REFRACTIVE SURGERY DECISION
MAKING: CANDIDATE
SELECTION WITH CASE REPORTS
DAVID I. GEFFEN, OD, FAAO ANDREW MORGENSTERN, OD, FAAO
JIM OWEN, OD, FAAO
DEMOGRAPHICS
• 81 Y/O FEMALE
• COMPLAINS OF POOR VA OU, WORSE OS, GLARE OU
• VERY ACTIVE PROPERTY MANAGER
• BCVA 20/25- OD 20/50 OS
• NS 1+, PSC1+ OD NS 2+ OS
• IOP 14 OD 15 OS GOLDMANN
• FUNDUS NORMAL – OCT NORMAL
• MANIFEST OD +0.25-0.50X90 OS -0.50-0.75X95
SURGERY
•LENSX
•RESTOR 3.0
•DISCUSSED POTENTIAL FOR GLARE
•DISCUSSED NEED TO TREAT OD
DAY 1 / WEEK 1 PO
“WOW THAT WAS
EASY!”
• UCVA 20/40
• IOP 25
• AC TRACE CELLS WOUND SECURE
• REVIEW DROPS
“NO PROBLEM WITH
DROPS”
• UCVA 20/40
• IOP 14
• AC DEEP AND QUIET
• CORNEA 2+ SPK
• MANIFEST -0.25-0.75X180 20/30+
2 MONTH / 3 MONTH PO
“THIS VISION IS NOT
RIGHT”
•UCVA OD 20/20- OS 20/40 •CORNEA – TRACE SPK •MANIFEST -0.25-0.75X175 20/30+ •CAPSULE - CLEAR •OCT - CME“IT SEEMS NO BETTER”
• UCVA OD 20/20- OS20/30 • CORNEA CLEAR • MANIFEST -0.25-1.00X175 20/25+ • OCT – NORMAL • TRACE - PCO
4 MONTH VISIT WITH SURGEON
• OPENED AK CUT
• 1 DAY UCVA 20/25+
• 1 WEEK UCVA 20/25 PT HAPPY WITH VA
• MANIFEST -0.25 SPHERE 20/25
HOW DO YOU TREAT A 58 YR OLD
•PT JK
•58 Y/O M
•PRESENTS FOR A REFRACTIVE CONSULTATION, DESIRES TO BE SPECTACLE FREE. AVID GOLFER
•RX: OD: -1.25 – 1.25 X X104 20/20 • OS: +0.50 – 3.50 X 67, 20/20 • +2.00 ADD J1 OU
EXAM
• K’S: OD: 44.25 / 43.12 X 80 • OS: 44.00 / 42.75 X 168• SLIT LAMP: CORNEAS CLEAR, LENSES CLEAR, ALL WNL
• FUNDUS: WNL
• PACHS: OD: 545
CHOICES
•WHAT SURGERY OPTIONS DO WE HAVE
LASIK OR PRK
ICL
RLE
WHY RLE
• TORIC IOL WILL CORRECT ASTIGMATISM
• TRULIGN WILL GIVE MODERATE NEAR VISION
ASTIGMATISM
•OVER 50% OF PATIENTS OVER 60 YEARS OF AGE EXHIBIT AT LEAST 1 DIOPTER OF ASTIGMATISM*
•HOFFER REPORTS OVER 23% HAVE OVER 1.50 D OF ASTIGMATISM*
• VITALE S, ELLWEIN L, COTCH MF, FERRIS FL 3RD, SPERRDUTO R. PREVALENCE OF REFRACTIVE ERROR IN THE UNITED STATES, 1999–2004. ARCH. OPHTHALMOL.126, 1111–1119 (2008).
• HOFFER KJ. BIOMETRY OF 7500 CATARACTOUS EYES. AM. J. OPHTHALMOL.90, 360–368 (1980).
