Lasik as a Solution for High Hypermetropia

ORIGINAL PAPER Lasik as a Solution for High

Hypermetropia
doi: 10.5455/medarh.2019.73.191-194
MED ARCH. 2019 JUN; 73(3): 191-194
RECEIVED: FEB 25, 2019 | ACCEPTED: APR 26, 2019
Alma Biscevic1, Ajla Pidro1, Melisa Ahmedbegovic Pjano1, Senad Grisevic1, Nina
Ziga1, Maja Bohac2
1
Eye Clinic “Svjetlost Sarajevo”, Sarajevo,
Bosnia and Herzegovina ABSTRACT
2
University Eye Clinic “Svjetlost” Zagreb, Aim: To evaluate safety and efficacy of Laser in situ Keratomileusis (LASIK) procedure for the
Zagreb, Croatia correction of high hypermetropia. Methods: Retrospective study of 160 patients (266 eyes) who
underwent LASIK procedure for the correction of hypermetropia between +3.00 and +7.00 di-
Corresponding author: Ajla Pidro, MD. Eye opters(D) and cylinder up to 2.00D from January 2013 and August 2015. All ablations were per-
Clinic Svjetlost, Adress: dr Mustafe Pintola formed with Wavelight Allegretto Eye-Q400Hzexcimer laser (Alcon, Forth Worth, TX, USA) with
23, Sarajevo. ORCID: 0000-0002-1272-3500. aberration free module and were centered on a corneal vertex. All flaps were made with Moria
e-mail: ajla@svjetlost-sarajevo.ba. M2 (Moria, Antony, France) mechanical microkeratome (90µm head). Preoperative and post-
operative uncorrected and corrected distant visual acuity (UDVA, CDVA), spherical equivalent
(SE) and a berrometry for 5mm pupil were measured. Measurements were taken at 1 week, 1,3,6
and 12 months after the surgery. Wilcoxon Signed Ranks Test was used for statistical analysis. 
Results: Postoperative UDVA was lower than preoperative CDVA at 1 week(p=0.001),
at 1 month there was no difference (p=0.099), and at 3,6 and 12 months UDVA was bet-
ter (p<0.0001). Preoperative SE was 4.69±1.20D (+3.75 to +7.50D). At 1 week SE
was 0.03±0.67D (-0.50 to +0.63D), while at 1 year regressed to 0.58±0.56D (+0.25 to
+0.88D). Sphere shifted from negative values targeted in treatment planning to com-
pensate for regression to positive values. There was significant difference in SE at ev-
ery time point (p<0.0005). There was a significant increase in coma (p<0.0001), trefoil
(p<0.0001, p=0.0006) and spherical aberration (p=0.022, p=0.0052) at 1 week and
1 month postoperatively, without change throughout the rest of follow up.  Conclusion:
LASIK for high hypermetropia showed satisfactory results in postoperative refraction with rea-
sonable regression without significant loss of lines of visual acuity. However, more test are
necessary to asses optical quality.
Keywords: LASIK, Hypermetropia, refractive surgery.

1. INTRODUCTION 2. AIM
Refractive surgery for hyperopia The purpose of this study is to
has been a challenge for surgeons evaluate safety and efficacy of LASIK
in last few decades (1, 2). Hyperopia procedure in high hyperopia.
contributes to around 1/3 of all of
refractive anomalies (3), but still the 3. METHODS
focus of corneal refractive surgery The study included 160 patients
has centered primarily on myopia. (266 eyes) that underwent LASIK
Many studies have reported high lev- procedure for hypermetropia cor-
el of safety and efficacy of Laser in rection. The range of diopters was
situ Keratomileusis (LASIK) in cor- between +3.00 and +7.0 diopters(D)
rection of low hyperopia(up to 4 D) and cylinder up to 2.00 D.
(1-2, 4-5). Preoperative examinations
The complications that have been All patients underwent a complete
limiting hyperopic LASIK in high preoperative ophthalmological ex-
hyperopia include decentration and amination. Inclusion criteria were:
© 2019 Alma Biscevic, Ajla Pidro, Melisa
regression, poor qualityof vision stable refraction, hypermetropia be-
Ahmedbegovic Pjano, Senad Grisevic, Nina Ziga, related to the induction of a signif- tween +3.00 and +7.00 D, astigma-
Maja Bohac icant high level of higher-order ab- tism ≤2.00 D. Ocular criteria were
errations which can affect the pre- those normally adopted in refractive
This is an Open Access article distributed under the
terms of the Creative Commons Attribution Non-
dictability, safety, and efficacy of the surgery. Exclusion criteria were un-
Commercial License (http://creativecommons.org/ treatment (6-8). stable hyperopia, age younger than
licenses/by-nc/4.0/) which permits unrestricted However, advances in eye trackers 18 years, active corneal disease, lens
non-commercial use, distribution, and reproduction and ablation profiles have led to im- opacities, irregular cornea on cor-
in any medium, provided the original work is properly provement in results of LASIK even neal topography, previous ocular
cited.
for high hyperopia (4-5, 9-12). surgery, history of ocular trauma,

