Experts say LASIK is procedure of choice among doctors, patients

PCON ROUND TABLE At the Optometric Refractive Surgery Society meeting in Akron, Ohio, Primary Care Optometry News gathered eight experts to discuss refractive surgery preoperative and postoperative comanagement. Led by Editor Michael D. DePaolis, OD, FAAO, panelists Thomas M. Chester Jr., OD, Brian S. Duvall, OD, Paul M. Karpecki, OD, Philip C. Roholt, MD, Donald C. Santora, MD, James T. Varnell, OD, Robert G. Wiley, MD, addressed procedure choice, pupil size, managing complications and enhancements.

ROUND TABLE PARTICIPANTS
Michael D. DePaolis, OD, FAAO, is Editor of Primary Care Optometry News. He is in private practice in Rochester, N.Y.	Philip C. Roholt, MD, is a refractive surgeon with offices in North Canton and Youngstown, Ohio.
Paul M. Karpecki, OD, is director of research for the Novamed/Hunkeler Eye Study Center and the clinical director of cornea and refractive surgery for Hunkeler Eye Centers.	Donald C. Santora, MD, is a refractive surgeon for The Vision Care Laser Centers and is in private practice in Meadville, Pa.
Brian S. Duvall, OD, is the clinical director for the TLC Northwest Laser Eye Center in Seattle. He was previously the executive director for TLC Indiana and director of optometric consultative services for the Orange Grove Center for Corrective Eye Surgery.	James T. Varnell, OD, is director of Optometric Services for Mann-Berkeley Eye Center in Houston.
Thomas M. Chester Jr., OD, is the optometric director for the Cleveland Eye Clinic in Cleveland.	Robert G. Wiley, MD, is medical director of the Cleveland Eye Clinic.

Michael D. DePaolis, OD, FAAO: Laser in situ keratomileusis (LASIK) is the most popular refractive surgery procedure, yet, in certain areas around the country, photorefractive keratectomy (PRK) is still very actively pursued. Now, there is Intacs (KeraVision Inc., Fremont, Calif.). How do you counsel that 2.5-D myope who you know is going to get a reasonable outcome with any of these three procedures?

Paul M. Karpecki, OD: We rarely do PRK anymore. However, in a low myope who may have corneal dystrophy or anterior membrane dystrophy where the epithelium has a good chance of being loose or sloughed off during procedure, we may lean toward PRK.

With Intacs being a bigger part of our practice now, we really don’t have a true, better procedure for low myopes. Because Intacs is a new technology, we make the decision to use it based on patient profile. If a patient had the first cell phone on his or her block and drives the newest model car, we consider that patient a possible candidate for Intacs, because he or she is good at adapting to new technology.

We actually decide whether we think a person would be better for Intacs or LASIK before we talk to them about procedures. It’s difficult to tell a patient the advantages of Intacs and the advantages of LASIK and let him or her decide. You’ve got to, more or less, fit the patient’s profile to the procedure.

For the person who likes to have something that has been around a long time, that has been tested and has been done thousands and thousands of times, we choose LASIK. For the person who likes new technology, Intacs works great. It gives an advantage of removability.

Philip C. Roholt, MD: From a primary care standpoint, I think the full gamut of procedures has to be explained. From a consulting ophthalmologist standpoint, our patients usually are referred in, so we don’t necessarily have to make that decision.

When a patient comes in expecting LASIK, if I know I can get good results, I will generally go ahead with LASIK unless I think there are some other options that have to be discussed.

Right now, I’m still not convinced that, for example, a –3 D will get as good of a result with an intracorneal stromal ring. On the other hand, if a patient has a very deep set eye, I’ll tell him or her right off the bat that I might not be able to comfortably get a nice flap. I tell him or her that I’ll try to do LASIK, but if there’s any problem at all, PRK is an option. I have had patients who have had PRK in one eye and LASIK in the other, and invariably they like LASIK.

Now, of course, Intacs is an option and theoretically, at least, Intacs maintain the prolate central cornea, whereas LASIK and PRK do not.

