A Saturday afternoon symposium, “Finishing the Job: The Playbook for Refractive Enhancements,” was the capstone to the “Closing the Gap” refractive webinar series, and it delved into managing enhancements after both lenticular and keratorefractive procedures.
Rahul Tonk, MD, and Kathryn Hatch, MD, moderated the session. Dr. Tonk presented on the diagnostic workflow and when to enhance and when not to enhance, recommending several guidelines.
First, he said to listen. This includes starting with a great history. It’s a little bit of “detective work” to find out the actual complaint the patient is having, he said. Is the vision actually fluctuating?
He also said to refract; you need to confirm the refractive error. “Don’t over-minus.” He suggested using the push-plus technique, especially with presbyopia-correcting IOLs. Demonstrate the change by using a trial frame or soft contact lens. He also said to ask the key question of if the change delivers a “wow.” “The patient has to be their absolute happiest for me to proceed. If they’re underwhelmed, I have to do more work,” he said.
Next, look closely at both the front and back of the eye. You need to look at the ocular surface, and check for MGD, blepharitis, and check the tear film. He also suggested looking at the posterior capsule, IOL position, and the vitreous and macula.
Consider additional testing, like corneal topography, wavefront aberrometry, and/or macular OCT.
Dr. Tonk also discussed when to enhance (“go”) and when not to advance (“stop”). Enhance when there is stable refraction, when the complaint matches the error, when masqueraders are ruled out, and when the patient has realistic goals, he said. But you should not enhance if the ocular surface is unstable, if the patient has unrealistic expectations, if the complaint is dysphotopsia, and if the patient is plano 20/20.
Also during the session, Dr. Hatch presented on excimer laser enhancement after KLEx.
She noted that you don’t really need to do many enhancements because it’s so precise. She mentioned a large cohort study of more than 60,000 patients where the enhancement rate was only 1.3%.
Enhancement options include thin-flap LASIK, thick-flap LASIK, PRK, re-SMILE (subcap lenticule extraction), and cap to flap (pseudo-CIRCLE). One of the first things Dr. Hatch looks at is the patient’s epithelial thickness map.
Dr. Hatch discussed the “cap to flap” technique, which she said is essentially converting the SMILE “cap” to a LASIK “flap.” It’s used for enhancement following lenticule extraction, though she did note that the CIRCLE software is available in Europe (but not in the U.S.), and the technique is off-label in the U.S.
Editors’ note: Dr. Tonk has financial interests with Alcon, Bausch + Lomb, and Johnson & Johnson Vision. Dr. Hatch has financial interests with Zeiss.