ORIGINAL PAPER | Med Arch. 2019 JUN; 73(3): 191-194 191

Lasik as a Solution for High Hypermetropia

uveitis, anterior or posterior synechiae, glaucoma, and

ocular hypertension. Patients with amblyopia and a po-
tential CDVA of less than 0.2 were also excluded.
Surgical procedure and postoperative care
Prior to the surgery, two drops of topical anesthetic
(Novesine, OmniVision GmbH, Puchheim, Germany)
were instilled at 2- minute intervals, and the eye was
cleaned with 2.5 % povidone iodine. A corneal flap was
made using Moria M2 mechanical microkeratome with
90 μm head (Moria, Antony, France). Wavelight Alle-
gretto Eye-Q 400Hz (Alcon, Forth Worth, TX, USA) was
used for the excimer laser treatment. The optical zone
was fixed at 6.5 mm as recommended by the manufac-
turer, and the wave front optimized program was used. Graph 1.
Graph 1. Scattergram
Scattergramcomparing
comparingachieved
achievedspherical
sphericalequivalent
equivalentrefraction 12 months
refraction 12 months
postoperatively (Y axis)postoperatively
and attempted (Y axis)
sphericaland attempted
equivalent spherical
refraction (X axis)
The Aberration FreeTM program was applied in all cas- SE – spehical equivalent, D- diopter, M – month
equivalent refraction (X axis). SE – spehical equivalent, D- diopter, M –
es. month
For all patients, the programmed treatment consisted
5
of cycloplegic spherical correction with manifest astig- 4,5 4,375
matic power and axis.“Wellington nomogram” provided 4
by the company was used for spherical correction. 3,5
The flap was lifted and excimer laser ablation was de- 3
livered to the stroma. Patients were instructed to con-
SE (D)
2,5
centrate on the fixation light throughout the ablation. 2
When the ablation was completed, the flap was repo- 1,5
sitioned after the interface was irrigated with balanced 1
0,375
0,375
salt solution, removing any debris. Postoperative therapy 0,5 0,5

included combination of topical antibiotic and steroid 0

Preop 1M 6M 12M
drops (Tobradex, Alcon, Forth Worth, TX, USA) 4 times Series1 4,375 0,375 0,375 0,5
daily for 2 weeks, and artificial tears (Blink, Abbott Med-
Graph 2. Spherical equivalent preoperatively and in follow up period.
ical Optics, Santa Ana, CA, USA) 6-8 times daily for at Graph 2. Spherical
SE – spehical equivalent
equivalent, preoperatively
D- diopter, and in follow up period.
M – month
least 1 month. SE – spehical equivalent, D- diopter, M – month
Postoperative evaluation 51
All patients were examined at 1 week, 1, 3, 6 and 12
49
months after the surgery. Results 1 year after the surgery
were analyzed in this study. At each visit UDVA, CDVA
Keratometry (D)

