- Email: [email protected]
November Consultation #3
CONSULTATION SECTION
Refractive Surgical Problem Edited by Jose L. G€ uell, MD
A 52-year-old-man came for consultation seeking refractive surgery. The uncorrected distance visual acuity (UDVA) was 20/40 in the right eye and 20/30 in the left eye. The corrected distance visual acuity (CDVA) (spectacle) was 20/20 with +2.00 diopters (D) and 20/20 with +1.75 D, respectively, with an addition (add) of +3.00 D in both eyes for reading. The rest of the ophthalmologic examination was normal. The patient had refractive lens exchange (RLE) with in-the-bag 1-piece hydrophobic acrylic intraocular lens (IOL) implantation in both eyes. Two weeks after surgery, the UDVA was 20/20 in the right eye and 20/40 in the left eye and the CDVA was 20/20 with 0.50 1.00 170 in the left eye. The patient was independent of spectacles for all distances and reported being highly satisfied. Two months later, the patient returned because of a progressive loss of visual acuity. At that time, the UDVA was 20/50 in the right eye and 20/20 in the left eye and the CDVA was 20/15 with +1.50 in the right eye and 20/20 with 0.25 +0.75 160 in the left eye, with an add of +1.75 D in both eyes for reading. The rest of the ophthalmologic examination was normal, including topography (Orbscan, Bausch & Lomb) (Figure 1), macular optical coherence tomography (OCT) (Figure 2), and double-pass evaluation (Optical Quality Analysis System, Visiometrics) (Figure 3). It was decided to wait 6 weeks before checking for refractive stability. Taking into account the provided data, would you ask for additional examinations? Do you have an explanation for the early postoperative refractive change? What strategy would you propose?
- It is reasonable to assume that the patient's right eye was close to emmetropia 2 weeks after surgery because the UDVA was 20/20. The spherical equivalent (SE) refraction in the left eye was 1.00 D. Two months later, the SE refraction was +1.50 D in the right eye and +0.125 D in the left eye. During that 2-month period, both eyes had a hyperopic shift of approximately 1.25 D. The cause of such a shift is hard to ascertain. It was not caused by a corneal deformity or by bilateral retinal pigment epithelial detachments (very unlikely possibilities even in the absence of the negative studies). It is possible that some ophthalmic viscosurgical device (OVD) was trapped behind the IOL in both Q 2012 ASCRS and ESCRS Published by Elsevier Inc.
eyes, which caused a myopic shift initially. As the OVD dispersed, the refraction shifted in a plus direction. The likelihood of this happening in both eyes is slim. The hyperopic shift was probably caused by a shift in the effective lens position posteriorly as the capsular bag contracted. Once refractive stability is achieved, laser in situ keratomileusis (LASIK) enhancement is appropriate to restore the original monovision effect. It would be reasonable to perform soft contact lens testing to see whether the patient tolerates having the right eye corrected for near. If that is not tolerated, LASIK in both eyes to restore the early postoperative refractive result is appropriate. I normally wait until 3 months postoperatively to perform LASIK enhancement to be sure the wound is secure. Robert K. Maloney, MD, MA(Oxon) Los Angeles, California, USA
- In this case, the right eye was emmetropic in the early postoperative period (2 weeks) and later became hyperopic. The left eye was slightly myopic postoperatively and later became myopic. This means that during the 2 months after surgery, there was a shift in SE toward hyperopia in both eyes. The case description does not mention capsular bag status. One could assume that excessive capsule fibrosis may have caused the IOL to move toward the posterior pole of the eye. The topography shows that the central corneal pachymetry reading does not exceed 445 mm in either eye. That makes me think that the abnormal biomechanical behavior of the cornea is causing bilateral flattening and that this is the most likely reason for this condition. At this point, it is not clear whether the changes in the corneal shape are finished. Thus, I would recommend continuous follow-up. I would observe the patient for at least the next 2 months. The topography shows moderate regular with-therule astigmatism in the right eye (1.80 D) and in the left eye (1.30 D). With regard to the additional examinations, I would perform confocal microscopy to search for the corneal changes characteristic of forme fruste keratoconus. Even if the refraction were stable during the followup, I will refrain doing any kind of keratorefractive 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.08.045
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CONSULTATION SECTION
Figure 1. Topography. Top: Right eye. Bottom: Left eye.
J CATARACT REFRACT SURG - VOL 38, NOVEMBER 2012
CONSULTATION SECTION
Figure 2. Posterior OCT scans. Left: Right eye. Right: Left eye.
