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Laser ablation plateaus as toric IOLs, presbyopic IOLs, femtosecond cataract surgery rise
Two-thirds of survey respondents said they would start to treat astigmatism at 0.75 D.
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The total volume of laser vision correction procedures has declined in the last half decade but remained stable for the last 2 years, according to an annual surgeon survey.
Toric IOLs, presbyopic IOLs and femtosecond laser-assisted cataract surgery are steadily gaining ground, Richard J. Duffey, MD, OSN Refractive Surgery Board Member, told colleagues during Refractive Surgery Subspecialty Day preceding the American Academy of Ophthalmology meeting.
Duffey presented results of the U.S. Trends in Refractive Surgery: 2013 International Society of Refractive Surgery Survey.
“Femtosecond laser-assisted refractive cataract surgery is on the rise. Femtosecond, toric and presbyopic IOLs are not high-volume refractive surgeries yet, like LASIK in its heyday. Multifocals trump accommodative IOLs, but neither have high penetration,” Duffey said. “[We saw] more astigmatism management, even low astigmatism, in surgical cataract patients.”
Duffey said that 27% of respondents reported performing corneal cross-linking, an increase of more than 10% from 2012.
Richard J. Duffey
“I think that people are thinking, ‘We’ve got to do something first for keratoconus, and this is probably the answer, even without the FDA’s endorsement at this point,’” he said.
The 17th annual survey is the fifth conducted online; 144 of 1,150 ISRS members, or 13%, responded. Only U.S. members were surveyed.
Procedure volume
Respondents performed 339,000 LASIK procedures, a slight increase from 2012, and 112,000 PRK procedures, a slight decrease. Total laser vision correction volume was the same in 2012 and 2013. PRK has comprised about 25% of total laser vision correction procedures since 2009, Duffey said.
Survey results showed that 56% of respondents performed five or more LASIK cases a month and 24% performed five or more PRK procedures a month, a fairly significant decrease for this particular volume from 2012, Duffey said.
Fifty percent of respondents implanted toric IOLs, 38% implanted presbyopic IOLs and 23% performed femtosecond laser-assisted cataract surgery, the latter being a significant increase from 2012, he said.
“To me, those are cataract surgeons who are committed to femtosecond laser technology and are comfortable with that technology in their hands. I think you’re going to see those numbers continue to rise as time goes on,” Duffey said.
Surgeon preferences
Excimer laser vision correction was preferred by 47% of respondents for a 30-year-old patient with 10 D of myopia; 38% preferred a phakic IOL for that same patient.
“I think when we can do a corneal laser and avoid an intraocular procedure, we do so,” Duffey said.
Fifty-eight percent of respondents favored LASIK or PRK for a 45-year-old patient with 3 D of hyperopia; 28% preferred refractive lens exchange (RLE) for the same patient.
Sixty-one percent favored RLE for a 45-year-old patient with 5 D of hyperopia.
“When you get into the hyperopes, that changeover occurs somewhere between 3 D and 5 D,” Duffey said. “We all know that refractive lens exchanges work better than laser vision correction beyond a certain level of hyperopia. There’s a limit to how much hyperopia that you can correct with lasers. Even though the [U.S. Food and Drug Administration] sets that limit at 6 D, most of us set it lower, in the 3 D to 4 D range.”
Seventy-three percent of respondents reported performing femtosecond laser LASIK flaps. Fifty-one percent preferred a flap thickness of 100 µm; 46% preferred a thickness of 120 µm to 130 µm.
“I think thinner is better,” Duffey said. “We can do that with both modern microkeratomes and femtosecond lasers.”
Sixty-one percent of respondents preferred a residual stromal bed thickness of 275 µm or more.
Presbyopia and astigmatism
Thirty-eight percent of respondents preferred monovision for presbyopia, 23% preferred modified monovision, 14% preferred multifocal IOLs, and 6% preferred accommodating IOLs in refractive lens exchange for pre-cataract presbyopia.
Results showed that in cataract surgery, 67% of respondents would offer to treat astigmatism at a threshold of 0.75 D.
“That’s a big number, and further, 90% of us will offer it once it reaches 1.25 D. We’re being more aggressive about astigmatism correction,” Duffey said.
For 0.5 D to 1 D of astigmatism, 55% of surgeons favored limbal relaxing incisions (LRIs), 32% preferred astigmatic keratotomy (AK) and 13% chose toric IOLs.
For 1.12 D to 2 D of astigmatism, 75% of respondents chose toric IOLs, 15% preferred AK and 10% preferred LRIs.
For 2 D or more of astigmatism, 96% of those surveyed preferred toric IOLs, 2% favored AK and 2% chose LRIs, Duffey said. – by Matt Hasson