August 2019

IN FOCUS

Cataract Surgery Post-LVC
Optimizing outcomes post-surgery


by Ellen Stodola EyeWorld Senior Staff Writer/Meetings Editor


Superficial punctate keratopathy can significantly degrade quality of vision following cataract surgery.


Viscoelastic material being removed following implantation of a Light Adjustable Lens
Source (all): Kevin M. Miller, MD

 

Following a cataract or refractive procedure, a patient may still need touch-ups or further procedures to obtain the desired outcome. Surgeons discussed postoperative considerations, when to consider a laser vision correction (LVC) touch-up, new technologies, and when an exchange may be necessary.

SPK after bilateral presbyopia IOLs

Kevin M. Miller, MD, said he “hand holds” patients during the first week after surgery as long as they don’t have any major issues. If patients aren’t happy, they might have some superficial punctate keratopathy (SPK), he said, but generally Dr. Miller examines them, talks to them, and tells them it’s still early.
Usually at 1 week, Dr. Miller will stop antibiotics but keep patients on steroids. If someone is on NSAIDs and it’s bad, he might consider taking them off, he said.
If SPK is a problem, at 1 week he’ll put them back on lubricating eye drops. Patients are usually off artificial tears for the first week because of the increased risk of endophthalmitis, but at 1 week, the risk is very low, he said.
Dr. Miller usually sees his patients at 1 day and 2 weeks after surgery. If they’re having issues at 2 weeks, he starts doing evaluations.
Bennett Walton, MD, said he classifies presbyopic IOL candidates into three categories with respect to dry eye and the ocular surface: good candidates, poor candidates who should not receive a presbyopic IOL, and those who deserve a chance at presbyopic correction but need to know the importance of dryness with their vision. 
Dr. Walton added that at 1 week postop, patients still fluctuate quite a bit, and if a patient responds well to reassurance and the refractive target has been hit, he may simply show a slit lamp photo of their staining pattern. “I have found photos a valuable tool for patient education and buy-in,” he said. “I also like the HD Analyzer’s [Visiometrics] tear film optical analysis.” In his experience, having objective measurements, whether through the HD Analyzer, topography, or photos of their staining pattern, can help get patient buy-in, which is crucial to successful treatment of dryness.
Luke Rebenitsch, MD, said he generally sees patients at 1 day, 1 week, 1 month, and 3 months postop. Having a little SPK at 1 week is normal, he said. He treats conservatively at first with artificial tears. If there is any meibomian gland dysfunction, he may add omega-3s.
He also likes to use the AcuTarget HD (Visiometrics) to look at the objective scatter index (OSI). This is mainly to be able to follow ocular surface disease and tear film over time, he said.

LVC touch-ups after cataract surgery

When determining how long to wait to offer LVC, Dr. Miller said there needs to be refractive stability, and the earliest he would do this is about 3 months after surgery.
In the cataract age group, Dr. Miller said he usually chooses PRK because he thinks LASIK causes more dry eye problems. “There’s more pain for the patient postoperatively, but I think we dodge the dry eye bullet more often when we do PRK,” he said.
Julie Schallhorn, MD, said she usually waits 3 months before a touch-up because she wants the refraction to be completely stabilized first. “If there is any hint of PCO forming, I will do a YAG before a touch-up refractive procedure, as PCO can affect your refraction,” she said. As the magnitude of refractive error is generally low, either LASIK or PRK would be good options, Dr. Schallhorn said, and the decision between them is based on patient-specific factors.
According to Dr. Walton, two conditions must be met before an LVC touch-up. First, the patient must have healed into new, stable, baseline vision, and he prefers to wait until 3 months. Second, the patient must like the projected refractive change, Dr. Walton said. Happiness in a trial frame before LVC indicates both that refractive error is addressing their residual problem and that LVC enhancement of a myopic result will not disappoint them. He noted that it’s important patients visually acknowledge the decrease in near that comes from correcting a slightly myopic result.
“I offer both LASIK and PRK, depending on the ocular surface of the patient,” he said. “Most patients prefer the faster and more comfortable recovery of LASIK.”