Dr. Karpecki: The top end of Intacs is —3 D. I really prefer it for those who are less than –2.50 D.

Brian S. Duvall, OD: Patients usually come in with an idea of what they want, and LASIK is, by far and away, what patients want. Although it is imperative to counsel patients and for them to know that there are other options, I think you definitely have to have a preference. Patients expect you to have a preference.

In that sense, if you’re going to do PRK, you must have a reason to confidently tell the patient why you think this should be the choice. That is where a lot of doctors fall down. Most doctors would not hesitate to recommend one brand of contact lens over another, but they are afraid to recommend one procedure over another.

I’m most confident with LASIK because of the patient conveniences, predictability and my experience.

Thomas M. Chester Jr., OD: When I speak with this patient, I speak from personal experience because I was that 2.5-D myope. I had all of the procedures available to me, and I chose LASIK because of shorter recovery time, quality of recovery and improved quality of vision. I didn’t feel as comfortable with Intacs when I made the decision for surgery. Six months from now, that may be different.

I wanted to be able to go back to work the next day, and my expectations were met with LASIK.

Robert G. Wiley, MD: LASIK is obviously catching hold in the public, in optometry and in ophthalmology. The acceptance is snowballing. I’m as excited about it as most of the people in this room. The results are spectacular, even in the low myopes. I had a patient with a prescription of plano/–1 D on whom I performed LASIK, and the patient was thrilled. It’s a great procedure.

However, that doesn’t mean that radial keratotomy (RK) isn’t good. I’ve done more than 4,000 RKs. I don’t do the Intacs rings. Any time patients get a red or irritated eye, you’re going to be worried about an infiltrate. I think that Intacs are not going to be a long-term solution for even low myopes.

Glaucoma a contraindication?

Dr. DePaolis: What do you tell glaucoma patients?

Donald C. Santora, MD: If their glaucoma is well controlled, I don’t see it as a contraindication to LASIK. In many of the studies that have looked at axon loss, the time that the suction ring was on and actual blood flow was cut off was rather high. The amount of time under my hands that the suction ring is on and the keratectomy is taking place is generally under 20 seconds. So, I don’t think it’s a real issue.

Dr. DePaolis: A paper presented at ARVO [Association for Research in Vision and Ophthalmology] this year showed that the Intacs outcome among rigid lens wearers was not as great as in some other groups. It was theorized that long-term rigid lens wear changes corneal topography. Obviously, making sure that you have an even playing field is of paramount importance in any refractive procedure. For daily soft, extended soft and rigid lens wearers, how long do you recommend that the lens wearers stay out of their lenses before being evaluated for refractive surgery?

James T. Varnell, OD: We try to explain to our comanaging doctors that we want to remove any influence that the contact lens has had on the cornea. Of course, we base all our surgeries on cycloplegic refractions, and we want to be able to show that there is a stable refraction and stable topography.

With that understanding, we can give them guidelines of 1 to 2 weeks with no soft contact lenses. We recommend 3 weeks of no wear for rigid gas-permeable lenses.

However, to meet the criteria of stable refraction and stable topography, there are always going to be patients who fall outside of this guideline. These are only general guidelines. Until patients meet the criteria of stable refraction and topography, they may have to delay the procedure.

If they’re wearing gas-permeable lenses, we insist that they come in for their initial evaluation with their lenses. That way, we can get them into glasses and out of contact lenses. We don’t want to tell them over the phone to stop wearing contact lenses and come in 3 weeks later. We always want to see them so we can help them get through that 3-week dilemma. We may try soft contacts to get them out of their rigid lenses, and then we may have to go to glasses at the end of that 3-week period. But ultimately, we want stable refraction and stable topography.

Dr. Duvall: Indirectly, it also works very well as a patient-screening mechanism. If patients are really troubled by the fact that they have to get out of their contact lenses, are fighting you every step of the way or are not following your directives, they may not be the best candidates for refractive surgery. It’s a tip-off that managing this patient could be a nightmare.

