Topical Ocular TRPV1 Antagonist SAF312 (Libvatrep) for Postoperative Pain After Photorefractive Keratectomy.

Purpose: Evaluation of safety and efficacy of topical ocular SAF312 (Libvatrep) in post-photorefractive keratectomy (PRK) pain. Methods: In this placebo (vehicle)-controlled, participant- and investigator-masked study, 40 participants were randomized (1:1) to two treatment sequences in a bilateral PRK crossover design (SAF312 2.5% followed by vehicle [or vice versa], one eye drop, four times daily for 72 hours after PRK). Primary endpoints were visual analog scale (VAS) pain scores at 6 hours after first drop of study drug and average VAS scores over 0 to 12 hours postoperatively. Secondary endpoints included postoperative oral rescue medication (ORM) use and adverse events (AEs). Results: All 40 participants completed the study. Both primary endpoints were met; mean difference in VAS pain scores between SAF312- and vehicle-treated eyes was -11.13 (P = 0.005, -25%) at 6 hours postoperatively and -8.56 (P = 0.017, -22%) over 0 to 12 hours. Mean VAS pain scores with SAF312 were consistently lower than with vehicle from 1 hour postoperatively up to 30 hours (P ≤ 0.10 observed in 8/11 time points). Less ORM was taken with SAF312 up to 0 to 72 hours postoperatively, with a trend of fewer participants taking ORM at 0 to 24 hours postoperatively with SAF312 versus vehicle. No serious AEs were reported. All ocular AEs were mild and transient, and none were drug related. SAF312-treated eyes showed no delay in wound healing and had a lower grade 4 conjunctival hyperemia 24 hours postoperatively versus vehicle-treated eyes. Conclusions: SAF312 was well tolerated and effective in reducing ocular pain post-PRK. Translational Relevance: Topical SAF312 presents a new therapeutic option for patients undergoing PRK.

Explantation of KAMRA Corneal Inlay: 10-Year Occurrence and Visual Outcome Analysis.

Purpose: To evaluate 10 years of KAMRA corneal inlay explantation and associated visual outcomes. Patients and Methods: Single-site retrospective chart review of 22 cases of AcuFocus KAMRA Inlay (ACI7000PDT) explantation (range 1 week-1 year). Uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), corrected distance visual acuity (CDVA), and manifest refraction at 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year post-explantation were reviewed. Results: The explantation rate was 8.2% across 10 years. All patients underwent KAMRA explantation due to dissatisfaction with their vision including blurry near vision, impaired night vision, decreased vision in dim lighting, streaks or halos, haze, and double vision. Mean UDVA pre-implant was -0.01±0.13 logMAR (logarithm of the minimal angle of resolution), 0.30±0.22 logMAR pre-explant, and 0.16±0.15 logMAR post-explant (n=20). Mean UNVA pre-implant was 0.37±0.09 logMAR, 0.38±0.13 logMAR pre-explant, and 0.42±0.21 logMAR post-explant (n=20). Mean CDVA pre-implant was -0.01±0.04 logMAR and 0.05±0.11 logMAR post-explant (n=17). Mean CDVA pre-explant was 0.04±0.07 logMAR and 0.04±0.11 logMAR post-explant (n=19). Significant differences were observed between pre-implant and post-explant UDVA (p=0.009), and between pre-explant and post-explant UDVA (p=0.02). All patients (100%) had 20/20 or better CDVA pre-implant but decreased to 73.7% post-explant. Sixty percent (12/20) of the patients lost UDVA Snellen acuity lines post-explant. MRSE was -0.31±0.29 D pre-implant and +0.26±0.77 D post-explant (p=0.007) with note of a hyperopic shift. The hyperopic shift in 31.6% (6/19) of patients did not resolve after explantation. Post-explant residual corneal haze occurred in 72.7% (16/22) of patients. Conclusion: Although the KAMRA corneal inlay is a removable device, patients may experience residual corneal haze, hyperopic shift, and deficits in UDVA after explantation compared to pre-implantation UDVA.

Review of Presbyopia Treatment with Corneal Inlays and New Developments.

