Refractive
April 2022
by Ellen Stodola
Editorial Co-Director
When choosing a refractive procedure, there is a lot of information for surgeons to go over with patients, and the possibility of needing implant surgery in the future is one point for discussion. Bryan Lee, MD, JD, Luke Rebenitsch, MD, and William Wiley, MD, shared how they counsel patients, specific considerations, and how changing technology has had an impact on this and may open more options in the future.
Technology is changing so quickly, Dr. Rebenitsch said, and the procedures of today are not the procedures of 20 years ago. For example, LASIK is very different today than it was 15–20 years ago. “We have better ablation patterns and larger optical zones, which do not necessarily preclude a patient from having a multifocal or advanced technology IOL in the future,” he said. Dr. Rebenitsch said that all patients under 40 are counseled that their crystalline lens is going to change, and there are options for when they develop presbyopia. Setting expectations is a win for patients and practices, he said.
In cases of hyperopic ablations, Dr. Rebenitsch advised caution and said that he might be more likely to recommend a refractive lens exchange earlier because even with modern technology, hyperopic ablations are more likely to prevent patients from having certain advanced technology IOLs. “What’s changed over time is we’re doing lenses earlier, especially for hyperopic patients,” he said.
Dr. Rebenitsch added that treatment for a –6 to –8 myope is usually when higher order aberrations increase with modern ablation profiles, so he may be more likely to place a phakic IOL, like the STAAR Surgical ICL, to allow them to have better vision now as well as more options in the future.
Additionally, he highlighted the benefits of the SMILE procedure in these cases because it leaves more of the surface of the cornea untouched. Any time you do a refractive procedure, it does make calculations more difficult for enhancement/lenses in the future, Dr. Rebenitsch added. But he noted that you can still do a LASIK flap over SMILE rather than doing PRK or lifting an old LASIK flap to enhance.
Dr. Rebenitsch also mentioned how a discussion on presbyopia plays into patient counseling. “From a refractive standpoint, it’s important to make patients happy now, but you also have to look at what’s best for them in the future,” he said. For example, for someone who is +3 and in their early 40s, Dr. Rebenitsch would not choose to do LASIK.
Dr. Lee said he never uses a trifocal or multifocal IOL in someone who has had corneal refractive surgery and he takes that into consideration if a patient has a cataract or has significant presbyopia. “In those situations, I mention that lasering the cornea now makes IOL power selection more difficult and may limit IOL options in the future,” he said. “If it merits more than just a passing mention, that is an indication that refractive lens exchange may be the better surgical option.”
A patient’s age may also play into this discussion. If someone has a clear lens and is in their 20s or 30s, Dr. Lee said he does not usually address future IOL issues, especially given the availability of the Light Adjustable Lens (LAL, RxSight). “I am confident that in the future, adjustability will extend to presbyopia-correcting IOLs as well,” he said.
However, he noted that he recommends a preoperative monovision trial for laser vision correction candidates who have symptomatic presbyopia and who have not tried it. “If they do not like monovision, they might be better off with refractive lens exchange,” he said. “I do not use specific age cutoffs because there is so much variability among patient needs and goals. However, I am reluctant to do corneal refractive surgery in a hyperope with significant presbyopia and would usually recommend lens exchange.”
When Dr. Lee performs cataract surgery on someone who had prior refractive surgery, he does not distinguish between LASIK and surface ablation. “I am more concerned about RK versus laser vision correction,” he said. “I expect that any corneal refractive surgery I perform will likely cause mild irregularity to the cornea but do not use that to help patients choose their procedure.”
Dr. Wiley said he thinks that as implant technology gets better, it does guide discussions on refractive surgery. “In the past, when implant technology was in its infancy, the motivation to delay or choose IOL options over corneal refractive options wasn’t there,” he said. “As IOL technology has advanced, the corneal refractive surgery mindset has changed.”
For example, he said that he was using corneal inlays quite frequently in his practice for a while. KAMRA (AcuFocus) provided distance and near over time, but one issue was that for it to work well, for most patients you had to do LASIK on both eyes and KAMRA on one.
Now that trifocals are on the U.S. market, Dr. Wiley noted that the same patient considering LASIK plus KAMRA might be a good candidate for a trifocal clear lens because it gives distance, intermediate, and near. The expense to the patient for a bilateral trifocal is similar to LASIK and KAMRA, he added, and it tends to be a better and easier approach with more longevity.
Dr. Wiley noted that hyperopic LASIK is being done less. A low hyperope or young hyperope tends to be able to accommodate and usually doesn’t come in until their 40s. Most hyperopes who come in are already experiencing distance and near vision loss, he added. Almost all hyperopic patients should be evaluated for lens surgery, as opposed to just corneal refractive surgery, Dr. Wiley said. He cautioned that once you do hyperopic LASIK, it may make the patient no longer a candidate for premium IOL surgery in the future and may limit options.
