mitomicin C
 
Profa. Dra. Ana Luisa Höfling-Lima
Titular e Chefe do Depto de Oftalmologia
Universidade Federal de São Paulo - UNIFESP/EPM
Vice Presidente-Associação Pan Americana de OYes ftalmologia

 

Dr Quesada:
 
In may opinion this is not a good candidate for LASIK because the retina re-detach can be develoment after surgery with LASIK, and the patient must know it.
I suggest PRK  6 month´s  to  12 month´s after the retinal surgery with the stability of refraction, another option is contact lens of course.
 
Saludos
 
Sorania Rodriguez M.D
CUBA

 

Dear Dr. Quesada:

This is not an uncommon situation. For this prescription you may perform a LASIK. Not less than 6-12 months after the retina surgery. Remember,if the retina re-detach it will in your hands, so is better to wait.

Samuel Boyd, MD
Vitreoretinal  Department
Boyd Eye Center
Panama, R.P.

 

Hi Dr. Queseda,

It does not matter what surgery any patient has had in the past or who did it and with what technology as long as we anatomically relate to the refractive error keeping refractive stability in check.

Answers:
1. Ofcourse
2. 3-6months with confirmed stability of refraction and routine diagnostics
3. Laser ASA / PRK

Best,

Arun C. Gulani, M.D.
Director: Gulani Vision Institute
Florida, USA

 

In my practice i would do a LASIK at 3 months.
 
Dr Cyres K. Mehta M.S (OPHTH) F.A.S.C.R.S(USA)FSVH (GERMANY)
Consultant Ophthalmic Surgeon and Director
Mehta International Eye Institute
Sea Side, 147 Colaba Road
Mumbai,India -400005

 

This is an automatically-generated notice.  If you'd like to be removed from the KMSG mailing list, please  send an e-mail to the KMSG <kmsg2007@kmsg.org >  If you wish to respond to this message, please send your reply to:

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kmsg2007@kmsg.org

Steep corneas LASIK vs Surface ablation

   
A NEW message,"Re:  The question  posted by, Jayne Weiss <jweiss@med.wayne.edu>, MD, USA, was sent by:
 
- Alexander Hatsis, MD (USA)
- Sujatha Mohan, MD (India)
 
- George Rozakis, MD (USA)
- Edna Almodin, MD (Brazil)
- Jayne Weiss, MD (USA) - UPDATE !!!!!!!!
- Guillermo Rocha, MD (Canada)
- Pablo Bohorquez, MD (Spain)
- Guillermo Avalos, MD (Mexico)
- Luis F. Restrepo, MD (Colombia)
- Rudy Gutierrez, MD (Guatemala)
- Pedro Ivan- Navarro (Colombia)
 
 
We would appreciate your reply if you have any comments  about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Jayne Weiss, MD
<jweiss@med.wayne.edu>
CC:kmsg2007@kmsg.org

Web address:
http://www.kmsg.org

 
The question read as follow:
 
 
Dear  Colleagues-

Would you do LASIK, surface laser or avoid any corneal procedure
 
47 year old female
 
 OD -5.50 +.50 x 180 20/20-2 OD //    OS - 5.75 20/25
 
Pachymetry     OD 516    //    OS 516
 
Corneal topography     OD 48.3 x 48.6 x 122    //    OS 49.1 x 49.9 x 118
 
Normal slit lamp exam
 
Question-
 
I am very concerned about the corneal steepening although do not see corneal ectasia.
I do not have access to intralase and am considering surface ablation.
 
Have you treated similar patients, if so what were results?
 
Would you perform LASIK or surface laser?
 
Thanks.
 
Jayne S Weiss MD
Detroit, MI
USA

 
KMSG Members,

This case shows us the metamorphosis of refractive surgery.  Only a few years ago many members would have recommended LASIK and surely PRK without hesitation.  Now we see LASIK ectasia and although PRK will most likely be fine no one can guarantee permanent stability with a cornea this steep.  I don't think we are ready to crosslink prophylactically yet.  Phakic implants have come a long way but they too are lacking.  The ICL cannot be precisely sized so there are many complications. You never know what gap you will get because the lens is vaulted and it cannot be sized.   The Verisyse  (Worst) lens needs a large sutured incision and in the future when the patient is older and needs cataract surgery we have to open the wound to remove the lens then close it for the phaco.  The Artiflex has a higher than normal incidence of endothelial cell loss at the time of implantation.  Too often the lens hits the endothelium as it opens in the anterior chamber.  Angle fixated lenses have historically been trouble to the endothelium and correctopia is related to poor sizing too.  The floating PRL is a perfect phakic implant lens when it fits but it too isn't sized.  Therefore the lesser of all the evils here would be a conventional surface ablation because although possible these cases rarely cause ectasia.

