COMPLEX CASE MANAGEMENT s PREVIOUS EIGHT-INCISION Trying to fix a refractive surprise after .

BY KARL G. STONECIPHER, MD; JACK T. HOLLADAY, MD, MSEE, FACS; DAVID COOKE, MD; BRET L. FISHER, MD; AND UDAY DEVGAN, MD

CASE PRESENTATION The most common question I have heard from other doctors lately runs along surgery, and now I have a refractive surprise. What can I do to fix it?” For my these lines: “I have a postrefractive surgery patient on whom I performed cataract next few turns as section editor of this series in CRST, I have recruited experts to provide some answers. Although the panel will be discussing fixes for refractive surprises, the goal is prophylaxis for future cases. How can ophthalmologists fine-tune cataract surgery planning in patients with a history of refractive surgery, and how can surgeons prevent postoperative problems with quality of vision? In each case, the presumption will be that no refractive information is available prior to the intervention. Following is the first case. (Figures 1–4 courtesy of Karl G. Stonecipher, MD)

Figure 1. Holladay Report on the Pentacam (Oculus Optikgeräte) prior to cataract surgery.

Figure 2. Holladay EKR Report on the Pentacam prior to cataract surgery. Figure 3. Preoperative measurements (top and bottom) with the OPD-Scan III (Nidek).

AUGUST 2018 | CATARACT & REFRACTIVE SURGERY TODAY 35 (Courtesy of Jack T. Holladay, MD, MSEE, FACS) Figure 4. Preoperative calculations (top and bottom) using the ASCRS IOL power calculator for prior RK. Figure 4. Preoperative calculations (top and bottom) using - - - Figure 5. The Holladay IOL Consultant Software (Holladay Consulting) with the Holladay 2 formula using a mean EKR65 of of Figure 5. The Holladay IOL Consultant Software (Holladay Consulting) with the Holladay 2 formula using a mean EKR65 36.55 D. - | AUGUST 2018 | AUGUST

—Case prepared by Karl G. Stonecipher, MD COMPLEX CASE MANAGEMENT This presentation is typical 26 years 26 typical is presentation This How would you have calculated the IOL power for this patient, and this patient, and IOL power for calculated the would you have How In the workup for cataract surgery, biometry was performed, and and cataract surgery, biometry was performed, In the workup for OD. was 20/150 One year after cataract surgery, the patient’s UCVA A 70-year-old man underwent eight-incision radial keratotomy (RK) keratotomy (RK) eight-incision radial 70-year-old man underwent A JACK T. HOLLADAY, MD, MSEE, FACS JACK T. HOLLADAY, MD, MSEE, FACS morning and a myopic shift through shift myopic a and morning Pentacam the of 1 Page day. the out in patient, this for Report Holladay total shows panel, central upper the µm 0.417 of aberration spherical highest the with IOL an so 1), (Figure spherical equivalent hyperopia that hyperopia equivalent spherical than morning the in greater be will Keratometric afternoon. late the in be therefore should measurements to morning the in thing first obtained the in result emmetropic an achieve after eight- or 16-cut RK, with 4.25 D 4.25 with RK, 16-cut or eight- after He wore a spectacle correction of -3.50 D. His manifest refrac manifest He wore a spectacle correction of -3.50 D. His cycloplegic refraction was his and tion was -3.75 +0.50 x 175º, both BCVA were refraction and +0.50 x 175º. His cycloplegic -3.25 20/20. are his IOL options? what the surgeon used the online ASCRS IOL power calculator for prior RK prior RK power calculator for ASCRS IOL the surgeon used the online ophthal (Figures 1–4). During cataract surgery, the to select the IOL ORA System with the to obtain useful analysis mologist was unable with a D SN60WF IOL (Alcon), The surgeon implanted a 28.50 (Alcon). postoperative target refraction of -0.50 D. cal history was significant for long-term use of fluticasone propionate propionate long-term use of fluticasone for was significant cal history The patient had mainly been (Flonase, GlaxoSmithKline). spray nasal changed to soft contact lenses when wearing but intermittently the was 20/100, and dominant right UCVA in his playing golf. The x 040º = 20/30. Glare was +4.00 +0.50 eye manifest refraction in that measured 20/60. without astigmatic incisions in 1992. The patient presented in 2017 for in 2017 for The patient presented 1992. incisions in without astigmatic eye. His medi his right in subcapsular cataract a posterior treatment of CATARACT & REFRACTIVE SURGERY TODAY

