Fix complications by using logic, targeting vision
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ROME — Complicated cases, no matter how bad they are, can be fixed by using logic and the tools of “a vision architect,” with the ultimate goal of restoring 20/20 vision, according to one surgeon.
“What I teach surgeons is to not just stop but ‘top’ the train wreck. The target is vision, not surgery, and you don’t want to just fix the complication and leave your patients dependent on glasses or contact lenses,” Arun Gulani, MD, said at OSN Italy.
More than 70% of Gulani’s practice is dedicated to correcting complications for patients from all over the world. He showed the case of one patient, a surgeon who had presented with a blinding central scar in a radial keratotomy cornea, 15 D of astigmatism, 200 µm of corneal thickness and cataract.
“I first stabilized and made the cornea measurable. Because the cornea was so fragile and ectatic, I did manual lamellar keratoplasty, a difficult task because I was going in between these full-thickness cuts. Then I performed a no-stitch, no-injection, no-sedation premium toric lens surgery and brought the patient straight to 20/25 vision. I repeated the same surgery on the other eye 1 year later, and the patient is now back to his profession, enjoys traveling the world and playing golf,” Gulani said.
Another patient, a pilot, was referred after having undergone premium cataract surgery. The procedure had been excellently done, but the surgeon had not realized that the patient had keratoconus.
“The patient came to me with hyperopia, irregular astigmatism, presbyopia and anterior corneal scarring along with keratoconus. On top of that, the surgeon had performed YAG capsulotomy to see if he could clear the vision, which made it difficult to exchange the lens implant,” Gulani said.
With such a case, a surgeon might be tempted to do “surgical acrobatics,” remove the lens, do a vitrectomy and implant another lens in the sulcus. But keeping in mind the principle of focusing on vision, not surgery, Gulani planned to make this patient myopic. Because the capsule was open, an IOL was already in place and the anterior chamber was deep enough, he implanted a piggyback lens and made the patient myopic.
“A few months later, I performed laser plastique surgery on the cornea, flattened it, removed the scar and made vision emmetropic. The patient is now 20/15 and back to being a pilot,” he said.
In a patient from Switzerland who presented with extremely high myopia from keratoconus, irregular cornea and posterior polar cataract, Gulani first stabilized the cornea with Intacs (CorneaGen) and then implanted a toric lens.
“I brought her to 20/20, and this patient traveled back to Switzerland on her own for the first time,” he said.
The last case he described was a patient with keratoconus who had undergone Intacs, PRK, PTK, cross-linking and ICL implantation (STAAR), had developed cataract and was unhappy with his vision.
“Having determined the corneal stability, I removed the ICL and removed the cataract. I left him aphakic for 1 week, then remeasured and, fully confident, I went for a toric premium lens that brought him straight to 20/20,” he said.
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Gulani A. Stop the train wreck: Taking refractive and premium IOL complications to 2020. Presented at: OSN Italy; July 10-11, 2021; Rome.
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