Presbyopia may represent the largest segment of refractive errors that is without an established and effective refractive surgery treatment. Corneal Inlays are materials (synthetic or allogenic) implanted in the stroma of patients' corneas to improve presbyopia. These inlays, introduced into the United States in 2015 via the small-aperture corneal inlay (KAMRATM, SightLife Surgical/CorneaGen, Seattle, Washington, United States), were met with an initial wave of enthusiasm. Subsequent models like the shape-changing corneal inlay (RAINDROPTM, Revision Optics, Lake Forest, California, United States) offered excellent results for patients, but longer-term research raised questions about patient safety. At the time of this article, no synthetic corneal inlays are available in the United States for the correction of presbyopia. Other options for presbyopia correction include allograft corneal inlays, trifocal synthetic corneal inlays, pharmacologic therapies, scleral incisions or additive techniques and PresbyLASIK. Presently, allograft inlays consist of corneal lenticules removed from patients undergoing Small Incision Lenticule Extraction (SMILE). We will review corneal inlays and other alternative procedures that may provide effective and predictable treatments for patients with presbyopia.

Human allograft refractive lenticular implantation for high hyperopiccorrection.

Hyperopia is a common form of refractive error in the United States. Many refractive errors can be treated with refractive surgery methods such as laser in-situ keratomileusis and photorefractive keratectomy; however, in patients with large degrees of hyperopia (≥+5.0 diopters [D]), these surgical methods are limited because of higher rates of refractive regression. Lenticule Intrastromal Keratoplasty (LIKE) is a surgical procedure that can be used to correct refractive errors in patients with high hyperopia. The authors describe the first intrastromal implantation of an allograft lenticule performed for the primary correction of hyperopia in the United States, and demonstrate that LIKE is potentially an effective procedure for the correction of high hyperopia. Mechanisms for achieving the intended refractive correction and the complications our patient experienced, including epithelial ingrowth and flap necrosis, are discussed.

Corneal Refractive Surgery in Patients with History of Optic Neuritis.

PURPOSE: The purpose of this study was to evaluate the risk of recurrence of optic neuritis after corneal refractive surgery in patients with a history of optic neuritis and to examine the safety and efficacy of the procedure in this population. METHODS: This was a retrospective chart review of patients with a history of optic neuritis who underwent laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) at a single tertiary center from June 1996 to December 2014. Fifteen eyes of 14 patients were included in this study. Visual acuity before and after the surgery was recorded. Patients were followed-up for over five years postoperatively for the recurrence of optic neuritis. RESULTS: The average LogMAR best corrected visual acuity (BCVA) preoperatively was 0.12 ± 0.19 (-0.10 to 0.60) and postoperatively was 0.06 ± 0.10 (-0.10 to 0.30). No eyes lost lines of BCVA. The average LogMAR uncorrected distance visual acuity (UDVA) after surgery was 0.12 ± 0.13 (0.00 to 0.48). Twenty-eight percent of patients reached a UDVA of 20/20 or better after refractive surgery. Optic neuritis recurred in 3/15 (20%) eyes and 3/14 patients (21%). CONCLUSION: While corneal refractive procedures appear safe in patients with a history of optic neuritis, our data suggest that their efficacy may be reduced.

Astigmatic correction with implantation of a light adjustable vs monofocal lens: a single site analysis of a randomized controlled trial.

AIM: To evaluate the light adjustable lens (LAL) vs a standard monofocal lens in achieving target astigmatic refraction and improving postoperative uncorrected distance visual acuity (UDVA). METHODS: This randomized controlled clinical trial included 40 patients with pre-existing astigmatism and visually significant cataract. Twenty-eight patients received the LAL and 12 control patients received a monofocal intraocular lens (IOL) after cataract extraction at a single institution. The patients with the LAL underwent adjustment by ultraviolet (UV) light postoperatively plus subsequent lock-in procedures and all patients returned to clinic for follow up of study parameters at 6, 9, and 12mo. Manifest refraction, distance visual acuity, and adverse events were recorded at each visit. RESULTS: The mean cylinder before adjustment in eyes with the LAL was -0.89±0.58 D (-2.00 to 0.00 D) and -0.34±0.34 D (-1.25 to 0.00 D) after lock-in (P=1.68x10-8). The mean cylinder in patients with the monofocal lens was -1.00±0.32 D (-1.50 to -0.50 D) at 17-21d postoperatively, which was statistically different from the LAL cylinder post lock-in (P=1.43x10-6). UDVA in the LAL group was 20/20 or better in 79% of patients post lock-in with good stability over 12mo compared with 33% of the control patients with UDVA of 20/20 or better. CONCLUSION: These results demonstrate that the LAL is more effective in achieving target refractions and improving postoperative UDVA in patients with pre-existing corneal astigmatism than a standard monofocal lens.

Surgical options for retreatment after small-incision lenticule extraction: Advantages and disadvantages.