From an age standpoint, Dr. Wiley said, for example, for a 30-year-old hyperope, by the time the patient needs lens surgery, the technology should have advanced enough where there might be an accommodating lens option. “You can be a little more aggressive with younger patients,” he said.
Dr. Wiley has also found a benefit to SMILE vs. LASIK in that it leaves more future advancement options open for the patient. If you do LASIK in a 30-year-old, and 30 years later they need an IOL, if you need to enhance after the IOL surgery, your only option is PRK, he said. You can’t easily lift the flap; there is a risk of epithelial ingrowth or scarring. He also said PRK after LASIK is not quite as predictable. “What’s nice with SMILE is you have the ability to convert SMILE to LASIK years or decades after,” he said. This leaves the potential to have a LASIK flap created in the future after an IOL and thus have a more predictable adjustment procedure if the need arises.
The future of implants
In the time since he completed ophthalmology training, Dr. Rebenitsch said that he’s found it exciting the way the conversation with the patient has changed. It has become less of a question of if a patient is a candidate for an advanced technology IOL and has shifted to what type of advanced technology IOL is an option for them. With the advent of extended depth of focus lenses, the LAL, and potentially with better accommodating lenses in the future, Dr. Rebenitsch said that every patient should qualify for something.
One of the things he’s most excited for is the IC-8 (AcuFocus). “Our practice placed more than 250 KAMRA inlays with a 95% satisfaction rate,” he said, adding that he thinks this pinhole technology is better in the sulcus or in an IOL. “For patients with aberrated corneas who have historically not qualified for anything, they now will have something that will manage astigmatism, give extended depth of focus, and give overall higher satisfaction and spectacle independence than we could have done in years past,” he said.
Dr. Rebenitsch also spoke about other technology that he’s looking forward to implementing, specifically those for presbyopia. He mentioned drops for presbyopia and the approval of VUITY (pilocarpine HCl ophthalmic solution, Allergan), the first of these products, noting that it will “act as a bridge” for many patients.
“What I’m really looking forward to is there should be an extended depth of focus ICL in the future,” Dr. Rebenitsch said. Presbyopic high myopes don’t have a lot of good options currently, he added, and an extended depth of focus ICL could create a bridge for these patients until they want to have cataract surgery.
Even for patients who have had dated corneal refractive surgery, Dr. Wiley said some newer technologies in the works could be useful, including the IC-8. A small aperture IOL is a great option for patients with previous RK, he said, especially because current technology doesn’t do a good job of giving multifocality or EDOF to these patients.
Dr. Wiley also mentioned other technology on the horizon, like the Gemini Refractive Capsule (Omega Ophthalmics), which he said is designed to go into the capsular bag to hold it open to allow for lens exchangeability.
He also noted the option of phakic IOLs, particularly the EVO (STAAR Surgical). It allows for a non-corneal altering procedure and keeps all options open for the long term, Dr. Wiley said. “As implantable contact lens technology evolves and doctors become more comfortable with that, we’ll see wider use for even medium to moderate prescriptions, we’ll see alternatives going forward for phakic IOLs, which are less invasive to the eye, and we’ll see that those truly do keep the broadest options open for the patient,” he said.
Dr. Wiley also mentioned the use of presbyopia drops in the future as more experience is gained with VUITY and as similar products are brought to market. It gives us some ability to consider that presbyopia myope who wants distance vision or monovision, he said. “With presbyopic drops, it gives more options for spectacle independence,” Dr. Wiley said.
These options could give some longevity to corneal refractive surgery, Dr. Wiley said. “In the past, once a patient had corneal refractive surgery then lens surgery, it was so permanent that you had to be so careful about what lens you chose because they would be married to it for their lifetime.” Now, Dr. Wiley said there is the understanding that there are some exchangeable options on the horizon.
About the physicians
Bryan Lee, MD, JD
Altos Eye Physicians
Los Altos, California
Luke Rebenitsch, MD
Medical Director
ClearSight LASIK/43 Vision
Oklahoma City, Oklahoma
William Wiley, MD
Cleveland Eye Clinic
Cleveland, Ohio
Relevant disclosures
Lee: AcuFocus
Rebenitsch: Carl Zeiss Meditec, STAAR Surgical
Wiley: Alcon, Allergan, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson Vision, Omega Ophthalmics, RxSight, STAAR Surgical
Contact
Lee: bryan@bryanlee.pro
Rebenitsch: Dr.Luke@ClearSight.com
Wiley: wiley@cle2020.com