Enhancements with previous LASIK for postop cataract patients

Dr. Rebenitsch offers LASIK whenever possible, and with the proper technique, he will lift an old flap (assuming he can see the edges of it). “We typically offer PRK when we’re unsure of the previous flap-making technology,” he said.
Dr. Rebenitsch said that it’s extremely important to obtain epithelial thickness mapping when doing PRK after previous surgery. “I truly believe epi mapping is going to be not only common but necessary when treating post-refractive eyes in the future,” he said.
Dr. Walton said the older the flap, the more likely it is to be microkeratome. “In my mind, that’s a greater risk for epithelial ingrowth afterward because we don’t have the squared off edge that we have with femtosecond flaps.” He added that he would consider surface ablation if he knows it is a microkeratome flap or it is old enough that it likely is.
Other than epithelial ingrowth, Dr. Walton thinks that there’s more accuracy in retreating LASIK than doing PRK over the flap. Rather than a younger refractive patient eye, these are cataract patients who have had decades of decompensation, he said, so you cannot assume their epithelium will grow back in the same pattern and thickness.
“Seldom does a week pass where I’m not operating on someone who’s post-LASIK, PRK, or RK,” Dr. Miller said. When it’s necessary to do an enhancement, Dr. Miller will often choose surface ablation or PRK on top of the flap for previous LASIK eyes. When you lift flaps more than a year out, you often get epithelial ingrowth, he said, and that’s a headache for everyone. “As much as PRK is painful for the patient during the recovery period, it’s the safer option,” Dr. Miller said. He added that in post-RK eyes, a lens exchange may be necessary.

Light Adjustable Lens

The Light Adjustable Lens (LAL, RxSight) is beginning to be used commercially in practice. The FDA is requiring RxSight to do another study on eyes that have had previous refractive surgery (such patients were excluded in the first trial). Dr. Walton is part of the LAL clinical trial for previous refractive patients and said they are a good fit clinically and also tend to have an appreciation for technology and what it can bring to their vision.
“I think the LAL is going to be a game-changer for the post-LVC patient,” Dr. Schallhorn said. “The clinical trial results for this lens are amazing. The ability to offer a near-guarantee of postop refraction is going to be very attractive to that patient population.”
“These technologies are not only going to make jobs of surgeons easier but will provide visual results that were more difficult to achieve in the past,” Dr. Rebenitsch said.

Touch-up vs. exchange with presbyopia-correcting IOLs

Dr. Rebenitsch said all patients at his practice are counseled that “presbyopic IOLs with current technology are a journey and not an immediate destination.” These patients will have to neuroadapt for at least 3 months, he said, but he noted that in the last 4 years, he has placed 1,300 multifocal IOLs and hasn’t had to do one exchange.
Dr. Walton said it’s important to know if refractive error is the only or main issue. If there’s anything else going on, it needs to be addressed or carefully explored, he said. The decision to do an exchange depends on the patient. “We tell patients at the beginning: ‘The lens we’re planning to give you tends to give good distance, good intermediate and even some at arm’s length, but it will not give tiny print and dim lighting.’ Most people see the broader range as a benefit, but 1% do have us remove it later if they are the minority who don’t neuroadapt to the nighttime driving vision,” he said.
To be a modern refractive cataract practice, being able to do an in-the-bag IOL exchange and have that conversation with patients should be a normal part of what is offered, Dr. Walton added. “It’s a basic necessity to offer full refractive cataract surgery, and that wasn’t the case 10 years ago.”

At a glance

• When enhancing a patient with previous LASIK, surgeons should be careful lifting the flap, as epithelial ingrowth is possible.
• Generally, in the immediate postop period, patients are still adjusting. Many surgeons wait up to 3 months before offering enhancements.
• The Light Adjustable Lens is one new technology that may have indications for post-refractive patients in the future, offering the opportunity for adjustments after surgery.

Contact information

Miller: kmiller@ucla.edu
Rebenitsch: Dr.Luke@ClearSight.com
Schallhorn: jschallhorn@gmail.com
Walton: drwalton@visiontexas.com

About the doctors

Kevin M. Miller, MD

Kolokotrones Chair in Ophthalmology
David Geffen School of Medicine at UCLA
Los Angeles

Luke Rebenitsch, MD
ClearSight LASIK
Oklahoma City

Julie Schallhorn, MD
Assistant professor of ophthalmology
University of California,
San Francisco

Bennett Walton, MD
Slade & Baker Vision
Houston

Financial interests

Miller: Alcon, Johnson & Johnson Vision, Carl Zeiss Meditec
Rebenitsch: Carl Zeiss Meditec, CorneaGen, STAAR Surgical
Schallhorn: None
Walton: RxSight, Alcon, Carl Zeiss Meditec, Johnson & Johnson Vision

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