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PKR to the hyperopia after radiaire keratotomii

PKR to correct hyperopia after radial keratotomy

Keratotomii radaire (KR) is a technique that allowed to correct nearsightedness by conducting deep corneal incisions, arranged in a star (where the term "radiaire"); and intended to provoke a central flattening of the cornea. This technique was the first operation of refractive surgery offered routinely to short-sighted patients, the late 1980s and early 1990s. The KR has been abandoned in the mid-1990s for the benefit of the excimer laser surgery (procedures to Refractive aiming - PKR then LASIK), much more accurate, and which, unlike that of the radial keratotomy, is stable in time.

The incisions of radial keratotomy are willing to 'Star', and their (even) number usually varies between 4 and 16 (2 to 8 pairs of incisions). The number of incisions is proportional to the degree of preoperative myopia.

Above: schematic representation of the layout of the incisions of radial keratotomy. The depth of the incisions should be close to 90% of the corneal thickness. The effect of the KR is indirect: flattening wished of the optical zone (ZO) Central, free of incision, is related to the relaxation and the camber of the peripheral cornea. Downstairs: James Œil of radial keratotomy at the beginning of the years 90: 8 radiaires incisions were conducted to correct myopia of 4.5 diopters.

Above: schematic representation of the layout of the incisions of radial keratotomy. The depth of the incisions should be close to 90% of the corneal thickness. The effect of the KR is indirect: flattening wished of the optical zone (ZO) Central, free of incision, is related to the relaxation and the camber of the peripheral cornea.
Downstairs: James Œil of radial keratotomy at the beginning of the years 90: 8 radiaires incisions were conducted to correct myopia of 4.5 diopters.

The radial keratotomy exposes to a late complication called 'hypermetropique shift', which is characterized by the gradual emergence and the accentuation of a farsightedness. This hypermetropisation seems to be linked to excessive corneal flattening, which is manifested also by daily fluctuations of vision. PKR (surface excimer laser) is an effective technique to correct hyperopia induced by the radial keratotomy.

 

Radiaire keratotomii: principles and historical

The idea to make incisions in the corneal tissue to change the curvature is old: it's the Norwegian Shiotz, which was the first ophthalmologist to describe the use of an incision of the cornea to correct theastigmatism (1).

Some years later, Lans published the first experimental work on the effects of the corneal not puncture incisions in rabbits. These results allowed the founding principles of the corneal incisionnelles techniques (2)

-radiaires cuts cause a peripheral camber and a central flattening of the cornea.

-transversal incisions cause a loosening of the Meridian on which they focus.

-more incisions are deep, and the effect is more marked.

 

If the radial keratotomy technique was popularized by Russian Fyodorov, attributed to the Japanese doctor Sato the paternity of the technique of radial keratotomy. It was observed that the realization of spontaneous posterior tear of the Descemet membrane (part of the cornea) caused a secondary flattening in patients with Keratoconus. He designed a special knife intended to be introduced into the anterior Chamber of the eye and make incisions in the deep surface of the cornea to correct nearsightedness. Many patients were operated in Japan in the early 1950s, and the first results were published in 1953 (3).

At the time, it was unclear the role of corneal endothelium (located on the deep surface of the cornea). Unlike the eye of rabbit, the endothelium of the human eye does not recur. The relaxing corneal incisions made at the back of the cornea, causing damage to the endothelium of irreversibly, were originally from the onset of swelling of the cornea: it is estimated that more than 70% of patients with Sato technique have developed some severe swelling of the cornea. It should be noted that Sato is recommended to achieve 40 incisions to the posterior side, and 40 to the front of the cornea.

During a visit to the Japan, the surgeon Russian ophthalmologist Fyodorov met Akiyama, a student of Sato, who had taught him the technique of his master. Back in the USSR, he used it to try to correct the myopia of some of his patients, but was disappointed by the initial results that he obtained with the technique of Sato. The prior art of radial keratotomy was also taken up by his colleague Yenaliev, who obtained more encouraging results thanks to a technique made more reproducible by control of the depth of the radiaires incisions. This led Fyodorov to back this technique at the end of the 1970s for the correction of myopia: the results published by Fyodorov in 1982 (4) were very encouraging... but never matched later.

