PREVIOUS MYOPIC LASIK MYOPIC PREVIOUS Ses, the Goal Is Prophylaxis for Future Cases

problems with problems with postoperative

—Case prepared by Karl G. Stonecipher, MD —Case prepared by Karl G. Stonecipher, MD Would a multifocal or extended depth of focus IOL be appropriate for be appropriate for of focus IOL a multifocal or extended depth Would contact lens trial failed. the UCVA is 20/50, and In the patient’s right eye, the +0.50 +0.75 x 165º. Glare visual of a manifest refraction BCVA is 20/40 with 1–4). 20/70 (Figures acuity is this patient? Figure 3. Preoperative measurements (top and bottom) with the OPD-Scan III (Nidek). the question I have heard from doctors most often lately goes something like this: “I have a “I have a from doctors most often lately goes something like this: the question I have heard 1 , OD; DAVID COOKE, MD; BRET L. FISHER, MD; MD; BRET L. FISHER, MD; , OD; DAVID COOKE, c | NOVEMBER/DECEMBER 2018 | NOVEMBER/DECEMBER

CASE FILES

of vision? In each case, the presumption is that no refractive information is available prior to the intervention. This month’s case for evaluation follows. of vision? In each case, the presumption is that no refractive A 59-year-old woman presents with decreased vision in her right eye. The patient underwent uneventful bilateral myopic LASIK for a -2.75 D spherical treatment for a -2.75 D spherical treatment bilateral myopic LASIK patient underwent uneventful eye. The decreased vision in her right with A 59-year-old woman presents As I mentioned in the August installment of this series (bit.ly/rscase1118), As I mentioned in the August Figure 2. Holladay EKR report on the Pentacam prior to cataract surgery. Figure 1. Holladay report on the Pentacam (Oculus Optikgeräte) prior to cataract surgery. Figure 1. Holladay report on the Pentacam (Oculus Optikgeräte) prior to cataract surgery. CASE PRESENTATION

Trying to fix a refractive surprise after cataract surgery. a refractive surprise after Trying to fix MD; RICHARD POTVIN, MAS BY KARL G. STONECIPHER, MD, FACS, FRCS AND UDAY DEVGAN, PREVIOUS MYOPIC LASIK MYOPIC PREVIOUS ses, the goal is prophylaxis for future cases. some answers. Although the panel will discuss fixes for refractive surprises, the goal is prophylaxis for future cases. to this subject and have recruited experts to provide planning in patients with a history of refractive surgery, and how can surgeons prevent How can ophthalmologists fine-tune cataract surgery quality a recent cortical cataract in her right eye. She tried monovision in the past, and nuclear sclerotic and address a to undergo surgery to wishes in 2006, and she it?” I am therefore devoting a few articles surgery, and now I have a refractive surprise. What can I do to fix it?” I am therefore devoting a few articles postrefractive surgery patient on whom I performed cataract CATARACT & REFRACTIVE SURGERY TODAY

