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Miss W presented with problems driving. Vision was poor at night, but passable through the day, although she was aware that it was not as good as it could be. She had had RK 12 years previously and reported good vision until recently. She wore no glasses or contact lenses, and had not had any correction since her RK surgery. Her last eye test was 11 years previously. Miss W was 35 years old and worked as a teacher's aid. Internal and external examinations were unremarkable. Miss W had 16 incision RK R&L extending to 1mm from the corneal centre. The RK incisions looked "wide" with reasonable scar tissue in the incision. There was no surface damage or staining with fluorescein and tear break-up time was 12 seconds R&L.

Post Op RK patient showing 8 radial incisions with moderate scarring. This picture is NOT from the case being presented, but is shown for consideration. Unaided vision was 6/60 RE and 6/36 LE. Miss W corrected to: RE: +7.25/-3.75x 120 6/24 KE: +5.50/-4.75 x 95 6/15 Topography showed significant corneal distortion in the peripheral zone as well as in the central 2mm optical zone. Trial contacts were fitted using VMC design lenses from Gelflex laboratories. These lenses had an optical zone of 6mm. Being a reverse geometry design, these lenses were chosen to align the lens geometry as close to the cornea as possible. Several lenses were trialed before fittings of: RE: 9.20 / 11.2 / +2.25 LE: 9.05 / 11.2 / +1.50 VMC design, Boston XO material, Blue tint. The lenses were judged to fit well and were ordered from Gelflex. They arrived 3 days later and Miss W arrived for her fitting. Vision was 6/6 RE and 6/7.5 LE. Fit was judged to be good using fluorescein and a slit lamp with cobalt filter.

Miss W returned for review 1 week later. She reported increased use of the lenses and good vision. She reported that her vision had not been as clear since before her RK surgery. Comfort was still an issue but the lenses were being worn up to 10 hours per day. The next aftercare visit was 2 weeks later. Comfort was still an issue, but the lenses were being worn 12 hours per day and vision was excellent. The lenses fitted well and no staining or other anomaly was present under slit lamp examination. Miss W returned 8 weeks later, having missed several appointments. She was wearing the lenses 6-10 hours per day but was still aware of the edges. The lenses were returned for adjustment and were refitted 2 days later.

Miss W was much happier and was asked to return in 2 weeks for review of her lenses. At this review, Miss W complained that the lenses were still causing discomfort and that wearing time was down to 4 hours per day, 3-4 days per week. Having worn the lenses for 3 months, it was decided to try soft toric lenses. New lenses were ordered from Gelflex, with parameters of: 8.7 / 14.5 / +7.75 / -4.00 x 120 8.7 / 14.5 / +5.75 / -5.00 x 95 40% material, blue handling tint The lenses were ordered with an increase in centre thickness of 0.06mm to compensate for corneal distortion, but to keep as thin as possible to retain oxygen transmissibility. On collection, Miss W had acuity of 6/9= RE and 6/12+ LE. The lenses fitted well and gave adequate movement. Miss W returned for aftercare 2 weeks later. She reported wearing time of 14 hours per day, 7 days per week. She noted that vision was not as good as with the hard lenses, but comfort was excellent and there was no awareness of the lenses over the full days wear. Miss W returned for an aftercare 2 months later and reported all being well and wearing time as 14-16 hours per day, 7 days per week. She was now confident with driving and was not willing to go out without her lenses. Vision and fit remained the same, and no staining was recorded.

DISCUSSION While excellent vision was made with reverse geometry Gas Permeable lenses, comfort could still not be made sufficient to wear on a full time basis. While visual acuity was significantly less with soft toric lenses, but wearing time was increased to as much as the patient chose. As much as the fitting and vision were excellent with the GP lenses, comfort remained an issue after 3 months. The soft toric lenses were able to get Miss W below the legal driving standard and with enough clarity to wear on a fill time basis.

This months case report is provided to us by Dr. Grant Mason in Melbourne, Australia. We gratefully acknowledge Dr. Mason's assistance.

