Challenging Refractive Surgery Cases Vance Thompson, MD, FACS Refractive and Cataract Surgery Vance Thompson Vision Sioux Falls, South Dakota
Financial Disclosures Research/consulting: Alcon AMO B & L AcuFocus Avedro Wavetec Zeiss Meditec Calhoun Vision Forsight/Nexis Vision Euclid LRG
The Psychology of Refractive Surgery A consideration in any situation where the patient is not happy with their vision Staff needs to be trained on how to handle these situations Patient and caring staff and doctor
Handling Patients Who Need An Enhancement The key to success of a refractive surgery practice
You can t count on the refraction being accurate when the best corrected vision is reduced.
Reduced BCVA Clinical Example Myopic 6 months after myopic LASIK Pre-op Mrx: -6.00D 20/20 6 mo po Mrx: -1.5-.50 X 180 20/30 slit lamp exam:. smooth flap What next?
You can t count on the refraction being accurate when the best corrected vision is reduced.
Reduced BCVA Clinical Example Myopic 6 months after myopic LASIK Pre-op Mrx: -6.00D 20/20 6 mo po Mrx: -1.5-.50 X 180 20/30 slit lamp exam:. smooth flap What next? treatment: treat island postop: Mrx: -.25 UCVA:20/20
1994 Case #1 Hyperopic Astigmatism 22 yo Caucasian male presents OD Mrx: +5.75-2.25 X 21 20/25+2 OS Mrx: +6.50-2.00 X 162 20/40+2 Small central congenital lens opacities very similar between the two eyes Amblyopic Recommendation: No Surgery
1999 Case #1 Hyperopic Astigmatism 27 yo Caucasian male presents OD Mrx: +5.75-2.25 X 21 20/25+2 OS Mrx: +6.50-2.00 X 162 20/40+2 Small central congenital lens opacities very similar between the two eyes Amblyopic Recommendation: No Surgery
2002 Case #1 Hyperopic Astigmatism 30 yo Caucasian male presents OD Mrx: +5.75-2.25 X 21 20/25+2 OS Mrx: +6.50-2.00 X 162 20/40+2 Small central congenital lens opacities very similar between the two eyes Amblyopic Recommendation: No Surgery
2006 Case #1 Hyperopic Astigmatism 34 yo Caucasian male presents OD Mrx: +5.75-2.25 X 21 20/25+2 OS Mrx: +6.50-2.00 X 162 20/40+2 Small central congenital lens opacities very similar between the two eyes Amblyopic Recommendation: No Surgery
2009 Case #1 Hyperopic Astigmatism 37 yo Caucasian male presents OD Mrx: +5.75-2.25 X 21 20/25+2 OS Mrx: +6.50-2.00 X 162 20/40+2 Small central congenital lens opacities very similar between the two eyes Amblyopic (OD dominant)
2009 Case #1 Hyperopic Astigmatism 37 yo Caucasian male presents OD Mrx: +5.75-2.25X21 20/25+2 OS Mrx: +6.50-2.00X162 20/40+2 Small central congenital lens opacities very similar between the two eyes Amblyopic (OD dominant) Really hoping to do something now even if I don t get a full correction I would like to lessen my prescription
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2009 Hyperopic Astigmatism 37 yo Caucasian male presents OD Mrx: +5.75-2.25X21 20/25+2 OS Mrx: +6.50-2.00X162 20/40+2 Small central congenital lens opacities very similar between the two eyes Amblyopic (very OD dominant) Really hoping to do something now even if I don t get a full correction I would like to lessen my prescription At age 37 he was not sure if he was ready for a lens based option Recommendation:
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2009 Hyperopic Astigmatism 37 yo Caucasian male presents OD Mrx: +5.75-2.25X21 20/25+2 OS Mrx: +6.50-2.00X162 20/40+2 Small central congenital lens opacities very similar between the two eyes Amblyopic Pupils in low light: 7 mm
