What is the Best Option for Hyperopia?

During the 2023 ESCRS Congress in Vienna, close to where the famous boxing arena saw two surgeons fighting one against the other on divisive topics, a single, brief showdown at the JCRS symposium between two illustrious surgeons took place between Pavel Stodůlka MD, PhD and Michael Knorz MD.

Opinions and clinical experiences were donned as gloves. A couple of very clever jabs, none below the belt, and some direct hits occurred here and there as the crowd cheered. The theme was refractive options for hyperopia between 2 and 9 dioptres, with Dr Knorz in support of lenticular options and Dr Stodůlka in favour of corneal refractive procedures.

Two different points of view emerged, placing patient happiness first on one side, and the rate of unhappy patients on the other.

“I will never do any corneal laser surgery over +3.0 D,” Dr Knorz said. “The reason is that about 15 years ago, I did a study for 1.0 to 3.0 D, 3.0 to 6.0 D, and 6.0 to 9.0 D, published in the Journal of Refractive Surgery, and the outcome was clearly inferior over 6.0 D with plenty more unhappy patients.”

“I think you are absolutely right [about] 10 years ago,” Dr Stodůlka replied, “but laser technology has really evolved over these years. I think LASIK for +4.0 D and +5.0 D is successful. And with SMILE, it is going to be even better: in 100 procedures, I have not seen a single unhappy patient.”

“Maybe you needed 100 patients with +6.0 D on the study, and I guarantee you would have 10% unhappy patients in that case,” Dr Knorz answered.

After the discussion, both contenders doubled down.

“I was more in favour of the intraocular solution for hyperopia from 2 to 9 dioptres, and apparently I am not a proponent of doing all on the cornea alone,” Dr Stodůlka said. “So, for patients who are older than 40, we do intraocular surgery and refractive lens exchange—typically with trifocal lenses, or it can be monofocal, monovision, EDOF, etcetera.

“For the younger patients, we still perform LASIK, and we hope we will soon be able to clinically perform hyperopic SMILE. I was part of the first international study, on more than 100 eyes, and the patients were very, very happy. The optical zones are large, and the results were exciting,” he said. “Hyperopic SMILE is going to take off quite soon.”

Dr Knorz’s defensive stance was perfectly in line with the German guidelines. “In Germany, we have a guideline that says you should not perform laser refractive surgery for more than +3.0 D of hyperopia. The reason for this is when you do higher ablations, even with moderate ablation algorithms, you create a lot of corneal aberrations [that] lead to significant visual disturbances in about 5 to 10% of patients,” he said. “So, we are not questioning the high success rate for those 90 to 95% happy patients. But we are concerned about the 5 to 10% of unhappy patients because, unlike the intraocular approach, they cannot be undone. That’s why one conclusion of my talk is you should not do LASIK, or SMILE, or PRK for more than +3.0 D of hyperopia.”

“I think the part where we do not have the same strategy was the young hyperopes with hyperopia higher than 3.0 D,” Dr Stodůlka said. “Professor Knorz would not perform LASIK or any kind of corneal refractive surgery. He fears the aberrations with the recent technologies of the latest generation of excimer lasers. With thicker flap and LASIK extra and with SMILE, we have very nice results—and we have happy patients, so that was a little bit different approach.”

“My main point of disagreement with Dr Stodůlka, who I really highly regard as a very good surgeon, is his focus on the success for the patient, while my focus is on the problem some patients may experience,” Dr Knorz said. “In our EuroEyes clinic, we perform more than 1,000 cases every year, and if you do these numbers and have 5% of unhappy patients, you will find yourself with a really significant number.”

“We both agreed that [in patients] over 40, we should only do refractive lens exchange because the hyperopic patient has no risk of retinal detachment,” Dr Knorz said. “The hyperopic patient has small eyes, shallow angles with high risk of glaucoma—all these things get better with a refractive lens exchange in addition to actually making them spectacle independent. On this we completely agree.”

Michael C Knorz MD is medical director of the FreeVis LASIK Center Mannheim, EuroEyes Group, Germany. knorz@eyes.de

Pavel Stodůlka MD, PhD is founder, chief surgeon, and CEO of Gemini Eye Clinics in the Czech Republic and Vienna, Austria. stodulka@lasik.cz