ORIGINAL ARTICLE. Accommodative Changes After Photorefractive Keratectomy in Myopic Eyes

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1 /10/ /0 VOL. 87, NO. 11, PP OPTOMETRY AND VISION SCIENCE Copyright 2010 Americn Acdemy of Optometry ORIGINAL ARTICLE Accommodtive Chnges After Photorefrctive Kertectomy in Myopic Eyes Frid Krimin*, Alirez Brdrn-Rfii*, Abbs Bgheri*, Medi Eslni*, Hom Byt*, Shil Armesh*, Mehdi Yseri, nd Anhit Amin-Shokrvi ABSTRACT Purpose. To determine the chnges of mplitude of (AA) nd fcility of (FA) in myopic ptients fter photorefrctive kertectomy (PRK). Methods. Using Technols 217Z excimer lser, 160 myopic eyes of 80 ptients underwent PRK. The ptients were ctegorized into two ge groups: 30 nd 30 yers. Chnges in AA nd FA were observed before PRK nd t 2 weeks, 1 month, nd 3 months fter PRK. The role of preopertive AA, FA, refrctive sphericl equivlent, ge, nd sex on postopertive AA nd FA ws evluted. Results. In younger ptients, the preopertive AA nd FA vlues D nd cpm chnged to D nd cpm (p 0.001), respectively, t 3 months fter PRK. In older ptients, the preopertive AA nd FA vlues D nd cpm chnged to D (p 1.000) nd cpm (p 0.001), respectively. Two weeks fter surgery, preopertive AA nd sphericl equivlent hd significnt effect on postopertive AA, wheres preopertive AA nd ge hd significnt effect on postopertive AA fter 3 months (p 0.001). Postopertive FA ws positively relted to preopertive FA nd femle sex (p 0.05). Conclusions. This study suggests tht some of the ner-vision problems in younger myopes in erly postopertive dys fter PRK might be due to decrese in AA nd FA, which will eventully increse. However, in older ptients, despite increse in FA, AA did not chnge. (Optom Vis Sci 2010;87: ) Key Words:, mplitude of, fcility of, photorefrctive kertectomy, PRK Accommodtion disturbnces such s insufficiency of ttributble to prepresbyopic stte, uncorrected nisometropi, indequte refrctive correction, nd symmetricl nucler sclerosis hve been reported in myopic ptients without ny history of refrctive surgery. 1 It hs been proposed tht corrected myopes hve higher effective compred with emmetropes nd hypermetropes. 2 They need ner ddition t n older ge, which might be due to higher effectiveness of concve vs. convex lenses nd prismtic effect of minus lenses for ner vision. 2 *MD PhD MSc Ophthlmic Reserch Center, Shhid Beheshti University of Medicl Sciences, Tehrn, Irn (FK, AB-R, AB, HB, SA), School of Medicine, Tehrn University of Medicl Sciences, Tehrn, Irn (ME), Deprtment of Public Helth, Tehrn University of Medicl Sciences, Tehrn, Irn (MY), nd Deprtment of Optometry, Shhid Beheshti University of Medicl Sciences, Tehrn, Irn (AA-S). Delyed fr nd ner visul recovery re of the most frequent shortcomings of photorefrctive kertectomy (PRK) in myopic ptients. 3,4 This might be due to the process of epithelil heling nd remodeling, defective precornel ter film, nd ccommodtive disturbnces. Most often, ner-vision complints continue despite full distnt visul recovery in the erly weeks fter surgery. These ner-vision complints might be not only due to disturbnces in mplitude of (AA) but lso due to other fctors such s infcility (inerti) of, sudden increse in the mount of required for ner vision, nd disproportionte such s spsm nd ill-sustined (poor stmin). 5 To the best of our knowledge, there is no published rticle in the literture evluting ccommodtive disturbnces, including AA nd fcility of (FA) in these ptients. The purpose of this study is to evlute AA nd FA chnges fter PRK in myopic ptients.