 

The American Bill realized the first radial keratotomy in the USA in 1978. At that time, the recommended number of incisions was 16: this number was lowered gradually, because studies showed that 4 incisions were sufficient to correct low myopia to medium (5). The sense of achievement of the incisions (centripetal: leaf towards the Center, or centrifugal from the Center to the blade) was also the issue of a fight between Refractive Surgeons debate. It was important to not continue the incisions too far to the Center under penalty to increase the risk of halos and duplication of the vision. Instrumentation also progress with the development of knives made in diamond blade; However, to create incisions, Fyodorov had used out of fragments of razor blade, that he was simply staring at on a "door blade!

In 1981, a study called PERK (Prospective Evaluation of Radial Keratotomy) was launched to study the results of a standardized procedure prospectively with the realization of 8 incisions on an optical area of 3 or 4 mm according to the initial refraction.

Detail of the incisions of radial keratotomy: 8 incisions are made, with a central area of 3 mm.

Detail of the incisions of radial keratotomy: 8 incisions are made, with a central area of 3 mm.

 

In total, the PERK study allowed to enlist 793 eyes of 435 patients with myopia was between 2 and 8.75 D. A year after the surgery, 60% of the eyes were to +/-1 D of the emmetropia, 30% were under corrected, and 10% were corrected more of a diopter. Five years after the intervention, the percentage of eyes with a farsightedness was 17 percent; This trend to the hypermetropisation was confirmed to the visit of 10 years (6), as 43% followed eyes had then developed a 'hypermetropique shift' more than one diopter. The risk of hypermetropique shift was higher among the patients who had a myopia more important, for which the Central optical zone (free from traces of incision) was narrower.

The radial keratotomy is to perform a biomechanical relaxation of the peripheral portion of the cornea. The induced peripheral camber causes central flattening (reduction of the corneal vergence). The incisions are interested in 90% of the peripheral corneal thickness (hatch). More incisions are deep and extend toward the Center, the more the correction (central Flattening).

The radial keratotomy is to perform a biomechanical relaxation of the peripheral portion of the cornea. The induced peripheral camber causes central flattening (reduction of the corneal vergence). The incisions are interested in 90% of the peripheral corneal thickness (hatch). More incisions are deep and extend toward the Center, the more the correction (central Flattening).

radial keratotomy technique is based on a central flattening of 'indirect' origin, linked to relaxation by the peripheral cornea strips section.

radial keratotomy (8 incisions) operated cornea in Cup OCT. There is an increase in peripheral camber (arrow), next to the incisions (not viewed on the Cup). The change of the central arch is a global flattening (anterior and posterior). Although the resolution of this OCT is not high enough, we guess a central epithelial thickening, which partially 'offsets' central flattening induced by peripheral relaxation.

radial keratotomy (8 incisions) operated cornea in Cup OCT. There is an increase in peripheral camber (arrow), next to the incisions (not viewed on the Cup). The change of the central arch is a global flattening (anterior and posterior). Although the resolution of this OCT is not high enough, we guess a central epithelial thickening, which partially 'offsets' central flattening induced by peripheral relaxation.

To fix strong corneal astigmatismes, achieving incisions transervsales ("Transverse cuts" or "T-cuts") were sometimes carried out, share and more arched Meridian, and perpendicular to the path of the radiaires incisions.

At the end of the 1990s, the introduction of the refractive surgery by excimer laser offered to refractive surgeons incomparably greater precision for corneal refractive surgery than that which could be obtained with techniques incisionnelles, not only in terms of local action (the precision of laser ablation is of the order of a micron), but also on a conceptual level. Indeed, rather than inducing a central flattening in an indirect way, through peripheral incisions, it became possible to sculpt a corneal 'ideal' according to a mathematical model profile accurate and less empirical. Despite the cost represented by the acquisition of an excimer laser, the radial keratotomy was quickly abandoned in favor of the PKR.

The hypermetropique shift is by far the most worrisome side effect observed after radial keratotomy. It is sometimes concomitant with the existence of refractive fluctuations, which cause a change of vision between sunrise and sunset.  In some patients, the secondary hypermetropisation seems to continue over the years, and sometimes results in having to prescribe fixes in scope of the order of 3 or 4 diopters, often associated in our experience to a noncompliant astigmatism (said astigmatism ' inverse'). This refractive drift is even more annoying that it occurs in patients operated in the 80s and 90s, when they had 30 years on average. Today, these patients have all reached or passed the age of presbyopia, and rely for reading glasses, or a correction, in addition to their correction by far.