2009 Hyperopic Astigmatism 37 yo Caucasian male presents OD Mrx: +5.75-2.25X21 20/25+2 OS Mrx: +6.50-2.00X162 20/40+2 Small central congenital lens opacities very similar between the two eyes Amblyopic Pupils in low light: 7 mm VISX Custom LASIK performed 1/2009
2009 Hyperopic Astigmatism Was myopic for awhile: 1 week OD UCVA: 20/50 Mrx: -0.25-2.25 X 85 20/25 OS UCVA: 20/50 Mrx: -1.25-.25 X 3 20/40 For awhile he was pretty happy Post op 1 year he was OD +3.00-2.50X87 and OS +1.5 -.75 X168 He continued to be frustrated
2009 Hyperopic Astigmatism Was myopic for awhile: 1 week OD UCVA: 20/50 Mrx: -0.25-2.25 X 85 20/25 OS UCVA: 20/50 Mrx: -1.25-.25 X 3 20/40 For awhile he was pretty happy Post op 1 year he was OD +3.00-2.50X87 and OS +1.5 -.75 X168 He continued to be frustrated Went for full correction enhancement We did a lift flap and laser with WL dialing in full correction
Hyperopic Astigmatism Post op he was OD 20/25 and OS 20/30 and fairly happy again Over the next year he became more frustrated with glare and halos One year post enhancement he still had the same vision but very frustrated with nighttime. Gas permeable contact lens over-refraction helped a little bit but not much.
Hyperopic Astigmatism Post op he was OD 20/25 and OS 20/30 and fairly happy Over the next year he became more frustrated with glare and halos One year post enhancement he still had the same vision but very frustrated with nighttime. Gas permeable contact lens over-refraction helped a little bit but not much. Recommendation:
Hyperopic Astigmatism Post op he was OD 20/25 and OS 20/30 and fairly happy Over the next year he became more frustrated with glare and halos One year post enhancement he still had the same vision but very frustrated with nighttime. Gas permeable contact lens over-refraction helped a little bit but not much. Recommendation: lens surgery
2011 Case #1 S/P Hyperopic Astig LASIK/Cong Cataracts/Amblyopic OS 2-28-11 OS: Tecnis Z9002 12-27-11 OD: B&L Model: LI61SE
2011 Case #1 S/P Hyperopic Astig LASIK/Cong Cataracts/Amblyopic OS 2-28-11 OS: Tecnis Z9002 12-27-11 OD: B&L Model: LI61SE Currently: OD: 20/20-2 Mrx: +.25 1.00 x 164 (clear) OS: 20/40-1 Mrx: -.50 -.50 x 105 (clear) But still nighttime glare and halos OD that are very bothersome pilo helps a lot Capsule is relatively clear
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2011 Case #1 S/P Hyperopic Astig LASIK / Cong Cataracts / Amblyopic OS / Big Pupils/ Implants/ Glare 2-28-11 OS: Tecnis Z9002 12-27-11 OD: B&L Model: LI61SE Currently: OD: 20/20-2 Mrx: +.25 1.00 x 164 (clear) OS: 20/40-1 Mrx: -.50 -.50 x 105 (clear) But still nighttime glare and halos OD that are very bothersome pilo helps a lot Recommendations? Gas permeable contacts? Custom enhance? Pupillary cerclage? asfj ad
2006 Case #2 29 yo Caucasian female presents Researching her options Failed contact lenses scarring her corneas Spectacle dependent Worsening night time glare OD: -3.00 -.50 x 110 20/15-1 OS: -3-00 -.50 x 56 20/15
Preop Topography OD A;lsdfja;lskdfj sdas;dlka;ds
Pre-op Topography OS A;lsdfja;lskdfj sdas;dlka;ds
Pre-op Wavefront OD A;lsdfja;lskdfj sdas;dlka;ds
Pre-op Wavefront OS A;lsdfja;lskdfj sdas;dlka;ds
2006 Case #2 29 yo Caucasian female presents Researching her options Failed contact lenses scarring her corneas Spectacle dependent Worsening night time glare OD: -3.00 -.50 x 110 20/15-1 OS: -3-00 -.50 x 56 20/15 Recommendation:
2006 Case #2 29 yo Caucasian female presents Researching her options Failed contact lenses scarring her corneas Spectacle dependent Worsening night time glare OD: -3.00 -.50 x 110 20/15-1 OS: -3-00 -.50 x 56 20/15 Recommendation: Short option: Custom PRK OU Long option: PTK first then Custom PRK OU
2006 Case #2 29 yo Caucasian female presents Researching her options Failed contact lenses scarring her corneas Spectacle dependent Worsening night time glare OD: -3.00 -.50 x 110 20/15-1 OS: -3-00 -.50 x 56 20/15 Recommendation: If it helps you in deciding my rough rule of thumb is that if you are not happy with your glasses image you most likely won t be happy with your laser corrected image
Scar Removal
Post-PTK Wavefront OD A;lsdfja;lskdfj sdas;dlka;ds
Pre-op Wavefront Post PTK Pre-op Wavefront Post-PTK Wavefront OD
Pre-op Wavefront Post PTK Pre-op Wavefront Post-PTK Wavefront OD
Pre-op Wavefront Post PTK Pre-op Wavefront Post-PTK Wavefront OD
Post-PTK Wavefront OS A;lsdfja;lskdfj sdas;dlka;ds
Pre-op Wavefront Post PTK Pre-op Wavefront Post-PTK Wavefront OD
Pre-op Wavefront Post PTK Pre-op Wavefront Post-PTK Wavefront OD
Pre-op Wavefront Post PTK Pre-op Wavefront Post-PTK Wavefront OD
2006 Case #2 29 yo Caucasian female presents Researching her options Failed contact lenses scarring her corneas Spectacle dependent Worsening night time glare OD: -3.00 -.50 x 110 20/15-1 OS: -3-00 -.50 x 56 20/15 Recommendation: Short option: Custom PRK OU Long option: PTK first then Custom PRK OU
Case #2 12/12/12 exam asfj ad
2013 Case #3 32 yo cauc male Pre-op: OD Mrx: -6.00-3.00 X 6 OS Mrx: -5.50-2.50 X 170
2013 Case #3 32 yo cauc male Pre-op: OD Mrx: -6.00-3.00 X 6 OS Mrx: -5.50-2.50 X 170 CTT 524 518
2013 Case #3 32 yo cauc male Pre-op: OD Mrx: -6.00-3.00 X 6 OS Mrx: -5.50-2.50 X 170 CTT 524 518 CustomVue LASIK OU 2010 elsewhere
Case #3
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2013 As;lfjlksjdf;lajsd;kfja;fj;lkj;lskjdf;alsdf Case #3
2013 Case #3
2013 Case #3
2013 Case #3 Recommendation?
How does this refraction look?
Case #3 post high myopia/cyl LASIK with residual cyl and HOA s
2013 As;lfjlksjdf;lajsd;kfja;fj;lkj;lskjdf;alsdf Case #3
Handling Challenging Cases The key to success of a refractive surgery practice Thank You!
Refractive cases Sonia H. Yoo, MD Professor of Ophthalmology University of Miami Miller school of Medicine Miami, Florida Financial Disclosures: Alcon, Allergan, Bausch and Lomb, Carl Zeiss Meditec, Optimedica, Transcend Medical
CASE #1 22-year-old male complaining of blurry vision in the left eye LASIK OU February 2012 LASIK retreatment OS June 2012
Preoperative evaluation, February 2012 Refraction: OD: -2.25 (-0.75) 51 OS: -2.25 (-0.50) 93 Pachymetry: OD: 518µ OS: 532µ Uneventful LASIK procedure on February 2 nd 2012
Operative report, February OD 2012 OS
Postoperative evaluation PO Week 1: OD: +0.25 (-0.75) 94 OS: +1.25 (-1.00) 138 PO Month3: OD: +0.25 (-0.75) 105 OS: +2.50 (-0.75) 144 LASIK Retreatment OS June 2012
OS Operative report, June 2012
Clinical evaluation, August 2012 Refraction: - OD: plano (+0.75) 10 20/20 - OS: +5.50 (+1.00) 105 20/400 - Slitlamp examination clear corneas Patient complaining of blurry vision in the left eye
Topography, August 2012
What to do now? LASIK enhancement? PRK? Contact lenses? Other options?