Dr. Chester: I believe that the stability factor is very important. I tell patients that consistency is a sign of accuracy. If we check corneal stability over and over again and we make sure that those numbers are the same, they’re going to have the best possible result surgically. Patients typically don’t have a problem with that.

Dr. Santora: I agree. I have patients come in with their hard contact lenses in. I do a complete exam that day, and then I schedule them for another appointment in a month with those contacts out. I put them in soft contact lenses if I can. I recheck that refraction, and I have them come in 2 weeks after that to check it again. I like to see two refractions that are the same after a month out of the hard contact lenses. If they ask why they have to come in so often, I tell them that my best chance for getting a procedure right the first time is to have good data. That’s what I’m shooting for.

Dr. Wiley: It is really important to follow not just the refraction stability, but the K readings, especially the quality of the K readings.

Dr. Karpecki: Another reason that it is important for the contact lenses to be out is to get a lot of oxygen into the cornea right before surgery. A lot of the patients who wear contact lenses into surgery often are the patients who will have the sloughing of epithelium.

Dr. DePaolis: The extended-wear literature tells us that these people have epithelial thinning. These are compromised epithelia at best, and we do our refractive surgeon colleagues a tremendous disservice by sending a patient in without a stable, healthy, oxygenated cornea.

Dr. Karpecki: At the same time, it gives you one more measurement right before surgery. It never hurts to have an extra data point.

Emphasis on pupil size

Dr. DePaolis: Let’s discuss pupils and the issue of postoperative glare and halos, which are the most annoying things to manage. Do you have a definitive pupil diameter at which you say you won’t do a procedure? Or is it very variable?

Dr. Roholt: Actually, I don’t place as much emphasis on pupil size as what has been touted in the literature. This is mainly because, once you get into the higher levels of myopia where the optical zone is going to have more effect in producing halos, you’re going to have more benefits in other ways. In other words, a –7 D or –8 D patient who has an 8-mm pupil in the dark is definitely going to have those glare and halo symptoms. However, he or she is going to be so much happier without the contact lens or without the appliances that he or she is really not going to complain about it that much. On the other hand, with –1 D, you know the ablation is relatively little, so you’re not going to have as many glare symptoms.

Generally, when you’re sticking to the range where LASIK works best, which is less than 10 D or 11 D, the symptoms are not going to be that drastic, so we don’t really emphasize it. I don’t think I’ve ever not done somebody because the pupil was too large, but informed consent is important. I let these patients talk to patients who’ve had the procedure with the same parameters.

Dr. Duvall: I don’t have a pupil size at which I would say it’s a contraindication. We’ve done many patients with very large pupils and very high prescriptions who do not complain about glare. At the same time, we’ve done patients with relatively small pupils and relatively small ablations who have real issues with the quality of vision after surgery. I don’t think there is a direct correlation there.

All patients need to be counseled about and have a good understanding of quality-of-vision issues, glare being one of them. Still, the bottom line comes down to patient expectations. Rather than having a good way to measure pupil size in ambient illumination, we need a more accurate way to measure patients’ understanding and expectations.

Dr. Varnell: I don’t look at a particular pupil size or amount of correction to determine whether I’m going to discuss the nighttime vision or glare problem. We routinely discuss that with all of our patients. In fact, our patient service counselors go over all of this with patients before they even see the doctors.

If a patient has a 6-mm pupil and he or she is having a 9.5-D correction, I will let the patient know that his or her night vision will not be the same as it is in the bright sunlight. When patients know that going in, it doesn’t seem to be a problem coming out.

Dr. DePaolis: One of my patients had been turned down by a surgical center solely because of her pupil size. So I dilated her pupils, selected a disposable contact lens that I knew had a fairly small optic zone and told her to enjoy her evening. She called me the next day and said that her night vision wasn’t that bad at all.

Dr. Duvall: That’s a great idea. The problem is that there is a lot of information floating around now about pupil size. If you do a procedure on a patient with large pupils who then has postop quality-of-vision issues, all of a sudden it’s pupil-related. You must weigh the level of concern of both the patient and referring doctor. If it’s excessive, a wider ablation profile may benefit them and their consciences.