2 834 Accommodtive Chnges After Photorefrctive Kertectomy Krimin et l. METHODS This study ws performed on myopic ptients who underwent PRK t Lbbfinejd Medicl Center, Shhid Beheshti University of Medicl Sciences, from Mrch to August The study protocol ws bsed on the Tenets of Declrtion of Helsinki nd ws pproved by the medicl ethics committee of Ophthlmic Reserch Center. All possible risks were explined, nd informed consent ws obtined from ll ptients. All ptients underwent thorough ophthlmologic exmintion before surgery including mesurement of uncorrected visul cuity nd best spectcle-corrected visul cuity (BSCVA), mnifest nd cycloplegic refrction, slit lmp exmintion, Goldmnn pplntion tonometry, nd fundus exmintion. In ddition, cornel elevtion topogrphy by Orbscn II (Busch nd Lomb, Rochester, NY) nd Ultrsonic pchymetry (Nidek UP-1000; Nidek Compny, Gmgori, Jpn) were performed. Inclusion criteri for surgery were ge 20 yers, sphericl equivlent (SE) between 1.00 nd 8.00 D, cylinder 1.00 D, BSCVA of t lest 20/40, nd stble refrction for t lest 1 yer before surgery. Ptients with history of previous oculr surgery, mesopic pupil size 6 mm, kertoconus or ny ecttic cornel disorder, kertoconus suspect by topogrphy, preopertive cornel opcity, ny cornel dystrophies, presence of pterygium, retinl disorders, collgen vsculr disorders, dibetes mellitus, glucom, ctrct, pregnncy, brestfeeding, nd systemic corticosteroid therpy were excluded. One of the uthors (H.B.) scheduled nd referred the ptients for refrctive nd ccommodtive mesurements. All pre- nd postopertive refrctive nd ccommodtive mesurements were performed by one skilled optometrist (A.A.S.), who ws msked to preopertive refrction, ge, surgery dte, nd lter durtion fter PRK. AA nd FA were mesured before nd t 2 weeks, 1 month, nd 3 months fter surgery. To minimize the effect of ftigue nd cycloplegic refrction, ccommodtive tests were performed the dy before usul follow-up visits. All ptients were requested to discontinue contct lenses 3 months before surgery becuse of its probble effects on the AA nd FA. To evlute the effect of ge on chnges in, the ptients were rbitrry divided into two groups: 30 nd 30 yers. Dt were nlyzed using SPSS sttisticl softwre (version 15; SPSS, Chicgo, IL). To compre the vlues within groups in different times, we used repeted mesure nlysis of vrince test. Multiple comprison correction ws performed by Sidk method. Anlysis of covrince ws performed to evlute the reltive role of different fctors on AA nd FA. Surgicl Procedure All ptients underwent PRK using Technols 217Z (Busch nd Lomb, Rochester, NY) in stndrd method. One surgeon (FK) performed ll procedures. Cornel epithelium ws removed by using ethnol (15%) for 20 s. Opticl zone ws 6 mm. At lest 400 m of residul cornel stroml bed ws kept fter bltion s sfe mrgin in ll cses. Mitomycin-C (0.02%) ws pplied for 10 s if bltion depth ws 70 m. Then, the stroml bed ws copiously irrigted with blnced sline solution. A bndge contct lens ws plced over the corne for 2 to 3 dys until epitheliliztion ws complete. All ptients received chlormphenicol (0.5%) for 1 week nd betmethsone (0.1%) four times per dy for 2 weeks. Steroid drop ws chnged to fluorometholone (0.1%) in the third week, which tpered off between second nd third months. Mesurement of AA Refrctive errors were corrected using tril frme during the ccommodtive tests. AA in diopters ws mesured using minus lens method in constnt illumintion with trget t 40-cm distnce. Minus hlf diopter (D) ws dded to the mesured mount of AA to compenste for minifiction resulting from minus lenses. The visul ner trget ws stndrd two prllel lines on the ner chrt. Incresing minus nd plus lenses with 0.25 D steps were subsequently plced in front of the ptients eyes until first sustined blur. The concept of blur ws explined to the ptient by inserting 0.25 D lens in front of his or her eyeglsses while looking with BSCVA. Subjective Accommodtive Fcility Mesurements Monoculr ccommodtive fcility for the test eye ws evluted t 40 cm. Accommodtive fcility in the ner ws mesured with 2.00 D lens combintion mounted in semiutomted flippers (Vision Co-opertive Reserch Center, Sydney, Austrli) with the subject viewing reduced 20/30 letters. The fellow eye ws occluded with filter (87C Wrtten filter; Estmn-Kodk, Rochester, NY), which trnsmits infrred light by llowing the photorefrctor (PowerRefrctor; Multichnnel Systems, Rutlingen, Germny) to obtin n objective dynmic reding of, while occluding the visul input to tht eye. For ptients older thn 30 yers, trget distnce ws 40 cm, nd 1.5 D lenses were used. The flipper, which ws interfced with computer, ws mounted on hndle tht contined mercury tilt switch for cycle detection nd strt button for the opertor. A commercil progrm (LbWindows/CVI, version 6.0; Ntionl Instruments, Austin, TX) ws used to run the flippers. The time between the flips ws recorded using n incorported 60-s timer. Ech time when the lens ws flipped by the exminer (i.e., when the subject tpped the tble to indicte clrity), the mercury switch triggered the circuit. The durtion nd frequency of ech ccommodtive phse ws recorded. As the first lens ws introduced, the timer ws ctivted by pressing the strt button on the flipper. Ech test ws performed for 60 s. The plus side of the flipper ws lwys presented first. The subjects were instructed s follows: You should look t the letters nd try to keep them cler. The mchine will put lens in front of your eye nd the letters will blur for short time nd then become cler gin. As soon s they re cler gin, plese tp the tble. The mchine will then chnge the lens, nd the letters might be blurred gin. Tp the tble s soon s you cn see the letters clerly gin. The mchine will go on repeting this procedure to see how often you cn cler the lenses in 1-min period. A dummy run, in which the flipper ws flipped t the mximum possible speed for period of 30 s, ws conducted to test the rection time of the opertor nd the mechnics of the flipper. The results showed tht the time tken to flip the lenses on verge ws 0.30 s, so tht opertor nd lens-chnge delys ccounted for roughly 0.6 s of ech cycle period.

3 RESULTS One hundred sixty eyes of 80 ptients (26 men nd 54 women) with men ge of yers (20 to 42 yers) were included. Men preopertive SE ws D ( 0.75 to 8.5 D), which improved to D ( 1.25 to 1.50 D) t 1 month nd D ( 1.50 to 1.00 D) t 3 months fter surgery (p 0.001). BSCVA ws logmr (0.4 to 0.0), logmr (0.4 to 0.0), nd logmr (0.7 to 0.0) before, 1 month, nd 3 months fter surgery (p 0.001). Three months fter surgery, 98.1% nd 90.6% of eyes were within 1D nd 0.5 D, respectively. In younger ge group, AA nd FA were more thn older group before surgery (p 0.001; Tbles 1 nd 2). After PRK, AA incresed significntly in younger group t 3 months fter surgery. However, in the older group, AA did not chnge significntly fter PRK (Fig. 1). In both the groups, the FA incresed significntly t 1 nd 3 months fter surgery (Fig. 2). Two weeks fter surgery, while evluting simultneous effect of different fctors (preopertive AA, preopertive FA, preopertive SE, ge, nd sex; djusted R ), preopertive AA (p 0.001) nd SE (p 0.04) hd significnt effect on the postopertive AA (Tble 3). Preopertive FA (p 0.001) nd ge (p 0.02) hd significnt effect on the postopertive FA (Tble 4). Preopertive AA nd ge were found to hve significnt effect on postopertive AA 3 months fter surgery (p 0.001; Tble 5). There ws no reltion between preopertive FA, preopertive SE, nd sex with postopertive AA. Considering the sme fctors, postopertive FA ws positively relted to preopertive FA nd femle sex (p 0.05). There ws no reltion between preopertive AA, preopertive SE, nd ge with postopertive FA (Tble 6). DISCUSSION This study showed tht AA nd FA incresed 3 months fter PRK in young myopic ptients wering spectcles. In older myopes, FA incresed significntly, wheres AA did not increse. In erly dys fter surgery, AA ws dependent on preopertive AA nd SE, wheres 3 months lter, it ws dependent on preopertive AA nd ge. Preopertive FA nd ge were effective on postopertive FA in erly dys fter PRK, wheres 3 months lter, the role of preopertive FA nd sex ws significnt. The mount of for ech ner trget by myopic ptient with or without corrective eyeglsses is less thn n emmetrope. 