Enhancements After Refractive Surgery

Rates trending downward, but some determining factors remain under surgeon control.

Cheryl Guttman Krader

Posted: Wednesday, December 1, 2021

Rates trending downward, but some determining factors remain under surgeon control.

Cheryl Guttman Krader reports from the 39th Congress of the ESCRS in Amsterdam.

A review of the published literature shows that residual refractive error and poor optical quality are the main reasons for retreatments after corneal and lens-based refractive surgeries. Encouragingly, data also show that outcomes and patient satisfaction after the primary procedure have improved over time, reported Thomas Kohnen MD, PhD.

Recognising however, that the risk of residual refractive error or poor optical quality is affected by a variety of preoperative, intraoperative, and postoperative factors, he counselled his colleagues to focus on prevention and be judicious when considering retreatment.

“Avoid residual refractive error and optical disturbances by performing good surgery and for the correct indications. Second, only do retreatment for these issues if the patient is bothered and not because you think the outcome is not perfect. We have to consider our patients’ satisfaction, not just our own,” Prof Kohnen advised.

Prof Kohnen discussed his centre’s experience and reviewed selected studies reporting outcomes for laser corneal refractive procedures, phakic IOL implantation, and refractive lens exchange. While the incidence of retreatment after refractive surgery has changed over time because of the ongoing procedure evolution, he concluded the overall incidence ranges from 1% to 5% and depends on the procedure and the refractive correction magnitude.

Published data demonstrate how patient satisfaction after LASIK has increased over time. A 2009 article reviewing the world literature reported that 95% of patients were happy with their outcomes. In 2016, a paper that included data from 97 articles published between 2008 and 2015 encompassing approximately 68,000 eyes reported 99% of patients were satisfied, and the rate of loss of fewer than two lines of CDVA was only 0.61%. Another paper published in 2020 reviewing a consecutive series of approximately 70,000 eyes treated with LASIK or PRK reported only 0.37% of eyes lost fewer than two lines of CDVA.

Literature reports on phakic IOL procedures also show outcomes have improved over time in parallel with advances in technology. For example, a study of eyes implanted with an ICL (Staar Surgical) showed a better functional outcome using the newer iteration with the central hole versus the model without the hole. Prof Kohnen referenced results from a study his group submitted for publication that showed excellent refractive predictability was achieved in eyes implanted with the central hole model (ICL V4c).

“The need for retreatment after ICL implantation will decrease significantly with the availability of the toric version that allows us to correct astigmatism,” he predicted.

Two papers from his group analysed outcomes in patients undergoing refractive lens exchange with an implant of trifocal or quadrifocal presbyopia-correcting IOLs. Both papers showed high predictability of the refractive result and attainment of an outcome very close to emmetropia, which is the target in these cases, Dr Kohnen said.

“Of course, these results were achieved in clinical studies, and we have to look at real-world outcomes,” he cautioned.

Thomas Kohnen MD, PhD is Professor and Chair, Department of Ophthalmology, Goethe University, Frankfurt am Main, Germany.

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