However, the realization of a technique of laser surface can be offered to most of the patients operated of radial keratotomy victims of a secondary hyperopia. She gives encouraging results, allowing patients to strongly reduce their dependence on corrective lenses. A detailed preoperative assessment is necessary to validate this type of information. It includes the realization of a topography of the cornea.

 

Corneal topography after radial keratotomy

Corneal topography is a systematic review to evaluate the result of a process of radial keratotomy.

Topographic examination reveals characteristic aspects, with the most spectacular can be the change of the posterior corneal topography. Indeed, the radial keratotomy is the only technique that causes a marked change after cornea geometry, since the entire corneal wall suffers the biomechanical effect of cuts... In laser surgery, corneal profile changes are restricted to the front of the cornea.

Topography of elevation Orbscan (Quadmap mode) of a cornea surgery radial keratotomy (8 incisons). The anterior and the posterior are Oblate: elevation, a rosette aspect is observed. The radial keratotomy causes a corneal flattening of biomechanical origin: radiaires incisions whose depth is about 80 to 90% of the thickness corneal sprovoquent peripheral relaxation, against which occurs a pronounced camber. Because of the laws relating to the overall conservation of the average curvature of the corneal dome, a secondary central flattening occurs. Unlike the phototablation laser, the radial keratotomy has no significant ablation volume corneal corneal thickness is kept.

Topography of elevation Orbscan (Quadmap mode) of a cornea surgery radial keratotomy (8 incisons). The anterior and the posterior are Oblate: elevation, a rosette aspect is observed. The radial keratotomy causes a corneal flattening of biomechanical origin: radiaires incisions whose depth is about 80 to 90% of the thickness corneal sprovoquent peripheral relaxation, against which occurs a pronounced camber. Because of the laws relating to the overall conservation of the average curvature of the corneal dome, a secondary central flattening occurs. Unlike the phototablation laser, the radial keratotomy has no significant ablation volume corneal corneal thickness is kept.

There is thus a parallelism between the anterior and posterior elevation maps, where you will find a profile aspherical oblate marked (appearance in "roundel", the center of the cornea being colored in cool colors because located under the sphere of reference). The computation of the factor of asphericity (Q) provides a positive value, and the spherical aberration induced is positive type.

map topographic curvature axial radiaire keratotomii

Map of axial curvature and refraction in the pupil (OPD) of a surgery radial keratotomy eye (4 incisions) and presenting a hypermetropique shift with astigmatism reverses. The Asphericity is very oblate (Q = 5.44), the very low (on average, approximately 33 D) keratometry. There is a significant gradient of refraction between the Center and the edges of the optical zone. At the Center, the refraction is hypermetropique type, while at the edges, it is myopic, because of the fast Arch of the cornea; This gradient reflects the presence of a high rate of positive spherical aberration (1,540 microns at 6 mm pupil).

Since the KR involves no removal of corneal tissue, the Central thickness and distribution of the peripheral corneal thickness is unchanged. Its discreet and irregular incisions corollary is some topographic irregularity, which generates a high rate of high degree of original corneal aberrations.

 

The PKR to correct hyperopia post-radial keratotomy

 

Surface laser excimer (PKR) techniques are to issue a correction based on the sculpture of the corneal stromal surface excimer laser. Myopia, astigmatism and farsightedness are accessible to this type of correction. Even if LASIK is the technique of choice to correct farsightedness, the realization of a LASIK is not desirable after KR, as geometry of the cornea is quite changed, and that the risk of reopening of the corneal incisions of keratotomii leading to a break-up of the flap exist. The presence of epithelium within the stromal incisions also facing complications specific to the level of the interface (the interface from the incisions epithelial invasion).

The PKR does not expose these complications because it doesn't involve creation of an interface. It is intended to increase the Central curvature of the cornea, to increase the optical power (vergence), whose failure explains hyperopia (see the) profile of ablation for the correction of hyperopia).

The hypermetropique photoablation to accentuate the shape of the central cornea, to correct farsightedness, related to excessive corneal flattening.