REFRACTIVESURGERY 36 s - - - - - Page 2 of the Holladay ReportHolladay the of 2 Page theusing calculation IOL The The thinnest part of the the of part thinnest The Holladay 2 with the same EKR65 for EKR65 same the with 2 Holladay implanted)one (the IOL D 28.50 a wasrefraction (actual D -3.77 is The6). Figure 175º, x +0.50 -3.75 currentthe reduce to needed amount foundbe may D) (28.50 power IOL refrac preoperative the changing by surpriserefractive current the to tion IOLthe on formula the and D), (-3.50 maps are typical of post-RK . post-RK of typical are maps kera (equivalent EKR65 the shows thein graph the in blue in tometry) It2). (Figure corner right-hand upper curveblue the that noting worth is D,36.55 at centrally begins (EKR65) atD 35.84 of minimum a reaches increasesgradually then and mm, 5 ofdiameter pupillary The power. in sug and small unusually is mm 1.88 EKR65 2-mm or 1- the using that gests havewould D) 35.99 and (36.55 values 4-mmstandard the than better been Theshown. is that D) (34.93 value ingraph the in peaks power multiple theand corner left-hand lower the right-handlower the in map EKR65 whyshow clearly 2 Figure of corner withindicated was IOL monofocal a irregularity. corneal severe emmetropiafor formula 2 Holladay (1-mmD 36.55 of EKR65 mean a with 5).(Figure IOL D 23.50 a yields zone) theusing refraction predicted The toric IOL because of the variability variability the of because IOL toric astig of axis and magnitude the in intra that suggested and matism, be would aberrometry operative impossible. almost and temporal mm 2.03 located is hours) clock (8 inferior mm 2.90 (upper µm 486 at normal vertex to is which 1), Figure of panel right (relative normal than less 6.6% center bottom at map pachymetry is thinning this Because 1). Figure of cornea, the of zone exposure the in had that incision an represents it likely was and significantly thinned cataract of time the at reopen to elevation back and front The surgery. - curvature maps confirmed the cor the confirmed maps curvature a contraindicated irregularity, neal panel of Figure 1, the quality of the of quality the 1, Figure of panel him giving poor, was cornea patient’s glare and halos of likelihood high a multifocal A IOL. monofocal a with broken The contraindicated. was IOL tangential and axial the in spokes | AUGUST 2018 | AUGUST

COMPLEX CASE MANAGEMENT With 1.011 µm of root mean square mean root of µm 1.011 With

(Johnson & Johnson Vision), would Vision), Johnson & (Johnson choice. best the been have (HOA) aberration higher-order is value normal (a error wavefront central upper the in shown µm), 0.37 Figure 7. The Holladay IOL Consultant Software with the postoperative refractive surprise using the Holladay R formula. as µm, -0.27 asphericity, negative IOL 1-Piece Tecnis the with available Figure 6. The Holladay IOL Consultant Software with the Holladay 2 formula using a mean EKR65 of 28.50 D. Figure 6. The Holladay IOL Consultant Software with the Holladay (Courtesy of Jack T. Holladay, MD, MSEE, FACS) MSEE, MD, Holladay, T. Jack of (Courtesy CATARACT & REFRACTIVE SURGERY TODAY