Alexander Hatsis, MD
USA

 
Dear jayne weiss,

Doing any corneal refractive surgery on this patient is asking for trouble.any cornea steeper than 48.5D & low pachy is a sure fire indicator of a post-operative problem.my suggestion would be to go for a phakic IOL if the patient is very keen on refractive surgery, If the patient is 10 yrs older refractive lens exchange  with  new generation multifocal IOLs can be discussed as an option after informing the pros & cons of clear lens extraction.

Regards

Sujatha Mohan, MD
India

 
I appreciate everyone’s fears of doing Lasik in this setting.   I would recommend a phakic lens but of course the patient came to the office for Lasik so that discussion may prove challenging and it is more expensive and time consuming etc/    I would probably say no to the patient for Lasik because of the corneal thickness and degree of myopia.  Having said that, I do not recall seeing KC develop in this clinical setting.  Perhaps others have.   
 
George W. Rozakis, MD
USA
 
Dear Pablo,
 
I wouldn'd do only lasik or PRK in this eye, but you can think about Ferrara ring. This isn't a precise result surgery, but would help this patient to be independent of glasses to far way .
 
You could correct this high astigmatism and perform one hipocorrection in this myopic left  eye, so he could keep his near vision. Also,  I'm thinking to do crosslinking in this cases of patients and PRK later. I'm doing crosslinkg in keratoconus and ectasias since september 2006 and I have  gotten  good results. Now, I'm thinking to start in frust conus and patients like that , over 40 years.I didn't do yet, I'm waiting for more long results from my crosslinkings.
 
Edna Almodin, MD
Brasil.
 
Thanks for your thoughts on this case, I didn't do the refractive procedure!

Jayne S Weiss, MD
USA

 
Dear Jayne: I certainly Would avoid any corneal procedure in a patient like this (I didn’t say cornea) even if the pachymetry was better, even if I knew the anterior and posterior surface elevations were normal. Even if she, my accounter and doctor Rabinowitz swear to me that she is not going to develop ectasia. Because nobody knows (at least not with our state-of-the-art technology) how normal the molecular biology and stromal architecture of her stroma is.  As a matter of fact its steepness looks like a tiger, smells like a tiger... and if it becomes a tiger,  the surgeon is the only one who is going to be in the cage.
 
In the other hand you do not mention if this patient has had the opportunity of having customized contact lenses. (Yeah, contact lenses, that piece of plastic that we surgeons try to bypass despite the fact that is a much safer, precise and reversible solution than phakic lenses). That would be a good solution until she becomes a more suitable candidate for IOLs in time.  New materials and new models of contact lenses for extremely flat or step corneas combined with adequate treatment of blepharitis or dry eye could increase the quality of life of many patients and it also would do well on our coronary arteries. Kind regards.
 
Pablo Bohorquez  MD PhD
Madrid (Spain)
 
Excellent success with ICL phakic IOL. I would consider that if you have doubts.
 
Regards,
 
Guillermo
 
Guillermo Rocha, MD, FRCSC
Canada
 
Dear Dr. Weiss:
 
This step corneas even if the topographies looks normal,are a sub-clinical KC. Lasik or surface ablation have a high risk.
 
Sincerely.
 
Guillermo Avalos MD
Mexico
 
Dear Dr. Weiss:
I won't even consider Excimer (either Lasik or surface) for this case. Such step Ks are highly suspicious of KC even with normal topos. I think that this case wis a very good one for ICL (if ACD ok).
Regards,
Luis F. Restrepo, MD (Pereira, Colombia)
 
How is the  ORA and corneal posterior surface?.
 
If you see the corneal curve, obviously the meassures are out of the normal values, it means that the outocomes are not so predictable.

Suggestions: 1. avoid laser excimer;  2.  taking in count the age, to consider lensectomy with IOL (you have several options, Multifocal OU, Mix and match, monocular correction. depending about the patient).       
 
