REFRACTIVE SURGERY COMPLEX CASE MANAGEMENT Section Editors: Karl G. Stonecipher, MD; Parag A. Majmudar, MD; and Stephen Coleman, MD Presbyopia, Anisometropia, and Unilateral Amblyopia BY MITCHELL A. JACKSON, MD; LOUIS E. PROBST, MD; AND JONATHAN H. TALAMO, MD CASE PRESENTATION A 45-year-old female nurse is interested in LASIK. She the AMO WaveScan WaveFront System (Abbott Medical does not wear glasses. She says there has always been a large Optics Inc.) for the patient’s right eye calculated a pre- difference in prescription between her eyes and that she scription at 4 mm of +2.20 -4.22 X 9 across a 5.75-mm rarely wore glasses in the past. Her UCVA is 20/200 OD, cor- pupillary diameter. This had a corresponding higher-order recting to 20/30 with +1.75 -4.25 X 180. Her UCVA is 20/40 aberration root mean square error of 0.20 µm. The OS, correcting to 20/15 with -0.75 -0.25 X 30. The patient is patient’s left eye had a calculated prescription of -0.56 right-handed, and her left eye is dominant. Central ultra- -0.21 X 31, also at 4 mm. The pupillary diameter of her left sound pachymetry measures 488 µm OD and 480 µm OS. eye was 5.25 mm, and the higher-order aberration root Figure 1 shows TMS4 (Tomey Corp.) topography of the mean square error was determined to be 0.17 µm patient’s right and left eyes, respectively. Both the (Figure 2). Klyce/Maeda and Smolek/Klyce Keratoconus Screening How would you counsel this patient regarding her suitability Systems are highlighted. Wavefront data, as derived from (Continued on page 49) AB Figure 1. Topography readings of the patient’s right (A) and left (B) eyes. 48 CATARACT & REFRACTIVE SURGERY TODAY JANUARY 2012 REFRACTIVE SURGERY COMPLEX CASE MANAGEMENT CASE PRESENTATION (Continued from page 48) setting. If you deem this patient a surgical candidate, please for laser vision correction? Comment on your general indicate what changes, if any, you would make to the treat- approach to patients with amblyopia as well presbyopia in this ment profiles as well as calculations for the flap’s thickness. AB Figure 2. Wavefront aberrometry readings for the patient’s right (A) and left (B) eyes. MITCHELL A. JACKSON, MD information would be especially relevant for this case, Various articles have supported LASIK in pediatric, because there is a higher risk of corneal instability from hyperopic, anisometropic amblyopia1; in the cases they the thin corneas and the high astigmatism in the patient’s described, the patient’s visual acuity improved in the right eye. amblyopic eye, and the amount of anisometropia was Refractive surgery on any 45-year-old patient must be reduced. In my experience, similar outcomes can be approached cautiously due to impending presbyopia. achieved in adults with symptomatic, hyperopic, ani- Counseling regarding the need for reading glasses and a sometropic ambloypia. contact lens trial with monovision, however, can success- The small amount of myopia in the dominant eye of this fully prepare such a patient for postoperative changes 45-year-old presbyope is beneficial, however, and the patient over the next few years. This would assist with the deci- has no stated symptomatology from the anisometropia. sion to treat both eyes or the right eye only in this case. Furthermore, although the corneal topography is normal in This patient also has high mixed astigmatism in her both of her eyes, the central pachymetry readings approach right eye that shows a normal symmetrical pattern on a level of two standard deviations for putting the patient at topography and matching WaveScan maps. I have found risk of corneal ectasia postoperatively. In my opinion, a bor- the Visx CustomVue LASIK laser treatment (Abbott derline case for any risk of ectasia in a monocular or ambly- Medical Optics Inc.) to be very effective for addressing opic setting is usually a setup for disaster. high mixed astigmatism, because the iris registration fea- I would not perform laser vision correction in this case ture allows for accurate alignment of the astigmatic axis. because of the benefits of mild myopia in a presbyope, There would still be a small risk of residual or regressive her asymptomatic anisometropia, and her heightened astigmatism, however, that could require an enhance- risk of ectasia. If another surgeon were brave enough to ment. In addition, the patient’s right eye demonstrates a proceed, my advice would be to perform PRK with mito- low but significant degree of amblyopia. Although I have mycin C to guard against corneal haze. noted an improvement in BCVA after customized correc- tions, this patient’s right eye definitely would not achieve LOUIS E. PROBST, MD the same level of postoperative UCVA as her left eye. She This case presents a number of challenges that individ- might therefore be somewhat disappointed, even if she ually are not insurmountable but that raise concern when were carefully and