Questions help determine when enhancements are warranted

Keypoints:

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 LASIK:

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."