CONSULTATION SECTION
Enhancement with surface ablation is not advantageous; because the cornea was previously deformed, subsequent excimer laser treatment would induce further spherical aberration. In addition, high hyperopic ablations are prone to regression and irregularity and have limited predictability. In cases of recurrent hyperopia after LASIK, RLE may be the best option. I would prefer a monofocal IOL for both eyes. Requirements for a multifocal IOL were not met in this case. There was no chance of excellent biometry, and a normal prolate cornea and good binocular function were not present. Standard monofocal IOLs have positive spherical aberration and can therefore partially compensate for the negative spherical aberration induced by the previous hyperopic ablation. Intraoperative autorefraction is useful after excimer laser surgery. I would consider lamellar graft surgery in this case of unsuccessful enhancement. Aylin Kılıc¸, MD Istanbul, Turkey
1051
approach is always successful. If creation of a new flap were required, I would have used a mechanical microkeratome to create a wider, deeper flap. It takes some force to lift a femtosecond laser–created flap, and the force might tear the corneal tissue. A microkeratome-created flap can be easily lifted without force. Because making a second cut, even with a microkeratome, does not completely prevent the formation of a thin sliver of tissue, I always try to lift the previous flap unless it is incomplete, too small, or dislocated. Photorefractive keratectomy (PRK) might be an option; however, hyperopic PRK in eyes with previous LASIK would have a high risk for subepithelial haze and regression. I would rather perform RLE if the patient does not want to risk flap complications. If this were a case of myopic regression, I would also try to lift the original flap. Alternatively, if I could determine the flap margin and approximate depth, I would create only a side cut inside the original flap margin using a femtosecond laser to prevent epithelial ingrowth. Ikuko Toda, MD, PhD Tokyo, Japan
REFERENCES lu G, Ertan A. Epithelial ingrowth after femtosecond 1. Kamburog laser-assisted in situ keratomileusis. Cornea 2008; 27:1122– 1125 2. Tran DB, Binder PS, Brame CL. LASIK flap revision using the IntraLase femtosecond laser. Int Ophthalmol Clin 2008; 48(1):51– 63 3. Vaddavalli PK, Yoo SH, Diakonis VF, Canto AP, Shah NV, Haddock LJ, Feuer WJ, Culbertson WW. Femtosecond laser-assisted retreatment for residual refractive errors after laser in situ keratomileusis. J Cataract Refractive Surg 2013; 39:1241–1247
- I would not have performed hyperopic LASIK in this patient who required more than +3.00 D of correction because of the possibility of regression and decreased quality of vision. Hyperopic correction by LASIK induces higher-order aberrations and sometimes results in loss of CDVA (with spectacles) and symptoms such as halo and glare. I would have suggested implantation of phakic IOLs (pIOLs) to this patient. However, patients with hyperopia often have a shallow anterior chamber and are thus not candidates for pIOLs. In that case, I would suggest multifocal contact lenses and wait to perform cataract surgery with implantation of multifocal IOLs. If this patient presented to me after initial hyperopic LASIK, I would try to lift the original flap. In my experience, flap lifting is always possible, even when the flap margin cannot be seen on slitlamp examination. I use fluorescein staining and/or light pressure at the peripheral cornea to find the flap margin. This
- I believe the risk related to creation of a new flap became too high from the moment the surgeon was not able to properly identify the edges of the flap. Often, preoperative high-resolution corneal optical coherence tomography (OCT) is helpful in this identification. Therefore, my primary approach for this patient would have been to perform personalized PRK with MMC 0.02% applied for 30 seconds, although the risk for regression and decentration might be relatively significant based on the excimer laser used. However, creating a new flap without properly identifying the limits of the old one can lead to more severe complications, such as deterioration in visual quality due to double interface syndrome. Furthermore, the new flap can be cut inside the old one, which is likely to create a buttonhole. Irregular astigmatism can also appear if the old flap slips or the new one is not positioned properly. Finally, attempting to relift an old flap created with a mechanical microkeratome creates a major risk for epithelial ingrowth. Refractive lens exchange might be a reasonable approach considering the high chance of regression and induced postoperative dryness. However, monovision with a monofocal IOL after a contact lens trial to test the patient's satisfaction and tolerance to monofocality is preferred over a multifocal IOL approach. The implantation of a multifocal IOL behind a
J CATARACT REFRACT SURG - VOL 40, JUNE 2014