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DAVID COOKE, MD

There is a high likelihood of prediction success in this eye for four reasons: (1) the amount of the prior laser correction is known; (2) the amount of laser correction was small (< 3.00 D); (3) there is essentially no astigmatism; and (4) the left column of the ASCRS calculator (known pre- and post-LASIK data) has consistent predictions. This patient is not likely to have a refractive surprise. I would be quick to consider a premium IOL. I have been impressed with the distance clarity achieved with the Tecnis Symfony IOL (ZXR00; Johnson & Johnson Vision). I would readily suggest a toric IOL to a patient such as this one, even if only mild astigmatism were present. Of note, we know that the ideal IOL power for emmetropia was 26.00 D. The right column of the ASCRS online calculator (no known preoperative data) shows wildly variable predictions, rang- ing from 23.69 to 27.20 D. This example illustrates the value of knowing the peri- refractive surgical data. These data are Figure 4. Preoperative calculations using the ASCRS IOL power calculator for prior myopic LASIK/PRK. often no longer available, yet perhaps half of my patients are able to estimate their preoperative reading distance (before and after laser vision correction). From this information, I generate power using the TNP_Apex_Zone4.0 approximate pre- and postoperative value from the Pentacam rotat- glasses prescriptions for my technicians ing Scheimpflug camera (Oculus to enter into the ASCRS calculator. Optikgeräte), the axial length, and, if available, the anterior chamber depth value obtained with standard biometry. RICHARD POTVIN, MASc, OD The ultimate IOL power calculation was based on the Shammas-PL formu- Warren E. Hill, MD, FACS, and I la.3 Based on this no-history method, looked at this issue specifically, and the 34%, 66%, and 91% of eyes were within calculations are available at no cost ±0.25, ±0.50, and ±1.00 D of the refrac- BRET L. FISHER, MD on the ASCRS website for interested tive target, respectively. surgeons.2 This method is an accurate option I routinely implant monofocal, toric, Using regression analysis, we for determining IOL power after LASIK and multifocal IOLs in patients who estimated post-LASIK/PRK corneal for myopia. have undergone myopic LASIK. If they

NOVEMBER/DECEMBER 2018 | CATARACT & REFRACTIVE SURGERY TODAY 35 , OD , OD c KARL G. STONECIPHER, MD KARL G. STONECIPHER, Editorial Advisory Board Executive Advisory Board CRST CRST Science in Vision, Akron, New York [email protected] Financial disclosure: Consultant (Alcon) Clinical Assistant Professor, Department of Clinical Assistant Professor, Department of [email protected] Financial disclosure: None Private practice, Devgan Eye Surgery, Los Angeles Partner, Specialty Surgical Center, Beverly Hills, Clinical Professor of Ophthalmology, Jules Stein Chief of Ophthalmology, Olive View UCLA Medical Member, [email protected]; Twitter @devgan Financial disclosure: Consultant (Alcon); Clinical Associate Professor of Ophthalmology, Professor of Ophthalmology, Clinical Associate TLC, Greensboro, Director of Refractive Surgery, Member, [email protected] (Alcon, Allergan, Financial disclosure: Consultant Great Lakes Eye Care, Niles, South Haven, and St. Joseph, Michigan Neurology and Ophthalmology, Michigan State University, College of Osteopathic Medicine, East Lansing, Michigan California Eye Institute, UCLA School of Medicine Center Ownership interest (CataractCoach.com, IOLcalc.com, LensGen, Specialty Surgical); Speaker’s bureau (Alcon) University of North Carolina, Chapel Hill University of North Carolina Johnson & Bausch + Lomb, Ellex, Espansione, Presbia, Refocus Johnson Vision, Nidek, Pogotec, Bausch + Group); Research (Alcon, Allergan, Refocus Group); Lomb, Ellex, Espansione, Presbia, Bausch + Speaker’s bureau (Alcon, Allergan, & Johnson Lomb, Ellex, Espansione, Johnson Vision, Nidek, Pogotec, Presbia, Refocus Group) [email protected] Financial disclosure: Consultant (Alcon); Medical Medical Director, The Eye Center of North Florida, St. Joe, Florida n n monitor (Ziemer) RICHARD POTVIN, MAS n n n n n n UDAY DEVGAN, MD, FACS, FRCS n n n n n n n BRET L. FISHER, MD n Chipley, Panama City, Panama City Beach, and Port SECTION EDITOR SECTION EDITOR n n n n n DAVID COOKE, MD n -

