13 - Refractive Surgery

l. The most common technique used clinically to measure wavefront

aberrations employs the Hartmann-Shack wavefront sensor.
What are the ocular structures that affect wavefront analysis?
a. cornea, anterior chamber, and lens
b. cornea and anterior chamber
c. cornea, anterior chamber, lens, and vitreous
d. cornea
2. What condition might prevent a 25-year-old patient from being a good
candidate for photorefractive keratectomy (PRK)?
a. pregnancy
b. posterior corneal scar
c. asthma
d. anterior corneal scar
3. What is the best way to diagnose epithelial basement membrane dystrophy
(EBMD, or map-dot-fingerprint dystrophy) using a slit lamp?
a. slit-lamp examination using direct illumination
b. Hruby lens evaluation
c. lissamine green staining
d. rose bengal staining
4. What is a common long-term complication of radial keratotomy (RK)?
a. infection
b. progressive hyperopia
c. development of nuclear sclerotic cataracts
d. globe perforation
5. What is the correct definition of coupling?
a. corneal change that occurs in the peripheral cornea on both sides adjacent to a
clear corneal incision
b. corneal change that occurs only with arcuate keratotomy (AK) incisions
c. when 1 meridian is steepened at the site of an astigmatic incision, which thus
induces corneal flattening in the meridian 90 from the axis of incision
d. when 1 meridian is flattened at the site of an astigmatic incision, which thus
induces steepening in the meridian 90 from the axis of incision

6. What characteristic of an astigmatic incision would result in a greater

magnitude of astigmatic correction?
a. shorter incision
b. incision placed at a larger optical zone
c. shallow incision
d. incision placed at a smaller optical zone
7. What is the most common indication for the use of intrastromal corneal ring
segments?
a. hyperopia
b. keratoconus
c. Fuchs dystrophy
d. astigmatism
8. Intrastromal corneal ring segments are made from which material?
a. collamer
b. silicone
c. polymethylmethacrylate (PMMA)
d. porcelain
9. Orthokeratology causes a temporary reduction in myopia by what
mechanism?
a. steepening of the corneal epithelium
b. flattening of the corneal stroma
c. steepening of the corneal stroma
d. flattening of the corneal epithelium
10. What optical effect is observed following wavefront-guided and wavefrontoptimized ablations but not with conventional excimer laser ablations?
a. better contrast sensitivity
b. more nighttime glare and halos
c. greater postoperative higher-order aberrations
d. more postoperative spherical aberration
11. When considering a patient for excimer laser surgery, most surgeons
prefer what minimum safe thickness for the residual stromal bed?
a. 150 m
b. 225 m
c. 200 m
d. 250 m

12. What is the risk of cutting a laser in situ keratomileusis (LASIK) flap with
a mechanical microkeratome on a cornea flatter than 40.00 D?
a. larger than expected diameter flap, with increased risk for a "buttonhole"
b. larger than expected diameter flap, with increased risk for a free cap
c. smaller than expected diameter flap, with increased risk for a "buttonhole"
d. smaller than expected diameter flap, with increased risk for a free cap
13. What is the principal mechanism by which collagen cross linking stabilizes
the cornea?
a. keratocyte apoptosis
b. compaction of stromal lamellae
c. collagen polymerization
d. covalent bonding
14. What possible postoperative effect of collagen cross linking should a
refractive surgeon advise patients to anticipate?
a. improvement in corrected distance visual acuity
b. potential endothelial cell damage with resultant corneal edema
c. altered index of refraction with subsequent change in spectacle correction
d. corneal steepening
15. Which one of the following statements about corneal cross linking is true?
a. It was shown to be safe and effective in post-refractive surgery patients in US
Food and Drug Administration (FDA) trials.
b. It cannot be combined with insertion of intrastromal ring segments.
c. It is an option for patients with keratoconus who have a corneal thickness of
275 m.
d. It may be utilized as a treatment for infectious keratitis.
16. What do all cases of phakic intraocular lens implantation require?
a. intra operative dilation
b. preoperative lens calculations
c. preoperative Schirmer testing
d. general anesthesia

