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REFRACTIVE COMPLEX CASE MANAGEMENT s DRY AND INCREASING AFTER LASIK What are the key considerations 20 years after surgery?

BY ALLON BARSAM, MA, MBBS, FRCOphth; DOUGLAS A. KATSEV, MD; AND DAVID A. GOLDMAN, MD

CASE PRESENTATION A 39-year-old woman underwent bilateral LASIK 20 years ago to treat approximately -8.50 D of myopia. The patient expressed a desire for a refractive enhancement. Upon examination, she had a manifest of -4.25 D and a pachymetry reading of 480 µm in each . Figure 1 shows topography measurements for each eye. The patient complained of dry eyes. Intermittent A B foreign body sensation was controlled with artificial tears. A slit-lamp examination showed a slightly low tear film. Tear film breakup time was within normal limits, and there was no corneal or conjunctival staining. How would you proceed?

—Case prepared by David A. Goldman, MD Figure 1. Preoperative topography measurements of the patient’s right (A) and left (B) eyes.

wear might account for the symptoms is healthy and there are no early of irritation, in which case I would ask changes that could be causing index her to reduce wearing time significantly myopia. If there are such changes, then and I would treat any meibomian gland a laser vision correction enhancement dysfunction to optimize the ocular would be unwise and a lens-based ALLON BARSAM, MA, MBBS, FRCOphth surface prior to surgical intervention. In option preferable. contrast, if the patient has fully corrected In my experience, most cases like this The patient has significant residual her refractive error with , I would one result from an undercorrection of myopia and symptoms of ocular surface want to confirm that she does not have the initial refractive error, and the resul- disease. Although topography shows no significant problems with her quality of tant blur can stimulate further myopic sign of late ectasia, the effective optical vision with this form of correction. If she progression, which typically stabilizes zone is only 4 to 5 mm. This accounts does, then it might be necessary to pri- after a few years. This patient would for the high positive spherical aberration. oritize optimizing the corneal shape with have been 19 years old when she under- Similarly, the treatment zone may not a topography-guided treatment instead went LASIK, so it is also possible that her be well centered on the entrance , of using a more standard wavefront- was not stable at the time of which could account for the remainder optimized profile. If the point spread initial treatment. of the higher-order aberrations. function simulated any problems with Assuming the ocular surface has Several areas of the history and exami- quality of vision, then I would favor a been optimized, the refractive error nation must be clarified. It would be wavefront-guided treatment. is genuine and stable, and the lens is reassuring to have optometric refrac- I would carry out a dilated examina- healthy, I would proceed with a LASIK tions over the past few years to confirm tion that included a cycloplegic refrac- enhancement. I would not lift the stability. It would also be important tion to ensure that there is no accom- flap after 20 years because the risk of to know how the patient corrects her modative element to the patient’s epithelial ingrowth would be unac- refractive error. For example, refractive error and to confirm that the ceptably high. I would perform corneal