The hypermetropique photoablation to accentuate the shape of the central cornea, to correct farsightedness, related to excessive corneal flattening.

The technique after KR is of achievement similar to that performed on non operated corneas. It is to remove the epithelium of the cornea on an area whose diameter is between 8 and 9 mm, and then deliver the laser correction; before asking a lens bandage for a few days.

During the PKR indicated to correct a secondary hyperopia after radial keratotomy, the epithelium is removed, before excimer laser correction is issued on the corneal stroma. The trace of the incisions is clearly visible.

During the PKR indicated to correct a secondary hyperopia after radial keratotomy, the epithelium is removed, before excimer laser correction is issued on the corneal stroma. The trace of the incisions is clearly visible.

The laser is intended to recambrer the central cornea: it is issued on the stroma désépithélialisé (putting naked layer of Bowman) averaged periphery.

Photograph taken after the grant of a 2.50 diopters of reverse hypermetropique astigmatism correction (+ 2.50 x 10 °). The eye had surgery of radial keratotomy (4 incisions) in the 1990s.

Photograph taken after the grant of a 2.50 diopters of reverse hypermetropique astigmatism correction (+ 2.50 x 10 °). The eye had surgery of radial keratotomy (4 incisions) in the 1990s.

If the PKR is usually done on a bilateral basis in routine, it is sometimes interesting to perform the procedure in a sequential manner (ex: one month apart) in farsighted patients, but having been made of radial keratotomy in the past. Indeed, the technique results are less predictable than for Virgin corneas of any surgery. The results obtained on the first eye surgery can be used to "refine" the correction of the second eye.

In my experience, and that of many Refractive Surgeons (7,8), the correction of hyperopia post KR is an effective technique, because it allows to reduce systematically the dependence on glasses for farsighted patients after radial keratotomy, and become presbyopic at midlife.  In certain indications, the use of a personalized treatment (guided by the Wavefront or corneal topography) seems interesting to increase the regularity of corneal profile. Freinateurs healing agents (Mitomycin C) are often used to limit the risk of regression of the treatment by excessive scarring.

 

Certainly, its accuracy is less than on corneas without surgical history, and the intensity of the phenomena of remodeling post-operative impose to aim a light sur-correction, to anticipate the regression of the induced effect.  You have to be patient: stabilization of the result is between 3 and 6 months after the completion of the PKR.

No severe complications were observed in the course of a PKR to the hyperopia post-KR, outside a regression partial of the effect printed by laser, sometimes accompanied by a pronounced scar reaction (haze). This reaction is about the periphery of the optical zone, and doesn't have a significant Visual impact.

So the refractive benefit of the PKR after radial keratotomy is variable, but relatively constant.  The multifocalite induced by hypermetropique profile (coupled with that which is usually induced by the incisions of radial keratotomy) allows the patient to reduce significantly its dependency to prescription glasses. The Asphericity oblate marked reduction reduces the rate of positive spherical aberration and allows an improvement in the quality of vision.

Here is the map topo-aberrometrique of a cornea performed before PKR to the hyperopia post radial keratotomy:

Topo map aberrometrique (OPD SCAN III) patient a candidate for a refractive surgery to correct a post KR farsightedness. The analyzed eye was operated of myopia by the technique of radial keratotomy some 20 years ago. Central refraction is hyperopic (+ 2.50 D). Uncorrected Visual acuity by far is 5/10, nearly Parinaud 10. On the outskirts of the pupillary area, the refraction is myopic (-5.75 D) with an oblique astigmatism of-3.75 D. This variation is induced by the profile very oblate of the cornea (rapid increase in camber of the Center to the periphery). The corneal Asphericity is measured at + 4.21: ellipse profile very oblate, which generates a rate significant positive spherical aberration (Corneal SA for Spherical Aberration)

Topo map aberrometrique (OPD SCAN III) patient a candidate for a refractive surgery to correct a post KR farsightedness. The analyzed eye was operated of myopia by the technique of radial keratotomy some 20 years ago. Central refraction is hyperopic (+ 2.50 D). Uncorrected Visual acuity by far is 5/10, nearly Parinaud 10. On the outskirts of the pupillary area, the refraction is myopic (-5.75 D) with an oblique astigmatism of-3.75 D. This variation is induced by the profile very oblate of the cornea (rapid increase in camber of the Center to the periphery). The corneal Asphericity is measured at + 4.21: ellipse profile very oblate, which generates a rate significant positive spherical aberration (Corneal SA for Spherical Aberration)

 

A surface photoablation (PKR) was issued to correct hyperopia by aiming a slight over-correction to allow the eye to see up close without correction (myopisation).  Six months after the intervention, the uncorrected Visual acuity is by far 5/10 and 10/10 close without glasses.

