August 2025 - 2
Author: Dr Alex Hamilton
A 30 year old male was referred for a second opinion to discuss his suitability for laser surgery. He was unable to wear glasses due to the nature of his work did not tolerate contact lenses.
His refraction, which had been stable for many years, was:
Right eye: -3.75 / -2.25 x 15 VA 6/4.5
Left eye: -3.00 / -1.00 x 157 VA 6/4.5
(Image above: Corneal tomography / Pentacam)
Which procedure is likely to be most appropriate for this patient?
A - LASIK
Oops! Try again
B - PRK
Oops! Try again
C - SMILE
Oops! Try again
D - ICL
CORRECT!
Answer D
The Pentacam of the left eye shows inferior steepening of the cornea. Both the right and left corneas are thin. Although the best corrected vision is excellent, these corneas are at risk of developing keratoconus if an ablative laser procedure is performed. As such, LASIK, PRK and SMILE are all best avoided in this case because they all remove corneal tissue and risk weakening the cornea.
An ICL (Implantable Collamer Lens) is the best surgical option for this man. An ICL is a lens that is implanted into the sulcus. ICLs are versatile and can correct refractive errors up to -20D of myopia and 6D of astigmatism. Patients must have a stable refraction, good endothelial cell count, a deep anterior chamber and an open angle on gonioscopy. They are reversible and long term data has shown them to be safe and effective.
The key to refractive surgery is choosing the correct procedure for the correct person. For many people glasses or contact lenses are the best option. For those who want a surgical solution, choosing the correct procedure requires taking into account:
- Age
- Social factors such as job and sports played
- Refraction
- Ocular factors such as dry eye, lens status
- Investigations such as Pentacam.
