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How Do We Best Care for Post-RK Patients?

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How Do We Best Care for Post-RK Patients? ARRRRRGH-K: How Do We Best Care for Post-RK Patients? A pictorial review. BY SHERAZ M. DAYA, MD, FACP, FACS, FRCS(ED), FRCOPHTH was a promising technique for the the 3- to the 8-mm optical zone correction of low myopia. RK relied were created, rather than the variable Unhappy RK on the effect of a series of deep radial number of 11-mm full-length incisions patients present incisions to relax the peripheral and used in the standard RK technique. flatten the central cornea in patients I was Dr. Lindstrom’s fellow in to ophthalmology with myopia. The number of incisions Minneapolis at that time, and I watched varied from four to 16 and sometimes some of his earliest procedures first- practices ambitiously 32, depending on the level hand. I performed RK for a couple of periodically; know of correction required, but all incisions years in my own practice, and for the extended from the pupil to the corneal past 27 years I have regularly looked how to improve periphery in a radial pattern, like the after patients with RK-related problems. spokes of a wheel. As a result, my perspective on the pro- their quality of life. The RK technique quickly became cedure has changed over the years. more sophisticated and relatively more reproducible through the introduction PROBLEMS AFTER RK of diamond knives, pachymetry, and RK worked by essentially producing ate complications of radial nomograms that were based on the controlled ectasia in the periphery of keratotomy (RK) can occur, patient’s age and level of correction. the cornea. Because the cornea is an and, for the newest generation The Russian technique was felt to be elastic dome, the periphery became of refractive surgeons unfamiliar more effective with deeper incisions elevated, and the central area flattened with this type of incisional sur- centrally, however, there was consider- to produce the desired outcome Lgery, management can be challenging. able risk of entering the visual axis. of correcting myopia. Despite their The goal of this pictorial review is to The main determinants of effect enhance understanding of the common of RK were the size of the optical complications of RK and the rationales zone, the number of incisions, and for several management approaches. the patient’s age. The realization that there was no need to cut to the limbus BACKGROUND gave rise to the concept of minimally RK, pioneered by Professor invasive RK (mini-RK). Introduced by Svyatoslav Nikolayevich Fyodorov in Richard L. Lindstrom, MD, in 1991, 1974, first performed in Russia, and mini-RK (Figure 1) minimized the adopted by US surgeons in particular invasiveness of RK by reducing the and ophthalmologists in the rest of number, depth, and area of incisions. the world in the mid to late 1980s, In mini-RK, incisions extending from Figure 1. This eye underwent mini-RK. AUGUST 2019 | CATARACT & REFRACTIVE SURGERY TODAY 61 s DEBATES IN REFRACTIVE SURGERY A B Figure 3. Repeat PRK with MMC was performed on this post-RK eye (A). A microkeratome superficial homoplastic anterior lamellar keratoplasty was performed to resolve the significant haze that developed (B). low-dose pilocarpine to constrict the pupil may resolve the problem. Progressive hyperopic shift. Perhaps the most common complication after RK, a progressive hyperopic shift is most often experienced by patients with symptoms of presbyopia. In addition to a loss of accommodation from presbyopia, Figure 2. Keratoconus developed in this eye after laser ablation to correct a progressive patients have lost the mechanism previously used to com- hyperopic shift. pensate for their hyperopia and thus are unable to see well at distance and near. positive effects, RK incisions cause several complications and Laser vision correction. The simplest option for most side effects over time (Table). These include a progressive refractive surgeons, but likely not the best, is to perform laser hyperopic shift, diurnal fluctuations in visual acuity, starbursts, vision correction (LASIK or PRK) to address the shift. I used ectasia, poor visual quality from increased spherical aberration, this technique starting in 1993, but long-term I have found and rupture of the keratotomy scars if traumatized. it only to cause more problems, including further hyperopic Shifts, fluctuations, and starbursts. In one study, 31% to progression and ectasia (Figure 2). 