November 02, 2016
3 min read
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Under what circumstances would you consider the off-label combination of corneal inlay surgery and LASIK?

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POINT

Two procedures in one setting

With the Kamra inlay, we have found the “sweet spot” for our happiest patients is a refractive error around –0.75 D. However, at least half of our presbyopic patients present with a refractive error significantly different from this value. In these cases, we have used LASIK to correct the refraction to this value.

Initially, we sequentially performed LASIK followed by implantation of the Kamra inlay about 1 month later. We achieved excellent results, but patients were dissatisfied with the longer healing process and having to undergo two procedures. Therefore, over the past 6 months, we have transitioned to combining LASIK with Kamra at the same surgical setting.

Shamik Bafna

When combining the procedures, it is important to ensure that there is at least a 100-µm separation between the LASIK flap and the inlay pocket. It is advisable to keep at least 250 µm between the inlay pocket and the endothelium. I typically create the LASIK flap at 110 µm and the Kamra pocket around 275 µm. I first dock temporally to create the pocket and then redock nasally to create the LASIK flap. After implantation of the Kamra inlay, I lift the flap to complete the LASIK procedure.

For our ametropic presbyopic patients, we perform LASIK alone in the dominant eye and combined LASIK/Kamra in the non-dominant eye. Patients are educated to expect excellent vision in the dominant eye the next day but a slower visual recovery in the non-dominant eye lasting up to 6 to 8 weeks. With this approach, we are achieving excellent results. Our patients are happy with both their uncorrected near and distance vision as well as being able to reach these outcomes with only one procedure.

Shamik Bafna, MD, is a cataract and refractive surgeon at Cleveland Eye Clinic. Disclosure: Bafna reports he is a consultant to AcuFocus.

COUNTER

LASIK before Kamra

The best candidates for a combined LASIK/inlay procedure are those who are presbyopic and for whom their distance correction is not in the “sweet spot” or final refractive error meant for that inlay.

What is beautiful about inlays is that you can either perform refractive correction and inlay placement at the same time or separate the two procedures — treat the refractive error now and place the inlay later. There is flexibility. Ideally, though, if I had a choice, I would do LASIK first.

Vance M. Thompson

We know that the Kamra inlay works best with a small amount of myopia (–0.5 D to –0.75 D) and that the inlay is more effective in a pocket than under a flap. Consequently, when we combine the Kamra with LASIK, we are dialing in a refractive correction that provides that small amount of myopia. We are also creating a pocket depth of 250 µm, or for a 110-µm flap, 130 µm under the flap.

I know surgeons have had good luck doing this all at the same time. However, I have had more experience with first dialing in the –0.75 D with LASIK, and then 1 to 3 months later coming back and doing the inlay in a pocket; or first doing the inlay in a pocket, and then returning to perform PRK over the inlay. However, you do not want to do LASIK over an inlay because femtosecond energy can negatively affect the material. But the excimer laser fine-tuned over the inlay works just great, like with PRK.

I encourage surgeons to perform combined LASIK/inlay procedures, in part because if you restrict your patients to those with corrective error that has already been optimized with an inlay, you are not going to do nearly the volume that you could. Still, sometimes after an inlay, refractive error changes slightly. So you need to be comfortable with handling refractive error both before and after an inlay to optimize the optics. I believe that the combined procedure will become increasingly popular.

Vance M. Thompson, MD, is an OSN Refractive Surgery Board Member. Disclosure: Thompson reports he is a researcher and consultant to AcuFocus.