6 This mens tht the ttempted effort of the ciliry body in myopic ptient is less thn norml individul, which could led to lower ctivity of ciliry muscles nd longer preservtion of Accommodtive Chnges After Photorefrctive Kertectomy Krimin et l This study showed tht AA will increse fter PRK in younger group. This increse ws not observed in ptients older thn 30 yers, which might be due to ciliry body nd zonulr fibers dysfunction nd lens stiffness in prepresbyopic popultion. It seems tht the younger the ptient is, the more the potentil for ciliry body nd lens microstructure to improve. In the other words, in younger ptients, presbyopi might be delyed fter refrctive surgery. Whether this increse is more thn ge-mtched norml popultion needs to be determined. This increse in younger group might be relted to postopertive pseudo resulting from multifoclity, sphericity, higher order oculr berrtions, nd resultnt better-thn-expected uncorrected ner visul cuity. 7 9 These fctors might influence the eye s depth of field, which in turn controls the pseudoccommodtive effect in ssocition with the remining optics of the eye. 10 Artol et l. 7 predicted tht the depth of field fter PRK cn be 0.2 to 1.0 D higher thn expected in normls. They suggested underlying intrcornel opticl interctions, coupled with the chnges in cornel front surfce multifoclity, re the most likely fctors responsible for higher thn norml AA in the ptient who underwent PRK. 7 They lso proposed both the cornel front surfce topogrphy nd the increse in totl oculr berrtions with specific reference to sphericl berrtion s responsible fctors for the pseudo nd better uncorrected ner visul cuity in ptients who underwent PRK. 7 It is known tht ccommodtive fcility rte is dependent on severl fctors, including oculr depth-of-focus; subject s criteri for cler vision; velocity nd AA; rection time; nd the time tken to chnge the lenses, together with the opertor s rection nd motor times It seems tht FA is lower in myopes thn emmetropes. 13 In this study, FA incresed fter surgery. This might be due to the effect of clerer vision nd more obligtory usge of on FA. Although it ws not sttisticlly significnt, the role of cler vision is lso suggested by the decrese in FA in younger group in the erly dys fter PRK. Both AA nd FA decresed erly dys fter PRK in younger myopes. This might prtly explin ner-vision complints of myopes in erly dys fter PRK. Although we did not hve ny subjective questionnire to evlute ptients symptoms, this finding suggests tht ccommodtive problems might be more frequently expected in younger ptients, especilly with higher refrctive errors. Decrese in AA nd FA could be ttributed to decresed visul cuity, blurred vision, pin, tering, lower or higher order berrtions, nd sudden increse in demnd of required for ner vision in ptient with previous myopi. Long-term usge of eyeglsses might induce sort of c- TABLE 1. Amplitude of in two ge groups Age group (yr) Before surgery (D) After surgery (D) 2 weeks 1 month 3 months P1 P2 P3 P4 P5 P Pired t-test: P1, P2, nd P3 compring before with 2 weeks, 1 month, nd 3 months fter surgery; P4 nd P5 compring between 2 weeks nd 1 nd 3 months fter surgery; nd P6 compring between 1 nd 3 months fter surgery.

4 836 Accommodtive Chnges After Photorefrctive Kertectomy Krimin et l. TABLE 2. Fcility of (cpm) in two ge groups Age group Before surgery (cpm) After surgery (cpm) 2 weeks 1 month 3 months P1 P2 P3 P4 P5 P Pired t-test: P1, P2, nd P3 compring before with 2 weeks, 1 month, nd 3 months fter surgery; P4 nd P5 compring between 2 weeks nd 1 nd 3 months fter surgery; nd P6 compring between 1 nd 3 months fter surgery. FIGURE 1. Men chnges of AA (OD or OS) in different ge groups before nd fter surgery. FIGURE 2. Men chnges of FA (OD or OS) in different ge groups before nd fter surgery. TABLE 3. Effects of different fctors on mplitude of using multiple liner regression nlysis 2 weeks fter surgery intervl Preopertive mplitude of Preopertive fcility of Preopertive sphericl equivlent Age Sex (mle) R (djusted R ). commodtive disturbnce, which my interfere with cler vision in erly dys fter surgery. This ccommodtive disturbnce is lso frequently seen fter switching of eyeglsses to contct lenses in myopic ptients. 6,15 It is lso known tht AA nd FA my be different between myopic ptients wering spectcles vs. contct lenses. 6,15 For minus power lens correction, the mount of required is greter for contct lens correction thn spectcle lens correction of equl power. 1,6 Refrctive error hs been shown to hve n effect on different ccommodtive mesurements 16 such s ccommodtive convergence or rtio, ccurcy of the ccommodtive response, tonic, 18,23,24 ner work-induced trnsient myopi, nd lower ccommodtive fcility. 16,22,29 The proportionl effect of these fctors on the AA nd FA my be different. We found the preopertive AA nd SE s significnt determinnts of postopertive AA in erly dys fter surgery. This emphsizes on the possible role of the mount of refrctive error on AA disturbnce. Three months fter surgery, preopertive AA nd ge were found to hve significnt effect on postopertive AA. These findings suggest tht ccommodtive disturbnces relted to the mount of refrctive error will improve few months fter surgery nd finlly the ge, nd rehbilittive potentil of ciliry body nd zonulr fibers, is the most importnt determinnt of AA. Preopertive FA nd ge hd significnt effect on postopertive FA 2 weeks fter surgery, wheres preopertive FA nd sex were p

