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  • Refractive Surgery: Simplicity Versus Complexity

    “This is really a tale of two pathways — that of simplicity, speed, and safety versus complexity, quality, and customization,” said Ronald Krueger, MD, as he offered a rapid-fire overview of current and future developments in refractive surgery during the “Innovation” (Ref05V) event at Friday’s Subspecialty Day. He divided approaches into four categories.

    Myopic laser vision correction is a category in which small-incision lenticule extraction (SMILE) and custom LASIK will coexist, he said. While SMILE is less invasive, faster, and potentially safer, topography-guided LASIK is improving and may provide better quality of vision. Based on historical trends, Dr. Krueger expects the market for SMILE to increase in the next decade.

    High hyperopic tissue implantation, such as implants placed in a SMILE pocket or under a LASIK flap, will add new therapies to the field, continued Dr. Krueger. Although they may be more complex, these implant techniques are potentially better than refractive lens exchange because they spare the lens and do not affect accommodation. He believes these methods will give rise to a new concept of refractive eye banking that will provide a source of refractive tissues — for example, to facilitate SMILE lenticule implants — and even allow commercial entities to supply tissue.

    Presbyopic IOL solutions, on the other hand, expand refractive options, said Dr. Krueger. Unlike standard extended depth-of-focus (EDOF) and trifocal intracapsular intraocular lenses (IOLs) — which can be difficult to explant — EDOF phakic IOLs are easier to remove if patients are dissatisfied. These lenses come in three categories: diffractive, refractive, and pinhole optics. Pinhole optics, in particular, can reduce glare and halos when the patient is looking at a distance, and they are tolerated in cases of astigmatism up to 1.5 D, with good visual acuity.

    Also in this group are light-adjustable lenses, which provide an adjustable blended-vision model. They appear complex, but it’s easier to adjust them than it is to explant a lens.

    “Accommodation restoration is the next frontier,” said Dr. Krueger about the final category. These approaches include topical drops (EV06) that can restore elasticity to the crystalline lens, and biomimetic accommodating IOLs (LensGen) that facilitate focus change via a posterior optical element and an accommodating anterior element.

    Finally, Dr. Krueger notes that SMART (Super Magnification Remove Reflective Technology) IOLs will return control back to patients. These multi-element lenses include nanoparticle technology that can be controlled using a smartphone to manage focus with good clarity and magnification.

    “Simplicity versus complexity, judge for yourself,” concluded Dr. Krueger. — Kanaga Rajan, PhD

    Watch Refractive Surgery Subspecialty Day. If you are registered for AAO 2020 Virtual, you have access to the archived presentations on the virtual meeting platform until Feb. 15, 2021. Log in to the virtual meeting platform: Next, from the Lobby screen, select “Sessions” from the top navigation; click “Agenda” from the drop-down menu; and click on the “Friday” tab.  

    Financial disclosures. Dr. Krueger: Alcon: C; Bausch + Lomb: C; Johnson & Johnson Vision: C; Ocutrx: O,C; Optoquest: C; Rx Sight: O; Strathespey Crown: O.

    Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.

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