Corrección de la presbicia tras cirugía cristaliniana. ¿Dónde nos encontramos en 2020? / Lens-based surgical correction of presbyopia. Where are we in 2020?

INTRODUCCIÓN: La presbicia es la pérdida progresiva e irreversible de la acomodación debido al envejecimiento. Es una de las principales causas de disminución de la calidad de vida en personas a partir de los 45 años derivada de la, muchas veces novedosa, dependencia de las gafas. El afán por corregirla por parte de los oftalmólogos, impulsados por el deseo de millones de personas que la padecen, se ha convertido en uno de los principales motores de desarrollo de la tecnología de las lentes intraoculares (LIO) durante los últimos 20 años. MATERIAL Y MÉTODOS: Esta revisión repasa las distintas alternativas que han permitido ir mejorando el enfoque quirúrgico cristaliniano de la presbicia; desde las lentes monofocales y la técnica de la monovisión, a las lentes acomodativas, pasando por las lentes multifocales refractivas y difractivas y terminando con las más recientes lentes de foco o campo extendido conocidas como EDOF. RESULTADOS: Cada una de estas LIO tiene sus ventajas, limitaciones e inconvenientes; y además, no existe la lente que se adapte a las necesidades de todos los pacientes. CONCLUSIONES: Es necesario conocer la variedad de lentes disponibles, y comprender en profundidad tanto sus propiedades ópticas como el impacto que estas van a tener luego en su rendimiento clínico y en la calidad visual de los pacientes. Esto nos debería ayudar a poder seleccionar la mejor alternativa para cada uno de ellos

INTRODUCTION: Presbyopia is the progressive and irreversible loss of accommodation due to aging. It is one of the main causes of loss of quality of life in people from 45 years of age, due to the, often novel, dependence on spectacles. The eagerness to correct it by ophthalmologists impulsed by the desire of millions of people who suffer from it, has become one of the main drivers for the development of intraocular lens (IOL) technology over the last twenty years. MATERIAL AND METHODS: This review briefly presents the different alternatives that have allowed us to improve the crystalline lens surgical approach of presbyopia; from monofocal lenses and monovision technique, accommodative, refractive, and diffractive multifocal lenses, and finally the most recent extended depth of focus/field lenses known as EDOFs. RESULTS: Each IOL has its advantages, limitations and disadvantages. Furthermore, there is no single lens that suits the needs of all patients. CONCLUSIONS: It is necessary to know the variety of lenses available, and to have an in-depth understanding of their optical properties, as well as the impact that these will have later on their clinical performance and on the visual quality of the patients. This should help us to select the best alternative for each of them

Lens-based surgical correction of presbyopia. Where are we in 2020? / Corrección de la presbicia tras cirugía cristaliniana. ¿Dónde nos encontramos en 2020?

INTRODUCTION: Presbyopia is the progressive and irreversible loss of accommodation due to aging. It is one of the main causes of loss of quality of life in people from 45 years of age, due to the, often novel, dependence on spectacles. The eagerness to correct it by ophthalmologists impulsed by the desire of millions of people who suffer from it, has become one of the main drivers for the development of intraocular lens (IOL) technology over the last twenty years. MATERIAL AND METHODS: This review briefly presents the different alternatives that have allowed us to improve the crystalline lens surgical approach of presbyopia; from monofocal lenses and monovision technique, accommodative, refractive, and diffractive multifocal lenses, and finally the most recent extended depth of focus/field lenses known as EDOFs. RESULTS: Each IOL has its advantages, limitations and disadvantages. Furthermore, there is no single lens that suits the needs of all patients. CONCLUSIONS: It is necessary to know the variety of lenses available, and to have an in-depth understanding of their optical properties, as well as the impact that these will have later on their clinical performance and on the visual quality of the patients. This should help us to select the best alternative for each of them.