47
and SE were measured. Slit-lamp examination, tonome-
45
try, and corneal topography was also performed.
Statistical calculation was performed with SPSS for 43
Windows (19.0, SPSS Inc, Chicago, Illinois, SAD) and 41
Microsoft Excel (11.0, Microsoft Corporation, Redmond,
WA, SAD). The comparison between the preoperative 39
Pre-op 3M 12M
and postoperative periods was performed with the Wil- K1 41,79 45,99 45,48
coxon signed rank test. Value of p<0.05 was considered K2 43,08 47,75 47,06
statistically significant. Graph
Graph3.3.Changes
Changesininkeratometry
keratometryininfollow
followup
upperiod
period
D-diopter, M-months, K – keratometry
D-diopter, M-months, K – keratometry
4. RESULTS
The study has been conducted from January 2013 and negative values targeted in treatment planning to com-
August 2015. Out of 160 patients (266 eyes) 93 were pensate for regression to positive values. There was sig-
males (58%) and 67 were females (42%). Average age was nificant difference in SE at every time point (p<0.0005).
42±11.3 years (range: 21 - 66 years). There was a strong correlation between the attempted
CDVA preoperatively was 0.77±0.24 (range: 0.6- and achieved corrections (R2 Z 0.65). (Graph 2).
0.9). Postoperative UDVA was lower than preoperative There was no statistically significant difference in post-
CDVA at 1 week (p=0.001), at 1 month there was no dif- operative values of keratometry and pachymetry during
ference (p=0.099), but at 3,6 and 12 months UDVA was follow up period. In Graph 3 keratometry changes are
significantly better compared to preoperative CDVA presents.
(p<0.0001). There was a significant increase in coma (p<0.0001),
Preoperative SE was 4.69±1.2D (range +3.75 to +7.50 trefoil (p<0.0001, p=0.0006) and spherical aberration
D). At 1 week SE was 0.03±0.67D (range -0.50 to + 0.63D), (p=0.022, p=0.0052) at 1 week and 1 month postopera-
while at 1 year regressed to 0.58±0.56D (range +0.25 tively, without change throughout the rest of follow up.
to +0.88D), as shown in Graph 1. Sphere shifted from

192 ORIGINAL PAPER | Med Arch. 2019 JUN; 73(3): 191-194

 Lasik as a Solution for High Hypermetropia

In our study efficacy index (defined as UDVA at 12 than in other studies: (ranging from 0.6115 to 0.9) (24).
month postoperatively / CDVA preoperatively) 1.037. Our results were morecomparable to Simon et al. report
Safety index (defined as CDVA at 12 months / CDVA ofsafety index 1.03 and efficacy index 1.40 (25).
preoperatively) 1.054. We plan to report the outcomes over a longer period,
because some studies found average increase in hyper-
5. DISCUSSION opia +0,54 over 5 years postoperatively, which is more
For few decades there have been many attempts to than expected physiologically and can be indicator of de-
correct hyperopia, but were not effective or safe enough stabilization of cornea after LASIK (20).
(9, 13). Recent literature on the other hand shows that
it is possible to achieve±0.50D one year after LASIK in 6. CONCLUSION
hyperopic patients, which is also demonstrated in our LASIK for high hyperopia showed satisfactory results
study (14). Result of our study do differ somewhat from in postoperative refraction with reasonable regression
current literature. Residual SE in our study was as high without loss of lines of visual acuity, however more test
as +0.40 D. Kanellopulus et al. report residual myopia of are necessary to asses optical quality. 
-0.39±0.30D after two years, and Gil-Cazora et al. hyper-
opia of +0.72±0.80D in first months after the surgery (15, • Author’s contribution: A.P, M.A.P, N.Ž and S.G gave substantial
16). In our study there was small myopic shift (p<0.001) contributions to the conception or design of the work in acquisition,
in first postoperative visits, but this slight over correc- analysis, or interpretation of data for the work. A.B and A.P had a part
tion was transitory. This can also be consistent with the in article preparing for drafting or revising it critically for important in-
natural progression of hyperopia in population (17). De- tellectual content, and A.B and M.B gave final approval of the version
sai et al. reported modest regression of refractive effect to be published and agreed to be accountable for all aspects of the
even after 5 years of followup (+0.40 ± 0.79 D) (18). Oth- work in ensuring that questions related to the accuracy or integrity
er older publications stated that under correction was of any part of the work are appropriately investigated and resolved.
expected in patients with SE +5.00 D. Those results were • Declaration of patient consent: The authors certify that they
guidelines for better planning, so this over correction have obtained all appropriate patient consent forms.
in first postoperative period was expected and planned • Conflicts of interest: There are no conflicts of interest.
(19). • Financial support and sponsorship: Nil.
Complications in this study were loss of 2 lines in two-
eyes (0.74%), loss of 1 line in one eye (0.37%), diffuse
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194 ORIGINAL PAPER | Med Arch. 2019 JUN; 73(3): 191-194