Enhancement with surface ablation is not advantageous; because the cornea was previously deformed, subsequent excimer laser treatment would induce further spherical aberration. In addition, high hyperopic ablations are prone to regression and irregularity and have limited predictability. In cases of recurrent hyperopia after LASIK, RLE may be the best option. I would prefer a monofocal IOL for both eyes. Requirements for a multifocal IOL were not met in this case. There was no chance of excellent biometry, and a normal prolate cornea and good binocular function were not present. Standard monofocal IOLs have positive spherical aberration and can therefore partially compensate for the negative spherical aberration induced by the previous hyperopic ablation. Intraoperative autorefraction is useful after excimer laser surgery. I would consider lamellar graft surgery in this case of unsuccessful enhancement. Aylin Kılıc¸, MD Istanbul, Turkey
1051
approach is always successful. If creation of a new flap were required, I would have used a mechanical microkeratome to create a wider, deeper flap. It takes some force to lift a femtosecond laser–created flap, and the force might tear the corneal tissue. A microkeratome-created flap can be easily lifted without force. Because making a second cut, even with a microkeratome, does not completely prevent the formation of a thin sliver of tissue, I always try to lift the previous flap unless it is incomplete, too small, or dislocated. Photorefractive keratectomy (PRK) might be an option; however, hyperopic PRK in eyes with previous LASIK would have a high risk for subepithelial haze and regression. I would rather perform RLE if the patient does not want to risk flap complications. If this were a case of myopic regression, I would also try to lift the original flap. Alternatively, if I could determine the flap margin and approximate depth, I would create only a side cut inside the original flap margin using a femtosecond laser to prevent epithelial ingrowth. Ikuko Toda, MD, PhD Tokyo, Japan
REFERENCES lu G, Ertan A. Epithelial ingrowth after femtosecond 1. Kamburog laser-assisted in situ keratomileusis. Cornea 2008; 27:1122– 1125 2. Tran DB, Binder PS, Brame CL. LASIK flap revision using the IntraLase femtosecond laser. Int Ophthalmol Clin 2008; 48(1):51– 63 3. Vaddavalli PK, Yoo SH, Diakonis VF, Canto AP, Shah NV, Haddock LJ, Feuer WJ, Culbertson WW. Femtosecond laser-assisted retreatment for residual refractive errors after laser in situ keratomileusis. J Cataract Refractive Surg 2013; 39:1241–1247
- I would not have performed hyperopic LASIK in this patient who required more than +3.00 D of correction because of the possibility of regression and decreased quality of vision. Hyperopic correction by LASIK induces higher-order aberrations and sometimes results in loss of CDVA (with spectacles) and symptoms such as halo and glare. I would have suggested implantation of phakic IOLs (pIOLs) to this patient. However, patients with hyperopia often have a shallow anterior chamber and are thus not candidates for pIOLs. In that case, I would suggest multifocal contact lenses and wait to perform cataract surgery with implantation of multifocal IOLs. If this patient presented to me after initial hyperopic LASIK, I would try to lift the original flap. In my experience, flap lifting is always possible, even when the flap margin cannot be seen on slitlamp examination. I use fluorescein staining and/or light pressure at the peripheral cornea to find the flap margin. This
- I believe the risk related to creation of a new flap became too high from the moment the surgeon was not able to properly identify the edges of the flap. Often, preoperative high-resolution corneal optical coherence tomography (OCT) is helpful in this identification. Therefore, my primary approach for this patient would have been to perform personalized PRK with MMC 0.02% applied for 30 seconds, although the risk for regression and decentration might be relatively significant based on the excimer laser used. However, creating a new flap without properly identifying the limits of the old one can lead to more severe complications, such as deterioration in visual quality due to double interface syndrome. Furthermore, the new flap can be cut inside the old one, which is likely to create a buttonhole. Irregular astigmatism can also appear if the old flap slips or the new one is not positioned properly. Finally, attempting to relift an old flap created with a mechanical microkeratome creates a major risk for epithelial ingrowth. Refractive lens exchange might be a reasonable approach considering the high chance of regression and induced postoperative dryness. However, monovision with a monofocal IOL after a contact lens trial to test the patient's satisfaction and tolerance to monofocality is preferred over a multifocal IOL approach. The implantation of a multifocal IOL behind a
J CATARACT REFRACT SURG - VOL 40, JUNE 2014
