REFRACTIVE ERROR AND SURGERIES IN THE UNITED … · refractive procedures • One eye (dominant)...
Transcript of REFRACTIVE ERROR AND SURGERIES IN THE UNITED … · refractive procedures • One eye (dominant)...
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REFRACTIVE ERROR AND SURGERIES IN THE UNITED
STATES
• 150 million wear eyeglasses or contact lenses
• 2.3 million refractive surgeries performed between 1995 and 2001
Introduction
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REFRACTIVE SURGERY: POPULARITY, EFFICACY,
SAFETY • LASIK (laser in situ keratomileusis) currently most performed procedure
• LASIK improves vision to 20/20 in up to 93.5% of patients with low to moderate nearsightedness
• Long-term outcomes of refractive surgery as yet unavailable
Introduction
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Primary care physicians’ understanding of refractive procedures helps ensure
quality patient care.
Introduction
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Refractive Errors
The human eye
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REFRACTIVE ERRORS
• Myopia—nearsightedness • Hyperopia – farsightedness • Astigmatism—irregularly shaped cornea,
causing blurred vision • Presbyopia—age-related loss of lens
flexibility, causing reduced near vision
Refractive Errors
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• Images focus in front of retina
• Severity is related to success of refractive surgery
Refractive Errors
MYOPIA (NEARSIGHTEDNESS)
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• Images focus behind the retina
• Renders refractive surgery less predictable, requires longer to stabilize
Refractive Errors
HYPEROPIA (FARSIGHTEDNESS)
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• Uneven curvature of cornea
• Causes separate areas of focus and consequent blurring
Refractive Errors
ASTIGMATISM (BLURRED VISION)
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PRESBYOPIA (LOSS OF FOCUSING ABILITY)
• Loss of accommodation with age • Manifests in early 40s • Cannot be halted or mitigated with
refractive surgery
Refractive Errors
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Snellen visual acuity chart
Refractive Errors
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SCREENING CANDIDATES FOR REFRACTIVE SURGERY
• Success relies on sound total eye health • Ameliorate correctable ocular disorders
prior to surgery
Presurgical Evaluation
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• Dry eye – Watery or dry eyes, visual
fluctuation
• Blepharitis (shown) – Burning, watering
Presurgical Evaluation
DISORDERS OF TEAR FILM AFFECTING REFRACTION
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CORNEAL DISORDERS AFFECTING ACUITY:
KERATOCONUS
Presurgical Evaluation
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CORNEAL DISORDERS AFFECTING ACUITY: CORNEAL SCARRING
Presurgical Evaluation
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• Iris defects may cause blurring or multiple images
• Large pupils may lead to the appearance of postsurgical glare (top) or halos (bottom)
Presurgical Evaluation
IRIS AND PUPIL CONDITIONS AFFECTING ACUITY
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LENS DISORDERS AFFECTING ACUITY
Presurgical Evaluation
Cataract seen through pupil as a white opacity
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RETINAL DISORDERS AFFECTING ACUITY
• Diabetic retinopathy • Retinal detachment • Cystoid macular edema • Retinal scar • Age-related macular degeneration
Presurgical Evaluation
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CNS DISORDERS AFFECTING ACUITY
• Amblyopia • Disorders of visual cortex • Ischemia
Presurgical Evaluation
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PATIENT EVALUATION FOR REFRACTIVE PROCEDURE
• Comprehensive process requiring excellent doctor-patient communication – Preoperative interview – Examination – Ancillary testing
Presurgical Evaluation
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PREOPERATIVE EXAMINATION: PATIENT
EXPECTATIONS • Possibly most important predictor of surgical “success”
• Patients demanding “perfect vision” not good candidates
Presurgical Evaluation
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PREOPERATIVE EXAMINATION: SOCIAL
HISTORY
• Visual needs of work or play: Needs of a teacher versus a young baseball player versus a middle-aged golfter/accountant
Presurgical Evaluation
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PREOPERATIVE EXAMINATION: MEDICAL
HISTORY
• Systemic diseases may compromise success – Diabetes – Collagen vascular (rheumatoid arthritis, lupus, Sjögren’s) – Immunosuppression – Pregnancy/nursing contraindicate procedure
Presurgical Evaluation
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PREOPERATIVE EXAMINATION: MEDICINES
• Contraindicated for LASIK – Accutane – Imitrex – Amiodarone
• Other medicines with possible effects – Antihistamines – ± Anticoagulants?