However, this requires more tissue removal, which can present a dilemma for those who have a high Rx where it’s most needed and tissue is often limited.

Managing wrinkles, defects, ingrowth

Dr. DePaolis: What are your guidelines on managing flap wrinkles, epithelial defects and ingrowth? When does it really get your attention? When is it something you can manage in-office as an optometrist, and when does the patient need to go back to the surgeon?

Dr. Varnell: I would hope that any of our referring doctors who have sent us a LASIK candidate would never see any wrinkles during the postop period. At 20 minutes postop, we make sure that they are not present. Then, we ask our patients to return the following morning for another evaluation. If we see any wrinkles at that time, particularly wrinkles that extend from the hinge to the edge of the flap, we will lift that flap and get rid of those wrinkles at that time.

Dr. DePaolis: You mentioned that you sometimes actually dilate pupils to get an idea of wrinkles. At what level of vision would you want a patient to come back in?

Dr. Varnell: It depends on how happy the patient is and what his or her complaints are. One patient had a 20/15 outcome 4 months after LASIK, but she had three images. She was very unhappy. She left her surgeon and came to me. I happened to be at a meeting last year where a paper was presented about this issue. I got on the phone with the presenter and followed his recommendations of treatment, which consisted of lifting the flap, irrigating with 80% hypotonic solution to internally stretch the flap and placing a bandage contact lens until the following day.

Dr. DePaolis: What about our surgeon colleagues? When do you want to manage these folks? If the patient is symptomatic and the comanaging doctor feels there is enough flap wrinkle to account for the visual symptoms, do you want to see the patient quickly?

Dr. Wiley: In our practice, fortunately, we just haven’t had much of a problem with wrinkles, even though we don’t see patients at 24 hours. I think the 24-hour visit should be with the comanaging optometrist. If you’re not seeing the patient in your own office at 24 hours, you’re missing the joy factor and the goodwill that comes with these patients.

If our comanaging optometrists see any questionable wrinkles, they’ll send patients in or we’ll go out and see patients in their practices with them. Nine out of 10 times, they’re insignificant or might even been gone by the next visit a week later. Fortunately, we haven’t had any dislodged flaps. However, in more than 2,000 LASIK cases, I have had to lift three flaps due to wrinkles, and a couple of them were beyond the 6-month period. In fact, one was beyond the 1-year period. All of them smoothed out very well. I don’t think it’s necessary to see wrinkles right away.

For radiating wrinkles that come from the edge of a hinge, which means the flap has shifted, you’ve got to get the surgeon involved. Nonspecific wrinkles that are not radiating from the hinge point can be due to the cap being a little different size than the bed. These frequently will go away on their own as the cap continues to adhere.

Dr. Roholt: This is a really difficult management problem, if not the most difficult. Patients can have perfect vision and horrendous complaints. A lot of it is related to patient expectations.

I’ve seen many patients who have what I think is a significant wrinkle, yet their vision is good and they have absolutely no complaints. And then, the few flaps I have lifted have seemed very minor to me. These flaps were lifted because of patient complaints of poor vision, diplopia/triplopia or shadowing.

If you see a wrinkle in the first week postop, I don’t know if you should send a patient back or not. Maybe we shouldn’t expect a 20/20 result within the first week, or maybe they will resolve on their own. Certainly, if it is a month or two postop and a patient is still having symptoms, we have to look at doing something.

Dr. DePaolis: Once you have decided that the most logical thing is to lift, irrigate and replace the flap, how quickly do you expect to know the benefits of doing that?

Dr. Roholt: Because my success rate at curing flap wrinkles has not been 100%, I cannot predict how soon you will see the benefits of retreatment. Usually, within 1 or 2 weeks, you should see some improvement — the wrinkle should be better and the symptoms should resolve. However, in one eye I did about 6 months ago, the wrinkle never went away, and there was no improvement.