repeatedly counseled preoperatively they are considered together as a whole. For all refractive about this expected outcome. procedures, I require posterior corneal imaging with the The patient’s corneas are thin, so PRK would be the most Orbscan (Bausch + Lomb) or the Pentacam Compre- appropriate option, given the associated high astigmatism hensive Eye Scanner (Oculus Optikgeräte GmbH). This and increased potential for corneal instability. She could JANUARY 2012 CATARACT & REFRACTIVE SURGERY TODAY 49 REFRACTIVE SURGERY COMPLEX CASE MANAGEMENT also benefit from corneal collagen cross-linking when the keratoconus, the anisometropia, asymmetric astigma- procedure becomes available in the United States. tism, and slightly skewed nature of the observed pattern There are altogether too many potential reasons for this of bowtie astigmatism coupled with below-average cen- patient to be disappointed in her postoperative outcome. tral corneal thickness measurements make it difficult to Although refractive surgery is possible, I would not recom- exclude forme fruste keratoconus without tomography. mend it. As such, I would carefully scrutinize elevation and thick- ness data from the Pentacam, Orbscan, or Galilei Dual JONATHAN H. TALAMO, MD Scheimpflug Analyzer (Ziemer Ophthalmic Systems AG) This patient has been functionally monocular for most before deciding to operate. (if not all) of her adult life, owing to amblyopia and un- Because the corneal thickness is below 500 µm and due dercorrected, presumed mixed astigmatism in her right to the level of astigmatism present, I would recommend eye. Before performing refractive surgery, the ophthalmol- surface ablation rather than LASIK in both eyes of this ogist would need to address three important questions. patient. I would not operate using the WaveScans shown First, can the patient’s right eye obtain useful vision if for her left eye due to the small physiologic pupillary size the refractive error is corrected? If not, I would counsel and low correction. I would use conventional ablation against surgery in the dominant eye, because a poor out- software with the Visx laser or a wavefront-optimized pro- come would be devastating to this functionally monocu- file with the Allegretto Wave Eye-Q excimer laser system lar patient. Before deciding whether to proceed with sur- (Alcon Laboratories, Inc.). The WaveScan image for the gery, I would establish whether the patient is able to read, patient’s right eye may be acceptable for a customized drive, and perform other activities of daily living with the wavefront-guided ablation if the refraction correlates well amblyopic eye. I would ask her to tell me why she desires with the cycloplegic refraction. Because visual recovery refractive surgery. I would explain to her that a complica- after PRK for mixed astigmatism can be prolonged for an tion in her dominant eye could result in the amblyopic attempted correction of the magnitude observed in the eye’s being the better-seeing one and that surgery on her patient’s right eye, I would recommend sequential surgery weaker eye will not fix the amblyopia. at least several weeks apart. ■ Second, would strabismus or other visual discomfort result from the correction of refractive error in the Section Editor Stephen Coleman, MD, is the director of patient’s right eye? A contact lens trial should reveal if she Coleman Vision in Albuquerque, New Mexico. Parag A. can tolerate anything close to full correction of the non- Majmudar, MD, is an associate professor, Cornea Service, dominant right eye. To determine the correct power, a Rush University Medical Center, Chicago Cornea Consultants, cycloplegic refraction should be performed to exclude Ltd. Karl G. Stonecipher, MD, is the director of refractive sur- latent hyperopia. Motility at distance and near should be gery at TLC in Greensboro, North Carolina. Dr. Coleman may examined before and after contact lens correction using a be reached at (505) 821-8880; [email protected]. prolonged, alternating cover test; this would be important Mitchell A. Jackson, MD, is the founder and to exclude any latent phoria. If the patient had findings director of Jacksoneye in Lake Villa, Illinois. consistent with accommodative esotropia when she was Dr. Jackson may be reached at (847) 356-0700; younger, it would be important to avoid even a slightly [email protected]. hyperopic spherical equivalent outcome in her left eye. Louis E. Probst, MD, is the national medical If the patient reported visual discomfort with full astig- director of TLC Laser Eye Centers in Chicago; matic correction in the right eye, I would refit the contact Madison, Wisconsin; and Greenville, South lens to achieve an undercorrection of cylinder with a mildly Carolina. He is a consultant to Abbott Medical myopic spherical equivalent in that eye, which could then Optics Inc. and TLC Laser Eye Centers. Dr.