. 2018;46(6):630-636. . August 2018;18(8):35-42. Clin Exp Ophthalmol n . 2015;41(2):339-347. . 2007;33:31-36. STONECIPHER, MD STONECIPHER, MD WHAT I DID: KARL G. WHAT I DID: KARL G. Cataract & Refractive Surgery Today UDAY DEVGAN, MD, FACS, FRCS FACS, FRCS UDAY DEVGAN, MD, I implanted a 26.00 D Tecnis SymfonyTecnis D 26.00 a implanted I The preoperative corneal values arevalues corneal preoperative The 4. Fisher B, Potvin R. Clinical outcomes with distance-dominant multifocal and monofocal intraocular lenses in post-LASIK cataract surgery planned using an intraoperative aberrometer. refraction of -0.25 +0.25 x 157º. Results157º. x +0.25 -0.25 of refraction eye,contralateral the for similar were andsurgery cataract underwent which IOLSymfony Tecnis a of implantation additionalNo eye. right the after week 1 forindicated been has intervention eye. either 1. Stonecipher KG, Holladay JT, Cooke D, et al. Previous eight-incision radial keratotomy. 2. Potvin R, Hill W. New algorithm for intraocular lens power calculations after myopic laser in situ keratomileusis based on rotating Scheimpflug camera data. J Cataract Refract Surg 3. Shammas HJ, Shammas MC. No-history method of intraocular lens power calculation for cataract surgery after myopic laser in situ keratomileusis. J Cataract Refract Surg IOL (model ZXROO, Johnson & Johnson& Johnson ZXROO, (model IOL Sixeye. right patient’s the in Vision) 20/20,was UCVA surgery, after months manifesta with 20/20 was BCVA and reasonable. On the OPD-Scan III WF/ III OPD-Scan the On reasonable. E convolved the printout, Corn/HO indicat 3), (Figure good pretty looks aberrationscorneal of degree low a ing extendedAn treatment. LASIK the after couldIOL multifocal or focus of depth isthing odd The eye. this in well work corneasflat very had patient the that achievednonetheless but LASIK before result.good a frequency of astigmatic keratotomy has keratotomy astigmatic of frequency performedbe must it because decreased aberrometry. before ------| NOVEMBER/DECEMBER 2018 | NOVEMBER/DECEMBER

The refrac The 4 CASE FILES Measuring and treating astigmatismtreating and Measuring In a retrospective review of 44 eyes44 of review retrospective a In In every case, however, I obtain intra obtain I however, case, every In measurementsaberrometry operative toinformation this use often most and amI that find I selection. IOL the finalize toricmultifocal and toric more using mywhereas past, the in than now IOLs of astigmatism. These readings frequent readings These astigmatism. of patternoverall no find can I If conflict. ly forpatient the treat I congruence, or anddisease surface ocular and eye dry weeksseveral measurements the repeat surgery.of day the on typically later, ring–based topography measurementstopography ring–based TopographyCorneal 9000 Atlas the with Pentacam Meditec), Zeiss (Carl System thewith measurements and imaging, LenstarMeditec), Zeiss (Carl IOLMaster autokera an and (Haag-Streit), LS900 estimatepreliminary a make to tometer both the multifocal and monofocaland multifocal the both them. between equivalent and group difficultmore often is patients these in corneas.unoperated with eyes in than Placidoobtain typically I Preoperatively, with Activefocus optical design and aand design optical Activefocus with group. control monofocal intraopera either using accuracy tive KTrue Barrett the or aberrometry tive calculatorASCRS the from calculation forhigh was selection power IOL for of 31 post-LASIK patients undergoingpatients post-LASIK 31 of cataract surgery, Dr. Potvin and I found visualdistance uncorrected equivalent thereceived who those among acuity AcrySof distance-dominant low-add IOLToric Multifocal D +2.5 ReStor IQ IOL with Activefocus (Alcon), in eitherin (Alcon), Activefocus with IOL required.as model, nontoric or toric the patientsgives IOL this experience, my In goodand vision distance monofocal-like little with vision near and intermediate disturbance.vision night them with monofocal or toric IOLs, butIOLs, toric or monofocal with them ofrange greater the them to explain I bilat with possible be would that vision rec my present, At IOLs. multifocal eral whenpatients these for ommendation for need their minimize to want they D+2.5 ReStor IQ AcrySof the is glasses had success with monovision in the past,the in monovision with success had for monovision re-create to willing am I CATARACT & REFRACTIVE SURGERY TODAY

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