Dr. DePaolis: Do you ever do anything different to manage a wrinkle than to lift the flap? I have heard reports of using bandage lenses to act as tamponades or corneal smoothers to roll the wrinkles out. In your hands as a surgeon, is it best to just lift the flap?

Dr. Santora: A year and a half ago, I lifted my first flap to take care of a wrinkle under the advice of someone who told me to lift the flap and to try a pressure patch. Symptomatically, the patient was better, but when I looked at the eye, I still felt that it hadn’t changed a whole lot.

I recently had two cases referred to me where there was a significant amount of wrinkling. The patients were approximately 1 month postop. I gave my opinion, but the patients preferred that I lift the flaps and try to fix the wrinkles. I tried the hypotonic saline. I diluted regular balanced salt solution to about 80% using sterile water, and I lifted the flaps and irrigated out the interface like I normally do. Then, I instilled a little bit of the 80% solution, and the next day, the patients were pretty happy. They were significantly symptomatically better. However, the wrinkles were still faintly visible.

Dr. Karpecki: I tell our comanaging doctors to look at four things to decide what to do. One is the best-corrected visual acuity. Two is whether they are having symptoms. Three, look at the gutter specifically, and see if there is a disparity from the top. Four, how does the patient compare his or her two eyes?

In those we’ve had to lift and refloat, every patient has said that one eye was causing significantly more symptoms than the other one, even though it may have looked similar.

Dr. Roholt:Another important thing is to use retroillumination, because these patients come in with triplopia or diplopia and you often won’t pick it up unless you retroilluminate.

Dr. Duvall: When a patient is referred back to me for a vague decrease in vision, it is almost always because of undetected striae. If retroillumination were used and the pupil was dilated, I don’t think it would be missed.

Dr. Karpecki: It never hurts to err on the side of being conservative. For comanaging doctors who are just getting started, if they are unsure about something, send it back for a second check.

Dr. Duvall: If the doctor is concerned about it, I can guarantee you that the patient has picked up on that concern. So, for the patient’s benefit, it is in your best interest to look at it. If it’s nothing, the patient feels good about it.

Dr. Wiley: From a refractive surgeon standpoint, I agree. We don’t care if we see that patient in our office every day. We want the patient to feel comfortable. We know how to handle the patient and make him or her feel good. We’d much rather have you over-refer.

Dr. Roholt: The difference between a refractive problem and the fold or the microstriae is that a patient will come in with a –0.25 D or a –0.75 D, and he or she will be sent in because there is a fold or a wrinkle. Then, you put the lens in, and the patient sees clearly. I don’t know if a contact lens is a good indicator, because it smoothes out any microirregularities.

Managing minor epithelial defects

Dr. DePaolis: Every clinician’s biggest fear is letting a chronically fulminating epithelial ingrowth obscure a good outcome. If a network comanaging OD calls you at 1 day and says one eye looks great and the other eye has got a little 1-mm by 1-mm epithelial defect, what should be done?

Dr. Chester: I recommend monitoring. I have only seen one obvious case of epithelial ingrowth in the past 2 years. This patient had significant epithelial ingrowth around the edge that was not causing any significant gutter problems, and we monitored it. In one eye, it got to a point where it stopped and started to retreat.

In the other eye, it moved forward and left a little bit of a residue, so we wanted to remove some of the residue. As the epithelial ingrowth encroaches on the pupillary margin, if it affects the vision, then you need to do something about it. But many times the epithelial ingrowth that we see may be a small cluster or a small grouping of cells that stop growing and don’t do anything beyond that.

Dr. DePaolis: What would you tell colleagues to look for in terms of monitoring it?

Dr. Wiley: One key thing that I look for is whether it is within 1 mm or 2 mm of the edge. If it is within 1 mm or 2 mm of the edge, it’s probably never going to be a problem.

If it has a retaining wall, watch it and draw it. Watch for an advancing line that is really a very thin layer of cells. If the thin layer of cells is stopped, it’s not a big deal.