To submit an article, contact lens or surgical case case report, please email
Co-MedicalDirector@surgicaleyes.org.

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If you have postrefractive patients with visual issues after refractive surgery, what do you recommend most often?

1) Contact lenses
2) Further surgery with current technology
3) Wait for newer technology
4) No further surgery
5) None of the Above

Please click here to answer the above poll. s

Last months poll results:

If you have postrefractive patients with long-standing complications, what is the complaint you hear most often?

1) Dry Eye 38%
2) Quality of Night Vision 38%
3) Quality of Day and Night Vision 0%
4) None of Above 0%
5) All of the Above 24%

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Contact Lenses: Where Now and Where to? Technology and the changing needs of the global contact lens population will determine the future of contact lenses. Brien Holden, PhD, DSc, OAM, Serina Stretton, PhD, Kylie Evans, BA, and Deborah Sweeney, BOptom, PhD. Contact Lens Spectrum. January 2003. From the article: "Currently there is much hype about using custom ablations to reduce the horrendous aberrations resulting from spherical LASIK. Making aberration-free or aberration-controlled contact lenses is far less difficult. The future will know no other type of contact lens." More

Reinnervation in the Cornea after LASIK. Bong Hwan Lee, Jay W. McLaren, Jay C. Erie, David O. Hodge and William M. Bourne. Investigative Ophthalmology and Visual Science. 2002; Volume 43:Pages 3660-3664. In this study, Researchers determined that nerve fiber bundles decreases by 90% immediately after LASIK and while subbasal nerve fiber bundles gradually return, their number remains less than half of that before LASIK at the one year mark. More

Risk factors and prognosis for corneal ectasia after LASIK. J. Bradley Randleman, MD, Buddy Russell, FCLSA, Michael A. Ward, MMSc, FAAO, Keith P. Thompson, MD and R. Doyle Stulting, MD, PhD. Ophthalmology (2003); 110: Pages 267-275. This retrospective nonrandomized comparative trial concluded that significant risk factors for the development of ectasia after LASIK include high myopia, forme fruste keratoconus, and low RSB. More

The Role of Ray Tracing Technology. David R. Hardten, M.D.Ophthalmology Management. February 2002. From the article: "Our visual system, though, has forward aberrations, that is, a light source from outside of the eye is focused by the visual system and imaged on the retina. Ray tracing, or LASEREFRACTION, technology from the Tracey Visual Function Analyzer (Tracey-VFA) measures forward aberrations by determining the retinal location of a light ray projected into the eye. With Hartmann-Shack devices, the lenslet array measures all points within the pupil simultaneously and is therefore susceptible to data confusion by highly aberrated eyes. The Tracey-VFA's LASEREFRACTION measures each point of light sequentially, minimizing confusion from the crossing of data points." More
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Dr. Dan Reinstein, MD MA(Cantab) DABO FRCSC

Dr. Reinstein combines extensive post-doctorate fellowship sub-specialty training in refractive surgery, ophthalmic ultrasound, and ultrasound bioengineering as well as his experience as a research scientist in his field. His special interests include the systematization of surgical technique and the assessment and correction of the complications of refractive surgery. See Case Histories.

In scientific research, Dr. Reinstein initiated and has led the development and use of a new 3D VHF digital ultrasound scanner that for the first time can provide thickness measurement of individual corneal layers as well as the anterior segment ocular dimensions with micronic precision. He has pioneered the use of this technology, with a focus on the study of the healing responses within the cornea and analysis of the complications of corneal refractive and intraocular lens implant surgery. This technology has received FDA approval for the commercial version: Artemis™ and is now available through Ultralink, LLC (www.arcscan.com) Because the Artemis can determine the exact anatomical basis for surface corneal irregularities, it provides information for the analysis of the optical complications of refractive surgery that cannot be obtained by any other means. Anatomical analysis of the cornea can provide answers as to the cause of irregular topography, thus bringing the field of corneal refractive surgery to a new level. Instead of relying only on the outside shape of the cornea, surgeons are now capable of separating epithelial from flap or mechanical changes producing unwanted irregular topography. The understanding of epithelial thickness profiles, stromal surface shape, and residual stromal bed measurements is proving vital to the ability to not only avoid complications, but to enable their accurate diagnosis and correction. Another unique capability of the Artemis™ is it's ability to measure angle-to-angle and sulcus-to-sulcus dimensions within the eye directly. This promises to greatly improve the safety on phakic intra-ocular lenses, which are currently under FDA review, but lacking final approval. For a list of publications on the Artemis technology, see: www.reinsteininstitute.com.