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- - - - - UDAY DEVGAN, MD UDAY DEVGAN, MD This patient received a 28.50 D 28.50 a received patient This IOLmonofocal a use only would I highly distorted by the corneal HOAscorneal the by distorted highly greata not is cornea This 3). (Figure diffractivewith IOL any for candidate extendedor multifocal whether rings, theaddress to PRK A focus. of depth helpwould surprise refractive D -3.00 butcase, this in result plano a achieve eyean flatten further also would it flat.very already is that IOL and ended up with a postopera a with up ended and IOL approximatelyof error refractive tive suggestingequivalent, spherical D -3.00 havelikely would IOL D 24.00 a that diopterEach result. plano a produced D 1.50 about is plane spectacle the at resultD -3.00 the so plane, IOL the at D4.50 is power IOL the that suggests preop best the retrospect, In high. too beenhave would information erative EKRHolladay the using by obtained Thatcornea. the for D 35.00 of value allin well work not might approach liestherein and however, eyes, post-RK dilemma. the cornealhis of because patient this for WF/Corn/ The HOAs. and irregularities OPDNidek the from printout HO isE convolved The story: the tells scan amount of residual refractive astigma refractive residual of amount I exchange, IOL an for plan To tism. result refractive known the use would theusing back-calculate then and new the at arrive to formula R Holladay caution exercise would I power. IOL how procedure, exchange the during continuinga found have I because ever, previousfor tendency increased and continued during open to incisions RK to need The eye. the of manipulation spoilcan incisions these of one suture unneces add and result refractive the cases. some to complexity sary - - BRET L. FISHER, MD BRET L. FISHER, MD To manage this patient’s refractivepatient’s this manage To I am comfortable implanting aimplanting comfortable am I Treating patients with a history of RK of history a with patients Treating approach, but an IOL exchange couldexchange IOL an but approach, lowthe of because considered be also cataract surgery on all eyes that havethat eyes all on surgery cataract someIn surgery. refractive undergone withthose especially eyes, post-RK zones,optical small or incisions more readingfinal a get to possible not is it livethe viewing by but capture, on topossible usually is it data, streaming compareand power IOL the estimate Usingestimate. preoperative the to it significantfew had have I method, this patients. post-RK in surprises refractive reasonablea be would PRK surprise, standard monofocal, a toric, or anor toric, a monofocal, standard eyes, post-RK in IOL accommodating havewould I case this in although accommodatingor monofocal a used astigma irregular the of because IOL cornealpreoperative on evident tism ascalculator, ASCRS the use I testing. generallyI and case, this in done was onselection power IOL initial my base Forresult. formula K True Barrett the wouldchoice initial my patient, this performI IOL. D 28.00 a been have duringaberrometry intraoperative can be challenging; most will be highlybe will most challenging; be can to continue or become to motivated theat but, independent, spectacle be unawarebe likely will they time, same topose they challenges special the of withdiscuss I surgeon. cataract the achiev of difficulty the patients these awith eyes in accuracy refractive ing haveI and surgery, refractive of history understandingtheir confirm them speciala signing by discussion the of document.consent informed an axis, as indicated in the Holladay Holladay the in indicated as axis, an patient. this for Report

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COMPLEX CASE MANAGEMENT DAVID COOKE, MD DAVID COOKE, MD Not surprisingly, several of my of several surprisingly, Not I find cataract surgery outcomes tooutcomes surgery cataract find I in my experience, they cause too cause they experience, my in iris posterior with problems many for potential a is there and chafing future. the in pigmentary cases these in IOLs toric avoid I define to inability the of because reoperate. My procedure of choice choice of procedure My reoperate. concerned am I exchange. IOL an is flatten corneal additional the about PRK a by produced be would that ing recom longer no I enhancement. because, IOLs piggyback using mend post-RK patients have had unin had have patients post-RK surgery, cataract after tended these encourage I case. this to similar myopia their endure to patients They forever. last not will it because I case which in agree, always not do the gift that keeps on giving. Post-RKgiving. on keeps that gift the tocontinue generally sort this of eyes sur cataract after even hyperopia, gain foraim intentionally therefore I gery. post-RKhyperopic in result D -1.00 a one.this like eyes be most unpredictable in post-RK eyes. post-RK in unpredictable most be preop do I thing important most The reason set to is cases these in eratively patientsto explain I expectations. able seconda need likely will they that isRK one, this like cases In operation. 20/20 with 1.011 µm of corneal irregu corneal of µm 1.011 with 20/20 of reports moderate to mild and larity halos. and glare change in power is needed to achieveto needed is power in change meansThis 7). (Figure emmetropia beshould IOL D 28.50 current the that anwith D, 23.50 to D, 5.00 by reduced I correction, this After exchange. IOL withBCVA patient’s the expect would near be to IOL monofocal aspheric the calculation screen of the Holladay the of screen calculation D -5.00 a that shows (R) Refractive CATARACT & REFRACTIVE SURGERY TODAY