Lentes intraoculares fáquicas: adaptándose a los cambios / Phakic Intraocular Lenses: Adapting to change

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Resultados visuales, independencia de gafas e insatisfacción tras implante de una lente intraocular difractiva trifocal / Visual outcomes, spectacle independence and satisfaction after diffractive trifocal intraocular lens implantation

OBJETIVO: Evaluar los resultados visuales, la independencia de gafas y la satisfacción tras el implante de una lente intraocular trifocal. MÉTODOS: Estudio retrospectivo de 5.186 sujetos intervenidos de facoemulsificación con implante de la lente trifocal difractiva FineVision Micro F12 (PhysIOL, Liège, Bélgica). RESULTADOS: La queratometría media preoperatoria fue 43,61±1,55 D y el cilindro queratométrico medio -0,86 ± 0,66 D. A los 3 meses, cambiaron a 43,59±1,56 y −0,71±0,46 D respectivamente. La esfera media pasó de 2,04±2,60 a 0,14±0,38 D y el equivalente esférico medio de 1,64±2,61 a −0,05±0,36 D. Más del 60% alcanzaron una mejor agudeza visual corregida de lejos. La mayoría presentó un defecto residual final (predictibilidad) menor de 1 D (99,1%). El 14,3% precisó un ajuste refractivo, el 2,2% capsulotomía posterior y se recolocó la lente intraocular en 5 casos. Un porcentaje elevado estaba satisfecho en términos de visión e independencia de gafas en todas las distancias. Aunque un 2% refirió un empeoramiento en la visión nocturna, únicamente un 2% estaba poco satisfecho y 20 pacientes insatisfechos. Las causas fueron: visión borrosa (7 casos), necesidad de gafas (10), disfotopsias (7) y sequedad ocular (4). CONCLUSIONES: La implantación de esta lente permite obtener buenos resultados visuales en las 3 distancias así como un alto grado de independencia de gafas y de satisfacción

PURPOSE: To investigate visual outcomes, spectacle independence, and patient satisfaction after trifocal intraocular lens implantation. METHODS: A retrospective study conducted on 5,186 patients who underwent phacoemulsification and were implanted with a diffractive trifocal intraocular lens (FineVision Micro F, PhysIOL SA, Liège, Belgium). RESULTS: The mean pre-operative keratometry was 43.61±1.55 D, and mean keratometric cylinder was -0.86±0.66 D. At 3 months post-operatively, values changed to 43.59±1.56 and -0.71±0.46 D, respectively. Mean sphere varied from 2.04±2.60 to 0.14±0.38 D, and mean spherical equivalent from 1.64±2.61 to -0.05±0.36 D. More than 60% of the patients achieved better corrected distance visual acuity. The majority had a final residual refractive error (predictability) lower than 1 D (99.1%), with 14.3% needing optical adjustment (bioptics). Posterior capsulotomy was performed in 2.2%, and the lens was replaced in 5 patients. A high percentage of patients were satisfied in terms of vision and spectacle independence at all distances. Although 2% referred to worsening of night vision quality, only 2% were not very satisfied and 20 patients were dissatisfied. The causes were: blurred vision (7 cases), spectacle dependence (10), dysphotopsia (7), and dry eye (4). CONCLUSIONS: The implantation of this model provided good visual performance in all distances, as well as high levels of spectacle independence and satisfaction

Optimización de la elección de talla para el segundo ojo basándose en el vault obtenido en el primero en la cirugía bilateral de lentes fáquicas de cámara posterior / Optimization of the lens sizing for the second eye based on the vault obtained in the first eye in bilateral myopic collamer phakic intraocular lens surgery

OBJETIVO: Evaluar el vault y la toma de decisiones en la selección del tamaño de la lente del segundo ojo en una serie de pacientes que recibieron implantes bilaterales de una lente fáquica de cámara posterior (pIOL) con puerto central para la corrección de la miopía. MÉTODOS: La muestra del estudio incluyó los pacientes a los que se implantó una pIOL de diferente tamaño entre ambos ojos de una serie total de 269 pacientes intervenidos mediante inserción bilateral secuencial en nuestra institución entre marzo de 2012 y mayo de 2015. Los procedimientos en cada paciente fueron separados en el tiempo para seleccionar el tamaño de la pIOL en los segundos ojos. El vault fue analizado objetivamente mediante tomografía de coherencia óptica. RESULTADOS: La decisión de modificar el tamaño de la pIOL se tomó en 25 pacientes. En 9 pacientes se implantó una pIOL más pequeña en el segundo ojo, mientras que en 16 pacientes se necesitó una talla más grande. La implantación de una talla más grande condujo a un aumento medio del vault de 251 ± 180 micras, mientras que una lente de menor tamaño se tradujo en una disminución media del vault de 542 ± 187 micras. En 5 pacientes, la pIOL implantada en el primer ojo se rotó verticalmente para reducir el vault. No fue necesario explantar ninguna lente. CONCLUSIONES: El vault en los ojos adelfos de pacientes intervenidos bilateralmente con una pIOL miópica puede ser optimizado valorando la talla a implantar en el segundo ojo en función del vault obtenido en el primer ojo

