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July 06, 2023
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At the cutoff value of 8 D of myopia, what is your preferred refractive surgery strategy?

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Click here to read the Cover Story, "Today’s LASIK candidates better targeted."

EVO Visian ICL has advantages

Many patients seeking independence from glasses or contact lenses do not have a specific procedure in mind when coming in for their refractive consultation.

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Other times, patients have preset opinions about what procedure they are expecting. One of their family members might have had laser vision correction, or they might have read about the good outcomes of SMILE, or more recently, they saw an ad for the EVO Visian ICL (STAAR Surgical). What all patients do have in common, however, is that they want the best and safest procedure possible for them that will give them the best opportunity to achieve a life without glasses or contacts.

Kathryn M. Hatch
Kathryn M. Hatch

When seeing a new refractive evaluation, there are several considerations such as ensuring refractive stability, their age including presbyopia considerations, visual and lifestyle demands as well as expectations. All patients undergo refraction, topography, tomography and corneal thickness measurements. In patients with adequately thick corneas who are potentially candidates for laser surgery as well as for phakic IOL implantation, I present the different options. I get a sense if that patient has heard of implant procedures. I sometimes explain that laser vision correction is a subtraction procedure because we remove tissue from the eye, while the EVO ICL is an addition procedure because we are implanting a new implant inside the eye on top of the natural crystalline lens. I also explain that ICL implantation is reversible, while laser surgery is not. Patients often express their comfort and interest in the procedures. With 8 D of myopia, they should also know that we need to ablate large amounts of tissue and that we will flatten the central cornea and may induce aberrations that can potentially affect vision, especially nighttime symptoms.

Our lasers are so advanced now that patients often do well with these high treatments, but there have been studies showing that they tend to be happier and experience fewer problems with the ICL. With the new EVO with fenestrations, we do not have to perform peripheral iridotomy, which was not fun, somewhat the “Achilles heel” of the procedure. Implantation is now a one-step procedure, and the issues of sizing, vaulting and potential risk for cataract formation are largely overcome. Because fluid and nutrients are naturally delivered to the anterior lens capsule, the EVO does not accelerate cataract development. However, because myopes tend to develop cataract at younger ages, they should be reassured that the ICL will present no problems at that stage because we are leaving the cornea in its pristine natural shape, while laser surgery might pose limitations in the choice of certain future IOL technologies.

Kathryn M. Hatch, MD, is a Healio | OSN Technology Board Member.

Laser vision correction may be considered

It is a wonderful time for refractive surgical vision correction because we now have many options to customize and tailor our treatment according to the patients’ needs and preferences.

George O. Waring IV
George O. Waring IV

For myopia specifically, we now have the EVO Visian ICL (STAAR Surgical), which is the latest-generation Implantable Collamer Lens, in addition to LASIK, SMILE and PRK. All of them can perform beautifully in a broad range of myopia. Historically, when we think of higher degrees of myopia, and these days even moderate degrees of myopia, we evaluate candidacy for the ICL technology for many reasons. However, some patients may be better suited, even with high myopia, for laser vision correction.

This would be the case in eyes with limited internal anterior chamber depth. In these eyes, high myopia can still be treated with laser vision correction, assuming that there is appropriate residual stromal bed.

Some patients may also have a personal preference for laser refractive surgery rather than an additive technology. Given candidacy for multiple procedures, we may have to take into account patients’ inclinations and motivations, which are often related to the good experiences of people they trust. They may have more of a comfort level for LASIK, for instance, if a loved one or trusted friend or family member also had LASIK. Given the appropriate candidacy, this is a fine choice.

LASIK, PRK and SMILE have all been shown to be safe and effective in higher degrees of myopia. If somebody has borderline residual stromal bed thickness for LASIK, then we can consider a thin or ultra-thin flap, and in special circumstances, we can even consider reducing the optical zone to preserve tissue. However, highly myopic patients tend to have larger pupils, so we want the broadest optical zone possible. In selected cases, we have also had excellent success with PRK in high myopia.

So, in a case in which a patient would be physiologically a better candidate for laser vision correction than ICL due to factors such as limited anterior chamber depth, we would readily recommend laser vision correction, given the appropriate candidacy for laser. Likewise, if patients are coming specifically for laser vision correction due to strong personal preference and they are good candidates for it, we would happily be able to provide this to them.

George O. Waring IV, MD, FACS, is Healio | OSN Presbyopia Section Editor.