Rudy Gutierrez,MD
Guatemala

 
Dear Dr Weiss:
 
It would be interesting to know how high the anterior and posterior surface elevation are. To me, I always reject for corneal refractive surgery any patient with corneal curvatures higher than 48. How is the Rabinowitz or Klyce-Maeda score for keratoconus on this patient?
 
Sincerely yours,
 
Pedro-Ivan Navarro MD
Bogota, Colombia
 
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Superior Ectasia

A NEW message,"Re:  The question  posted by, Eduardo Viteri eviteri@ecuadorlaser.com, MD, ECUADOR, was sent by:
 
Eduardo Viteri, MD (Ecuador) - UPDATE !!!
Luis Lu, MD (USA)

 
Ernesto Otero, MD (Colombia)
Felipe Vejarano, MD (Colombia)
Emilio Mendez, MD (Colombia)
Alfredo Amigó, MD (Spain)
Klaus Ditzen, MD (Germany)
José Miguel Varas-Prieto, MD (Ecuador)
Ivan Ossma, MD (Colombia)
Gabriel Oliveros, MD (Colombia)
Juan Guillermo Ortega, MD (Colombia)
 
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Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

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Eduardo Viteri, MD
<eviteri@ecuadorlaser.com >
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Web address:
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The question read as follow:
Dear colleagues:
This is a 51 years old female, presenting progressive decrease of visual acuity OD to 20/40 and asking for presbyopia Phaco-refractive surgery. She had astigmatic LASIK performed in another country 5 years ago (can’t obtain previous record, she does not remember even the physician’s name).  Her refraction is +1.50 (-0.75 @ 160º) and the lens is fairly clear.
Pentacam exams (attached) demonstrate thinning and ectasia at the supero-nasal corneal quadrant.  OS does not reveal any abnormality.
I have excellent results in inferior corneal ectasias implanting one INTACS segment and I am considering to implant one in this case.  I would appreciate your comments and suggestions.
This case emphasizes the importance of corneal topography in the pre-op evaluation of Phaco refractive cases.
Thanks in advance,
Eduardo Viteri
Guayaquil, Ecuador
 
Last Answers:
Dear Fellows:
I deeply appreciate your interest on this case.  At this point I would like to comment on three aspects that has been mentioned so far:
·         Pentacam accuracy or artifact
·         Diagnosis
·         Treatment possibilities
 Pentacam exam
I am attaching a Placido Corneal Topography exam (BBVRPlacido.jpg) of the same eye.  Although it does not provide the same numbers, it confirms the peripheral supero-nasal corneal steepening and the slit lamp photo shows the area of corneal thinning.  So we can discard an artifact.
 Diagnosis
The cornea presents a localized area of peripheral thinning, not inflammatory, covered by epithelium and with minimal vessel growth.  There are no lipid deposits and the white dots  that appear on the photo seems like a reflection from the upper lid border (you can see that at the slit lamp photo - I apologize for this artifact). It does not look like a fully developed Terrien’s disease (as the attached image from Duane) but it could be a case at an early phase or a furrow degeneration.  Let’s not forget that the patient also had a LASIK procedure that can produce a magnification of the corneal curvature changes.

Treatment
We have no evidence of progression other than the symptom of recent visual acuity loss, but considering the progressive nature of the possible diagnosis, I think it is worth to explore for options to improve the central corneal curvature (implant of corneal ring segments) and/or to try to make it more stable (maybe cross linking, as José Miguel Varas mentions), before performing a phaco on a fairly transparent lens.  I rule out a multifocal IOL.

Thanks again and I am looking forward for your comments.

Eduardo Viteri
Guayaquil - Ecuador

 
Dear Eduardo,
 
I have a patient with a similar clinical picture caused by a Wegener's granulomatosis. You should classify this patient as having a Peripheral Corneal Thinning which can be caused by several entities including collagen diseases, Terrien's marginal degeneration (which usually induce an irregular and against the rule astigmatism), or perhaps even a variation of a Furrow.
 
With a +1.50 -0.75 x 160 , BCVA of 20/40 and a clear lens I would probably stay away from multifocal implantation. The IOL power calculation will be challenging, had a previous corneal refractive surgery, and still you have the problem as the correction of the residual astigmatism.
 