PURPOSE: To assess vault and the decision-making process involved in selecting the size of the lens for the fellow eye in a series of patients who received bilateral phakic collamer intraocular lens (pIOL) implants with central hole for correction of myopia. METHODS: The study sample included all patients who underwent bilateral insertion of a different size pIOL from a pool of 269 patients who underwent sequential bilateral insertion of a pIOL from March 2012 to May 2015 in our institution. Procedures were separated in time to assess the value of the vault and select the pIOL size in second eyes. Vault was analysed objectively using optical coherence tomography. RESULTS: The decision to change the size of the pIOL in the fellow eye was taken in 25 patients. A smaller pIOL was implanted in the second eye in 9 patients, whereas a lens that was 1 size larger was necessary in 16 patients. Implantation of a larger lens led to a mean increase in vault of 251 ± 180 microns; implantation of a smaller size lens led to a mean decrease in vault of 542 ± 187 microns. In 5 patients, the pIOL implanted in first eye was rotated vertically to reduce lens vault. No lenses had to be explanted. CONCLUSIONS: Vault in fellow eyes can be improved in patients receiving bilateral myopic pIOL implants by modifying the pIOL size based on the vault value obtained in the first eyes

Neuralgia lagrimal recurrente desencadenada por procedimientos oftalmológicos / Recurrent lacrimal neuralgia secondary to ophthalmological procedures

No disponible

Visual outcomes, spectacle independence and satisfaction after diffractive trifocal intraocular lens implantation. / Resultados visuales, independencia de gafas e insatisfacción tras implante de una lente intraocular difractiva trifocal.

PURPOSE: To investigate visual outcomes, spectacle independence, and patient satisfaction after trifocal intraocular lens implantation. METHODS: A retrospective study conducted on 5,186 patients who underwent phacoemulsification and were implanted with a diffractive trifocal intraocular lens (FineVision Micro F, PhysIOL SA, Liège, Belgium). RESULTS: The mean pre-operative keratometry was 43.61±1.55 D, and mean keratometric cylinder was -0.86±0.66 D. At 3 months post-operatively, values changed to 43.59±1.56 and -0.71±0.46 D, respectively. Mean sphere varied from 2.04±2.60 to 0.14±0.38 D, and mean spherical equivalent from 1.64±2.61 to -0.05±0.36 D. More than 60% of the patients achieved better corrected distance visual acuity. The majority had a final residual refractive error (predictability) lower than 1 D (99.1%), with 14.3% needing optical adjustment (bioptics). Posterior capsulotomy was performed in 2.2%, and the lens was replaced in 5 patients. A high percentage of patients were satisfied in terms of vision and spectacle independence at all distances. Although 2% referred to worsening of night vision quality, only 2% were not very satisfied and 20 patients were dissatisfied. The causes were: blurred vision (7 cases), spectacle dependence (10), dysphotopsia (7), and dry eye (4). CONCLUSIONS: The implantation of this model provided good visual performance in all distances, as well as high levels of spectacle independence and satisfaction.

Optimization of the lens sizing for the second eye based on the vault obtained in the first eye in bilateral myopic collamer phakic intraocular lens surgery. / Optimización de la elección de talla para el segundo ojo basándose en el vault obtenido en el primero en la cirugía bilateral de lentes fáquicas de cámara posterior.

PURPOSE: To assess vault and the decision-making process involved in selecting the size of the lens for the fellow eye in a series of patients who received bilateral phakic collamer intraocular lens (pIOL) implants with central hole for correction of myopia. METHODS: The study sample included all patients who underwent bilateral insertion of a different size pIOL from a pool of 269 patients who underwent sequential bilateral insertion of a pIOL from March 2012 to May 2015 in our institution. Procedures were separated in time to assess the value of the vault and select the pIOL size in second eyes. Vault was analysed objectively using optical coherence tomography. RESULTS: The decision to change the size of the pIOL in the fellow eye was taken in 25 patients. A smaller pIOL was implanted in the second eye in 9 patients, whereas a lens that was 1 size larger was necessary in 16 patients. Implantation of a larger lens led to a mean increase in vault of 251 ± 180 microns; implantation of a smaller size lens led to a mean decrease in vault of 542 ± 187 microns. In 5 patients, the pIOL implanted in first eye was rotated vertically to reduce lens vault. No lenses had to be explanted. CONCLUSIONS: Vault in fellow eyes can be improved in patients receiving bilateral myopic pIOL implants by modifying the pIOL size based on the vault value obtained in the first eyes.