REFRACTIVESURGERY 40 s Editorial Advisory Board CRST Clinical Professor of , Baylor Clinical Professor of Ophthalmology, Baylor [email protected] Financial disclosure: Consultant (AcuFocus, Alcon, Clinical Professor of Ophthalmology, Jules Stein Stein of Ophthalmology, Jules Clinical Professor Olive View UCLA Chief of Ophthalmology, @devgan [email protected]; Twitter (Alcon); Financial disclosure: Consultant of North Florida, Medical Director, Eye Center [email protected] Financial disclosure: Consultant (Alcon); Medical College of Medicine, Houston ArcScan, Carl Zeiss Meditec, Elenza, Johnson & Johnson Vision, Oculus, RxSight, Visiometrics); Ownership interest (AcuFocus, ArcScan, Elenza, RxSight, Visiometrics) Eye Institute, UCLA Eye Institute, Medical Center Ownership interest (CataractCoach.com, Surgical); IOLcalc.com, LensGen, Specialty Speaker’s bureau (Alcon) Panama City, Florida Monitor (Ziemer)     Member,     n n n n n n n n BRET L. FISHER, MD n n n JACK T. HOLLADAY, MD, MSEE, FACS

KARL G. STONECIPHER, MD KARL G. STONECIPHER, Executive Advisory Board CRST Private practice, Devgan , Private practice, Devgan Eye Surgery, Great Lakes Eye Care, St. Joseph, Michigan Clinical Assistant Professor, Department of [email protected] Financial disclosure: None Clinical Associate Professor of Ophthalmology, Professor of Ophthalmology, Clinical Associate TLC, Greensboro, Director of Refractive Surgery, Member, [email protected] (Alcon, Allergan, Financial disclosure: Consultant Los Angeles Lomb, Ellex, Espansione, Presbia, Refocus Group); Refocus Group); Lomb, Ellex, Espansione, Presbia, Bausch + Speaker’s bureau (Alcon, Allergan, Lomb, Ellex, Espansione, Johnson & Johnson Vision, Nidek, Pogotec, Presbia, Refocus Group) Neurology and Ophthalmology, Michigan State University, College of Osteopathic Medicine, East Lansing, Michigan University of North Carolina, Chapel Hill University of North Carolina, North Carolina Johnson & Bausch + Lomb, Ellex, Espansione, Presbia, Refocus Johnson Vision, Nidek, Pogotec, Bausch + Group); Research (Alcon, Allergan,        UDAY DEVGAN, MD n DAVID COOKE, MD DAVID COOKE, MD n n n n SECTION EDITOR SECTION EDITOR n n n n n - -

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BIT.LY/STONECIPHER0818 COMPLEX CASE MANAGEMENT STONECIPHER, MD STONECIPHER, MD WHAT I DID: KARL G. WHAT I DID: KARL G. WATCH IT NOW s Once the patient’s refraction sta refraction patient’s the Once postoperatively. well done bilized after cataract surgery, I per I surgery, cataract after bilized on based PRK transepithelial formed the of video (a trial contact a bit.ly/ at viewed be can procedure desired patient The stonecipher0818). has he and correction, monovision CATARACT & REFRACTIVE SURGERY TODAY

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