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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
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.
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