17. What is the best refractive surgical option for a 45-year-old patient with a
manifest refraction of +5.00 D sphere and a central corneal thickness of 560
11m?
a. LASIK
b. PRK
c. refractive lens exchange
d. conductive keratoplasty
18. What preoperative test is most crucial for determining the available
strategies for astigmatism correction in the evaluation of a patient for
refractive lens exchange?
a. manual keratometry
b. simulated keratometry from an autorefactor or topographer
c. topography for pattern evaluation
d. Scheimpflug measurement of lenticular astigmatism
19. A 42-year-old man with diabetes mellitus reports worsening distance vision
for 6 months; his findings are as follows: most recent hemoglobin A1c
(HgbA1J value, 9.5; corrected distance visual acuity (CDVA, also called bestcorrected visual acuity), 20/15 in each eye (OD, -2.50 sphere; OS, -2.00 sphere);
and normal ophthalmologic evaluation.
What is the most appropriate refractive treatment?
a. contact lens fitting
b. eyeglass correction
c. repeat refraction in 3- 6 weeks
d. laser refractive surgery
20. What is the best initial therapy for a 53-year-old woman with intermittent
blurred vision and corneal punctate epitheliopathy who underwent
uncomplicated bilateral LASIK 6 weeks previously?
a. antibiotic drops
b. corticosteroid drops
c. non steroidal anti-inflammatory drops
d. preservative-free artificial tear drops

21. A 22-year-old man is referred for a LASIK evaluation. He has noted

worsening visual acuity over the past 3 years that has required several
eyeglass prescription changes. He states that he had good vision with soft
contact lenses as a teenager but that he cannot see well with his current soft
contact lens prescription. A manifest refraction reveals 3.00 D of non
orthogonal astigmatism, and manual keratometry shows irregular mires.
What is the most appropriate test for establishing a diagnosis of forme fruste
keratoconus?
a. corneal pachymetry
b. corneal topography
c. cycloplegic refraction
d. slit-lamp photography
22. A 65-year-old man had uncomplicated bilateral, 16-incision RK with a 3mm optical zone 15 years previously. Currently, his CDVA has decreased to
20/50 OU due to clinically significant posterior subcapsular cataracts; cataract
surgery with intraocular lens (IOL) implantation is planned.
What method is best for determining the appropriate IOL power in this
situation?
a. historical clinical history method utilizing keratometry readings from before and
after radial keratometry and the change in refraction
b. hard contact lens method to calculate the change in refraction with and without a
hard contact lens
c. American Society of Cataract and Refractive Surgery (ASCRS) Online PostRefractive IOL Power Calculator
d. Placido disk-based automated keratometry system to determine keratometry
values

Answers
1. c. Wavefront analysis with a Hartmann-Shack aberrometer measures the
wavefront error of the entire visual system, from the tear film to the retina.
With this device, a low-power laser beam is focused on the retina, and the reflected
light is then propagated back through the optical elements of the eye, at which
point the resultant wavefront is measured and analyzed.

2. a. Pregnancy can cause a temporary change in the refraction, which makes

refractive surgery potentially less accurate. It is generally recommended that
surgeons wait approximately 3 months after delivery to obtain a stable preoperative
refraction and perform refractive surgery.
Because breastfeeding is also associated with changes that may affect the
refraction, many surgeons recommend waiting for several months after the
cessation of breastfeeding before proceeding with refractive surgery.
As laser in situ keratomileusis (LASIK) requires cutting a flap in the anterior
cornea, patients with stromal scarring in the anterior cornea may experience
problems during flap creation whether by microkeratome or femtosecond laser;
thus, photorefractive keratectomy (PRK) may be preferable for these patients.
Additionally, patients with small anterior stromal scars may preferentially benefit
from PRK, as it may be possible to reduce the scar with the refractive ablationespecially with myopic treatments. Controlled asthma is not a contraindication to
PRK.

3. a. Epithelial basement membrane dystrophy (EBMD; also called anterior

basement membrane dystrophy) occurs when the epithelial layer of the cornea is
not well attached to the Bowman layer. Eyes with EBMD are predisposed to
epithelial loosening or sloughing and even frank epithelial defects during the
LASIK procedure. Epithelial problems after LASIK increase the risk of diffuse
lamellar keratitis (DLK) and epithelial ingrowth under the flap.
The best method to detect EBMD is using a broad slit beam from the side to see the
irregular epithelium. Other techniques include using retroillumination or
fluorescein dye to identify subtle changes in the epithelium. Eyes with significant
EBMD may do best with a surface ablation procedure rather than LASIK.