Dr. Chester: I have heard it explained that the line is like the ocean. When the ocean comes up on the shore, it leaves a little bit of a residue, and you can see how far the water has come up. That is exactly what the line looks like with epithelial ingrowths once they begin to recede.

Dr. Roholt: Another thing about edge ingrowths is that if the epithelium at the edge has been closed, then there generally is no problem along the rim of the cut. However, if you have some fluorescein uptake, indicating that there is some abrasion over the edge, then that’s trouble. It certainly is going to get worse and not go away on its own. So, if you put fluorescein there and find a little epithelial defect along the rim, it’s probably time to take care of it.

Dr. Varnell: If epithelial defects do involve the edge of the flap, I would recommend a bandage contact lens.

I would also recommend that patients continue with their antibiotics. Depending on the size of the epithelial defect, you should consider decreasing the amount of corticosteroids being used topically to allow the epithelium to heal quickly so you decrease the possibility of epithelial ingrowth.

Dr. DePaolis: If an OD is monitoring the patient and he or she feels that it is a viable epithelium, when do you want to see the patient back?

Dr. Santora: I’d like to see them back as soon as possible.

Dr. Duvall: Ingrowth is one of the things that I tend to be more aggressive with, and I tend to pull the trigger a little bit quicker. We’ve all seen the horrific slides of enormous flap melts that have occurred due to ingrowth that went either unmonitored or untreated.

In the majority of patients, treating ingrowth is fairly straightforward. And in most situations, the risk of a melt and the risk of having subsequent problems concerns me enough that I don’t like to leave it. It’s better just to go back and get it.

Detecting, treating Sands of the Sahara

Dr. DePaolis: Are you feeling any differently now about Sands of the Sahara than you were a year ago in terms of detection, etiology and treatment?

Dr. Duvall: Only that more things are being diagnosed as Sands. Many presentations remotely similar are quick to be labeled as “Sands.” But that means doctors are looking for it and staying on top of things.

As far as our understanding of it, we know a little more now about what is going on than we did a year ago, and our understanding is increasing. I’m definitely more comfortable in identification and treatment of Sands.

Dr. DePaolis: When is Sands more likely to appear time-wise?

Dr. Karpecki: Days 2 to 7, and a predominant symptom is photophobia.

Dr. DePaolis: Tim, you showed a couple of cases where you lifted the flap and did a culture and they turned out to be culture negative. I think that’s where you just can’t afford to roll the dice. If it is an infection in the bed, if you don’t act promptly, the outcome could be disastrous.

As in patients with contact lens microbial keratitis, is anterior chamber reaction of any diagnostic value in these people? In a true infection, we might be inclined to see more of an anterior chamber reaction.

Dr. Roholt: That is a big “might” because we can have a cornea that we know to be infectious with minimal anterior chamber reaction. It’s quite variable and won’t give us a lot of information.

When I was doing automated lamellar keratoplasty in 1993, I had a patient who had this. I had no idea what it was. I treated it with steroids, and it went away. Vision came back very well.

Treat with steroids. I don’t think you need to pull the flap back. I have never seen one so severe that I felt I had to.

Additionally, they should have antibiotic coverage. They should not be taken off antibiotics. I did have one patient who was definitely infectious. She had LASIK about 2 years ago. She slept from that night at 5:00 or 6:00, when she went home, until 11:00 the next morning. She got up, and the eye felt good. Then, she went back to bed and slept for 2 more hours. When she woke up, she had a terrible pain. Sure enough, there was a Sand-type appearance. I treated her predominantly with antibiotics, and it resolved. She came to have good vision, but that is an unusual case. I think excessive sleep allowed bacterial growth in the stagnant tear pool.

Dr. Karpecki: We’ve only had two possible Sands cases in about 10,000 procedures, but we’re starting to get a lot more calls from doctors regarding really severe cases where the cornea is starting to melt. How do you decide when to lift the flap and irrigate and when to treat with steroids?

Dr. Santora: There are three grades of Sands. For grade I, you watch and put the patient on steroids. For grade II, you watch a lot closer. When you get to grade III, which is a really diffuse, white, snowy appearance on the interface, you’ve got to lift it and irrigate. I really don’t have that much experience, though. I saw a grade I twice in my practice, and I just watched it.