ASTIGMATISM
•
IOL master , not refraction, is the critical measurement
•
Some astigmatism change may occur during surgery
(typically 0.5D for a 2.2mm clear corneal incision)
•
Depending on location, may increase or decrease existing
corneal astigmatism
(incision on steep meridian reduces astigmatism)
•
Any suitable cataract patient with >0.75D of “resultant”
preoperative astigmatism may benefit from a toric IOL
correction
TRADITIONAL, HANDHELD DIAMOND KNIFE
•MANUALLY EXECUTED BY “TRACING” CORNEAL MARKS
•INCONSISTENT DEPTH CONTROL
•UNPREDICTABLE EFFECT DUE TO IMPRECISE WOUND ARCHITECTURE AND DEPTH
•NO IMAGE-GUIDED SURGICAL PLANNING OR VISUALIZATION
LASER ARCUATE INCISION
•
Square edge
•
Uniform depth (no ripples)
•
Precise, reproducible
–
Arc shape
–
Arc length
–
Diameter
DESIGNED FOR A WIDE RANGE OF ASTIGMATIC PATIENTS
ACRYSOF® IQ TORIC IOL IS DESIGNED TO ACCOMMODATE A VARIETY OF CATARACT PATIENTS WITH ASTIGMATISM
STAAR
™
TORIC IOL
• TWO MODELS 1.50 D AND 2.25D
TECNIS
®
TORIC IOL: SPECIFICATIONS
• WAVEFRONT-DESIGNED TORIC ASPHERIC SURFACE
• +5.0 D TO +34.0 D IN 0.5 D INCREMENTS 17 Lens Model ZCT150 ZCT225 ZCT300 ZCT400 Cylinder Powers 1.50 D 2.25 D 3.00 D 4.00 D Corneal Plane1 1.03 D 1.55 D 2.06 D 2.74 D Correction Range (Based on combined Corneal Astigmatism )2 0.75–1.50 D 1.50–2.00 D 2.00–2.75 D 2.75–3.62 D 2013.03.05-ME6511
1. Based on average pseudophakic human eye. 2. Preoperative Keratometric cylinder plus surgically-induced astigmatism
TRULIGN™ TORIC IOL
KEY PROPERTIES
• 5.0-MM OPTIC BODY
• BICONVEX SHAPE
• RECTANGULAR HINGED HAPTICS
• APPROVED DIOPTRIC POWER RANGE FROM +4.00 TO +33.00 D
• CYLINDER POWERS 1.25, 2.00, AND 2.75 D
• ROUND-TO-THE-RIGHT ASYMMETRIC POLYIMIDE LOOPS
x
o o
SPECIFICATIONS
Model
The Bausch + Lomb TRULIGN Toric posterior chamber IOL is a modified plate haptic lens with hinges across the plates adjacent to the optic. Axis marks on the anterior surface denote the flat meridian of the lens.
