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REVIEW
Cover
Focus
Refractive Surgery
45-year-old hyperopic presbyope,
since no clear option has yet emerged.
On the survey, the most popular options
were LASIK monovision (24
percent), bifocals (22 percent), CLE/
multifocal IOL (15 percent) and CLE/
accommodative IOL (11) percent. All
the other options were chosen by less
than 10 percent of the surgeons (the
results appear in the graph on p. 35).
“This is a difficult question,” says Arkansas’
Dr. Brown. “While I am not a
fan of clear-lens extraction and IOL
implantation in a 45-year-old patient,
for the hyperope, using CLE with a
multifocal IOL and confirming with
[ORA intraoperative aberrometry]
has, in my experience, produced excellent
results.”
Robert Epstein, MD, of McHenry,
Ill., will alter his course of action depending
on the patient. “If the patient
is otherwise a LASIK candidate,
wavefront-guided LASIK would be
done on the distance eye and possibly
PRK on the near eye to minimize the
risk of late ectasia,” he says. “[For]
48-year-olds the answer would be a
bifocal procedure on the non-dominant
eye, so there are some people
whom I tell to wait until they are older.
But hyperopic presbyopes have a
lot to gain from refractive surgery and
are the most appreciative.”
For the patient in need of an enhancement
of her LASIK, surgeons
are divided nearly down the middle:
50 percent will lift the previous flap
and ablate and 45 percent will perform
a surface procedure on top of
the flap. Five percent will re-cut a flap
and ablate. For his part, Dr. Epstein
prefers to take the surface ablation
route. “I prefer PRK over the LASIK
flap only,” he says. “After many episodes
of cells in the interface over the
past 23 years since I started LASIK
I just find it easier to go with the
slower healing of PRK for the sake of
the predictability of having no problems
with cells. When we used to do
LASIK reoperations we did find a
lower rate of epithelial cells in the
interface when suturing the flap with
the Barraquer eight-bite, anti-torque
suture, and cells could be squirted
from the interface postoperatively,
but it is just too much trouble. PRK
is fine.” Dr. Salinger, however, thinks
a procedure that involves lifting the
flap is better in the end. “I prefer it
if the available corneal thickness allows
for this option,” he says. “If the
patient chose LASIK for the initial
procedure, then lifting the flap and
performing another LASIK is the fasthealing
alternative that he is probably
hoping for in terms of a second vision
correction procedure.”