Surgeon: High myopes seek refractive surgery, weigh options

MIAMI — With recent media attention on advanced technologies for refractive surgery, high ametropes are increasingly curious to learn whether refractive surgery options are available for them, according to Terrence P. O'Brien, MD.

"We have to consider ethical principles for higher safety, especially with these elective procedures," he said at the Bascom Palmer Eye Institute's Inter-American Clinical Course on Ophthalmology here. "You must be careful to discuss the risks and benefits, especially the long-term risks. Our motto is primum non nocere — first, do no harm. That is true of these higher myopes to avoid complications."

"As we consider patients with high myopia, we do not want to totally discount laser surgery," he said, noting that the Food and Drug Administration has approved custom laser vision correction for myopia and myopic astigmatism, and recently for higher degrees of myopia.

"The real fear factor you will hear about with higher ablations is the potential to create an unstable cornea," he said. "If corneal thickness is insufficient, we clearly have to look at an alternative."

Refractive lens exchange (RLE) is a surgical option often avoided, but its risks may be worth the potential rewards for highly myopic patients, Dr. O'Brien said. Advantages of RLE include avoiding corneal alterations and the risk of haze and poor contrast sensitivity that can occur with laser vision correction. It is also performed using familiar cataract surgical skills, he noted.

A small incision should be used for RLE to avoid inducing astigmatism, and low or no phaco power should be used for extraction of the soft lens. The capsule should also be polished to reduce the risk of posterior capsular opacification, he said.

Dr. O'Brien recommended using a foldable acrylic IOL with a 6 mm or greater diameter.

"If one is going to consider this, the surgical technique should be modified to reduce risk," he said.

Disadvantages of RLE include the risk of PCO, loss of accommodation, and possible complications including vitreous loss, cystoid macular edema, endophthalmitis and rhegmatogenous retinal detachment.

An alternative to RLE is phakic IOL implantation, which has the advantages of excellent refractive results, fast recovery, preserved accommodation, reversibility and an unaltered cornea, he said.

"One of the problems with this is space," in high hyperopes, Dr. O'Brien said. "We know from anatomic studies that there is not a lot of space in these eyes, and with phakic IOLs there is often limited space."