Model
Recommended Starting A-constant
Recommended
Starting ACD DiameterOverall Available Now Diopter Power TRULIGN™
Toric IOL BL1UT 119.1* 5.61 mm* 11.5 mm
17.0 to 25.0 D in 0.50 D steps
Cylinder powers–IOL plane 1.25, 2.00, 2.75 D Cylinder powers–corneal plane 0.83, 1.33, 1.83 D Optic body diameter 5.0 mm
Anterior surface Aspheric with axis marks Posterior surface Aspheric toric (cyl at 1.25, 2.00, 2.75 D)
Material–body and plates Silicone with enhanced UV protection; 10% UV cutoff at 400 nm Material–loop (haptics) Polyimide
Refractive index at 35oC 1.43
Edge design 360º posterior square edge Delivery system Crystalsert® IOL Delivery System
THE TRULIGN™ TORIC IOL PROVIDES
A BROADER RANGE OF VISION
TRULIGN Toric Standard Toric
TORIC IOL’S
•MAIN CONCERN WITH TORIC IOL’S IS MISALIGNMENT
•3 DEGREES OFF = LOSS OF 10% OF TORIC POWER
•10 DEGREES OFF = LOSS OF 33% OF TORIC POWER
•20 DEGREES OFF = LOSS OF 66% OF TORIC POWER
LENSX
®
LASER ARCUATE INCISIONS
IMAGE-GUIDED SURGICAL PLANNING WITH 3D
VISUALIZATION
•REAL TIME CORNEAL THICKNESS
•COMPUTER PROGRAMMED INCISIONS
- % DEPTH
- INCISION LENGTH AND POSITION - 3D VISUALIZATION OF INCISION PLACEMENT •PREDICTABLE INCISION WIDTH,
TUNNEL LENGTH
•TITRATABLE INCISIONS
- ADJUSTABLE DURING SURGICAL PROCEDURE - ADJUSTABLE POST-OP AT SLIT LAMP
ORA SYSTEM™
(OPTIWAVE™ REFRACTIVE ANALYSIS)
• PROVIDES INTRA-OPERATIVE REFRACTIVE INFORMATION • ATTACHES TO MOST SURGICAL
MICROSCOPES FOR ON-DEMAND INTRAOPERATIVE MEASUREMENTS OF SPHERE, CYLINDER AND AXIS • ENABLES REAL-TIME SURGICAL
COURSE CORRECTION • “GET IT RIGHT – RIGHT ON THE
TABLE” THE FIRST TIME • EVERY ORA SYSTEM CONNECTS
LIVE TO WAVETEC SERVERS TO CAPTURE EVERY PROCEDURE AND PUSH SOFTWARE UPGRADES
SURGERY
• AFTER LONG DISCUSSION PT CHOSE RLE
• OD: B+L TRULIGN WITH LENSX AND LRI
• OS: B+L TRULIGN WITH LENSX AND LRI
• GOAL: OD: PL OS: -0.50
3 MONTH POST-OP
•UCVA: OD: 20/15, J3 OS: 20/30, J1
FEELS VISION IS GREAT GOLF GAME IS GREAT!
PATIENT DEMOGRAPHICS
• 39 YO MALE
• NO TOBACCO/ALCOHOL
• NO GLASSES
• OHX
• POKED IN OS BY CHILD 2010 WITH SUBSEQUENT CORNEAL INFILTRATE. RESOLVED WELL
• NO MED/SURG
• ORIENTED TO TIME, PLACE AND PERSON
EXAMINATION
•EOM’S
• FULL RANGE OF MOTION OU
•PUPILS • PERRLA –APD
•VISUAL FIELD
• FULL TO FINGER COUNT
• FACIAL AMSLER – NORMAL OD AND OS
EXAMINATION
• CC: COMP EXAM AND DECREASING VA OD BUT VERY GRADUAL
• VASC: OD 20/30 OS 20/20 • K’S • OD 42/42.75 @ 001 • OS 42.25/42.75 @ 168 • MANIFEST • OD +0.75 -1.00 094 20/20 • OS +0.50 -1.25 068 20/20
EXAMINATION (CONT)
•IOP - GOLDMANN• OD 15.0 • OS 15.0 •SLIT LAMP EXAM
• ADNEXA, LIDS AND LASHES,CONJUNCTIVA, IRIS, LENS ALL CLEAR OU • CORNEA: EBMD OD>OS
• VITREOUS, MACULAE AND PERIPHERAL RETINA: CLEAR OU • OPTIC DISC
• OD 0.4/0.4
• OS 0.5/0.55
DIAGNOSTIC TESTING
• OCT OPTIC NERVE AND MACUALE OU
• FUNDUS PHOTOS OU
• PENTACAM – SPECIFICALLY FOR PACHYMETRY • OD 573 UM
• OS 585 UM
• RNFL - NONGLAUCOMATOUS • 96 UM
• 100 UM
PENTACAM TO CHECK PACHYMETRY
WHATS THE DIAGNOSIS?????