5 Accommodtive Chnges After Photorefrctive Kertectomy Krimin et l. 837 TABLE 4. Effects of different fctors on fcility of using multiple liner regression nlysis 2 weeks fter surgery TABLE 6. Effects of different fctors on fcility of using multiple liner regression nlysis 3 months fter surgery intervl p intervl p Preopertive mplitude of Preopertive fcility of Preopertive sphericl equivlent Age Sex (mle) R (djusted R ). Preopertive mplitude of Preopertive fcility of Preopertive sphericl equivlent Age Sex (mle) to R (djusted R ). TABLE 5. Effects of different fctors on mplitude of using multiple liner regression nlysis 3 months fter surgery intervl Preopertive mplitude of Preopertive fcility of Preopertive sphericl equivlent Age Sex (mle) R (djusted R ). found to be effective on postopertive FA 3 months lter. Interestingly, femle sex ws found to hve positive effect on postopertive FA. We cnnot definitely justify this finding, but it could be due to higher coopertion nd enthusism of women nd needs to be evluted in future studies. There re some limittions in our study. The follow-up period of the study is not long enough to judge bout the stbiliztion course of AA nd FA fter surgery. We did not evlute other spects of dynmics, which might be ffected fter PRK. We did not hve control group to compre with norml popultion. Although, our dt re suggestive of higher frequency of ner-vision problems in younger myopes, we did not subjectively evlute their frequency nd severity using questionnire in these ptients. In conclusion, this study suggests tht some of the ner-vision problems in younger myopic ptients fter PRK might be due to decresed AA nd FA in erly postopertive dys. However, AA nd FA will eventully increse compred with preopertive vlues. In erly dys fter surgery, the mount of preopertive SE hs negtive reltion to postopertive AA; however, fter few weeks, P its role will be replced by ge. Three months fter surgery, preopertive AA nd ge nd preopertive FA nd sex re effective fctors on postopertive AA nd FA, respectively. In older ptients, compred with preopertive vlues, despite the increse in FA, AA does not chnge. ACKNOWLEDGMENTS We pprecite the enthusistic coopertion of Frhd Shrei, MSc, for his kind review nd beneficil comments for this mnuscript, nd Seed Ansri, MSc, Hed of Deprtment of Optometry, Negh Eye Center, Tehrn, for his kind coopertion nd instrument preprtion. None of the uthors hs ny finncil interests to ny products mentioned. None of the uthors hs ny conflict of interest. Received My 20, 2010; ccepted July 23, REFERENCES 1. Goss DA, Eskridge JB. Myopi. In: Amos JF, ed. Dignosis nd Mngement in Vision Cre. Boston, MA: Butterworths; 1987: Abrhm LM, Kurikose T, Sivnndm V, Venktesn N, Thoms R, Muliyil J. Amplitude of nd its reltion to refrctive errors. Indin J Ophthlmol 2005;53: Tneri S, Zieske JD, Azr DT. Evolution, techniques, clinicl outcomes, nd pthophysiology of LASEK: review of the literture. Surv Ophthlmol 2004;49: Dstjerdi MH, Soong HK. LASEK (lser subepithelil kertomileusis). Curr Opin Ophthlmol 2002;13: Ciuffred KJ. Accommodtion, the pupil, nd presbyopi. In: Benjmin JB, Borish IM, eds. Borish s Clinicl Refrction. Phildelphi, PA: W. B. Sunders; 1998: Ktz M. The humn eye s n opticl system. In: Dune TD, Jeger EA, eds. Clinicl Ophthlmology. Phildelphi, PA: J. B. Lippincott; 1985: Artol A, Ptel S, Schimchk P, Ayl MJ, Ruiz-Moreno JM, Alio JL. Evidence for delyed presbyopi fter photorefrctive kertectomy for myopi. Ophthlmology 2006;113: Scher K, Hersh PS. Disprity between refrctive error nd visul cuity fter photorefrctive kertectomy: multifocl cornel effects. J Ctrct Refrct Surg 1997;23: Wilson SE, Klyce SD, McDonld MB, Liu JC, Kufmn HE.

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