Dr. Duvall: I’ve seen three cases in approximately the last 4,000 procedures. One of them was very dense. The patient’s acuity was down in the 20/100 range, best-corrected, with a hyperopic shift of about 1 D or 1.5 D. There were also related striae. The flap was lifted and irrigated underneath, and the patient was put on oral and aggressive topical steroid therapy. The patient’s uncorrected visual acuity ended up 20/30. Would it have resolved on topicals alone without oral and surgical intervention? I don’t know.

Dr. Varnell: Several years ago, a patient presented with what I now believe to be an aberrance of typical Sands. The clinical picture was similar to an interface infection with a dense 3-mm infiltrate at the level of the interface. The flap was lifted and cultured. The interface was irrigated with antibiotic and the flap returned to the proper position. The culture was negative. The patient was treated with aggressive antibiotics and steroids and did very well. Since that original presentation, I have seen 3 other cases with similar clinical presentations. These later cases were not irrigated as the original, but treated topically with steroids aggressively and with antibiotic coverage.

Dr. Santora: If I ever saw anything like that, I would try steroids first and see the patient back frequently, at least every day. If there was either no improvement or any worsening, I’d quickly lift the flap and irrigate.

Dr. Duvall: Is anybody seeing their patients back sooner than 1 week to look for Sands?

Dr. Karpecki: Only if there is something on day 1 that is suspicious. Otherwise, we really don’t have any other indication to bring them in sooner than that.

Timing of enhancements

Dr. DePaolis: When do you feel comfortable doing an enhancement?

Dr. Chester: You need to wait at least 3 months. In some cases, it takes even longer than that to establish the 20/happy factor. It’s difficult to determine a cutoff. I have patients who are uncorrected to 20/30 or 20/25, and they are perfectly happy. Then on the flip side, I have patients who are 20/15 or 20/20 who are not happy and want an enhancement. Those are the patients where we may take 6, 9, 12 or 18 months to re-treat if we even do re-treat. However, if there truly is a need for an enhancement, we like to take care of it within a 3- to 6-month period.

Dr. Duvall: Three months is pretty standard. It is important to look at the initial preoperative refraction. Higher refractions may take longer to stabilize in some patients. Also, how much has the patient regressed over what time frame? Patients who have initial undercorrections tend to stabilize quicker, and their needs and desires lead to quicker enhancement.

I think it’s reasonable to treat those people earlier, because their prescriptions are stable sooner.

Dr. DePaolis: Recognizing that every patient is different, how long after the initial procedure can you lift the original flap without cutting a new one?

Dr. Wiley: It is very easy for me to lift the flap at 2 to 3 months. However, some doctors will re-cut at 3 months. I have lifted them at 18 months, and it was not a problem. It is a little bit harder. If patients had any inflammatory reaction in the interface, then the flaps are going to be very hard to lift. You want to look at the quality of that flap. Look very carefully at the microscope, and review the early notes to see if there was any notation that there were some problems with the flap.

Make sure it’s a healthy, thick flap. If you try to lift a thin, unhealthy flap that had evidence of Sands or some other inflammatory interface reaction, that’s a problem.

It’s a little easier to make the cut a second time. If I know a patient had epithelial problems the first time, such as a loose epithelium or a longer time to heal, then I would rather re-cut.

Also, if a patient needs hyperopic treatment, I would rather re-cut. I want a nice, fresh surface if I can. Especially with a hyperopic treatment, you’re going to need a bigger optical zone to re-treat.

Dr. Roholt: I’ve lifted a flap 3 years postop, and it came up. However, generally, a flap obviously likes to come up sooner rather than later. Three years ago, I would sometimes enhance at 2 weeks. Of course, I ended up doing more enhancements because there was further healing to be had.

In general, I think the 3-month rule is good. If patients are unhappy, you may have to go sooner.