• TOTAL DUMB LUCK
INCIDENCE OF KERATOCONUS
•REPORTED IN LITERATURE BETWEEN ~1:500 TO ~1:2000
•INCREASED FREQUENCY AFTER 1995??
COLLAGEN CROSS LINKING
• VITAMIN B2 AND UV-A LIGHT
“WHY DON’T MY CONTACTS
WORK ANYMORE”
•67 Y/O FEMALE
•SUCCESSFUL ACUVUE BIFOCAL CL WEARER
•WORE MONOVISION PRIOR TO BIFOCAL
•NO MEDICAL HISTORY, NO FAMILY HISTORY
•TRENDS TOWARD “EASY GOING” ON DELL SURVEY
•CURRENT COMPLAINT – CONTACTS NOT COMFORTABLE
•NO VISION COMPLAINTS
EXAM
MANIFEST OD -3.00 SPHERE 20/40OS -5.50-1.00X105 20/30-SLE TBUT 4-6 SECOND
CORNEAL STAIN WITH FL 2+ OU EROSION ALONG LID MARGIN
NUCLEAR SCLEROSIS 1+ OU BRUNES 2+ OU FUNDUS OLD CR SCARS AWAY FROM MACULA
TREATMENT
•DISCONTINUE CLS
•HOT COMPRESS BID
•AT QID
•RTO 2 WEEKS
“PT VERY UPSET ABOUT BEING OUT OF CLS 2 WEEKS”
2 WEEK VISIT
BCVA OD 20/40 OS 20/30SLE TBUT – 4-6 SECONDS
NO CHANGE IN STAINING NO CHANGE WITH LIDS PATIENT ADMITS WEARING CONTACTS “SOME” ADD RESTASIS BID RTO 2 WEEKS
VISITS
BETTER AT 2 WEEK VISIT
EYES MORE COMFORTABLE “OKAY” NOT WEARING CL’S
1 MONTH AFTER RESTASIS
TBUT 6-8 SECONDS CORNEA CLEAR BCVA OD 20/40 OS 20/30 DISCUSSED CE WITH IOL
LENS OPTIONS
• SINGLE VISION IOL – LOSES NEAR VISION FROM CL’S
• MONOVISION IOL- GREATER “DISPARITY” THAN WHEN SUCCESSFUL WITH MONO
• MULTIFOCAL IOL – SIMILAR TO CURRENT CLS
• ACCOMMODATIVE IOL – NEED GLASSES FOR NEAR
TREATMENT
RESTOR 3.0 IOL OUUCVA OD 20/25 OS 20/25 J2OU
MANIFEST OD PLANO -0.25X180 20/25+ OS PLANO -0.25X100 20/25+ PT VERY HAPPY WITH VISION
BINOCULAR DEFOCUS CURVE
Refraction (D) ∞ 20/25 20/32 20/40 20/50 20/63 20/80 20/100 20/20 +1.00 +0.50 0.00 -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 -4.00 Snellen
HISTORY
•50 Y/O WHITE FEMALE (MARRIED)
•RN FOR BLOOD BANK
•NO MEDICINES OR MEDICAL ALLERGIES
•MEDICAL HISTORY NEGATIVE
•OCULAR HISTORY NEGATIVE
•FAMILY HISTORY NEGATIVE
CLINICAL FINDINGS
• UCVA • OD 20/30 • OS 20/30-• MANIFEST • OD +1.00-1.00X104 20/20 • OS +0.75-2.00X078 20/20 • CYCLOPLEGIC • OD +1.00-1.00X106 20/20 • OS +1.00-2.00X80 20/20CLINICAL FINDINGS