Presurgical Evaluation
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PREOPERATIVE EXAMINATION: OCULAR
HISTORY • Contact lens wear • Trauma • Previous surgery • Glaucoma • Ocular HSV • Family history
Presurgical Evaluation
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• Tolerated by 85% of population with up to several weeks’ adjustment period
• Contact lens trial before procedure
• Can be used in a variety of refractive procedures
• One eye (dominant) set for distance and one eye set for near or intermediate (as shown)
Presurgical Evaluation
PREOPERATIVE EXAMINATION: MONOVISION
POSSIBLE?
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PREOPERATIVE EXAMINATION: OCULAR
EXAMINATION • Visual acuity • Pupil exam • Ocular motility • Confrontation visual fields • Intraocular pressure • Slit-lamp exam • Dilated fundus exam
Presurgical Evaluation
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• Corneal topography (as shown on top)
• Pachymetry (as shown on bottom)
• Wavefront analysis • Ultrasound/interfer-
ometry to measure axial length
Presurgical Evaluation
PREOPERATIVE EXAMINATION: ANCILLARY
TESTING
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PROCEDURES IN REFRACTIVE SURGERY
• Incisional corneal surgery – RK, AK
• Corneal inserts – Intacs
• Photoablative procedures – LASIK, LASEK, PRK
• Conductive keratoplasty • Intraocular surgery
– Phakic IOLs – Natural lens replacement
Refractive Procedures
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• Developed in the 1970s
• Multiple radial cuts into corneal stroma to correct mild to moderate myopia
• No longer the most popular, safest, or most stable refractive procedure
Refractive Procedures
RADIAL KERATOTOMY (RK)
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RADIAL KERATOTOMY (RK): COMPLICATIONS
• Lack of stability—refractive fluctuations and shifts
• Complications – Irregular astigmatism – Glare – Wound dehiscence
Refractive Procedures
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• Tangential incisions in cornea used to correct astigmatism
• Same risks as RK • Often used in
conjunction with cataract surgery
Refractive Procedures
ARCUATE KERATOTOMY (AK)
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• Circular rings of polymethylmethacrylate (PMMA) placed in mid peripheral stroma
• Treats low myopia • Removable/exchangeable
Refractive Procedures
INTRASTROMAL CORNEAL RINGS (INTACS)
Vertical placement of INTACS Cross section of cornea with INTACS
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PHOTOABLATIVE PROCEDURES
• Excimer (“excited dimer”) laser – Allows precise removal of
corneal tissue – Pattern can be “customized”
• Used for PRK, LASEK, LASIK
Refractive Procedures
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PHOTOREFRACTIVE KERATECTOMY (PRK):
PROCEDURE • Alcohol placed to loosen epithelium • Central epithelium debrided • Laser ablation • Epithelium grows back from periphery
under bandage contact lens
Refractive Procedures
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PRK: ADVANTAGES AND DISADVANTAGES
• Advantages – No corneal flap complications – Long-term stability – Can perform on thin cornea
• Disadvantages – More patient discomfort – Inconvenience: usually done one eye at a time – Slightly higher risk of infection – Risk of haze (mitomycin C may minimize) – Glare/halos
Refractive Procedures
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1. Alcohol used to loosen epithelium 2. Epithelium carefully rolled back 3. Laser ablation of underlying surface 4. Tissue removed by laser 5. Epithelium replaced and protected with bandage contact
lens 1 2 3 4
5
Refractive Procedures
LASER SUBEPITHELIAL KERATOMILEUSIS (LASEK):
PROCEDURE
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LASEK: ADVANTAGES AND DISADVANTAGES
• Advantages – Same as PRK – Epithelial flap replacement helps with post-op pain
