LASIK & LASEK for Residual Refractive Errors After Refractive Lens Exchange Ruth Lapid-Gortzak MD, Jan Willem van der Linden, BOpt, Ivanka van der Meulen, MD, Carla Nieuwendaal, MD, Maarten Mourits, MD, PhD Retina Total Eye Care, Driebergen. Dept. of Ophthalmology, Academic Medical Center, Amsterdam The Netherlands R.Lapid@amc.nl R. Lapid has received speakers and Advisory board fees from Alcon, and an unrestricted research grant from Oculentis. The other authors have no financial interest. Goodmorning, I would like to show you our results with laser vision correction after restor implantation

Bioptics: LASIK or LASEK after a lenticular intra-ocular procedure After RLE small refractive errors can cause significant complaints of VA No consensus for RLE or bioptics. What is the minimal refractive error or the minimal loss of lines on UDVA to consider a corneal laser procedure? Bioptics is the name we use for a laser vision correction after implant lens surgery. There is no consensus on RLE or bioptics procedures. The big question is what is the lowest refractive error that one would like to correct for the patient?

Bioptics Surprise in post-Restor SE or VA Planned bioptics for pre-op corneal astigmatism Prospective case series. Single surgeon (RLG) for RLE and bioptics LASIK: XP microkeratome 120 micron flaps (Technolas) LASEK: 30 sec 20% alcohol Laser platform: Technolas z217 Planoscan Indication for bioptics were 2: if there was a surprise refraction post-op, or if there was a pre-operative cylinder that needed attention. The study was done prospectively, we used the technolas z 217 standard treatment.

Demographics 45 eyes of 26 patients Mean age 58.9 (range:51.5 - 66.17 years) 80.7% males 27 eyes LASEK, 18 eyes LASIK Hyperopes 22 eyes, myopes 23 eyes We desrcribe the outcome of 45 procedures. The mean age was nearly 59 years old. 27 had LASEK and 18 eyes had LASEIK.

Pre-operative data: LASIK LASEK 18 # eyes 27 57.1(51.5-63) Age (range) 60.1(54.5-66.2) 0.50 + 0.72 (-1.875 +1.25) Pre-op SE 0.34D + 0.73D (-0.75 +1.5) 1.21+0.62 (+0.75- +1.50) Pre-op sphere 1.09 + 0.2 (-0.25 +2.5) -1.01+0.62 (0- -2.25) Pre-op cylinder -1.44 + 0.59 (-0.5 – 2.75) 0.63+0.2 (0.32-0.9) Pre-op UDVA 0.58 + 0.19 (0.32-0.8) 1.1+0.16(0.9-1.5) Pre-op CDVA 1.05 + 0.17 (0.7-1.25) 0.96+0.09 (0.8-1.0) Pre-op UNVA 0.96 + 0.23 (0.8-1) 191 d+ 62d (125-362 days) Mean time from RLE 175 d + 70d (84-364) The pre-operative data show that the mean pre-op SE was aroudn 0.50 diopter in LASIk and 0.34 D in LASEK. However, when we look at the preop mean sphere and cylinder we come to the conclusion that most pateints had a crosslcylinder like refractive error. Mean pre operative UCVA was between 0.58 and 0.63. Reading was overall not a problem for these patients. Time from the RLE had amean of 175 to 191 days – give or take a half year.

Post-operative data LASIK: 3months 6months # eyes 18 14 (4 eyes lost to follow up) Efficacy D 0.98 1.03 Safety D 1.07 1.10 Efficacy N 1.01 Mean UCDA 1.08 (20/19) 1.13 (20/17) Post op SE 0.29D + 0.34D (-0.25 +1.00) 0.10D + 0.23 (-0.25 to +0.625) Post op Sphere 0.43 + 0.33 (0 +1.25) 0.23 + 0.75 (0 +0.75) Post op Cylinder -0.30 + 0.39 (0 -1.00) -0.25 + 0.39 (0 -1.00) In the 18 eyes with lasik the mean post op se was 0.29, with a significant reduction in both the sphere and the cylinder. This remained stable in th eyes in which we have a 6 month f-u

Post-operative data LASEK 3 months 6 months # eyes 27 24 (3 eyes lost to fu) Efficacy D 0.94 1.08 Safety D 1.06 1.12 Efficacy N 1.03 1.01 Mean UCDA 0.99 (~20/20) 1.13 (20/17) Post op SE 0 + 0.5D (-0.625 +0.625) -0.06 + 0.22D (-0.62 to +0.62) Post op Sphere 0.17 + 0.50 (-0.25 +1.25) 0.04 + 0.23 (-0.25 to +0.75) Post op Cylinder -0.32 + 0.42 (0 -1.25) -0.20 + 0.28 (0 to -0.75) In the 27 LASEK eyes we see that they are mostly emmetropic post-operatively. This outcome was statistically significant

Attempted versus achieved sphere & cylinder correction after LASIK & LASEK after RLE Here we see the attemtped versus the achieved corrrection. The blue dots are LASEK and the red dots are LASIK Bot h graphs show mostly good congruency between attempted and achieved corrections. In the sphere corrections deviations from target were mostly undercorrections. With the cylinder corrections the deviations from target were more spread out.

Safety and predictability at 3 and 6 months: Safety: we see that most patients did not loose or even gained lines. Loos of lines at 3 months was due To a residual refractive error. The lines lost and gained are shown here. We see that the majority of patient don’t loose lines. The loss of lines in LASEK was in a patient with a map dot fingerprint dystrophy who had to have his procedure. In LASIK there was no good reason for the residual refraction. Efficacy: All were within 1.0D of Target refraction, at 6 months we see that close to 90% are within 0.5D of target refraction.

Snellen VA before and after LASIK and LASEK in multifocal RLE Snellen VA pre-op (blue hues) versus post-op (red hues) Snellen lines The blue hues are the pre-op va and the red hues the post op VA, on top the LASIk outcomes and under the LASEK outcomes. We see a shift post laser to better UCVA. What I find really surprising that an ucva of 1.25 or better is achievable with this approach. Snellen lines LASEK

Literature Piñero DP, Espinosa MJ, Alió JL, J Refract Surg. 2009 Nov 11:1-9 Good outcomes. Especially in myopes. Different types of multifocal IOL’s used and did not mention whether standard or wavefront treatment was used Muftuoglu et al, JCRS June 2009, p.1063-1071 Similar results in cataract patients with multifocal implants. Both standard tx and wavefront. Five different surgeons. Femtosecond laser used to create flap. No data on LASEK. There aren’t many publications on bioptics. One of the recent ones showed similar results for LASIK with a femtosecond laser flap. There is no data on LASEK.

Conclusion: Bioptics for small refractive errors is predictable, effective, and safe. RLE patients are very demanding Multifocal toric will possibly decrease the need for bioptics Wait with performing corneal laser procedure for post RLE tearfilm stabilization YAG capsulotomy in our clinic is done on indication only In conclusion: bioptics for small refractive errors is predictable effective and safe, these are demanding patients. The results with multifocal toric lenses will probably reduce the need for bioptics. We routinely try to wait out 6 months, in order to overcome initial tearfilm instability as a result of the lens surgery