Comparación de 5.468 retratamientos tras láser in situ queratomileusis levantando el lentículo o mediante queratectomía fotorrefractiva sobre el lentículo / Comparison of 5468 retreatments after laser in situ keratomileusis by lifting the flap or performing photorefractive keratectomy on the flap

Objetivo: Describir los resultados visuales del retratamiento tras láser in situ queratomileusis (LASIK) levantando el lentículo previamente o realizando queratectomía fotorrefractiva (PRK) sobre él, establecer si el riesgo de crecimiento epitelial de la interfase (CEI) es mayor cuanto más tiempo ha pasado entre el LASIK inicial y el retratamiento por levantamiento y determinar la incidencia de la opacidad corneal (haze) tras PRK. Métodos: Estudio retrospectivo de 4.077 pacientes (5.468 ojos) tratados mediante LASIK y retratamiento para estudiar los resultados visuales e identificar los casos de CEI y haze corneal. Resultados: Se estudiaron 5.196 ojos de 3.876 pacientes retratados de miopía levantando el lentículo y 272 ojos de 201 pacientes retratados mediante PRK en el lentículo. No se encontraron diferencias estadísticamente significativas entre los retratamientos en predictibilidad, eficacia y seguridad. Se encontró un total de 704 casos de CEI tras levantar el lentículo; se necesitó limpieza quirúrgica en 70. La limpieza quirúrgica disminuyó el índice de eficacia al compararlo con el de los pacientes con CEI que no precisaron limpieza (p = 0,01). Las diferencias en términos de seguridad y predictibilidad no fueron estadísticamente significativas. La incidencia de haze corneal tras la ablación de superficie sobre el lentículo previo fue del 14,34%, aunque ninguno de estos casos fue clínicamente relevante. Conclusiones: Los resultados visuales son similares entre los pacientes retratados mediante levantamiento del lentículo o mediante PRK. La incidencia de CEI levantando lentículo fue del 13,55%. La incidencia de CEI aumenta a medida que aumenta el tiempo entre el procedimiento primario y el retratamiento (AU)

Purpose: To assess visual outcomes of retreatment after laser in situ keratomileusis (LASIK) by lifting the flap or performing photorefractive keratectomy (PRK) on the flap, as well as to establish whether there was an increased risk of epithelial ingrowth (EIG) when LASIK and lifting of the flap are separated by a long time interval and to determine the incidence of corneal haze after PRK. Methods: Retrospective study of 4077 patients (5468 eyes) who underwent LASIK and subsequent retreatment were reviewed in order to study their visual results and identify cases of EIG and corneal haze. Results: Enhancements included 5196 eyes from 3876 patients that were retreated by lifting the flap, and 272 eyes from 201 patients that were retreated by PRK on the flap. No statistically significant differences were found between the retreatments in terms of predictability, efficacy, and safety. A total of 704 cases of EIG were found after lifting the flap, for which surgical cleansing was necessary in 70. Surgical cleansing decreased the efficacy index when compared with patients with EIG who did not need cleansing (P = .01). Differences in terms of safety and predictability were not statistically significant. The incidence of corneal haze after ablation of the surface of the previous flap was 14.34%, although none of these cases were clinically relevant. Conclusions: Visual outcomes were similar between patients who were retreated by lifting the flap and those who underwent PRK. The incidence of EIG when the flap was lifted was 13.55%. The incidence of EIG increases with the time elapsed between the primary procedure and retreatment (AU)

Comparison of 5468 retreatments after laser in situ keratomileusis by lifting the flap or performing photorefractive keratectomy on the flap. / Comparación de 5.468 retratamientos tras láser in situ queratomileusis levantando el lentículo o mediante queratectomía fotorrefractiva sobre el lentículo.

