Transient pseudophakic hyperopia after previous radial keratotomy : Journal of Cataract & Refractive Surgery

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Letter

Transient pseudophakic hyperopia after previous radial keratotomy

Osher, Robert H. MD

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Journal of Cataract & Refractive Surgery 35(12):p 2176, December 2009. | DOI: 10.1016/j.jcrs.2009.10.013
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I read the excellent review of intraocular lens (IOL) selection following refractive surgery1 and would like to suggest amending Hoffer's recommendation for prompt surgical correction of an unintended refractive error in one specific situation: the patient with unexpected hyperopia who has had radial keratotomy (RK). The following case demonstrates an important lesson.

A 60-year-old cardiologist had bilateral RK 25 years earlier, with the surgeon making 8 deep incisions around a 3.0 mm optical zone. All 5.0 diopters (D) of myopia were corrected, and the patient achieved an emmetropic result. She was lost to follow-up but subsequently presented with late progressive hyperopic astigmatism measuring +1.25 +2.50 × 45. Uneventful microcoaxial phacoemulsification with torsional ultrasound was performed through a 2.2 mm incision strategically placed between the radial incisions. The toric IOL, +23.5 SN60T5 (Alcon, Inc.), was selected after multiple formulas had been reviewed, an approach similar to that advocated by Hoffer.

On the first postoperative day, the uncorrected distance visual acuity (UDVA) measured 20/50 despite a clear cornea. I was shocked to find a refractive error of +4.0 D, which corrected the acuity to 20/20. Because I was aware of a video about hyperopic shift in eyes with RK (V. Centurion, MD, “Hyperopic Shift After Phacoemulsification in Eyes with Previous Radial Keratotomy,” Video Journal of Cataract and Refractive Surgery, volume XXI, issue 3, 2005), I resisted the temptation to exchange or piggyback the IOL. The hyperopia diminished by approximately 1.0 D each week and at the 1-month postoperative visit, the UDVA measured 20/25 with a refractive error of +0.75 sphere. The patient was pleased with the visual outcome, and I was equally happy that I had not promptly intervened.

I do not understand why this dramatic hyperopic shift occurs in the early postoperative period. Albert Neumann, MD, an RK pioneer, frequently lectured about the “leaky epithelial syndrome” that would result in transient hyperopia. I am also aware that another pioneer in refractive surgery, Spencer Thornton, MD, emphasized the importance of intraocular pressure that could change the corneal curvature in RK patients, resulting in fluctuation of the refractive error. While an obvious explanation is not clear to me, I am certain that the syndrome described by Centurión exists and necessitates restraint in this select group of patients.

REFERENCE

1. Hoffer KJ. Intraocular lens power calculation after previous laser refractive surgery. J Cataract Refract Surg. 2009;35:759-765.
© 2009 by Lippincott Williams & Wilkins, Inc.