Dr. Reinstein is in private practice in London, UK as medical director of the London Vision Clinic in the Harley Street district.

Family - lives in central London with his veterinarian wife Ursula and their two children Julia and Maxwell.

Hobbies - Concurrently with his medical career Dr. Reinstein has been playing the saxophone for 25 years including two years of study on a performance scholarship at the Berklee College of Music, and he continues to play jazz on a regular basis.

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Future Profiles to follow from Top Doctor Posters on our Bulletin Board:

Frank Holly PhD, W Trattler MD, Gregg Russell OD, Ken Minarik OD, Ophthinfo MD, James Salz MD, Clint Hoxie OD, Tracy Lynn Swarz, OD, Donald F. Ezekiel OD, Steven Lee OD, Sam Omar MD, Alejandro Tirado OD, Demetrian Dornic MD, Ricardo Trigo MD, Arthur Epstein OD, Chris Marmo OD, Hollis Stavn OD, Eirit Yonatan OD, Paul Klein OD, Robert Bard OD, Neal A. Sher MD, Jim Dillard OD, Gregg Feinerman MD, Steven Shum OD, Richard Bursua OD, Jason Jedlicka OD, Mark Ventocilla OD, Barrie Soloway MD, Carlton Chan OD, Jack Miller OD, Brian Boxer Wachler MD, Ken Maller OD, Joe B. Goldberg OD, Bruce Butts OD, Kraig Abe OD, Paul Blaze OD, Frank Goes MD, Bill Berke OD, David L. Davidson OD, Joe B. Collins OD, James Stevenot OD, Jeffrey Martin OD, Johnathan Christie, OD.
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CLES Meeting/Stein Lecture

Surgical Eyes Los Angeles, CA Meeting - February 22, 2003

Orbscan topographies (comment invited)

Can lasik sufferers really move on?

Correlation Between Large Pupils and Refractive Complications

Lasik in the News

• Surgical Eyes Meeting at Cedar Sinai, Los Angeles, CA - Saturday, February 22, 2003. Hosted by SE participating doctor James Salz, MD. Please sign up now. Space is limited! Our biggest meeting ever.
  

• Washington/Oregon Support Group Meeting on Saturday, March 1st, 2003 at Vision NorthWest in Tigard, Oregon, from Noon to 4:00 PM Lunch will be provided from Noon to 1:00 PM with an open meeting from 1:00 to 4:00 PM. John Wilkins, OD will be attending and will answer as many questions as possible. Please contact organizer Brenda Ross for more information!
  
  
• Pictures from our past meetings at Emory - Atlanta, GA and Cohosted by Gelfex - New York, NY in 2002. Some of the presentations made by doctors at both meetings will be available online.
  
  
• Surgical Eyes Meeting at Indiana Eye Care, Greenwood, IN - early March 2003 hosted by Dr. Charles McCormick III.
  
  
• Surgical Eyes Meeting in London, England - early May 2003 hosted by SE participating doctor Dan Reinstein, MD.

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The Surgical Eyes Web Site received over 14,275,000 hits in 2002 alone. This Newsletter is now featured on the front page of our Web Site with a growing subscriber base of over 3,500 readers - a technologically sophisticated interactive forum on refractive surgery complications featuring interaction between leading MDs, ODs, PhDs and a caring global network of patient participants.

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Chief Medical Editor
Gregg Russell, OD

Editor/Art/Production/Circulation
Ron Link

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Research Editors
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• Mark Bilafer
• Paul Fitzpatrick
• John Vernosky

Copy Editor
• Kirsten Taylor

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