By using these concepts, almost any situation can be addressed and worked on by the inside-out or outside-in technique to move toward emmetropia without performing highly interventional, painful, debilitating procedures. At the same time, the ocular integrity is well preserved and stable.
Challenging cataract surgeries approached in a staged fashion can be used not only to design vision as mentioned in Part 1 of this column, but also to optically manipulate the interior of the eye to present stage 2 as the final refractive surgical component—reaching the end zone and keeping all the principles intact with the welcome side effect of having the patient become cheerleader as you reach the end zone.
The next column will highlight numerous case scenarios of patients who were considered to be complex cases referred to me from around the world. I will outline with images and videos my thought process and journey toward their best vision potential using the outside-in and the inside-out approaches. Until then, here are a few case studies to whet the appetite:
Case 2 (slide 2) is that of a patient who was referred with a corneal scar along with multiple LASIK surgeries. This scar was peeled along with simultaneous laser. The patient had 20/20 vision for 8 years when age-related cataracts developed. Following cataract removal recently, the patient again has 20/20 vision.
The patient in case 3 (slide 3) had a central, deep herpetic corneal scar that nearly caused an excavation in the cornea with best corrected 20/400 vision. Following “In Cornea” Laser approach he had a moderately smooth cornea, such that the patient was satisfied with the uncorrected 20/40 vision. Later, when an age-related cataract developed, given the complex nature of the cornea with poor visibility and difficult calculation, I used a femtosecond laser to perform a perfect rhexis in preparation for an aphakic staged technique to then perform toric IOL placement as a staged process 1 week later following accurate aphakic refraction (with an acknowledgement to Richard Mackool, MD) to an excellent end point of 20/25.