I would offer her a monovison GPCL trial for her right eye.
 
Respectfully,
 
Luis W. Lu, MD
USA
 
Dear Eduardo,
 Most slit based devices including the Pentacam have unpredictable measurements when there is a significant reduction in the tranparecy. I agree that this is not a superior ectasia but most likely an artifact from the device. Even if it were, I don't believe an intra-corneal ring would help as it would still be inside of the area of thinning (even if you placed it at 7mm). In the short term you might see a change but in the long run it would continue to deteriorate.

Ernesto Otero, MD
Colombia 

 
Dear Eduardo, to me this is a TERRIEN MARGINAL DEGENERATION, based in your clinical photo, also the Km measurements of the Pentacam at the center are very regular, for me just make your Phaco as any other case.

Luis Felipe Vejarano,, MD
Colombia

 
Dear Eduardo,

I think your patient had a past history of a unilateral Terriens degeneration which lead to the marginal ectasia we are seeing now. It is probably stationary and because of the location  is not affecting to much the pupillary axis. Most of the ectatic area is cover by the upper lid and and is not the cause of the mild lose of vision which I think is due to the hyperopia. I will not recommend you a corneal ring for this specific case. I do not do PRELEX but with this specific patient I will fill more confortable doing phaco surgery with a scleral incision .

Warm regards

Emilio Mendez, MD
Colombia

 
Dear Eduardo:
We have been using Pentacam regularly now for two years This Projection device is sensible to any lack of transparency resulting in artifacts like in the case you are presenting where a vascularized leucoma is to be seen superior nasally. I believe that ectasia is unlikely the reason of worsening in BCVA. A reflection topography ( "Eye Sys type") is frequently useful in combination with Pentacam and could be diagnostic in this case.
Un cordial saludo

Alfredo Amigo MD
Spain

 
Dear Dr.Viteri,

Implantation with one ICR-segmentring is a very good idea.

Klaus Ditzen,M.D.
Germany

 
Dear Eduardo:

Just looking the picture it looks like a Terrien's marginal 
degeneration. Although it tends to be bilateral and has a male 
preponderance it is possible to be present in females at any age in 
one eye only.

I think Crosslinking is unexplored in such cases.

Saludos,

José Miguel Varas-Prieto, MD
Ecuador

 
Eduardo  
It would seem to me that there is a high likelihood of this NOT being ectasia but really artifact pentacam images due to the corneal opacity as seen on the slit lamp photo. It would be interesting to see what other's think. 

Ivan Ossma
Cali, Colombia 

 
Dear Eduardo:

What I can see in  the topography and paquimetry maps is that the center of the cornea is not affected, I can read K1 in 42.7 and K2 43.7 for a difference of 1.1 D. I think the bad vision(20/40) in this patient is caused by the progresive postlasik hyperopia. You only have to make the incision in the steepest axis. Take care calculating the IOLm in this postlasik cornea. I follow recomendations given to us by Dr Arce, ask the Total Mean Power Map in the Orbascan, calculate the 2 mms central area( given in diopters), and the average is introduced as tke K´s in the IOL Master. My recomendation : use aspheric multifocal IOL ( AcriLisa or the new Aspheric Restor).

Gabriel Oliveros
Bogotá, Colombia.

 
Dear Eduardo:
It’s a very interesting case you present. In fact, I agree with you that is important always to perform topographic analysis in Phaco- refractive cases, in order to document astigmatism, for IOL calculations with Pentacam or for cases with eventual refractive surprises. 
One option in this case is consider that the optical zone in the ablation during the first lasik was compromising the posterior side of the flap at the hinge, if the surgeon didn’t protect the flap at the ablation time, creating a double effect in ablation in that zone. I have seen two cases in my clinic, so it’s important control the zone of the laser treatment and avoid treating the hinge zone.
Yours truly,

Juan Guillermo Ortega, MD
Colombia

 
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Superior Ectasia Topography
Terrien From Duane
Superior Ectasia Pachy oculus pentacam
Superior Ectasia
Superior Ectasia Slit Lamp

Topographers and lasers

Ken Hoffer, MD (USA)
Raul Suarez, MD (Mexico)
 
We would appreciate your reply if you have any comments  about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

José Miguel Varas-Prieto, MD
jm@varas.com
CC:kmsg2007@kmsg.org

Web address:
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The question read as follow:
 
Dear Colleagues:

It is true what many of you have said concerning the benefits and limitations of the PENTACAM system. If you were looking for a new device would any of you prefer a Galileo to overcome the parallax flaw and the lack of Placido rings? 

