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Questions help determine when enhancements are warranted


An ophthalmologist details several questions clinicians must answer when deciding whether to use an excimer laser to perform enhancements after PRK or LASIK, lamellar surgery, incisional surgery, lens surgery, or corneal surgery.


Dr. Binder, in private practice in San Diego, enumerated important points to consider before using the laser to perform enhancements after PRK or LASIK, lamellar surgery, incisional surgery, lens surgery, or corneal surgery:

"With each individual procedure, there are very specific questions you have to address," Dr. Binder added, again providing several questions to ask.

With PRK:

"You can't use a femtosecond laser on an eye that's had previous PRK for fear of gas breakthrough going through the center of the cornea," he said.


With previous lamellar surgery:

With previous incisional surgery:

"You risk gas breakthrough with a femtosecond laser when operating on incisional cases," he said, "and if you perform a destabilizing procedure such as LASIK over an RK eye, you may destabilize that cornea further, so you might lean toward doing surface treatment."

With previous lens surgery:

With previous corneal surgery:

"If you have previous thermokeratoplasty and you put changes and holes in Bowman's layer, a femtosecond laser won't work with that procedure because you'll have vertical gas breakthrough," Dr. Binder said. "You might consider surface surgery."

Basic rules

He concluded: "I'll finish with these basic rules: In enhancing a previous case, avoid overcorrection, consider conventional versus custom surgery depending on the patient's needs, and attempt one eye at a time so you can avoid unexpected outcomes.

"Enhancements are less predictable than primary cases, and that's something you really have to keep in mind. Determine [patient] expectations, match expectations to what is achievable whenever possible, and confirm refractive stability of the eye. Your findings must [match up] to the symptoms, because if they don't, you're going to be in trouble."

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