• Disadvantages – Inconvenient: usually performed one eye at a time – Same risks as PRK – Glare/halos
Refractive Procedures
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1. Suction ring stabilizes globe 2. Microkeratome creates thin stromal flap with a
hinge 3. Flap reflected back 4. Laser ablation sculpts cornea 5. Stromal flap replaced 1 2 3 4
5
Refractive Procedures
LASER IN SITU KERATOMILEUSIS
(LASIK): PROCEDURE
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LASIK: ADVANTAGES AND DISADVANTAGES
• Advantages – Little discomfort – Fast visual recovery – Long-term stability
• Disadvantages – Thin corneas not good candidates – Flap complications – Glare/halos – Diffuse lamellar keratitis (DLK)
Refractive Procedures
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LASER DIFFERENCES
• Conventional laser – Laser program “imprints” standard refraction onto cornea
• Wavefront-guided or “custom” laser – “Imprints” patient’s custom refraction – Theoretically removes aberrations in cornea – Higher chance of reaching refractive goal in low/moderate
myopes
• Either can be used for PRK/LASEK/LASIK
Refractive Procedures
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LASIK: OTHER ISSUES
• Enhancement – LASIK flaps can be lifted for later retreatment/refinement of
refraction
• Monovision – Dominant eye set for distance – Other eye for intermediate or near – Careful explanation of visual outcome necessary for patient
satisfaction
Refractive Procedures
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• Fine conducting needle delivers radiofrequency energy into peripheral cornea
• Locally shrinks collagen fibers
• Corrects low hyperopia/astigmatism
• Induces myopia to give presbyopes greater focus at near
Refractive Procedures
CONDUCTIVE KERATOPLASTY
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CONDUCTIVE KERATOPLASTY: ADVANTAGES AND DISADVANTAGES
• Advantage – Relatively safe, quick, and noninvasive
• Disadvantage – No long-term data demonstrating stability
Refractive Procedures
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INTRAOCULAR SURGERY
• Improved technology and techniques allow for relatively safe “elective” intraocular surgery – Phakic IOL – Clear lens extraction – Accommodative IOL
Refractive Procedures
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• IOL inserted into eye with natural lens still in place
• Allows for accommodation
• Typically used in younger high myopes
• Avoids ablation of cornea
• Removable • Small risk of cataract
and iritis
Refractive Procedures
PHAKIC INTRAOCULAR LENSES (IOLs)
Phakic IOL in place
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NATURAL LENS REPLACEMENT
• Replacing noncataractous crystalline lens with IOL for refractive purpose
• Indications – Not a good photoablative candidate – Cornea too thin, too flat, too steep – High myopia/hyperopia
Refractive Procedures
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NATURAL LENS REPLACEMENT: ADVANTAGES AND DISADVANTAGES
• Advantages – Same procedure as cataract surgery – Avoids risks of flap creation and corneal ablation – Corrects high degree of myopia/hyperopia
• Disadvantages – Risk of intraocular surgery
� Endophthalmitis, hemorrhage, retinal detachment – Patient expectations
Refractive Procedures
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Accommodative IOL Multifocal IOL
Refractive Procedures
IOLs USED IN REFRACTIVE PROCEDURES
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REFRACTIVE SURGERY: THE FUTURE
• Ongoing improvement in current lasers and techniques
• Customizable intraocular lenses – Programmable in-situ with certain wavelengths of light – Smaller incisions and instruments improving safety profile
• Knowledgeable PCPs can help counsel and advise patients considering refractive procedures
Surgery