Epithelial mapping key to keratoconus screening, therapeutic surgery
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NEW ORLEANS — Dan Z. Reinstein, MD, offered pearls for therapeutic custom ablation at Refractive Surgery Subspecialty Day at the American Academy of Ophthalmology meeting.
“The key is that you need to have epithelial mapping, and it’s not just for therapeutic surgery,” Reinstein said. “You need it for keratoconus screening.”
Reinstein described therapeutic refractive surgery as “trying to fix a problem with a topography-guided treatment.” Treatments fall into one of four categories: asymmetric primary, zone enlargement, recentration and irregularly irregular. According to Reinstein, epithelial mapping is the only way to exclude keratoconus because a physician cannot rely on the sensitivity of the back surface to determine if keratoconus is present.
“What you really want to be looking at is fixing unhappy post-refractive patients,” he said.
Reinstein divides these patients into two overlapping categories: zone enlargement and coma decentration. Zone enlargement patients have a small optical zone the surgeon is attempting to make bigger by lowering spherical aberration. Coma decentration patients may have abnormal topography and difficulties driving at night, and their eyes can be made to look “superbly virgin” with treatment while the spherical aberration is fixed at no extra cost.
At Reinstein’s own practice, 73 topography-guided treatments were performed out of more than 9,000 procedures. This means that he will need a topography-guided element to help patients see better approximately 1% of the time.
Reinstein said a decision tree can aid in topography-guided treatment. For regularly irregular global problem on the topography, such as a small optical zone with little epithelium irregular, use topography-guided treatment. However, if most of the information is located in the epithelium and little in the topography, topography-guided treatment should not be used as it will waste tissue.
“2021 should be the year that no refractive surgeon leaves without his or her Christmas present as an epithelial mapping device for their practice,” he said.
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Reinstein DZ. Therapeutic custom ablation: my pearls. Presented at: American Academy of Ophthalmology meeting; Nov. 12-15, 2021; New Orleans.
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