PURPOSE: To assess visual outcomes of retreatment after laser in situ keratomileusis (LASIK) by lifting the flap or performing photorefractive keratectomy (PRK) on the flap, as well as to establish whether there was an increased risk of epithelial ingrowth (EIG) when LASIK and lifting of the flap are separated by a long time interval and to determine the incidence of corneal haze after PRK. METHODS: Retrospective study of 4077 patients (5468 eyes) who underwent LASIK and subsequent retreatment were reviewed in order to study their visual results and identify cases of EIG and corneal haze. RESULTS: Enhancements included 5196 eyes from 3876 patients that were retreated by lifting the flap, and 272 eyes from 201 patients that were retreated by PRK on the flap. No statistically significant differences were found between the retreatments in terms of predictability, efficacy, and safety. A total of 704 cases of EIG were found after lifting the flap, for which surgical cleansing was necessary in 70. Surgical cleansing decreased the efficacy index when compared with patients with EIG who did not need cleansing (P=.01). Differences in terms of safety and predictability were not statistically significant. The incidence of corneal haze after ablation of the surface of the previous flap was 14.34%, although none of these cases were clinically relevant. CONCLUSIONS: Visual outcomes were similar between patients who were retreated by lifting the flap and those who underwent PRK. The incidence of EIG when the flap was lifted was 13.55%. The incidence of EIG increases with the time elapsed between the primary procedure and retreatment.

Técnicas quirúrgicas no cristalinianas para la corrección de la presbicia / Non-lens-based surgical techniques for presbyopia correction

Introducción: La presbicia es el error refractivo más prevalente. Con el envejecimiento progresivo de la población, su corrección quirúrgica supone un importante reto tanto para la comunidad oftalmológica como para los millones de pacientes que la padecen y que cada vez demandan más alternativas a su corrección mediante gafas o lentes de contacto. Material y métodos: Esta revisión presenta una discusión sintetizada sobre las teorías fisiopatológicas de la presbicia y una descripción actualizada y analítica de las técnicas quirúrgicas no cristalinianas utilizadas para tratar la presbicia. Resultados: Los procedimientos corneales incluyen varios tipos de implantes corneales y técnicas fotoablativas que generan una córnea multifocal, o una monovisión. Los procedimientos esclerales ejercen una tracción sobre la esclera supralenticular que supuestamente mejoraría la amplitud de acomodación. Conclusiones: Ninguna de ellas permite eliminar completamente la necesidad de gafas para la visión cercana, pero muchas de ellas permiten mejorar la situación refractiva de los pacientes. Son necesarios más estudios, con métodos rigurosos y estandarizados, para evaluar los cambios en la visión cercana de los pacientes, y con un mayor seguimiento postoperatorio para corroborar la utilidad real y práctica de muchas de estas técnicas (AU)

Introduction: Presbyopia is the most prevalent refractive error. With a progressive aging population, its surgical correction is an important challenge for the ophthalmology community, as well as the millions of patients who suffer from it, and who are increasingly demanding alternatives to its correction with glasses or contact lenses. Material and methods: A review is presented with a synthesised discussion on the pathophysiological theories of presbyopia and an updated and analytical description of the non-lens involvement surgical techniques used to treat presbyopia. Results: Corneal procedures include various types of corneal implants and photo-ablative techniques that generate a multifocal cornea, or monovision. Scleral procedures exert a traction on supralenticular sclera that supposedly would improve the amplitude of accommodation. Conclusions: None of the techniques are able to completely eliminate the need for near -vision glasses, but many of them manage to improve the refractive status of the patients. More studies with rigorous and standardised methods and longer follow-up are needed to evaluate the changes in the near vision of the patients, in order to corroborate the real and practical usefulness of many of these techniques (AU)

Non-lens-based surgical techniques for presbyopia correction. / Técnicas quirúrgicas no cristalinianas para la corrección de la presbicia.

INTRODUCTION: Presbyopia is the most prevalent refractive error. With a progressive aging population, its surgical correction is an important challenge for the ophthalmology community, as well as the millions of patients who suffer from it, and who are increasingly demanding alternatives to its correction with glasses or contact lenses. MATERIAL AND METHODS: A review is presented with a synthesised discussion on the pathophysiological theories of presbyopia and an updated and analytical description of the non-lens involvement surgical techniques used to treat presbyopia. RESULTS: Corneal procedures include various types of corneal implants and photo-ablative techniques that generate a multifocal cornea, or monovision. Scleral procedures exert a traction on supralenticular sclera that supposedly would improve the amplitude of accommodation. CONCLUSIONS: None of the techniques are able to completely eliminate the need for near -vision glasses, but many of them manage to improve the refractive status of the patients. More studies with rigorous and standardised methods and longer follow-up are needed to evaluate the changes in the near vision of the patients, in order to corroborate the real and practical usefulness of many of these techniques.