4. b. Although infection, loss of corrected distance visual acuity, and globe

perforation can occur in rare instances after radial keratotomy (RK), progressive
hyperopia due to progressive corneal flattening is much more common.
The Prospective Evaluation of Radial Keratotomy study found that, 10 years
postoperatively, 43% of eyes were overcorrected by more than 1.00 D. Also,
diurnal fluctuation of vision is a common adverse effect of RK.
5. d. When 1 meridian is flattened from an astigmatic incision, an amount of
steepening occurs in the meridian 90 away; this phenomenon is the concept of
coupling.
6. d. The longer the incision, deeper the incision, and smaller the optical zone, the
greater the astigmatic correction.
7. b. Initially, intrastromal corneal ring segments were approved by the US Food
and Drug Administration (FDA) and used for the correction of myopia; because of
reduced predictability, however, they have fallen out of favor for treatment of
myopia.
They are now used almost exclusively in patients with keratoconus.
8. c. Intrastromal corneal ring segments have always been made of
polymethylmethacrylate (PMMA).
9. d. Orthokeratology involves the overnight wearing of rigid contact lenses to
create a temporary flattening effect on the corneal epithelium.
10. a. Wavefront-guided and wavefront-optimized ablations offer better contrast
sensitivity than conventional excimer laser ablations do because they reduce the
amount of higher order aberrations.
11. d. Leaving a residual stromal bed of less than 250 m thickness puts the patient
at risk for corneal ectasia.
12. d. Corneas flatter than 40.00 D are more likely to have smaller-diameter flaps
and are at increased risk for creation of a free cap. Remember that cutting a flap
with the same blade in a second eye usually results in a thinner (not thicker) flap.

13. d. Corneal collagen cross linking combines riboflavin (vitamin B2), which is a
naturally occurring photosensitizer found in all human cells, and ultraviolet A
(UVA) light to strengthen the biomechanical properties of the cornea via covalent
bonding of the collagen fibrils. Although there may also be a slight flattening of the
cornea, the most important effect of the cross linking is that it stabilizes the corneal
curvature and prevents further steepening and bulging of the corneal stroma.
14. b. The UVA light used to activate riboflavin in the cross linking procedure is
toxic to corneal endothelial cells. In the presence of riboflavin, approximately 95%
of the UVA light irradiance is absorbed in the anterior 300 m of the corneal
stroma.
Therefore, most studies require a minimal corneal thickness of 400 m after
epithelial removal to prevent corneal endothelial damage and secondary corneal
edema by the UVA irradiation.
Thinner corneas may be thickened temporarily with application of a hypotonic
riboflavin formulation prior to UVA treatment.
15. d. Corneal collagen cross linking has had good results in stabilizing ectasia and
reducing both myopia and astigmatism resulting from post- refractive surgical
causes as well as naturally occurring conditions such as keratoconus; it has not yet
been approved by the FDA as safe and effective.
Some investigators have combined cross linking with other refractive modalities
(such as intrastromal rings) with promising early results. Patients with thin corneas
are not candidates for this procedure because of the endothelial toxicity of the UVA
irradiation.
Interestingly, there have been reports of collagen cross linking employed
successfully to treat fungal and bacterial infections of the cornea.
This use may represent a potential new application of this technology.
16. b. Implantation of posterior chamber phakic intraocular lenses (PIOLs) requires
intra operative pupillary dilation in order for the lenses to be inserted behind the
iris, whereas implantation of iris-fixated or anterior chamber PIOLs does not. As
PIOLs are not associated with significant dry eye, a preoperative Schirmer test is
not required for patients not suspected of having dry eye.
PIOLs can be inserted using topical anesthesia, making general anesthesia
unnecessary for most patients. All PIOLs currently require a peripheral
iridotomy/iridectomy either preoperatively or intra operatively to prevent pupillary
block.
All PIOLs also require preoperative calculations to determine the correct lens
power.

