UNFINISHED BUSINESS IN REFRACTIVE SURGERY

As refractive surgery enters its fourth decade, visual outcomes will continue to improve thanks to both new technologies and refinements of older approaches, predicted Gunther Grabner MD, salzburg, Austria. Even presbyopia, the “last frontier†of refractive surgery, is being crossed as new corneal and lens options emerge and assessment tools improve. “There’s a lot of unfinished business in the field of refractive surgery,†said Dr Grabner, who gave the Barraquer Lecture at the joint meeting of the American Academy of Ophthalmology and the Asia-Pacific Academy of Ophthalmology. he noted that for every technique that has succeeded, such as LASIK, others have faded away, such as radial keratotomy, or never really caught on, such as conductive keratoplasty. however, technological advances may bring back some less popular techniques, he noted.

For example, the precision of femtosecond laser technology may make astigmatic keratotomy more predictable and less technically challenging, Dr Grabner said. intrastromal astigmatic keratotomy also shows promise, and would leave the epithelium intact. As a result, he expects astigmatic incisional procedures of all types to gain popularity. While phakic intraocular lenses have had their share of complications, with many pulled from the market due to endothelial damage, some newer angle-supported and iris-supported designs reduce the risks, Dr Grabner noted. iris-claw toric lenses offer significant refractive advantages with low risk, he noted.

Similarly, new hydrogel and biosynthetic materials and lens designs may make corneal onlays viable for refractive surgery, Dr Grabner said. Tests have shown these materials produce better visual outcomes and fewer complications than epikeratophakia using earlier hydrogels or donor grafts. A range of new approaches is emerging for presbyopia correction, including hydrogel corneal implants and the pin-hole implants. Unlike laser corneal procedures, these implants are reversible, and they do not carry the risk of intraocular procedures, Dr Grabner noted. he considers the KAMRA pin-hole device to be a top choice for presbyopia in patients who do not need cataract surgery.

Development of technologies that assess the outcomes of presbyopia treatment in more meaningful, functional ways also helps improve outcomes. Devices such as the salzburg Reading Desk, developed by Dr Grabner and colleagues, more accurately measure reading speed and acuity than Jaeger charts and stopwatches. These assessment tools should be used in clinical practice to quantify outcomes and help determine how the various presbyopia correction options compare. Dr Grabner was chosen for the Barraquer Award, which honours a physician who has made significant contributions in the field of refractive surgery, in part for his work on the salzburg Reading Desk. The lecture and award are named for refractive surgery pioneer Jose i Barraquer MD.

Dr Grabner founded the first eye bank in Austria in 1977, and founded cornea and uveitis clinics, and a centre for refractive corneal surgery at the second University Eye Clinic in Vienna. since 1993 he has been director and full professor at the Paracelsus Medical University in salzburg.