After issuance of the photoablation of surface (PKR) to correct hyperopia and aim an over-correction to allow the patient to read closely without correction. Refraction became slightly myopic, with marked reduction of astigmatism and the difference between the refraction of Central and peripheral refraction. Visual acuity without correction is 5/10 by far, Parinaud 2 closely. The corneal Asphericity is slightly oblate (Q = + 0.54), and the positive spherical aberration was divided by 3.

After issuance of the photoablation of surface (PKR) to correct hyperopia and aim an over-correction to allow the patient to read closely without correction. Refraction became slightly myopic, with marked reduction of astigmatism and the difference between the refraction of Central and peripheral refraction. Visual acuity without correction is 5/10 by far, Parinaud 2 closely. The corneal Asphericity is slightly oblate (Q = + 0.54), and the positive spherical aberration was divided by 3.

 

The presence of a high rate of corneal irregularities is a potential indication for the issuance of a custom photoablation. In the following example, the patient, 51 years old and operated from radial keratotomy in the 1990s, complained for a decade of 'triple vision' of the left eye, which is also farsighted. The triple (triplopie) vision in one eye is a symptom whose causes are generally similar to those of the double vision (diplopia) eye.

In this example, the triple vision is explained by the irregularity of the cornea, and the presence of a rate high a high degree optical aberration called trefoil. Reviewing aberrometrique allows to quantify these anomalies and the simulation of the retinal image of a light spot (PSF) actually reveals a division into three lobes.

triplopie monocular radial keratotomy

Review aberrometrique (OPDscan III) topo on the left eye of a surgery patient radial keratotomy. The patient reported a triple vision of bright spots like the headlights, led, etc. This triplopie is caused corneal deformation due to the effects of the incisions of radial keratotomy. The simulated image of a point of light (bottom left) corroborates the patient visual disorders.

In this situation, the simple correction of hyperopia from + 2.50 D would allow the patient to win uncorrected Visual acuity, but would not necessarily solve the triple perception of bright lights. The remediation strategy must move towards a (custom) personalized correction guided by corneal topography. Indeed, it is here the deformation of the cornea which is responsible for the symptoms.

In this mode of correction, a previous corneal topography is made (Topolyzer Vario) and transmitted by network excimer laser. The EX500 (Wavelight) excimer laser software interprets this topography, and sets a custom ablation profile taking into account the corneal topographic irregularities.

This profile presents here 3 peripheral main lobes, and virtually no photoablation at the centre (as for the correction of hyperopia). This type of ablation arch selectively the flat areas of the cornea, and regularize the corneal profile in addition to reducing the hyperopia.

profile of hypermetropique ablation

Profile of hypermetropique ablation. Areas of warm colours correspond to areas of maximum photoablation. The Division into 3 major lobes of the laser photoablation meets the need to regularize the corneal profile, whose deformation in trefoil is at the origin of a triplopie.

Reviewing topo aberrometrique carried out a few months after the issuance of this custom photoablation allows you to see the correction of hyperopia and significant improvement of Visual quality. The patient reported the disappearance of the triplopie; uncorrected Visual acuity by far is equal to 10/10.  There is also a significant improvement in Visual acuity closely (Parinaud 4 without correction, against Parinaud 16 without correction before the procedure).

review after restatement for keratotomii radiaire topoaberrometrique

Topo aberrometrique realized after correction by custom photoablation review shows the correction of hyperopia and improvement of Visual quality. Note the much more "compact" appearance of the simulated image of a bright point on the retina (PSF).

 

In conclusion, hyperopia after radial keratotomy is not a fatality. Laser correction results are very encouraging and allow many patients to find a better quality of vision and reduce their dependence on glasses for distance and near vision.

