Refractive Surgery
Shifting sands of refractive decision making

AT A GLANCE

• Refractive decision making changes from primarily excimer laser to PRK and impants • Their decisions are different than they might have been a decade ago: age, need for surgery, elective IOL placement • Paradigms will continue to shift as new technology becomes available

From the reemergence of PRK to the question of lenses the refractive equation has changed

For the future, new presbyopic solutions, such as the Revision Optics inlay, will like be a part of the paradigm shift

At the start of the new decade, it’s a good opportunity to evaluate the current decision making process of refractive surgeons today and to consider how these might have changed from say a decade ago. We asked several leading practitioners to share their views on the chan-ging paradigm.
Douglas D. Koch, M.D., professor and the Allen, Mosbacher, and Law Chair in Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, sees the paradigm as having shifted from the strictly excimer laser perspective that prevailed around the year 2000 because there are now more things to offer patients. “We now are much more comfortable and willing to discuss lens surgery as a primary option for patients certainly in their 40s and 50s.” Another change he finds is that PRK is now much more a part of the decision making equation then it was a decade ago, when the procedure was on the backburner. “I would say that the change has been a more balanced presentation of what we offer patients in terms of LASIK refractive surgery, the capability of offering high myopes also the Visian Implantable Collamer Lens (ICL, Staar Surgical, Monrovia, Calif.) or the Verisyse (Ophtec USA, Boca Raton, Fla.) and certainly a consideration of refractive lens exchange if they’re in their 40s and 50s or older,” Dr. Koch said. “I think concomitant with that, at least in my practice, has been the near abandonment of laser refractive surgery of the cornea in patients 55 and older.” While Dr. Koch still considers doing some laser refractive surgery in this population if they have clear lenses, he often decides to go with an intraocular approach here. “If they have an early cataract I find myself a little gun-shy about doing corneal refractive surgery, when I think that it will not benefit them for any prolonged period of time,” he said.

Pivoting on patient selection

Daniel S. Durrie, M.D., clinical professor of ophthalmology, University of Kansas, Overland Park, Kan., sees a lot of the decision making changes as hinging around patient selection for the various refractive technologies. “What’s going on how has more to do with patient selection for the use of the technologies that are maturing than anything else,” he said. “What we’re looking at now is who is a good candidate for which IOL or who’s a good candidate for surgery at all.” From there he finds discussions often evolve about the risk of ectasia and problems such as dry eyes. He also finds that there’s a lot more thought as to when’s the best age to perform LASIK surgery. “I think that it’s age 18-24 but that isn’t the norm,” Dr. Durrie said. “Most practitioners are still doing it when people fail on their contact lenses in their late 30s and early 40s.” However, from the patient’s perspective this may not be the best approach. “The risk of contact lenses goes away with surgery when you’re young, the expense of contact lenses and glasses go away, and the inconvenience,” Dr. Durrie said. “You get more out of LASIK the earlier you do this.” He envisions a time when this will be like orthodontics and practitioners will be performing this as early as possible.
Likewise, Dr. Durrie thinks that the same rationale now goes for IOLs. He points to a presbyopic friend of his with Plano acuity who mentioned that she was interested in refractive correction for her growing presbyopia. “She said why wouldn’t I just have that lens implant thing because then I can‘t get a cataract down the road,” he said. “That would not have been thought of about 10 years ago, but it has some logic to it.” In his own practice, he has seen the age that people have been opting for IOLs drop dramatically. “It has gone from 75-65 and the average now is 54,” Dr. Durrie said. “We’re doing a lot more people with lens exchanges in their late 30s.”

Continued excimer edge

Roger F. Steinert, M.D., Irving H. Leopold professor, chair of Ophthalmology, director, Gaven Herbert Eye Institute, and professor of biomedical engineering, University of California, Irvine, Calif., sees excimer laser treatment as continuing to remain in the leading position in the treatment pyramid. “Volume-wise and percentage-wise excimer laser is the dominant form of refractive surgery,” he said. “LASIK is still dominant but PRK has had some resurgence.” While there are currently a few surgeons who have decided that they don’t want to deal with flaps, for the majority it is a question of which to use when. “Even the surgeons who offer both have realized that there is a place for PRK, both with correction and when there might be some concern about inducing ectasia,” Dr. Steinert said.
“I also think that a very big drama is dry eye because we now have come to appreciate that both PRK and LASIK will cause some degree of post-op dry eye, but that it tends to be a much more substantial issue and persistent issue with LASIK.” As a result, in cases of a border-line dry eye patient this may push the surgeon to opt for PRK instead of LASIK.
On the flip side, however, Dr. Steinert has also seen a growth of interest in whether or not to use of femtosecond flaps—now a pivotal question in the decision making paradigm. “The issue of ectasia is being appreciated as a potentially major one for a large number of people,” Dr. Steinert said. He finds that many practitioners are now deciding to go with thinner LASIK flaps of 110 microns or so. Lenses he sees as continuing to be reserved for special cases. “There’s an appreciation that when we get into higher levels of myopia that this may be a better alternative he said. “Also, for high hyperopes when they do get cataracts when they’re elderly it’s actually a higher risk procedure because there is very little room in the eye.” As a result, he finds that surgeons are adding refractive lens exchange to the paradigm for such specific indications like hyperopia.
Some practitioners are still holding back he thinks, because they are hoping for better lens options in the future. “They don’t feel that the intraocular lens solutions that we have right now are good enough to aggressively pursue people who have clear lenses,” Dr. Steinert said. Going forward, Dr. Steinert sees the paradigm as continuing to shift. Soon this is likely to include two new refractive options for the treatment of presbyopia—a 2 mm hydrogel plus powered inlay (Revision Optics, Lake Forest, Calif.) and the AcuFocus (Bausch and Lomb Surgical San Dimas, Calif.) pinhole concept. “Both of those have to potential of having some significant appeal for a presbyopic solution for some people,” he said.
Also, he hopes that there will be more lens options to factor into the paradigm. “We’ll see some slow growth in lenticular solutions if we do in fact have a product that really can start to deliver reliable correction of presbyopia with minimal side effects and minimal risk,” he said. “The Synchrony lens is the first of those products that’s in the pipeline that has everybody excited at least about the potential.”

Editors’ note: Dr. Koch has financial interests with Abbott Medical Optics (Santa Ana, Calif.), Alcon (Fort Worth, Texas). Dr. Durrie has financial interests with AMO and Alcon. Dr. Steinert is a has financial interests with AMO and ReVision Optics (Lake Forest, Calif).

Contact information

Durrie: 913-491-3330, ddurrie@durrievision.com
Koch: 713-798-6443, dkoch@bcm.tmc.edu
Steinert: 949-824-0327, roger@drsteinert.com