One thing to keep in mind is that enhancements have a higher risk of epithelial ingrowth. You have up to a 10% chance of epithelial ingrowth.

I haven’t done many re-cuts, because I always preferred to lift flaps, but once you get past 6 months, it’s reasonable to consider a re-cut.

Dr. Santora: Generally, if I see a stable refraction and the patient is unhappy, I’ll try to re-treat at about 3 months. I’ll go up as far as 6 months for lifting the flap.

After 6 months, I tell patients to wait a year, and I’ll cut a new flap.

Dr. Wiley:I know many good surgeons, though, who feel comfortable re-cutting a flap at 3 months. I would rather wait 6 months or longer before re-cutting a flap.

Correcting hyperopia, astigmatism

Dr. DePaolis: Do you feel confident with the technology, where it is today, to say we’ll lift a flap or create a new flap to correct hyperopia and astigmatism? For example, say a patient preoperatively is –5 D and he or she ends up +1 D, –1 D axis oblique.

Dr. Roholt: A +1 D, –1 D is not a problem. However, if you get up to the +2 D range or above, then it can be a problem.

I have one patient who is very happy, and she’s 20/25 or so and she’s been a +2 D. She’s been that way for 2 years, and she is plano in the other eye. She’s 40, and she can apparently accommodate so it doesn’t matter to her. Hyperopic retreatments for overcorrection do work and are necessary when symptomatic.

I don’t think re-treatments are really an issue. One thing that has not been worked out is the nomograms for treating overcorrections. Now, we’re not dealing with a virgin cornea, so that treatment zone at 5 mm to 5.5 mm is going to coincide with the optical zone of the previous myopia treatment. The power is exponentially related to the optical zone size.

If we’re putting this new treatment at the optical zone, you probably need less. So, for example, for a +2 D, you may only have to put in 60% of the treatment.

The comanaging doctor should not make promises that it will be fixed perfectly the first time. It may take some more fine-tuning. You should be able to get 20/20 vision, but it may not come right away.

Dr. Duvall: Patients ought to be counseled that you might not make it perfect, period. If you re-treat them, you’re going to do everything you can to get them as comfortable and as happy as possible. Patients should understand that they did not respond as expected following the initial procedure, and they may not respond the way you want them to a second time.

Dr. Varnell: The technology, as well as the algorithms, will get better.

For Your Information:

• Paul M. Karpecki, OD, can be reached at 4321 Washington, Suite 6000, Kansas City, MO 64111; (816) 931-4733; fax: (816) 931-9498; e-mail: pkarpecki@novamed.com. Dr. Karpecki has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Philip C. Roholt, MD, can be reached at 4425 Metro Circle NW, N. Canton, OH 44709; (330) 823-1680; fax: (330) 823-3831. Dr. Roholt has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Brian S. Duvall, OD, clinical director for TLC Northwest Laser Eye Center, can be reached at 3500 188^th St. SW, Suite 600, Lynnwood, WA 98037; (425) 771-1200; fax: (425) 771-1700; e-mail: brian.duvall@lzr.com. Dr. Duvall has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Thomas M. Chester Jr., OD, can be reached at Cleveland Eye Clinic, 2740 Carnegie Ave., Cleveland, OH 44115; (216) 621-6132; fax: (216) 621-2803; e-mail: akeyedoc@ohio.net. Dr. Chester has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Donald C. Santora, MD, can be reached at 505 Poplar St., Meadville, PA 16335; (814) 724-5122; fax: (814) 724-8276. Dr. Santora has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Robert G. Wiley, MD, can be reached at the Toledo LASIK Center, 1500 North Superior St., Healthmark Pavilion, Riverside Hospital Campus, Toledo, OH 43604; (419) 729-8781; fax: (419) 729-8919; e-mail: DrBob2020@toast.net. Dr. Wiley has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• James T. Varnell, OD, can be reached at Mann-Berkeley Eye Center, 1200 Binz, Suite 1000, Houston, TX 77004; (713) 526-1600; fax: (713) 526-0679; e-mail: rberke6016@aol.com. Dr. Varnell has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.