Eyeworld Daily News

EW SHOW DAILY 34 Monday, April 28, 2014 Meeting Reporter I n 2013, said John A. Vukich, MD, Madison, Wis., 79% of ASCRS members said they used 20/20 uncorrected visual acuity (UCVA) as their target for laser vision correction (LVC); 44% used the Randleman criteria for LVC patient selection; and 36% believed that LASIK leads to a significant increase in dry eye risk. Dr. Vukich was quoting the results of the 2013 ASCRS Clinical Survey that included 1,041 unique respondents, which has been used to guide the Society's educational pro- gramming. Whatever their basis, the per- ceptions revealed by the survey are no longer supported by the growing body of data on LVC. At the EyeWorld CME Education sympo- sium on "Today's Innovations in Corneal Refractive Diagnostics, Treatments, and Techniques," a group of experts presented data in an attempt to overturn—or at least better inform and contextualize— those perceptions. According to the ASCRS Clinical Survey, about 18% of procedures performed were surface ablations. This number, said Steven J. Dell, MD, Austin, Texas, is driven by con- cerns for dry eye and ectasia—and is, based on the enormous dataset from Optical Express (U.K.), much too high. The Optical Express data in- cluded 44,475 eyes (22,866 patients) that underwent LASIK and 1,846 eyes (1,007 patients) that underwent PRK. The LASIK eyes fared better in terms of binocular uncorrected distance visual acuity (UDVA) on postop day 1. The PRK eyes eventu- ally caught up at 3 months, with no significant difference between the two groups at that point, but visual recovery is clearly protracted. The trend in terms of dry eye was similar: at 1 month, 85% of eyes that underwent LASIK had little or no dry eye problems compared with only 79% of eyes that underwent PRK. Both groups improved over time, with the PRK eyes catching up: At 3 months, 90% of the LASIK group and 87% of the PRK group experienced little or no dry eye problems. The Optical Express data was also analyzed to determine predic- tive factors for ectasia. The data revealed that anterior curvature appeared to be most predictive; sig- nificantly, the Randleman criteria Realigning perceptions on laser vision correction by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer was found to have a low predictive value. Of 205,285 eyes, 8.9% treated were in the moderate risk category and 4.1% were in the high risk cate- gory following the Randleman crite- ria. Only eight developed ectasia. In other words: "You would have to incorrectly tell 3,400 cases 'no' to correctly identify eight ectasia cases using the Randleman criteria," said Dr. Dell. The criteria is thus of "little statistical use." Cost might also drive some surgeons and patients to choose sur- face ablation over LASIK. There is certainly an additional device cost to LASIK; however, the additional costs of surface ablation—which include the cost of recovery translating into time away from work and additional medication—in sum are "greater than any additional costs for a prac- tice to perform a femtosecond laser flap," he said. Finally, 20/20 "simply isn't good enough anymore," according to Jason P. Brinton, MD, Overland Park, Kan. Out of 104 eyes (52 patients), they found that 96% achieved 20/20 UDVA monocularly at day 1; binocularly, 98% achieved 20/16 UDVA. Just 1 month later, 100% were seeing 20/20, 92% 20/16, 66% 20/12.5, and 10% 20/10 with binocular summation. Dr. Brinton concluded: "20/20 or 'satisfied' is no longer the gold standard." Instead, he proposed VA beyond 20/20, efficacy ratio, and gain in lines of UCVA compared to preop BCVA as better metrics for current laser vision correction. EW Editors' note: This event was supported by an unrestricted educational grant from Abbott Medical Optics. Steve Schallhorn, MD, discusses the evolution of diagnostic information used to drive laser ablations at a symposium addressing a number of common misperceptions about the procedure. aspiration, iris color, surgical time, and patient's age. Inflammation is also influenced by comorbid con- ditions, both systemic and ocular. The significance of inflamma- tion might be made most obvious by looking at cystoid macular edema. Postop CME is seen in 1–2% of cases; the incidence is even higher when CME is diagnosed angiograph- ically. CME impacts both short- and long-term visual acuity, cost of care, and patient satisfaction. CME, said Keith A. Walter, MD, Winston-Salem, N.C., is "the enemy," resulting in 33% of eyes with best corrected visual acuity outcomes of 20/40 or worse and 28% developing an epiretinal mem- brane. Surgeons currently have their choice of a number of anti-inflam- matory agents with advanced for- mulations that make them safer for the ocular surface, enhance efficacy through increased penetration and tissue concentration, and require less dosing for better patient com- pliance. To control inflammation, particularly to prevent CME, Dr. Walter recommended using an NSAID in every case. NSAIDs, he said, totally shut down prostaglandin formation and are now available in once-daily formulations with excellent data. They can be used with or without steroids. He did, however, caution against using generics, which are only required to demonstrate bioe- quivalence in the bottle in animal, clinical, and bioavailability studies, and so may not have the best vehi- cles to maximize tissue penetration and concentration. Ultrasound energy also impacts inflammation. In addition to tech- nique, new technology such as the femtosecond laser can reduce—and, in the future, perhaps even elimi- nate—the amount of ultrasound energy used during surgery, said Steven J. Dell, MD, Austin, Texas. The laser, he said, delivers energy more efficiently, with less heat and less collateral damage than ultrasound. EW Editors' note: This event was supported by an unrestricted educational grant from Bausch + Lomb. Inflammation continued from page 32

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