Will you wait for a device that is both useful as the Galileo and also able to link corneal wavefront data to your laser? Up to this moment there is no "universal language" between topographers and lasers. Technically that should not be difficult. Do you know anybody working on that "universality"?

Saludos,

José Miguel Varas-Prieto
Guayaquil, ECUADOR

 
Last answers:
 
The IOL Power Club will be addressing these issues especially regarding the measurement of true corneal power in LASIK corneas at their 4th Scientific Session in St. Pete, FL in Nov after the AAO in Atlanta.
Right now there are a list of papers published as well as presented at ASCRS that show the Holladay report on the Pentacam is currently not accurate in determining this value and should not be relied on for IOL power calculation.
 
KJH

Kenneth J Hoffer, MD
Clin Prof of Ophthalmology, UCLA

 
I have been working with Pentacam since January 2007.
 
All computer equipments are able to change very quickly.
 
When a I was a resident I developed  a topographer based on Placido disk.
From my point of view the new equipments that are created to evaluated cornea that means the hole cornea and the anterior segment should avoid the use of  Placido rings, because the information provided from this reflections rings, it´s not the must accurate.
 

 
RAUL SUAREZ S.MD
JEFE DEL DEPTO DE CORNEA Y CIRUGIA REFRACTIVA
INSTITUO DE OFTALMOLOGIA CONDE DE VALENCIANA

 
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Young Miopic patient

Soriana Rodriguez, MD (Cuba)

Vicente Amias, MD (Spain)
Klaus Ditzen, MD (Germany)
Gabriel Quesada, MD (El Salvador)
Emilio Mendez, MD (Colombia)
Luis Lu, MD (USA)
Jorge Cazal, MD (Spain)
Mariano Fernandez , MD (Guatelmala)
Jose G. Guerrero F, MD (Argentina)
Pedro Ivan-Navarro, MD (Colombia)
Raul Suarez, MD (Mexico)


We would appreciate your reply if you have any comments about this subject.

Please, send to me a copy of the answer (cc), as we are going to publish all the questions and answers received.

Sincerely.

Jairo Hoyos-Chacon, MD
KMSG Hot Line coordinator

Jorge Pradas, MD
<jpchacon@gmail.com>
CC:kmsg2007@kmsg.org

Web address:
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The question read as follow:

Dear fellows,

I have a myopic patient, man 30 years old, he has had in 2001 a vitrectomy surgery due a retinal detachment. Previous to the surgery the BCVA was 20/20-

Actually:
BCVA RE = -8.00 -1.00 x 130º = 20/60
LE = -9.00 -1.25 x 100º = 20/20-

He has a posterior subcapsular cataract in his right eye secondary to the vitrectomy surgery. Pachymetry 550 (RE) and 562 (LE) microns.

Retina = RE with some lattice degenerations and LE with a 360º panfotocoagulation.

I am planning to do a cataract surgery in his RE, but I am wondering if to implant a Multifocal IOL. What would you do in his LE? Phaco (multifocal IOL)? Lasik? Phakic lens?

Sincerely

Jorge Pradas, MD
Spain
 
Last answers:

Dr Jorge:

I consider that before any treatment is very important that you know the answer to these questions:

- The cause of the retinal detachment in RE in 2001, traumatic or not traumatic?
- Did the retinal detachment involved the macula?
- Is the cataract the principal cause of the bad vision of RE ?, if the anwers is YES, then I suggest cataract surgery wtih asferic monofocal IOL

In the left eye I suggest contact lens because the risq of the rtinal detachment in this eye can be high.

Sorania Rodriguez Sanchez MD
CUBA
 
Dear Jorge and friends

My opinion in this case is that a multifocal IOL in the right eye is contraindicated, because high myopia tends to get worse during live. Macular degeneration and Fuchs maculopathy is frequent in myopes of 10 diopter. The eye you are going to operate has had a retinal detachment, it means that his myopia is severe and complications will continue to appear.

Exact biometry is difficult in large eyes and patient may need later lasik surgery.