Figure 3. Basic double-pass examination results. Left: Right eye. Right: Left eye. J CATARACT REFRACT SURG - VOL 38, NOVEMBER 2012
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procedure. My preferred strategy would be IOL exchange or additional IOL implantation in the ciliary sulcus. I would make the selection based on the degree of capsule fibrosis and the posterior capsule status. If the fibrosis were moderate and the posterior capsule intact, I would perform IOL exchange. In all other cases, an add-on IOL would likely be a better option. The surgeon's experience with the 2 procedures may be the primary driver in the final decision. The optics of the IOL implanted are not specified. Nevertheless, that the patient is using the plus add for the near vision makes me think that the IOLs are monofocal. That is why when choosing an IOL (for exchange or addition), I would discuss with the patient implanting a multifocal IOL that preferably has a toric component.
of the capsular bag during the early course of healing after RLE. I would wait another month and perform a LASIK or laser-assisted subepithelial keratectomy procedure to correct the refractive error should the patient agree. Michael C. Knorz, MD Mannheim, Germany
- The double-pass evaluation results and the refraction do not match. Subjective refraction in the right eye was given as +1.50 D; however, the double-pass system gives 0.25 D. The results in the left eye also do not match. Comparing refraction only, there was a +1.50 D hyperopic shift in the right eye and a +1.00 D hyperopic shift in the left eye. These changes are frequent with many IOL types and are caused by changes in the effective axial IOL position resulting from contraction
- This 52 year-old-patient had lens-based rather than corneal-based refractive surgery for low hyperopia. It is unclear whether multifocal or monofocal IOLs were placed; however, the patient was content with the early postoperative results of surgery, with apparent emmetropia in the right eye and low myopia with astigmatism in the left eye. Two months later, an asymmetric hyperopic shift is observed and the patient is dissatisfied with the results of surgery. Moreover, unless incorrectly reported, there has been a marked shift in the astigmatism axis in the left eye. Interestingly, the cylinder axis at this time in the left eye is not congruous with the corneal curvature. Given acceptably normal (and presumably unchanged) corneal parameters and normal macular architecture, only changes in the position and character of the capsular bag–IOL complex can account for the observed hyperopic/astigmatic shift. The doublepass result is consistent with the refractive error, which is greater in the left eye. We suspect that postoperative
Figure 4. A curette is used to clean the distal anterior subcapsular LECs after the capsular bag is filled with OVD.
Figure 5. Subincisional LECs are removed with a capsule-polishing device.
Boris Malyugin, MD, PhD Moscow, Russia
J CATARACT REFRACT SURG - VOL 38, NOVEMBER 2012
Refractive Surgical Problem Edited by Jose L. G€ uell, MD
A 52-year-old-man came for consultation seeking refractive surgery. The uncorrected distance visual acuity (UDVA) was 20/40 in the right eye and 20/30 in the left eye. The corrected distance visual acuity (CDVA) (spectacle) was 20/20 with +2.00 diopters (D) and 20/20 with +1.75 D, respectively, with an addition (add) of +3.00 D in both eyes for reading. The rest of the ophthalmologic examination was normal. The patient had refractive lens exchange (RLE) with in-the-bag 1-piece hydrophobic acrylic intraocular lens (IOL) implantation in both eyes. Two weeks after surgery, the UDVA was 20/20 in the right eye and 20/40 in the left eye and the CDVA was 20/20 with 0.50 1.00 170 in the left eye. The patient was independent of spectacles for all distances and reported being highly satisfied. Two months later, the patient returned because of a progressive loss of visual acuity. At that time, the UDVA was 20/50 in the right eye and 20/20 in the left eye and the CDVA was 20/15 with +1.50 in the right eye and 20/20 with 0.25 +0.75 160 in the left eye, with an add of +1.75 D in both eyes for reading. The rest of the ophthalmologic examination was normal, including topography (Orbscan, Bausch & Lomb) (Figure 1), macular optical coherence tomography (OCT) (Figure 2), and double-pass evaluation (Optical Quality Analysis System, Visiometrics) (Figure 3). It was decided to wait 6 weeks before checking for refractive stability. Taking into account the provided data, would you ask for additional examinations? Do you have an explanation for the early postoperative refractive change? What strategy would you propose?
- It is reasonable to assume that the patient's right eye was close to emmetropia 2 weeks after surgery because the UDVA was 20/20. The spherical equivalent (SE) refraction in the left eye was 1.00 D. Two months later, the SE refraction was +1.50 D in the right eye and +0.125 D in the left eye. During that 2-month period, both eyes had a hyperopic shift of approximately 1.25 D. The cause of such a shift is hard to ascertain. It was not caused by a corneal deformity or by bilateral retinal pigment epithelial detachments (very unlikely possibilities even in the absence of the negative studies). It is possible that some ophthalmic viscosurgical device (OVD) was trapped behind the IOL in both Q 2012 ASCRS and ESCRS Published by Elsevier Inc.
