Structural considerations can lead to improved surgical outcomes for patients
This article was reviewed by William J. Dupps Jr., MD, PhD
Most technologies naturally evolve over time. However, in the case of LASIK, does the procedure need to? William J. Dupps Jr., MD, PhD, made his case for the impact of biomechanical information and how structural considerations may actually improve outcomes.
“Isn’t LASIK good enough?” asked Dr. Dupps, professor of ophthalmology, Cole Eye Institute, Cleveland Clinic. “Why do we need to worry about biomechanical or structural assessment? We are doing just fine.”
This is a common sentiment, noted Dr. Dupps, adding that he believes that most surgeons still are looking for ways to deliver even safer, more precise outcomes.
Dr. Dupps describes what he calls a “precision gap” in refractive surgery planning.
“There is a remarkable degree of precision available in our preoperative assessment tools on one hand and in the treatment delivery systems on the other,” he said. “But there is a striking gap in how we leverage those capabilities to develop and customize treatment plans.”
Moreover, Dr. Dupps noted that surgeons leave a lot of information on the table when they take a plan to the operating room.
“If we are seeking ultimately to reduce the number of refractive outliers, improve the ability to dial in very specific optical outcomes in individual cases, and minimize the risk of structural weakening that can lead to refractive outliers or progressive corneal instability, then we will need to develop treatment planning paradigms that incorporate preoperative corneal biomechanical information and use all pertinent outcome-driving data in our predictive models,” he said.
Current status of planning
Dr. Dupps pointed out that most refractive surgery treatment planning—whether for LASIK, PRK, SMILE, intracorneal rings, or incisional refractive surgery—is currently retrospective, i.e., based on historical outcomes; probabilistic and not deterministic; and minimally personalized in that treatment plans are often driven by a very limited subset of the patient’s data.
For example, most laser refractive surgery is performed using only the refractive error as an input, which some surgeons modify using nomogram software packages that generate empirical treatment adjustments based on previous outcomes for that treatment system.
A smaller number of procedures are performed using customized topography or wavefront-guided treatment patterns, but even in these treatments, large amounts of potential outcome-driving features of the patient are not used in treatment planning.
“All corneal refractive procedures are either directly mediated by biomechanical effects (incisions, corneal ring segments and crosslinking) or affected by them (LASIK, PRK and SMILE), yet we lack a unifying clinical decision tool that uses this knowledge in a predictive way,” Dr. Dupps said.