 

References

 

(1) Schiotz HA. Ein Fall von hochgradigern Hornhautastigmatismus nach Starextraction. Besserung auf operational Wege Arch Augenheilk, 1885; 15: 178-181

(2) Lans LJ. Completed investigations uber project von astigmatism durch nicht-perforiende corneawunden. Graedes Arch invest, 1898; 45: 117-152

(3) Sato T. Akiyama K, Shibata H. A new surgical approach to myopia. Am J invest, 1953; 36: 823-829

(4) SN, Agranovski A.A. Fyodorov. Long term results of anterior radial keratotomy. Ocular Therapy Surg 1982; 1: 217-223

(5) Salz JJ, Villaseñor R, Elander RA et al. oven-incision radial keratotomy for low to moderate myopia. Ophthalmology 1986; 93:727 - 738

(6) GO Waring, III, Lynn MU, McDonnell PJ, and the PERK study group. Results of the prospective evaluation of radial keratotomy (PERK) study 10 years after surgery. Arch invest, 1994; 112:1298 - 1308

(7) Anbar R, Malta JB, JB Barbosa, Leoratti MC, Beer S, Campos M. also keratectomy with mitomycin-C for consecutive hyperopia after radial keratotomy. Cornea. 2009; 28 (4): 371-4

(8) Ghanem RC, Ghanem VC, Ghanem EA, Kara-José N. Corneal wavefront-guided also with mitomycin-C keratectomy for hyperopia after radial keratotomy: two-year follow up. J Cataract Refract Surg. 2012; 38 (4): 595-606.

 

 

 

27 Responses to "PKR for Hyperopia after radial keratotomy"

  1. Richard says:

    You have made to the hyperopia in 2011 of the left eye, at that time only the vision in that eye had dropped. Today I see very well that (Director) eye of the vision from a distance up to 60 cm. I feel that the right eye sees worse by far, I think it became farsighted also, following the keratotomii. Is it possible to operate to get a vision especially closely and intermediary? (40 cm to 2 m)

  2. Dr. Damien Gatinel says:

    It is possible to operate your right eye in PKR also (technical always reference against hyperopia induced after radial keratotomy) and aim at a slight "sur-correction", so that you can actually see this eye from near and intermediate vision without glasses. Thus, your independence with the glasses will be increased, thanks to the combination of the visions of the left eye and the right eye.

  3. Paradot says:

    Hello doctor,
    I find your site fortuitously and I have a question to ask you.
    I'm 51 years old. I am hyperopic appeared 2 years after a radial keratotomy in 1987, strongly astigmatism and of course on longsighted.
    Is the PKR technique still possible? Is this recommended in my case? Is the profit only to have less powerful corrective lenses? What difference does it have for the presbyopia? How long has she been practicing? What is the hindsight, especially in time and with the aging age of patients? I am somewhat chilled following the evolution of my first intervention!
    Is this technique practiced everywhere in France or are there specialized centres?
    Thank you for the time you will take to answer me.
    cp

  4. Dr. Damien Gatinel says:

    As indicated on this page, the PKR is an effective technique to correct hyperopia post radiaire Keratotomii, regardless of the age of the patient or the period since the initial intervention. Back with the PKR is more than 20 years, and in this indication says, my personal experience is favourable: glasses less powerful and less frequent, improvement of far and simultaneously gain in intermediate vision and near vision. A topographical record must be performed to validate the possibility and a pre-surgical consultation is necessary in order to ensure that the eye is 'healthy', apart from the scars of the radial keratotomy. This technique can be done at an authorized for refractive surgery Center.

  5. TROTS NATHALIE says:

    Hello.

    I just read the article on the PKR and regains hope. I had a radial keratotomy in the 1990s. At summer for 10-15 years, but I'm now long-sighted, astigmatism, and presbyopia, at age 55, with a strong fluctuation in my view between the morning and evening (not to mention difficulty "dark/light" and dark.) I see better at night without glasses than with. On the other hand I have to go back almost every year at the eye doctor, because my view is changing quickly and always (not in a good way, unfortunately). I work bcp on computer, it can worsen and speed up evolution. I really feel that it will never end. Is that an intervention is possible in my case without too much risk?