•SLE – WNL •FUNDUS – WNL •PACHYMETRY • OD 524 • OS 533 •TBUT > 15 SECONDS •K’S • OD 43.6@65 43.3@155 • OS 43.9@156 43.4@66•DISCUSSED NEED FOR READING GLASSES AT LENGTH
POST-OP VISITS
•
DAY 1
•UCVA OD 20/20-1 OS 20/25
•SLE – TRACE EDEMA OU
•RTO 1 WEEK
•
DAY 7
•UCVA OD 20/20 OS
20/20-•SLE – FLAP WELL POSITIONED
•RTO 3 WEEKS
POST-OP VISITS
•
DAY 12
•
PATIENT REPORTS VERY POOR NEAR VISION
•
UCVA OD
OS
20/20-•
SLE
TBUT 8 SECONDS OUTRACE SPK OU
• MANIFEST
• OD +0.50 SPH 20/20 • OS +1.00 SPH 20/20 • CHANGED AT TO SYSTANE FREE
•1 MONTH POST-OP
•NEAR VISION BETTER BUT STILL CAUSES NAUSEA AND DIFFICULTY AT WORK • UCVA
• OD 20/20 • OS 20/20
• SLE –TBUT 10 SEC OU TRACE SPK OD • MANIFEST
• OD +0.25 SPH 20/20 • OS +0.50-0.50X90 20/20
•
2 MONTH POST-OP
•
STILL HAS NAUSEA WHEN READING
•
UCVA
•OD 20/20•OS
20/20-•
SLE –
TBUT 8-10 SECONDS NO SPK•MANIFEST
• OD +0.25 SPH 20/20
• OS +0.50 SPH 20/20 •ADD GENTEAL GEL AT NIGHT
• 3 MONTH POST-OP
• NEAR COMPLAINTS LESS OKAY WITH +1.00 READERS
• UCVA • OD 20/20
• OS 20/20
• SLE –TBUT 10-12 SECONDS
• MANIFEST • OD +0.25 SPHERE • OS +0.50 SPHERE
•
5 MONTH VISIT
•
VA AT NEAR WORSE
•
UCVA
• OD 20/25 • OS 20/20•
SLE – WNL
•
MANIFEST
• OD +0.50 SPHERE 20/20 • OS +0.50 SPHERE 20/20•
TRIAL +0.50 CONTACT LENS OU
• PATIENT REPORTS GREATLY IMPROVED VA AT NEAR, NO NAUSUA, CAN READ CHARTS WITHOUT CORRECTION
• CYCLO
• OD +0.50 SPHERE
ENHANCEMENT SURGERY
•TREAT BOTH EYES FULL WAVESCAN TREATMENT
•OD +0.85-0.23X116
•OS +0.97-0.18X86
DAY 1
•OD 20/20
•OS 20/20
•VA SEEMS VERY GOOD AT NEAR
• DAY 7 POST – ENHANCEMENT
• AWOKE WITH VA IN OD BLURRY • OD 20/70
• OS 20/20
• SLE – VERTICAL STRAIE OD / DISLODGED FLAP
STRIAE
•
FLOURESCEIN MAKES
IT EASIER TO SEE AS
VALLEYS AND
MOUNTAINS
DIFFERENTIATE WITH
NEGATIVE STAINING
STRAIE TREATMENT
• FLAP LIFT WITH EPITHELIAL DEBRIDEMENT/ HYPOTONIC SALINE
• DAY 1 – FLAP WELL POSITIONED / BANDAGE CONTACT LENS IN PLACE
• DAY 2 – UCVA 20/60 / BANDAGE IN PLACE
• DAY 4 – UCVA 20/50 / BANDAGE CL REMOVED / CELLS AT EDGE OF FLAP?
