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Decision Tree

Decision Tree

TheRLE Decision Tree

As new refractive surgical technolo- including a larger range of treatable gies and techniques become available, refractive errors, elimination of age- selecting the most appropriate solution based crystalline lens scatter and future WHEN IS A for each patient becomes increasingly , the ability to provide bilateral LENTICULAR challenging. There are now eight types near vision, and less disruption of the of refractive surgical procedures: LASIK, corneal surface. SOLUTION PRK, small-incision lenticule extraction With proper patient selection, these PREFERRED OVER (SMILE), corneal inlays, phakic IOLs, advantages can lead to excellent out- refractive lens exchange, refractive comes and extremely satisfied patients. A CORNEAL surgery, and CXL (Figure). Each This article details the decision-making PROCEDURE? procedure has particular advantages process we use in our practice to and disadvantages for a given patient. determine an individual’s suitability for MANY FACTORS The decision process for patients , and specifically for RLE. AFFECT THE around age 50, who are now enter- ing the second stage of dysfunctional PATIENT SELECTION CHOICE. lens syndrome (DLS), is particularly Needs evaluation. As with any complex, as there is significant over- refractive surgery patient, the process BY LANCE KUGLER, MD lap among available options in this of determining whether the patient age group (see Is Dysfunctional Lens is an appropriate candidate for RLE Replacement LASIK for Baby Boomers?). begins with a thorough assessment of This cohort includes many natural his or her visual needs, including occu- plano presbyopes or post-LASIK pational requirements, leisure activities, patients who have enjoyed excellent hobbies, and any anticipated changes distance vision for many years, so they to those needs in the near and distant often have high expectations. future. Understanding the patient’s Refractive lens exchange (RLE) has expectations of what the surgery will gained acceptance in recent years as provide to him or her is also crucial. advances in IOL design, ocular biom- Objective testing and examination. etry, and the ability to enhance post- In our practice, we divide the patient operative have led to evaluation process into two phases. In LASIK-like precision and the ability to phase 1, we determine visual acuities, correct near and intermediate vision in dominance, and manifest refrac- addition to distance. RLE has significant tion, and we perform topography/ benefits over corneal refractive surgery, tomography (Pentacam, Oculus