[Atypical presentation of ocular hypertension following myopic LASIK]. / Presentación atípica de la hipertensión ocular en los pacientes intervenidos de LASIK miópico.

OBJECTIVE: We present a masquerade syndrome recently described following uneventful laser in situ keratomileusis (LASIK). If misdiagnosed or left unattended, this condition can lead to severe visual loss. METHODS: Findings concerning ten patients who underwent uneventful myopic LASIK, but who presented with a granular haze in the interface in the early postoperative period, are described. Initially, some of the patients were treated for diffuse lamellar keratitis with an intensive course of topical steroids, but, rather than improving, the haziness of the interface worsened or remained the same, and was even accompanied by the development of epithelial edema. RESULTS: Tonometry led to the diagnosis of ocular hypertension induced by the steroid therapy. The clinical picture resolved completely with topical hypotensive treatment and with the cessation of steroid treatment. CONCLUSION: In the early postoperative period following LASIK an atypical presentation of ocular hypertension can occasionally be observed. A high index of suspicion of this diagnosis must be maintained due to the inaccuracy of tonometry after LASIK and the similarity of this clinical picture with diffuse lamellar keratitis. These cases emphasize the importance of taking into account underestimation of the intraocular pressure after myopic LASIK.

Presentación atípica de la hipertensión ocular en los pacientes intervenidos de Lasik miópico / Atypical presentation of ocular hypertension following myopic Lasik

Objetivo: Se presenta un síndrome mascarada descrito recientemente en los pacientes sometidos a queratomileusis in situ asistida por láser excimer (LASIK). Si no se diagnostica a tiempo o si no recibe el correcto tratamiento, puede conducir a una pérdida visual severa.Métodos: Se exponen los casos clínicos de diez pacientes intervenidos de LASIK miópico sin incidencias, y que en el postoperatorio precoz presentaron un haze granular en la interfase corneal de ambos ojos. Algunos inicialmente fueron tratados como queratitis lamelares difusas con corticoides tópicos intensivos. La turbidez de la interfase en lugar de mejorar, se mantuvo o empeoró, desarrollando incluso edema epitelial.Resultados: La tonometría condujo al diagnóstico de hipertensión ocular inducida por los esteroides. La clínica se resolvió completamente con tratamiento médico hipotensor tópico y suprimiendo los corticoides.Conclusión: Esta presentación atípica de una hipertensión ocular puede producirse tras un LASIK reciente. La inexactitud en las técnicas tonométricas tras esta cirugía y la similitud del cuadro con la queratitis lamelar difusa deben hacernos mantener un alto índice de sospecha clínica. Estos casos enfatizan la importancia de la subestimación de la PIO tras el LASIK miópico

Objective: We present a masquerade syndrome recently described following uneventful laser in situ keratomileusis (LASIK). If misdiagnosed or left unattended, this condition can lead to severe visual loss.Methods: Findings concerning ten patients who underwent uneventful myopic LASIK, but who presented with a granular haze in the interface in the early postoperative period, are described. Initially, some of the patients were treated for diffuse lamellar keratitis with an intensive course of topical steroids, but, rather than improving, the haziness of the interface worsened or remained the same, and was even accompanied by the development of epithelial edema.Results: Tonometry led to the diagnosis of ocular hypertension induced by the steroid therapy. The clinical picture resolved completely with topical hypotensive treatment and with the cessation of steroid treatment.Conclusion: In the early postoperative period following LASIK an atypical presentation of ocular hypertension can occasionally be observed. A high index of suspicion of this diagnosis must be maintained due to the inaccuracy of tonometry after LASIK and the similarity of this clinical picture with diffuse lamellar keratitis. These cases emphasize the importance of taking into account underestimation of the intraocular pressure after myopic LASIK

PIO y LASIK / IOP and LASIK

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Presión intraocular y LASIK miópico / Intraocular pressure and myopic LASIK

No disponible