•DAY 10 • UCVA
20/25-• EPITHELIAL INGROWTH
• ADDED MURO 128 QID
PRE EPISCRAPE PHOTO
•1 MONTH POST FLAP STRETCH
•UCVA 20/30+ •MANIFEST OD +0.50-1.25X165 20/20 •TBUT 4-6 SEC •NO CHANGE IN INGROWTH •MEDS • RESTASIS BID • MURO 128 QID • AT QID
• 2 MONTH POST FLAP STRETCH
• UCVA 20/60
• MANIFEST +1.25-1.50X158
20/20-• TBUT 10-12 SECS
PRE EPISCRAPE PHOTO
• INSERT PICTUREPOST EPISCRAPE
• DAY 1 • UCVA 20/30 • CELLS GONE • TBUT 4-6 SECONDS • 1 MONTH VISIT • UCVA 20/40 • CELLS RETURNING • ADD MURO 128 • MANIFEST OD +1.00-1.00X165 20/20•2 MONTHS POST EPI-SCRAPE • UCVA
20/30-• MANIFEST +1.75-1.50X160 20/20
• CELLS STABLE
• TBUT 9-10 SECONDS
•3 MONTHS POST EPI-SCRAPE • UCVA 20/30-• MANIFEST +1.50.0.75X165 20/30 • CELLS STABLE • CONSIDER PRK ENHANCEMENT •4 MONTH • MANIFEST +1.50-1.25X168 • CYCLO +1.50-1.25X165
PRE PRK WAVESCAN
PRE-PRK TOPOGRAPHY
PRE PRK TREATMENT PLAN
PRK POST-OP
•
DAY 1
•20/60 BCL IN PLACE•
DAY 4
•20/70 BCL REMOVED / RE-EPITHELIALIZED•
DAY 15
• 20/20-•CELLS NO CHANGE•PATIENT HAPPY WITH NEAR AND FAR VISION
•
3 MONTH VISIT
•20/20
•NO CHANGE WITH CELLS MOVING TO ENGLAND
KERATOCONIC PATIENT
• BS
• WHITE MALE
• DOB 9/17/47
• LONG HISTORY OF KERATOCONUS
• FIRST SEEN 5/21/07
•
KERATOCONUS IS A PRIMARY EYE DISEASE THAT RESULTS IN A
DEFORMATION OF THE CORNEA AND LOSS OF VISION.
•
THE CORNEA THINS AND BECOMES CONE SHAPED
•
THERE IS USUALLY (ALWAYS??) A GENETIC BASIS.
•
LOTS OF THEORIES ABOUT MECHANISM:
•
TISSUE JUST WEAKER THAN NORMAL, UNDERGOES
STRUCTURAL FAILURE, WHICH TRIGGERS MANY THINGS
•
THERE IS AN INABILITY TO HANDLE
OXIDATIVE STRESS IN THE CORNEA,
DUE TO CONGENITALLY ABNORMALLY
ENZYMES, WHICH CAUSES OXIDATIVE
DAMAGE, APOPTOSIS, AND SO ON
•
ECTASIA IS A CLINICAL STATE THAT HAS THE
PROPERTIES AND COURSE OF KERATOCONUS, BUT
OCCURS AFTER REFRACTIVE SURGERY
•
MOST COMMONLY, POST LASIK
•
HAS OCCURRED WITH PRK AND PTK
•
MANY THEORIES:
• SOME CORNEAS ARE WEAKER THAN OTHERS
• SOME ARE DESTINED TO HAVE KC
• SOME ARE DUE TO MECHANICAL INACCURACY (FLAP TOO THICK)
• SURGERY SETS UP AN OXIDATIVE STRESS CASCADE, THAT IN TURN TRIGGERS KC.
• POST PRK KERATOCYTE APOPTOSIS CAN BE BLOCKED BY ANTIOXIDANTS.