60 CATARACT & REFRACTIVE SURGERY TODAY | MAY 2018 IS LENS SURGERY THE NEW LASIK? s

Optikgeräte), endothelial , optical scatter index (OSI) measurement with the HD Analyzer (Visiometrics), meibomian gland imaging, tear-film aberrometry, and anterior segment slit-lamp examination. Pertinent findings in phase 1 include magnitude of refractive error, BCVA, keratometry measurement, axis and magnitude of , topographic regularity, , dry eye status, lens clarity, OSI measurement, and presence of corneal disease. With this information, we can determine whether the patient is a candidate for a corneal refractive procedure such as LASIK, a lens-based procedure such as RLE, both, or neither. An in-depth discussion and review of test- ing takes place with the patient, and a decision is made as to which procedure and technique will most likely be used. In phase 2, we obtain Placido-disc topography and wave- front aberrometry (iTrace, Tracey Technologies), macular OCT, optical biometry with the Lenstar (Haag-Streit) or Figure. The refractive surgery procedure spectrum. (Abbreviations: SMILE, small-incision lenticule extraction; ASA, advanced surface ; RLE, refractive lens exchange.) IOLMaster (Carl Zeiss Meditec), and any specific testing that may be needed based on phase 1 findings. IOP is checked with an Icare tonometer (Icare USA), and the are dilated. as lattice degeneration, an evaluation by a retina subspecialist After cycloplegic refraction is obtained, slit-lamp and posterior is recommended. This consultation may identify areas requir- segment examinations are performed. ing prophylactic treatment, and it also helps patients Pertinent findings in phase 2 include lens clarity, higher- understand the importance of retina health and attention to order aberrations arising from the corneal surface and inter- retinal symptoms. nal optics, macular health, peripheral retinal health, and axial length. Armed with this additional information, the surgical SURGICAL PLAN plan is refined. Once a definitive decision has been made to pursue RLE, The ultimate decision as to which of the eight procedures will the next step is to determine which technologies and tech- be used is complex and involves a multitude of subjective and niques will be used to achieve the desired result. For patients objective considerations. However, certain objective consider- with strong distance or night vision demands, bilateral mono- ations may help clarify the decision (Table). focal or toric IOLs are excellent options. For patients with For patients at increased risk for , such as a desire for spectacle-free near and/or intermediate vision, those with long axial lengths and/or retinal conditions such extended depth of focus (EDOF) IOLs, multifocal IOLs, or a combination of the two may be used. Blended vision, or TABLE. CORNEAL PATHOLOGIES AND CORRESPONDING monovision, with monofocal or toric IOLs is also an excellent INTERVENTIONS approach. It is well tolerated, particularly in patients with a More Likely to Recommend history of using blended vision with contact lenses. Finding In all cases, existing astigmatism must be managed. There are Corneal Procedure RLE many techniques available to manage astigmatism, including Age (years) <50 >55 performing limbal relaxing incisions (LRIs) or on-axis paired Refraction Low Hyperopia, High Myopia corneal incisions, implanting toric IOLs, or combining the RLE procedure with a corneal procedure such as LASIK or PRK. Topography Normal, Regular Irregular (Editor’s note: For more information on managing astigmatism, DLS Stage 1 2, 3 see Toric IOLs for Astigmatism Correction, by Sneha Konda, BS; OSI <0.7 >1.0 and Balamurali K. Ambati, MD, PhD, MBA, on pg 63.) Aberrometry Low Total High Internal POSTSURGICAL PLAN Tear Film Normal Abnormal Perhaps just as important as the surgical plan is the PVD None Present Present postoperative plan. Despite tremendous advances in IOL calculation technology, including improved formulas, more Axial Length Long Short accurate biometry, and the availability of intraoperative aber- Abbreviations: RLE, refractive lens exchange; DLS, dysfunctional lens syndrome; rometry, an enhancement rate of 10% or higher is reasonable OSI, optical scatter index; PVD, posterior vitreous detachment and expected.

MAY 2018 | CATARACT & REFRACTIVE SURGERY TODAY 61 - Figure. DLS is characterized by Figure. DLS is characterized by loss of accommodation, early opacities, and increased HOAs. n - - and Physician CEO, Kugler Vision, Omaha, Surgeon and Physician CEO, Kugler Vision, Omaha, Director of Refractive Surgery, University of [email protected] Financial disclosure: None acknowledged Nebraska Nebraska Medical Center    LANCE KUGLER, MD n n n n the outcome is best achieved withachieved best is outcome the procedure. lens-based or - a post a and management Astigmatism operative enhancement plan are critical success. to - - Executive Advisor Patients with stage 2 DLS are informed that informed that Patients with stage 2 DLS are moved toward lens-based We have Founder and Medical Director, Waring Vision Institute, Founder and Medical Director, Waring Vision Institute, [email protected] Financial disclosure: None acknowledged Waring Vision Institute, Mount Pleasant, South Carolina [email protected] Financial disclosure: None acknowledged Mount Pleasant, South Carolina CRST      of the problem, if that is what they are interested in. Furthermore, dysfunctional dysfunctional in. Furthermore, are interested they of the problem, if that is what procedure that can is a single lens replacement (ie, refractive lens exchange) image at the retinal cataract formation, improve binocularity, prevent preserve IOLs. In our practice, -correcting with plane, and restore depth of focus become has in many ways it makes sense, dysfunctional lens replacement, when LASIK for the baby boomers. GEORGE O. WARING IV, MD, FACS n n n n LARISSA GOUVEA, MD n n n they can either wait to develop cataracts or cataracts or develop wait to they can either addresses which pursue a lens-based procedure, and visu presbyopia, their congenital ametropia, formation. cataract al quality and prevents future general, these patients Keep in mind that, in options. presented to us for vision correction in life, particularly refractive procedures earlier a multifacto patients. It is hyperopic in our rial decision-making process in order of: ensure lifestyle, and cost. We safety, optics, candidates for a that, although they may be 2 DLS patients understand our stage source addresses the laser cornea-based procedure, a laser lens-based procedure - - , by David A. Goldman, MD, Goldman, A. David by , (Editor’s note: For more infor more For note: (Editor’s Piggyback IOL as an Enhancementan as IOL Piggyback Refractive have at theirat have surgeons Refractive DLS stages 1, 2, or 3, the decision pro decision the 3, or 2, 1, stages DLS whetherdetermining by begins cess their lives. their implantation, IOL piggyback on mation see Technique 69.) pg on SUMMARY proceduresof array complex a disposal employcan they that techniques and desired patients’ their achieve to inare patients Whether outcomes. : a spectrum of changes of spectrum : a 2018 - MAY