JULY 2018 | & TODAY 37 - - phth

Editorial Advisory Board WILLIAM F. WILEY, MD Editorial Advisory Board Executive Advisory Board n CRST CRST CRST Europe Based on the patient’s current age,current patient’s the on Based Member, [email protected] Financial disclosure: None Sansum Clinic, Santa Barbara, California [email protected] Financial disclosure: Consultant Private practice, Cleveland Eye Clinic, Ohio, and Private practice, Cleveland Eye Clinic, Ohio, and Member, [email protected] Financial disclosure: Consultant (Alcon, Carl Zeiss Director, AB Vision, London and Hertfordshire, Member, Financial disclosure: Consultant (Rayner) Private practice, Goldman Eye, Palm Beach Assistant Professor of Clinical , Florida (Bausch + Lomb, Shire) Clear Choice Custom LASIK, Ohio Meditec, Johnson & Johnson Vision) Gardens, Florida Bascom Palmer Eye Institute, Palm Beach Gardens,          30-second application of mitomycin Cmitomycin of application 30-second surgery,after month One eye. each in andOU, 20/20 was UCVA patient’s the improvementthe about ecstatic was she 2). (Figure SECTION EDITOR n n the patient’s age at the time of theof time the at age patient’s the somethat suggests surgery original pres been have might myopia latent Furthermore,developed. later and ent hersince passed had time significant war would which treatment, original regression.of amount large a rant bedstromal residual and topography, awith PRK recommended I thickness, n n n DOUGLAS A. KATSEV, MD n n n n n ALLON BARSAM, MA, MBBS, FRCO n n n DAVID A. GOLDMAN, MD n n B ------A Although 4.00 D of myopia repre myopia of D 4.00 Although My preference here would be PRK.be would here preference My If the patient does not have a cata a have not does patient the If WHAT I DID: DAVID A. GOLDMAN, MD WHAT I DID: DAVID A. GOLDMAN, MD sents significant regression after LASIK,after regression significant sents vision correction selected, it would bewould it selected, correction vision patientthe to explain to important touch- additional that preoperatively necessary. be might ups and it would avoid potential complica potential avoid would it and assuch flap the relifting to related tions disadvantageThe ingrowth. epithelial remodeling,epithelial to relates PRK of lay extra time, over when, occurs which flatteningthe alter cells epithelial of ers regres cause and LASIK by produced PRKfor cells epithelial Removing sion. themake can healing subsequent and necessitat hit, to hard refraction target touch-up. PRK a ing laserof method the of Regardless fractive multifocal IOL or the occasionalthe or IOL multifocal fractive receivesshe if glasses reading for need thatcases In IOL? accommodating an myopicof degree high a such require my surgery, refractive after correction accommodatingan usually is preference Lomb). + Bausch (Crystalens, lens lenshave to not prefers she if or ract, considerwould I surgery, replacement abla Surface LASIK. or PRK performing thebelow tissue less remove would tion stable,more be thus and flap original after LASIK or a myopic shift caused bycaused shift myopic a or LASIK after to willing she Is lens? sclerotic nuclear a theincur and surgery cataract undergo dif a from halos of effects side potential Figure 2. Postoperative topography measurements of the patient’s right (A) and left (B) eyes. measurements of the patient’s right (A) and left (B) Figure 2. Postoperative topography ------| JULY 2018 | JULY

COMPLEX CASE MANAGEMENT DOUGLAS A. KATSEV, MD DOUGLAS A. KATSEV, MD After optimization of the ocular sur ocular the of optimization After Lifitegrast ophthalmic solution 0.5%solution ophthalmic Lifitegrast This post-LASIK patient has a com a has patient post-LASIK This improve tear quality. tear improve LASIKa between is decision the face, sur cataract refractive and enhancement presbyopicearly of is patient The gery. regressionmyopic problem the Is age. sometimes demanding. I would also rec also would I demanding. sometimes takingbegin patient the that ommend ais (MediNiche) Lasine nutraceutical. a andsupplement, DED priced reasonably beforeuse patient for developed was it tosurgery cataract and LASIK after and in refractive surgery cases—especiallysurgery refractive in considerwould I Additionally, here. true speedto plugs punctal of placement the punctaland Lifitegrast recovery. her Iand ways, different in DED treat plugs excel be to combination the found have arewho one this like patients for lent case because of its fast onset of action.of onset fast its of because case agentthis pair usually not do I Although ophthalmic etabonate loteprednol with +Bausch (Lotemax, 0.5% ointment dowould I cases, DED simple for Lomb) importantoften is time because here so mon complaint, and the cause of herof cause the and complaint, mon consideration.careful warrants myopia however,step, first important most The (DED).disease eye dry her address to is thisin choice my be would Shire) (Xiidra, surface enhancement with mitomycin C.surface enhancement eyeeach in target would I zone. optical 6.5-mm a with original flap thickness. Provided I could could I Provided thickness. flap original laserfemtosecond the with flap a create inter original the cleared anteriorly that basalthe cleared posteriorly and face prefer my µm, 30 least at by epithelium carefullyand make to be would ence aperform to than rather flap new a lift OCT (Avanti Optovue, Haag-Streit) Optovue, (Avanti OCT andepithelial the both measure to CATARACT & REFRACTIVE SURGERY TODAY

REFRACTIVESURGERY 38 s