PURPOSE
To determine the long-term safety and effectiveness of laser in-situ keratomileusis (LASIK) in the treatment of refractive errors following penetrating keratoplasty (PK).


METHODS
A retrospective review was performed of 57 eyes of 48 patients with anisometropia or high astigmatism who were unable to wear glasses or a contact lens after PK and who underwent LASIK for visual rehabilitation. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BCVA), and corneal transplant integrity were recorded before surgery as well as up to 60 months after LASIK.


RESULTS
The mean follow-up after the LASIK was 21.4 +/- 14.2 months (range 3 to 60 months). Mean preoperative spherical equivalent (SE) was -4.19 +/- 3.38 D. The mean preoperative astigmatism was 4.67 +/- 2.18 D. Preoperative BCVA was 20/40 or better in 42 eyes (74%). At 2 years the mean SE was -0.61 +/- 1.81 D, and mean astigmatism was 1.94 +/- 1.35 D for the 28 eyes with follow-up. UCVA was 20/40 or better in 12 eyes (43%), and BCVA was 20/40 or better in 24 eyes (86%) at 2 years. A gain in BCVA of 1 line or more was seen in 8 eyes (29%). Two eyes (7%) had loss of 2 or more lines of BCVA at 2 years. There were 9 eyes (16%) that developed epithelial ingrowth. Five eyes (9%) in this series had repeat corneal transplants.


CONCLUSIONS
LASIK is effective for reducing ametropia after PK. Proper patient counseling is necessary because the results of LASIK after PK are not as good as, and complications are more frequent than in eyes with naturally occurring myopia and astigmatism. Complications are especially common in patients with mismatch of the donor and host cornea or in those with poor endothelial cell function.

Long-term analysis of LASIK for the correction of refractive errors after penetrating keratoplasty

We present a review of keratorefractive and intraocular approaches to managing residual astigmatic and spherical refractive error after cataract surgery, including laser in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), arcuate keratotomy, intraocular lens (IOL) exchange, piggyback IOLs, and light-adjustable IOLs. Currently available literature suggests that laser vision correction, whether LASIK or PRK, yields more effective and predictable outcomes than intraocular surgery. Piggyback IOLs with a rounded-edge profile implanted in the sulcus may be superior to IOL exchange, but both options present potential risks that likely outweigh the refractive benefits except in cases with large residual spherical errors. The light-adjustable IOL may provide an ideal treatment to pseudophakic ametropia by obviating the need for secondary invasive procedures after cataract surgery, but it is not widely available nor has it been sufficiently studied. Financial Disclosure Dr. Manche has equity in Calhoun Vision, Inc., Krypton Vision, Refresh Innovations, Inc., Seros Medical, LLC, and Veralas, Inc. He is a consultant to Oculeve, Inc., Best Doctors, and Gerson Lehrman. Dr. Sales has no financial or proprietary interest in any material or method mentioned.

Managing residual refractive error after cataract surgery

Purpose of review Presbyopia-correcting intraocular lenses are widely available. Residual ametropia is one of the most common issues that can result in patient dissatisfaction. Options for correcting refractive surprises include piggyback intraocular lens implantation, corneal incisional surgery and laser correction. Excimer laser surgery is a safe and predictable method to correct residual amounts of ametropia in pseudophakic patients with monofocal intraocular lenses; however, there is scant published literature regarding this technique. Recent findings Presbyopia-correcting intraocular lenses require emmetropia for the best visual outcome, as small amounts of astigmatism or residual refractive errors can limit their visual performance. Laser-assisted in-situ keratomileusis and photorefractive keratectomy are safe and effective results in pseudophakic patients. Surgeons can refine the refractive outcome after intraocular lens implantation with the excimer laser to achieve better results and higher patient satisfaction. Summary Excimer laser corneal surgery for fine-tuning residual ametropia after presbyopia-correcting intraocular lenses is a safe adjunct treatment to increase patient satisfaction. Which technique (photorefractive keratectomy or laser-assisted in-situ keratomileusis) to use depends on surgeon preference and patient characteristics, as both demonstrate similar results in published literature. Knowledge of all available refractive methods and technologies are crucial for improving outcomes in these patients.

Refractive enhancement following presbyopia-correcting intraocular lens implantation