What about IOL surgery to rescue refractive surgery disasters?
CASE #2 78 year-old-man Complaining of decreased vision and glare OU for several months Medicines: Flomax for BPH
January 2012 Refraction: OD = -2.00 +2.00 x 85 20/25 OG = -3.75 +3.50 x 95 20/30 Scheduled for CE OS first
Topography
Acrysof Toric calculator OS
IOL power calculation TORIC IOL OU - OD: SN6 AT7 16.5D - OS: SN6 AT9 16D
POD#1 CE OS Jan 2012 20/25 OS without correction! Slitlamp examination: small piece of retained cortex IOP: 24 mmhg
POM#2 February 2012 OS: 20/25 but complaining of blurry and double vision Slitlamp: retained cortex IOP controlled by Cosopt (11mmHg) Cortical lens fragment removal
POD#1 cortex removal March 2012 Refraction OS : Plano +3.50 x115 20/60 IOL axis on meridian 45 instead of meridian 100
How would you manage this refractive surprise? Contact lens? Arcuate keratotomy? IOL reposition? Immediately? When the IOP is controlled without medication? When the AC is quiet?
IOL reposition OS POD#1 IOL reposition OS 20/20 without correction!
What about OD? March 2012: CE with ruptured capsule, anterior vitrectomy What IOL to use? Sulcus IOL: MA60AC 16.5D POW#1: 20/50 OD Slitlamp exam: corneal edema IOP: 12 mmhg (Cosopt)
POM#1 CE OD April 2012 UCVA OD 20/60 OD= -2.50 +3.00 x 95 20/20 OS= 20/20 without correction What to do now?
Topography OD Pachymetry 574 µ OD
After refractive stabilization (4 months later) Femtosecond laser assisted arcuate keratotomy (FAK)
Topography July 2012 POD#1 post FAK UCVA 20/200 Refraction OD -2.50 +1.00x135 20/25
Topography September 2012 POM#2 post-ak UCVA 20/100 Refraction OD -3.75 +2.25x135 20/25
Case #3 35-year-old male Complaining of dependency on glasses Has never tried contact lenses
Refractive evaluation Manifest Refraction: - OD = -3.75 20/20 - OS = -3.00 +1.25 x 75 20/20 Cyclopegic refraction: - OD = -3.50 - OS = -3.00 +1.25 x 65 Pupill diameter: 5mm OU Dominant eye: OD Slitlamp ex., IOP and fundus: WNL
Preop topography OD U/S PACHY = 543 µ
Preop topography OS U/S PACHY = 501 µ
Preop topography OD
Preop topography OS
LASIK OU Refractive surgery 7/12/2001 Targeted for distance in both eyes Flap: 130 µ, Mora CB microkeratome VISX conventional treatment : - OD = -3.20 - OS = -2.70 +1.25 x 65 Uneventful surgery
Postoperative evaluation POD#1 : UCVA OD: 20/20 (-1) and OS: 20/20 (-2) POY#3 (2004): UCVA 20/20, 20/25 with refraction OD = plano and OS = -0.75 +0.75 x40 POY#6 (2007): - UCVA 20/25, 20/40-2 with refraction OD = -1.0sph and OS = -1.0 +0.50 x 35 - BSCVA 20/20, 20/20
To retreat or not to retreat That is the question!
itrace February 2012
Pentacam April 2012
Anterior segment OCT - 2012 Residual stromal bed = 285 microns
Anterior segment OCT 2012
How would you retreat?
Thank you for your attention