Daniel S. Durrie, MD: I don't operate on people who have an asymmetric bow tie or a yellow spot that is not in the center of an Orbscan. LASIK would magnify the problem. We will have better technology for them down the road. Doctors may think they induced keratoconus, but it is something they missed preoperatively.

Stonecipher: What are you doing for patients with halos? Do you use drugs to modify pupil size?

Ronald R. Krueger, MD: Alphagan [brimonidine tartrate, Allergan] seems to help sometimes. But if patients have both day and night vision problems, pharmacology won't make much difference.

Stephen G. Slade, MD: We need to be very careful and make sure patients don't have residual cylinder that wasn't picked up. Sometimes you can go back and re-treat them and fix the problem, which is actually a refractive problem and not necessarily related to their pupil. In some cases, night driving glasses help address a residual refractive error. You may not be able to do any more, but if you just give them glasses and Alphagan, it may really make a big difference.

Krueger: If you gave them monovision and they are happy with it but have problems driving at night, just give them nighttime glasses to correct both eyes for distance.

Steven C. Schallhorn, MD: I tried over-minusing a little in a young patient for night driving glasses - night myopia - which can induce a little accommodation that they can easily handle, such as -0.5 D, and it constricts their pupils too.

Stonecipher: I perform confocal microscopy with form fruste suspects. It allows you to pick up keratoconus and Vogt's striae at an early stage. Many of these patients just don't seem quite right with Orbscan or have normal pachymetry but have fine little striae.

Schallhorn: The U.S. Food and Drug Administration recently approved the humanitarian use of custom ablation profile [CAP] method [Visx]. It allows you to customize the ablation by modifying the diameter and the power of the correction and lets you determine where you put the correction on the cornea. It is flexible in treating conditions where we have not had any options before, such as central islands or decentered ablations. I'm not certain whether therapeutic wavefront-guided ablations would be a better option than a CAP procedure at this time. Should patients wait for a therapeutic wavefront-guided ablation, which could perhaps do a much better job of guiding a treatment or get CAP now for an isolated central island?

Slade: We did about 200 topographically based ablations with CAP for various conditions and the decentrations worked out pretty well. The treatments were computer-guided and generated from the topography. That is a real plus for that laser, but the laser is still guided by the surgeon. It just allows you to pick an ellipse or a sphere, choose where you want to put it, and choose the depth and diameter of that ellipse or sphere. It's the only machine right now approved to do that.

Stonecipher: If you have a central island or a decentration and wavefront does not seem appropriate, what do you do?

Ioannis G. Pallikaris, MD: It depends whether the patient is a hyperope or a myope. For hyperopic cases, I am increasingly using radio-frequency-based conductive keratoplasty for patients older than 40 in the way that I used to do relaxing incisions. It's the same principle. You can also use intracorneal rings [Intacs].

Stonecipher: Are Intacs the answer for ectasia?

Durrie: I have used Intacs in about 20 patients who had keratoconus or some kind of inferior asymmetry. They stretch and lower the bump; they don't really cure the asymmetry. If you have a keratoconus patient who is heading toward a transplant, you can stabilize that and sometimes improve best-corrected vision. However, you have to make sure patients understand that you are just going to stabilize their keratoconus and that you will not be getting them to 20/20.

The other option may be the conductive keratoplasty radio-frequency procedure. I have worked with Dr. Antonio Mendez in Mexico using CK to shrink the cornea in patients who have a high spot down below. Putting in a couple of radio-frequency spots outside the high spot to pull it down might work just as well as trying to push it up on the superior area. Once the CK device is approved, we can just use it off-label in these patients and see what happens.

Stonecipher: What about wavefront-based contact lenses? Can we make a contact lens today to help the unhappy LASIK patient see better?

Marguerite B. McDonald, MD: There are two companies pursuing this. Polyvue Technologies is just starting a clinical trial using soft lenses with a wavefront corrective pattern. Their laboratory experiments look good. Another company is making radially asymmetric soft and hard lenses. Basically a small, handheld unit called the Scout topographer is used to snap a picture and that is sent to a laboratory to generate a custom lens. About 150 optometrists in the United States have this system right now, but ophthalmology is just starting to get into it. The Wave Contact Lens System is available through EyeQuip in Ponte Vedra, Fla. (1-800-EYE-TOPO, info@ eyquip.com).

Stonecipher: If a patient comes in with irregular astigmatism and monocular diplopia, do we perform a wavefront-guided custom ablation? Or do we say: "Sorry, there is nothing we can do but, in the near future, wavefront technology will be available to correct your problem and then a re-treatment is possible to improve your vision"?

In my practice, we have been somewhat successful with a surgeon-guided customized ablation. It has not been the panacea, but a number of patients who were extremely unhappy became 50% or 60% happier. The surgery got them back to square one, where they were more comfortable in terms of late-night problems and driving problems.

Marc A. Michelson, MD: About 2 years ago, I began to use the old Summit Apex Plus Laser to perform custom ablations in the phototherapeutic keratectomy mode. I narrowed the beam size to a 2-mm spot and performed random spot ablations in areas I thought were topographically related to the abnormalities. Patients who came in with specific abnormal refractive errors, such as an axis of cylinder, that didn't correspond to anything you could see topographically, I believe, could not have a treatment based on the refractive data only. You have to look at something beyond that. I have been very successful performing selected PTK treatments in areas corresponding to topographical elevations in a small number of patients whose initial treatments created non-homogenous ablations, resulting in central islands or irregular astigmatism. None of these patients lost lines of vision after these custom treatments. I saw significant improvements in symptoms, such as ghosting and night vision disturbances. But I caution, this represents only a select number of patients, what I would call my collection of patients with severe visual dysfunction who have been improved. Briefly, the technique is a limited application of PTK randomly applied to the high spots in selected areas.

Stonecipher: What are your pearls for treating unhappy patients and what happens when you don't have a wavefront machine? What are you using to help you make the diagnosis?

Paolo Vinciguerra, MD: It is relatively easy to treat them with focal treatment, to normalize them without using masking fluids. For one -16-D patient, we used the mask we developed, which lets you progressively expose the opposite side, and then you can re-center and remove a few microns. According to the calculation, you remove one-third of the original ablation, so it's not so much. In most of those cases, you can solve everything with a few microns of additional ablation.