  6. Dr. Damien Gatinel says:

    The farsightedness and the astimgatisme induced by the radial keratotomy operation usually gives good results. It doesn't solve the problems of Visual fluctuations, but allows to regain comfort and Visual acuity in vision from far and near. A preoperative assessment is necessary in order to measure precisely the importance of induced hyperopia.

  7. Dominique Poletti says:

    Doctor.
    I am sixty years old and I had a radial keratotomy at the age of 20.
    Would PKR be effective in correcting a little myopia and an increasingly strong hyperopia.
    Kind regards

  8. Dr. Damien Gatinel says:

    The PKR is effective to correct optical defects late observed after Keratotomii radaire, such as myopia, hyperopia, or astigmatism. It is most frequently observed a tendency to the hypermetropisation with time (hypermetropique shift).

  9. Denis says:

    Doctor, do you operations in the Middle East (Dubai) as some of your colleagues? If not, then d, a visit, a week in europe is it possible d, have a visit pre operation and surgery the same week?
    Thank you for your answer

  10. Dr. Damien Gatinel says:

    I don't operate to the Rothschild Foundation, and it is possible in the light of the remoteness of some patients to achieve consultation and intervention during the same week, although in principle a period of 15 days is required between consultation and intervention according to the legislator. However, enquiry with respect to the benefits and side effects of refractive surgery (which are relatively standardized for common fixes) generally allows the patient to mature more quickly his thinking after the initial consultation, and shorten time to deal with exceptional circumstances.

  11. David says:

    Hello, I am 46 years old and I had surgery 20-25 years ago from a radial keratotomy and my sight has deteriorated since the change in brightness me gene and I sometimes struggle to make the point. At the time my surgeon told me that the scalpel was better than the laser... Since he switched to the laser but is not very hot to operate on again me, my surgeon prescribed glasses to see close but he told me that it was not possible to prescribe me glasses to see far, he told me that my eyes are a little twisted, I think he's talking about cuts, thought that I is still operable?

  12. Dr. Damien Gatinel says:

    To check your operability, a preoperative assessment including corneal topography measurement of optical correction (measure possibly associated with astigmatism and hyperopia), is necessary. Even in case of significant "deformity" of the earlier corneal corneal curvature, a correction can be considered, for example using a "guided by corneal topography" mode "" However, when the incisions are very deep and eventually cause a "local yawn", astigmatism induced by the laser photoablation reduction can be difficult if not impossible. However, the reduction of hyperopia induced by the radial keratotomy generally to improve visual comfort and the uncorrected acuity.

  13. Alex says:

    Hello doctor,
    I read with great attention your study related to an operation by PKR after radial keratotomy. I'm 65 years old. Operated from radial keratotomy in May 1987 to both eyes. Cataract surgery with the right eye on the 01/06/2016 then Excimer PKR Laser Intervention for astigmatism of the right eye induced by previous interventions. You indicate in your report: "It is advisable to be patient: the stabilization of the result obtained occurs between 3 and 6 months after the realization of PKR". Should I infer that no recovery of visual acuity is possible before? This August 23rd, no appreciable improvement is noticeable.
    To read you,
    Thanks again.

  14. Dr. Damien Gatinel says:

    It must actually wait a few months after PKR on a cornea surgery in advance of Keratotomii Radiaire (KR). This seems related to the fact that when the PKR, the removal of the epithelium would significantly alter the topography of the cornea under underlying (the one who receives the laser correction). Wait for the resurfacing of the surface corneal by neo epithelium formed to judge the result in functional terms.

  15. Françoise says:

    Hello doctor,
    I was operated by KR in 1988 with a small myopia. I have been hyperopic since about 2005 and this has worsened in my opinion brutally. I have read that it is possible to reoperate (after necessary examinations), but I wonder if age is a contraindication and if the prospect of a possible cataract problem later and an operation to remèdier it is not an obstacle. I do not want to undermine the outcome of this last operation by weakening my eyes.
    Has the "shift hypermétropique" been frequently observed?
    Thank you

  16. Dr. Damien Gatinel says:

    The 'hypermetropique shift' is a common type of evolution after radial keratotomy. It probably corresponds to an accentuation of the effect of the cuts over time. Later cataract occurs, is not an obstacle to the realization of a PKR. Instead, the central flattening of the cornea (thanks to the PKR) reducing to the cornea to regain a somewhat more physiological curve. The PKR (surface laser) after radial keratotomy results are encouraging: both distance vision and near vision benefit from this intervention. A pre-surgery can confirm the indication.

