title: Arcuate keratotomy for asymmetrical steep islands after laser in situ keratomileusis and automated lamellar keratoplasty.
abstract: OBJECTIVE
  To determine the safety and efficacy of arcuate keratotomy (AK) to reduce or eliminate steep asymmetrical islands after laser in situ keratomileusis (LASIK) and automated lamellar keratoplasty (ALK).
  
  
  METHODS
  Rancho Bernardo Laser and Vision Center, San Diego, California, USA.
  
  
  METHODS
  This retrospective and noncomparative interventional study comprised 8 eyes of 5 patients who received arcuate incisions to reduce topographically defined asymmetrical steep islands after LASIK (n = 7) and ALK for hyperopia (n = 1). The islands occurred unexpectedly after standard excimer laser treatment (VISX Star and S2) for myopic astigmatism that induced irregular astigmatism and unwanted optical effects. Cases occurred consecutively over 16 months, an incidence of less than 1%. Arcuate incisions extended 30 or 45 degrees in LASIK eyes based on the amount of residual refractive astigmatism and were placed at 7.0 mm on the steep axis. Radial incisions were limbal sparing to a 5.0 mm optical zone following the Casebeer nomogram. Outcome measures were uniformity of postenhancement topography, uncorrected visual acuity (UCVA), postenhancement refraction, and reduction in unwanted optical effects.
  
  
  RESULTS
  The preenhancement mean spherical equivalent (SE) in the LASIK eyes was -0.99 diopters (D) +/- 0.48 (SD); the astigmatism ranged from 0.50 to 1.75 D. After incisional keratotomy, the mean SE was -0.21 +/- 0.12 D and the net residual astigmatism was reduced to a range of 0 to 0.75 D. All 8 eyes had AK to reduce topographically defined steep islands that were causing visual blurring and unwanted optical effects including ghosting, halos, and polyplopia. After enhancement, there was a marked reduction in the asymmetrical steep islands by topography, fewer unwanted optical effects, less refractive astigmatism, and improved UCVA. Two patients retained small inferior steep areas that may indicate forme fruste keratoconus, although this condition was not detected preoperatively by topographical indices.
  
  
  CONCLUSIONS
  Uncorrected visual acuity improved and unwanted optical effects were reduced after AK on the peripheral axis of asymmetrical steep islands that occurred after uneventful LASIK and hyperopic ALK. This relatively simple incisional approach may be used until more advanced topography-linked ablations with rapid and precise eye tracking are perfected and widely available.
authors.affiliation: Rancho Bernardo Laser and Vision Center, 16766 Bernardo Center Drive, San Diego, CA 92128-2501, USA.
authors.forename: James
authors.initials: J
authors.lastname: Pulaski
mesh_terms: D000328:Adult; D003315:Cornea / Q000473:pathology; D003316:Corneal Diseases / Q000150:complications / Q000209:etiology* / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D006956:Hyperopia; D020731:Keratomileusis, Laser In Situ / Q000009:adverse effects*; D015948:Keratoplasty, Penetrating / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D013508:Ophthalmologic Surgical Procedures; D012086:Reoperation; D012189:Retrospective Studies; D014786:Vision Disorders / Q000209:etiology; D014792:Visual Acuity