I recommend you an aspheric monofocal IOL. In the left eye I would fit a contact lens and as a second option a phakic posterior chamber lens: ICL that can be explanted if needed.

Vicente Amías, MD
Barcelona, Spain
RE: multifocal IOL; LE Monofocal IOL

Best regards

Klaus Ditzen,M.D.
Germany
 
I would recomend an IQ IOL on the right eye; and phakic IOL on the left eye, util he needs a cataract surgery on that eye.

Gabriel Quesada MD
Centro Panamericano de Ojos
El Salvador

 
Dear Jorge
I will do a "slow motion phaco " with multifocal iol implantation in the RE. My preference will be an Acrilisa calculated for plano and 117.9 constant, the retina certainly is a concern and I will ask for a pre and post op Retina especialist evaluation of these case. For the left eye if there are no lens changes whatsoever and no family history of cataract I will implant an Artisan phakic lens as long as the cell count and ACD permits.

Good luck

Emilio Mendez
Colombia
 
Dear Dr. Pradas,

This 30 year old male patient with a -8.50 of SE and prior Pars Plana Vitrectomy with FG exchange for a phakic RD in 2001, who presented to your office with a "gas cataract" requiring cataract surgery.

In our practice, and after a careful super 66 or 78D lens exam of the macula is performed, PAM (potential acuity meter) or laser interferometry is ordered to be sure he has a potential for good visual outcome in case it was a case of macula-off RD.
We also explain to the patient the fact that the incidence of new retinal breaks and retinal detachment after cataract surgery in previous surgery for RD is near 5% in average, depending of multiple risk factors including being a male, young, with an axial length > 25.0 mm . Cataract Surgery is nowdays considered to be an independent risk factor.

Then I would prodeed to perform the cataract surgery for this right eye. Although a multifocal does not impair a good visualization of the peripheral retina, I would also offer a Hydrophobic 6.0mm-optic lens after a large CCC in case my fellow retinal surgeon will need to go back in.

As for the left eye concern, I will simply offer him a contact lens if possible. The incidence of Retinal Detachment after cataract surgery in a high myope is 8% (regardless of the 360 prophyllactic argon laser treatment) in 8 years, with 50% within the first year. Now, if he has a re-detachment, the risk in the opposite eye is over 25%. I will try to follow him very closely if you have to perform lensectomy for him, as 75% of those RDs appear within the first year.

Best,

Luis W. Lu, MD
USA
 
Dear Colleague:

After operating the right eye and with it out of the post of follow up and with a special inform consent, for the left eye on this patient in light of today evidence we do not dout that phakic IOL is the best way to go or CL ?

Warmest Regards

PS of course retinal check for the left eye is mandatory w/wo surgery

Jorge Cazal;MD
Barcelona,Spain
 
Jorge:

For me it´s important that before going though any surgery, you have to be sure that the 20/60 vision is related to the cataract itself. Do you know if the Retinal Detrachment in 2001, included the macular region?? I am telling you this , becuase you are going to perform a expensive surgery , in wich the patiet is expecting an important vision recovery?? and maybe the cataract is not the real cause of the bad visual acuity.

Later on, depending upon results of the first surgery , you just have two choices, a Phakic IOL or Multifocal one.

Regads.

Mariano Fernandez, MD
Guatelama
 
Right Eye : cataract surgery ,with asferic monofocal IOL

Left Eye : 1° Phakic IOL (Artisan model) 2° Lasik (Wave front ) 3° Contact lens

Good Luck


Jose G. Guerrero F.
Mendoza - ARGENTINA
 
Dear Dr Pradas:

Phakic IOL would be a nice option for the fellow. Lasik surgery is risky for corneal ectasia due amount of myopia to be treated, undercorrection could be another option.

Sincerely yours,

Pedro Navarro MD
Bogota, Colombia
 
Dear Jorge.

I will perform cataract surgery with a multifocal IOL .

Even this patient my not have cataract in the left eye in the short time I will
suggest to practice phaco and also a multifocal IOL in the left eye.

I f you perform lasik you will generate a oblate cornea so aberration generate by lasik will be quite different from the aberration generated bye the multifocal.

SALUDOS

RAUL SUAREZ S.MD
JEFE DEL DEPTO DE CORNEA Y CIRUGIA REFRACTIVA
INSTITUO DE OFTALMOLOGIA CONDE DE VALENCIANA
 
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