  17. Françoise says:

    The surgeon who operated on me was not providing the traditional annual visits after those of control, I consulted two other ophthalmologists and they terrified me, especially after the occurrence to the hyperopia. For them, my eye as a result of the incisions would become susceptible to infections and particularly fragile, that's why I read with attention your article and thank you for your answer.

  18. Françoise says:

    I misspoke. It would be all eyes operated by KR who would now be fragile, not mine particularly. Sorry to ask you again, I want to be reassured. Where to practice this balance?
    Thank you.

  19. Bernard Brugnon says:

    Hello Mister Dr. Ganeshan
    Is it possible to have me operated by PKR, having been by KR in 1991, then cataract very recently, but having high degree aberrations?
    By thanking you in advance for your reply, well cordially.
    B. Brugnon

  20. Dr. Damien Gatinel says:

    A PKR after radial keratotomy (KR) is quite conceivable in the absolute, even after cataract surgery (which does not concern the cornea but the crystalline). However, in your case, it is advisable to verify that the topographic characteristics of the cornea are suitable for this type of surgery. This usually concerns the correction of myopia, astigmatism, or hyperopia. The correction of high degree aberrations is possible, but it can be accompanied by certain limitations. A detailed examination (including corneal topography and ocular wavefront analysis – Aberrométrie) is necessary to judge the desirability of such a correction.

  21. Bernard Brugnon says:

    Hello Mister Dr. Ganeshan
    Thank you very much for your prompt and complete reply.
    Well cordially
    B. Brugnon

  22. Bernard Brugnon says:

    Hello, Doctor Ganeshan,
    I return to you for a supplementary question: the right eye to good visual acuity by far in good light conditions (-0.25, astigmatism-1.25 to 125 °), but as soon as the brightness decreases comes a high myopia of this eye.
    An operation via PKR would it solve this problem very complicated to live?
    Thanking you in advance for your answer, well cordially
    B. Brugnon

  23. Bertrand says:

    Hello doctor,
    I was operated in LASIK for Forte Hyperopia a little over a year ago. The operation had gone badly, and the result having too régréssé, the surgeon had retouched me in TransPRK (not possible to raise the flap on one of the eyes, which had been damaged during the first intervention). Today, 5 months after the retouching TransPRK, the result is bad: Return of a hyperopia of the order of + 1, and a lot of abers (halos at night, very slight diplope of one eye). Do you think that it is possible to consider, in the near future, a retouching in PRK with treatment guided by the Aberrometry, so as to at least recover a vision by far correct?
    Thank you
    Kind regards
    Bertrand

  24. Laurence says:

    Hello doctor,

    After being operated by radial keratotomy in 1988, a hyperopia began to appear 2 years ago, and continues to progress since then.
    After reading your article, I would be tempted by an operation by PKR to correct this hyperopia.
    But I wonder if I should not wait until my hyperopia has stabilized (if it stabilizes one day) before attempting an operation by PKR.
    If not, will I not have to be reoperated, if this hyperopia continues to worsen?

    Thank you for your reply, and thank you for putting your knowledge at the disposal of the largest number.

  25. Dr. Damien Gatinel says:

    It is important not to rub your eyes when they are irritated, as this can help to "play" the K-R's incisions and may be contributing to this late evolution. It is not necessarily necessary to obtain a perfect stabilization to study the possibility of laser intervention for the KR by PKR.

  26. Laurence says:

    Thank you for your advice.

    I actually noticed that I tend to rub my eyes when I have trouble waking up in the morning, I will not do it again.

  27. Laurence says:

    Hello doctor,

    To follow up on my message from 26/2, I recently learned that my ocular tension is quite high (22).
    Exams have shown that my eyesight is not affected, but my ophthalmologist wants me to start a treatment to bring down this tension.
    I ask myself the following questions:
    – Could this treatment allow an improvement in my hyperopia (I see a lot more blurry in the morning)?
    – Is high ocular tension a brake on an operation by PKR?
    Because from what I understood, a thick cornea (mine has a normal thickness) would protect in case of ocular tension.
    But if we retouch it by PKR, it will become less thick?

    Thank you very much for your clarifications.

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