17. c. Compared with other refractive surgery procedures, refractive lens exchange
carries a higher risk of retinal detachment and an overall higher complication rate;
therefore, it is usually reserved for patients who fall outside the treatment ranges
for other surgical techniques.
Most patients with refractive errors ranging from +3.00 D to -6.00 D are reasonable
candidates for LASIK or PRK, and patients with normal accommodation stand to
incur diminished near visual acuity even with use of multifocal intraocular lenses
(IOLs).
Patients with high hyperopia generally are not good candidates for LASIK and
would thus benefit more from refractive lens exchange.
18. c. Manual keratometry and simulated keratometry values can both provide
information on the amount of regular corneal astigmatism present.
However, neither evaluation can determine irregular corneal astigmatism or
identify a corneal ectatic disorder such as keratoconus or pellucid marginal
degeneration.
Such disorders must be recognized preoperatively in order to decide what treatment
options are available for any residual astigmatism.
Whereas patients with regular astigmatism are potential candidates for a variety of
treatment strategies, including toric IOLs or multifocal IOLs with bioptics
(utilizing LASIK or PRK postoperatively), patients with significant irregular
astigmatism are not candidates for bioptics and may not be suitable for toric IOLs if
the irregularity is too great.
19. c. Elective ocular surgery should not be performed in a diabetic patient with
poor or erratic blood glucose control.
The blood sugar of a patient with diabetes mellitus must be well controlled at the
time of examination to ensure an accurate refraction, as the refractive error may
fluctuate with changes in the blood glucose level.
For this reason, it is also not advised to prescribe eyeglasses or contact lenses in
patients with diabetes mellitus whose blood glucose control is labile.
20. d. Dry eye symptoms after LASIK and PRK (advanced surface ablation) are the
most common adverse effects of refractive surgery.
Corneal nerves are severed when the flap is made, and the cornea overlying the flap
is significantly anesthetic for 3-6 months and even as long as 1 year
postoperatively.
As a result, most patients experience a decrease in tear production. Patients who
had dry eyes prior to surgery or whose eyes were marginally compensated before

surgery may experience more severe symptoms afterward. In addition, patients who
develop dry eyes after LASIK or surface ablation have an abnormal tear film and a
poor ocular surface, leading to reports of fluctuating vision between blinks
intermittently throughout the day.
Frequent application of preservative-free artificial tears often alleviates symptoms.
Additional treatments include topical cyclosporine, lubricant ointments, and
punctal occlusion.
21. b. Keratoconus is considered a contraindication to LASIK and surface ablation.
Creating a LASIK flap and removing stromal tissue results in a loss of structural
integrity of the cornea and increases the risk of ectasia, even if keratoconus had
been stable prior to treatment.
Forme fruste keratoconus is important to diagnose during the screening
examination for refractive surgery.
Although keratoconus can be diagnosed through slit-lamp examination and manual
keratometry, more sensitive analyses using corneal topography and corneal
pachymetry can reveal findings consistent with early keratoconus.
No specific agreed-upon test or measurement is diagnostic of a corneal ectatic
disorder, but both corneal topography and corneal pachymetry should be part of the
evaluation because subtle corneal thinning or curvature changes can be overlooked
on slit-lamp evaluation.
The existing literature on ectasia and longitudinal studies of the fellow eye of
unilateral keratoconus patients indicate that asymmetric inferior corneal steepening
or asymmetric bow-tie topographic patterns with skewed steep radial axes above
and below the horizontal meridian are risk factors for progression to keratoconus
and post-LASIK ectasia. With current technology, LASIK should not be considered
for these patients.
22. c. There are numerous ways to perform IOL calculations in eyes that have
undergone refractive surgery.
Unfortunately, none is perfect. Small, effective central optical zones after refractive
surgery (especially after RK) can lead to inaccurate measurements, because
keratometers and Placido disk-based corneal topography units measure the corneal
curvature several millimeters away from the center of the cornea.
Also, the relationship between the anterior and posterior corneal curvatures may be
altered after refractive surgery (especially after laser ablative procedures), leading
to inaccurate results.
Historical methods and rigid contact lens over refractions are often fairly accurate.
Manual keratometry is often less accurate than automated keratometry. Currently,
the best option for calculation of IOL powers in post-refractive surgery patients is

probably the American Society of Cataract and Refractive Surgery (ASCRS)

Online Post-Refractive IOL Power Calculator. This resource is available on the
websites of the ASCRS and the American Academy of Ophthalmology (AAO) and
is updated with new formulas and information as they become available.