PURPOSE To evaluate refractive and visual outcomes of secondary piggyback intraocular lens implantation in patients diagnosed as having residual ametropia following segmental multifocal lens implantation. METHODS Data of 80 pseudophakic eyes with ametropia that underwent Sulcoflex aspheric 653L intraocular lens implantation (Rayner Intraocular Lenses Ltd., East Sussex, United Kingdom) to correct residual refractive error were analyzed. All eyes previously had in-the-bag zonal refractive multifocal intraocular lens implantation (Lentis Mplus MF30, models LS-312 and LS-313; Oculentis GmbH, Berlin, Germany) and required residual refractive error correction. Outcome measurements included uncorrected distance visual acuity, corrected distance visual acuity, uncorrected near visual acuity, distance-corrected near visual acuity, manifest refraction, and complications. One-year data are presented in this study. RESULTS The mean spherical equivalent ranged from -1.75 to +3.25 diopters (D) preoperatively (mean: +0.58 ± 1.15 D) and reduced to -1.25 to +0.50 D (mean: -0.14 ± 0.28 D; P < .01). Postoperatively, 93.8% of eyes were within ±0.50 D and 98.8% were within ±1.00 D of emmetropia. The mean uncorrected distance visual acuity improved significantly from 0.28 ± 0.16 to 0.01 ± 0.10 logMAR and 78.8% of eyes achieved 6/6 (Snellen 20/20) or better postoperatively. The mean uncorrected near visual acuity changed from 0.43 ± 0.28 to 0.19 ± 0.15 logMAR. There was no significant change in corrected distance visual acuity or distance-corrected near visual acuity. No serious intraoperative or postoperative complications requiring secondary intraocular lens removal occurred. CONCLUSIONS Sulcoflex lenses proved to be a predictable and safe option for correcting residual refractive error in patients diagnosed as having pseudophakia.

Piggyback intraocular lens implantation to correct pseudophakic refractive error after segmental multifocal intraocular lens implantation.

Purpose of review Bioptics treats complex refractive errors by combining refractive techniques with different mechanisms of action, usually using an intraocular implant (a phakic or pseudophakic intraocular lens) followed by a corneal procedure (laser ablation, intrastromal implant). Recent findings In myopia and hyperopia, bioptics with phakic intraocular lenses or refractive lens exchange and subsequent excimer laser yields improved predictability and unchanged safety, compared with sole intraocular lens surgery. Complications are related mainly to intraocular lenses. In keratoconus and pellucid marginal degeneration, intracorneal rings have been successfully combined with phacoemulsification or with phakic intraocular lenses in a limited number of eyes. In the author's series, angle-supported phakic intraocular lenses were implanted in 12 eyes to correct a mean regression of -8 D after excimer laser (reverse bioptics), achieving a mean spherical equivalent of -0.3 D, mean best spectacle-corrected visual acuity of 0.7, and mean uncorrected visual acuity of 0.5, with 83% of eyes within 0.5 D of spherical equivalent. Summary Bioptics improves vision and halos and adds no particular risks to phakic or pseudophakic intraocular lens implantation in either myopia or hyperopia. Reverse bioptics, with phakic intraocular lenses or refractive lens exchange, can be used to correct regressed corneal surgery.

Bioptics: where do things stand?

Purpose To review the cases of patients who had excimer laser refractive surgery to correct unintentional or undesired ametropia after cataract extraction with intraocular lens (IOL) implantation. Setting Wilmer Laser Vision Correction Center, Wilmer Eye Institute, Baltimore, Maryland, USA. Methods In this retrospective noncomparative review of consecutive cases, the Wilmer Laser Vision Correction Center's database was searched for patients who had laser in situ keratomileusis or photorefractive keratectomy to correct ametropia after cataract extraction with IOL implantation. Results Using the Visx Star excimer laser system (Visx, Inc.), 11 procedures were performed in 11 eyes of 10 patients a mean of 47 months (range 2 to 216 months) after cataract extraction with IOL implantation. Except for 1 patient with a silicone plate lens, all patients received 3-piece poly(methyl methacrylate) lenses. The mean age at time of excimer treatment was 75 years (range 70 to 81 years). Before laser surgery, the mean spherical equivalent of patient eyes was −3.76 diopters (D) ± 2.50 (SD) (range −6.50 to +0.75 D), spherical refraction ranged from −9.00 D to plano, and the highest cylindrical refraction was +5.50 D. At last follow-up (mean 12.2 months; range 1 to 38 months), the mean manifest spherical equivalent was −0.88 ± 1.43 D (range −2.75 to +2.13 D). Changes in mean manifest spherical equivalent were highly significant (P = .03, Wilcoxon signed rank test for paired values). There was no difference between targeted and achieved postoperative refraction (P = .34, Wilcoxon test). Increasing age was correlated with a hyperopic shift (r = 0.525, P = .05). All patients were satisfied with their final uncorrected visual acuity (UCVA), which improved in every case. Except for 1 patient in whom an epiretinal membrane developed, best spectacle-corrected visual acuity remained unchanged or improved. Conclusions In this series of patients, who were a few decades older than the typical excimer laser candidate, laser refractive surgery was a safe, effective, and predictable method to correct ametropia after cataract extraction with IOL implantation. It may be a viable, noninvasive alternative to intraocular surgery, which has potential complications. Although satisfactory for all patients, final UCVA was not as high as that reported in laser refractive surgery patients in general, and this result may be because of prior cataract extraction with IOL implantation or increased age.

Excimer laser surgery for correction of ametropia after cataract surgery.

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Excimer laser surgery for correction of ametropia after cataract surgery.