54% of patients developed progressive hyperopia 5 to 12 years Some have described good short-term results after PRK after RK surgery as a result of continued peripheral corneal with mitomycin C (MMC),4 but patients can develop severe elevation and central flattening.1 In another study of RK haze caused by the activated keratocytes. The post-RK patient eyes, mountaineers experienced a moderate hyperopic shift in Figure 3 developed haze after PRK with MMC. After a at high altitudes that returned to baseline on descent.2 The second PRK treatment with adjunctive MMC (Figure 3A), causes were determined to be relative hypoxia and a relative the patient developed more significant haze that persisted reduction in corneal metabolism because of the RK incisions.2,3 for more than 2 years. I used a microkeratome to perform a Ectasia. In some cases, particularly inferotemporal, RK superficial homoplastic anterior lamellar keratoplasty, which incisions become more ectatic over time. This is often removed the anterior cornea and replaced it with a free the case in eyes that have epithelial cysts or are originally LASIK-type flap, resulting in restoration of the patient’s visual predisposed to developing keratoconus, and ectasia is acuity and a reduction in starbursts (Figure 3B). sometimes exacerbated by the performance of additional Lasso stitch. Another option is the lasso stitch. There are corneal ablative surgery for hyperopic correction. By ablating two useful variations: the Grene lasso developed by R. Bruce elevated areas, this secondary intervention steepens the Grene, MD, and the double lasso stitch. Either technique can cornea but also thins mechanically weak tissue, thereby be especially useful in patients with diurnal fluctuations in contributing to ectatic progression (Figure 2). visual acuity. It can also slow or arrest progressive hyperopic Poor visual quality from increased spherical aberration. change in the long term. In the Grene lasso technique, a RK patients often report a deterioration in visual quality Mersilene 10-0 nonelastic suture (polyethylene terephthalate; as they age. In most cases, these patients have developed Ethicon) is placed through each RK incision at a 7-mm optic spherical aberration in their crystalline lenses, which zone and tightened to achieve steepening that is double the compounds the spherical aberration induced by RK. TABLE. EARLY AND LATE COMPLICATIONS OF RK MANAGEMENT STRATEGIES Early Starbursts Starbursts. The location of RK incisions in the pupillary zone can cause starbursts. The phenomenon is most Diurnal fluctuation evident at night when the pupil is dilated and when there Late Progressive hyperopia are point sources of light. Most RK patients adapt to Poor visual quality from increased spherical aberration starbursts, but, if they find the condition debilitating, then prescribing brimonidine tartrate ophthalmic solution or Ectasia 62 CATARACT & REFRACTIVE SURGERY TODAY | AUGUST 2019 DEBATES IN REFRACTIVE SURGERY s A B A Figure 4. Single (A) and double (B) lasso sutures. In the single-suture technique, sutures are passed through the incisions; in the double-suture technique, the sutures are passed through the stroma so they lie over the incisions. B intended amount. Patients are myopic Cataract surgery or refractive lens initially. As the suture cheese-wires exchange. Patients who have cataracts through the stroma, however, the cor- or who are of age for a refractive lens nea flattens, and the refraction heads exchange can benefit from lensectomy toward emmetropia. and implantation of a small-aperture In the double-suture technique, lens. The IC-8 IOL (AcuFocus; not two lasso sutures are fashioned at the approved by the FDA) can provide C 7- and 9-mm optical zones. Rather post-RK patients with increased depth than pass the suture through the of focus; I have found that the lens incisions, the surgeon passes the sutures is also forgiving of astigmatism and through the stroma so that they lie eliminates starbursts. The patients over the incisions. Once the sutures in whom I have implanted the IC-8 cheese-wire into the midstroma, they bilaterally (Figure 6) have achieved provide a similar effect as a single lasso spectacle independence. Piggybacking suture placed through the incisions. is an alternative: An XtraFocus M93L Figure 6. AcuFocus IC-8 IOLs were implanted bilaterally The overlay technique of the double small-aperture IOL (Morcher; not in a patient who had undergone RK. The edge of the lasso is technically easier to perform approved by the FDA) is placed in the small-aperture IOL can be seen within the pupil of the than the Grene lasso and produces a sulcus over a monofocal lens in the right eye (A). In the left eye (B), retroillimination reveals similar effect without disrupting the RK capsular bag. the IC-8 IOL and the RK incisions (C). incisions (Figures 4A and 4B). Meticulous surgical planning is Phakic IOL implantation. A more important regardless of the approach to practices periodically. An understanding accurate alternative compared to lens surgery, and IOL power calculations of the procedure’s complications and lasso suturing and laser ablation is are challenging in RK patients. A options for their management can implantation of a hyperopic phakic variety of options are available, but allow surgeons to help patients achieve IOL (Figure 5) such as the Visian ICL my personal preference is to use the better visual outcomes and improve (STAAR Surgical) or the Artisan/ keratometry readings from the Holladay their quality of life. n Verisyse (Ophtec/Johnson & Johnson Report (Pentacam, Oculus Optikgeräte) Vision).
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