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dysfunctional lens syndrome (DLS) Enhancements may include LRIs,include may Enhancements Patients undergoing RLE must bemust RLE undergoing Patients Once patients are diagnosed and staged with DLS, we reassure them that this is we reassure them that this and staged with DLS, patients are diagnosed Once Enter the concept of Enter Many early presbyopic patients, bothered by their new reading glasses reading presbyopic patients, bothered by their new early Many LASIK, PRK, SMILE, piggyback IOL piggyback SMILE, PRK, LASIK, Patients exchange. IOL or implantation, abe will there that aware be also should capsu Nd:YAG for need universal nearly ofcourse the over time some at lotomy high likelihood that they will need anneed will they that likelihood high sortsome of procedure enhancement mustsurgeons and RLE, their following ifprocedures such offer to prepared be ato referring means that if even needed, expertise.additional for colleague educated before surgery that there is ais there that surgery before educated defer to a corneal-based procedure. In patients with advancing opacity and HOAs defer to a corneal-based procedure. recommend a cataract procedure. 3 DLS—we daily activities—stage affecting their we demonstrate that we can perform vision correction on the cornea or on the on the cornea or vision correction perform that we can we demonstrate a with presbyopia only—stage 1 DLS—we typically suggest In patients internal lens. in which case hyperopes, to high are moderate they cornea-based solution, unless In patients with an early opacity and increasing procedure. we suggest a lens-based a lens-based procedure, unless they recommend HOAs—stage 2 DLS—we typically of retinal detachment), in which case we may (due to risk myopes high axial are ble-pass wavefront technology (HD Analyzer, Visiometrics) to quantify and analyze to quantify (HD Analyzer, Visiometrics) technology wavefront ble-pass and ray-tracing devices (iTrace, Tracey quality, light scatter and retinal image ocular streamline lens index. These diagnostics can dysfunctional create a Technologies) to of DLS. and improve patient education clinical decision-making process the eyes, where of their are taken on a digital tour Our patients process. a normal aging had progressed through the natural aging changes of the crystalline lens.) lens.) the crystalline aging changes of progressed through the natural had of accommodation, early the lens due to loss of a dysfunctionality characterized by aberrations (HOAs). Although many patients higher-order opacities, and increased advanced diagnostic devices UCVA, 20/20 distance DLS (Figure) may still have with includ aging lens, of an objectively quantify the characteristics and visual function densitometry, dou Optikgeräte) for lens Oculus Scheimpflug imaging (Pentacam, ing correction (LVC) procedures at the corneal plane have never been better. better. been (LVC) procedures at the corneal plane have never correction approved by the now corneal inlays are Furthermore, presbyopia-correcting viewed as less invasive procedures could be FDA. In some ways, cornea-based some time trend us noticed a procedures; however, most of intraocular than returning were underwent cornea-based presbyopic LVC ago: Patients who off. (In actuality, they correction had worn their vision years later, stating that BY GEORGE O. WARING IV, MD, FACS; AND LARISSA GOUVEA, MD MD, FACS; AND LARISSA GOUVEA, MD BY GEORGE O. WARING IV, on spectacles. reducing their dependence in hopes of to us come bifocals, or a reality. Laser vision can make this that Today, we have several procedures IS DYSFUNCTIONAL LENS REPLACEMENT LASIK FOR BABY BOOMERS? FOR BABY LASIK REPLACEMENT LENS IS DYSFUNCTIONAL CATARACT & REFRACTIVE SURGERY TODAY

62 IS LENS SURGERYIS LENS NEW THE LASIK? s

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