eyes, which caused a myopic shift initially. As the OVD dispersed, the refraction shifted in a plus direction. The likelihood of this happening in both eyes is slim. The hyperopic shift was probably caused by a shift in the effective lens position posteriorly as the capsular bag contracted. Once refractive stability is achieved, laser in situ keratomileusis (LASIK) enhancement is appropriate to restore the original monovision effect. It would be reasonable to perform soft contact lens testing to see whether the patient tolerates having the right eye corrected for near. If that is not tolerated, LASIK in both eyes to restore the early postoperative refractive result is appropriate. I normally wait until 3 months postoperatively to perform LASIK enhancement to be sure the wound is secure. Robert K. Maloney, MD, MA(Oxon) Los Angeles, California, USA
- In this case, the right eye was emmetropic in the early postoperative period (2 weeks) and later became hyperopic. The left eye was slightly myopic postoperatively and later became myopic. This means that during the 2 months after surgery, there was a shift in SE toward hyperopia in both eyes. The case description does not mention capsular bag status. One could assume that excessive capsule fibrosis may have caused the IOL to move toward the posterior pole of the eye. The topography shows that the central corneal pachymetry reading does not exceed 445 mm in either eye. That makes me think that the abnormal biomechanical behavior of the cornea is causing bilateral flattening and that this is the most likely reason for this condition. At this point, it is not clear whether the changes in the corneal shape are finished. Thus, I would recommend continuous follow-up. I would observe the patient for at least the next 2 months. The topography shows moderate regular with-therule astigmatism in the right eye (1.80 D) and in the left eye (1.30 D). With regard to the additional examinations, I would perform confocal microscopy to search for the corneal changes characteristic of forme fruste keratoconus. Even if the refraction were stable during the followup, I will refrain doing any kind of keratorefractive 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.08.045
2055
2056
CONSULTATION SECTION
Figure 1. Topography. Top: Right eye. Bottom: Left eye.
J CATARACT REFRACT SURG - VOL 38, NOVEMBER 2012
CONSULTATION SECTION
Figure 2. Posterior OCT scans. Left: Right eye. Right: Left eye.
Figure 3. Basic double-pass examination results. Left: Right eye. Right: Left eye. J CATARACT REFRACT SURG - VOL 38, NOVEMBER 2012
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CONSULTATION SECTION
procedure. My preferred strategy would be IOL exchange or additional IOL implantation in the ciliary sulcus. I would make the selection based on the degree of capsule fibrosis and the posterior capsule status. If the fibrosis were moderate and the posterior capsule intact, I would perform IOL exchange. In all other cases, an add-on IOL would likely be a better option. The surgeon's experience with the 2 procedures may be the primary driver in the final decision. The optics of the IOL implanted are not specified. Nevertheless, that the patient is using the plus add for the near vision makes me think that the IOLs are monofocal. That is why when choosing an IOL (for exchange or addition), I would discuss with the patient implanting a multifocal IOL that preferably has a toric component.
of the capsular bag during the early course of healing after RLE. I would wait another month and perform a LASIK or laser-assisted subepithelial keratectomy procedure to correct the refractive error should the patient agree. Michael C. Knorz, MD Mannheim, Germany
- The double-pass evaluation results and the refraction do not match. Subjective refraction in the right eye was given as +1.50 D; however, the double-pass system gives 0.25 D. The results in the left eye also do not match. Comparing refraction only, there was a +1.50 D hyperopic shift in the right eye and a +1.00 D hyperopic shift in the left eye. These changes are frequent with many IOL types and are caused by changes in the effective axial IOL position resulting from contraction
- This 52 year-old-patient had lens-based rather than corneal-based refractive surgery for low hyperopia. It is unclear whether multifocal or monofocal IOLs were placed; however, the patient was content with the early postoperative results of surgery, with apparent emmetropia in the right eye and low myopia with astigmatism in the left eye. Two months later, an asymmetric hyperopic shift is observed and the patient is dissatisfied with the results of surgery. Moreover, unless incorrectly reported, there has been a marked shift in the astigmatism axis in the left eye. Interestingly, the cylinder axis at this time in the left eye is not congruous with the corneal curvature. Given acceptably normal (and presumably unchanged) corneal parameters and normal macular architecture, only changes in the position and character of the capsular bag–IOL complex can account for the observed hyperopic/astigmatic shift. The doublepass result is consistent with the refractive error, which is greater in the left eye. We suspect that postoperative
Figure 4. A curette is used to clean the distal anterior subcapsular LECs after the capsular bag is filled with OVD.
Figure 5. Subincisional LECs are removed with a capsule-polishing device.
Boris Malyugin, MD, PhD Moscow, Russia
J CATARACT REFRACT SURG - VOL 38, NOVEMBER 2012