ECTASIA—ANATOMICAL BASIS
•
MICHAEL SMOLEK, PH.D. OF NEW ORLEANS HAS
DETERMINED THE STRUCTURE OF THE CORNEA MAY
EXPLAIN WHY ECTASIA IS MORE LIKELY AFTER LASIK
•ANTERIOR STROMA IS CROSS-LINKED
•POSTERIOR STROMA IS NOT
HISTORY
• CHRONIC ALLERGIES- EYE RUBBING
• FAMILY HX- TRANSPLANT, KC
EXAM
•DECREASED BSCVA •REFRACTION- MYOPIA >8D •US CORNEAL PACHYMETRY •RETINOSCOPY •MANUAL K’S- IRREG, >47•WAVEFRONT- INCREASED COMA
•ORBSCAN/PENTACAM- POST FLOAT, THICKNESS GRADIENT
•ASSYMETRY BETWEEN EYES
•ENHANCEMENTS
ECTASIA--SCREENING
•OTHER THINGS
• STEEP K: K>47 (RABINOWITZ)
• I/S RATIO AT 3.0 MM >1.4
• ADD PARACENTRAL K INFERIORLY AND SUPERIORLY • DIVIDE THE INFERIOR TOTAL BY SUPERIOR TOTAL • DIFFERENCE IN K FROM RIGHT TO LEFT
• HIGH MYOPIA • <-9.0? • <-8.0?
ECTASIA--SCREENING
• TOPOGRAPHY—THE PRIMARY TOOL • ASYMMETRICAL ASTIGMATISM
• AKA FFKC • “SMILEY FACE” PELLUCID MD
TOPOGRAPHY—A COMMENT
•NOT EVERY CASE OF ASYMMETRICAL ASTIGMATISM RELATES TO KC OR ECTASIA.
•OTHER CAUSES INCLUDE DISPLACED CORNEAL APEX OR OTHER FORMS OF MISSHAPED CORNEA.
•AT LEAST 50% ARE PROBABLY BENIGN. YOU JUST DON’T ALWAYS KNOW WHICH 50%.
TOPOGRAPHY—A COMMENT
•
QUESTION: WHICH PATIENT SHOWS TYPICAL
ASYMMETRIC ASTIGMATISM?
They are all the same topo of the same person, Just printed with different Scales:
A: Automatic Adjustment B: Standard, w/ 0.25D steps C: Standard, w/ 0.50D steps
SUMMARY OF ASYMMETRIC
BOWTIE
Good
Bad
Dangerous
SIGNS AND SYMPTOMS
•PT REPORTS DISCOMFORT WITH CURRENT RGP’S
•REPORTS HALO AND GLARE AT NIGHT
•CURRENT RGP’S OD: 20/40-2
• OS: 20/70-1
• ADD +2.00 20/25
•SLIT LAMP: GRADE 2 3-9 STAINING, GRADE 2- GPC
•MINOR THINNING OD, MODERATE OS, VOGTS STRAIE
INITIAL TREATMENT
• MR: OD: -7.50 – 1.00 X 123,
20/25-• OS: -10.50 – 0.50 X 125, 20/80
• REFIT INTO NEW RGP’S
• KERATOCONIC DESIGN WITH ACUITY: OD: 20/20-, OS 20/25
• PUT ON RESTASIS BID AND BLINK QID OU
3 YEARS LATER
• VISION HAS DECREASED IN OD TO 20/60
• PT SAYS EVERYTHING FEELS LIKE LOOKING THRU A “FILM”
• GRADE 2+ NS WITH OIL DROPLETS IN OD
• GRADE 1+ NS IN OS
• CORNEA RELATIVELY STABLE
HOW TO PROCEED?
•WHAT IOL TO SELECT?
•MONOFOCAL •TORIC •ACCOMMODATIVE •MULTIFOCAL
SELECTION
• WE PERFORMED SURGERY • OD 8/17/10, IMPLANTED CRYSTALENS 50, 4.0 • OS 11/16/11, IMPLANTED CRYSTALENS AO 400• LIMBAL INCISIONS MADE TO MINIMIZE ASTIGMATISM
POST OP RESULTS
• 1 YEAR AFTER SECOND EYE
• MR: OD: -0.25 -1.50 X 53. 20/25
• OS: +2.00 -3.25 X 127, 20/30 –
• ADD: +2.00, 20/20 NEAR
• PT VERY HAPPY WITH JUST WEARING SPECTACLES AND HAS DECIDED TO DISCONTINUE RGP WEAR