Since the inception of small-incision lenticule extraction (SMILE), many surgeons have speculated the lack of an adequate and standard retreatment procedure will impede its popularity. However, more than 1 million patients worldwide have had this surgery, with visual outcomes nearly equivalent to current laser in situ keratomileusis (LASIK) results. With the procedure's growing popularity, some patients will inevitably have a postoperative residual refractive error from regression, overcorrection, undercorrection, and astigmatic induction and will require retreatment. To our knowledge, literature reviewing major retreatment options is limited. Options include surface ablation, thin-flap LASIK, secondary small-incision lenticule extraction, and a cap-to-flap procedure (CIRCLE) in which a femtosecond laser is use to create cuts that convert the small-incision lenticule extraction cap into a LASIK flap. This review discusses major advantages and disadvantages of these options and compares the visual outcomes based on the existing literature. An algorithmic approach created from this analysis is presented to guide retreatment decision-making.

A Modified Small-Incision Lenticule Intrastromal Keratoplasty (sLIKE) for the Correction of High Hyperopia: A Description of a New Surgical Technique and Comparison to Lenticule Intrastromal Keratoplasty (LIKE).

Patients with high hyperopia are generally confined to either spectacle wear or contact lenses as a primary means of refractive correction. For this patient population, the surgical corrective methods, such as hyperopic laser assisted in-situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) are imperfect options due to induction of higher-order aberrations, optical regression, and loss of best corrected distance visual acuity. Recently, there has been growing interest in lenticule implantation underneath a flap via lenticule intrastromal keratoplasty (LIKE) for high hyperopia correction (+3 diopters to +10 diopters). We instead propose a modified surgical technique (small-incision lenticule intrastromal keratoplasty, sLIKE), in which the lenticule is implanted inside an intrastromal pocket thereby causing less injury to the subbasal nerve plexus injury, less postoperative dry eye symptoms, less reduction in biomechanical strength, and lower chances for epithelial ingrowth. We provide an overview of these novel surgical techniques to treat high hyperopia, and compare the associated advantages and disadvantages. In addition, we will discuss the enhancement options and methods of optimization for both surgical techniques.

Initial Single-Site Surgical Experience with SMILE: A Comparison of Results to FDA SMILE, and the Earliest and Latest Generation of LASIK.

INTRODUCTION: The primary objective was to show our initial surgical single-site experience with small incision lenticule extraction (SMILE) after the official enrollment in March 2017 following Food and Drug Administration (FDA) approval for simple myopia in late 2016 in the United States and, subsequently, compare our results to the earliest and most advanced generation of excimer platforms for laser-assisted in situ keratomileusis (LASIK) surgery. METHODS: This was a retrospective single-site study of 68 eyes from 35 patients who had SMILE surgery. The patients' preoperative and postoperative uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest sphere, manifest cylinder, intraoperative complications, and preoperative and postoperative visual symptoms were collected. We compared our findings to the results from the FDA SMILE study, and to the three earliest (1999-2000) and three of the most updated (2013-2016) platforms for LASIK. RESULTS: The cumulative UDVA was 20/20 and 20/40 or better in 74% and 100% of patients, respectively. The intended target refraction was within ± 0.5 and ± 1.00 D in 80% and 93% of cases, respectively. The prevalence of dry eyes decreased by nearly half from 1-week to the 6-month postoperative interval. Patients noted improvement in glare (17%), halos (17%), fluctuation (25%), and depth perception (8%) at the 6-month interval compared to preoperative levels. CONCLUSIONS: This study's findings are consistent with current SMILE reports. Notably, the results are superior to the earliest generation of LASIK, however inferior to the latest excimer platforms. SMILE does meet the efficacy and safety criteria met by FDA; however, there is a definite need for further improvement to reach the superior refractive outcomes produced by the latest generation of LASIK platforms.

Ectasia following small-incision lenticule extraction (SMILE): a review of the literature.

PURPOSE: Four cases of corneal ectasia after small-incision lenticule extraction (SMILE) have been reported. In this review, we provide an overview of the published literature on corneal ectasia after SMILE and risk factors associated with this complication. METHODS: Case reports were identified by a search of seven electronic databases for pertinent heading terms between 2011 and July 2017. We identified patient characteristics and surgical details including preoperative topography, central corneal thickness, and anterior keratometry (Km). Residual stromal bed (RSB) values not reported were computed using VisuMax ReLEx SMILE software Version 2.10.10. Preoperative ectasia risk was measured using the Randleman Ectasia Risk Score System (ERSS). Percent tissue alteration was calculated for each patient as described by Santhiago et al. RESULTS: Seven eyes of four patients developed corneal ectasia post SMILE. Two patients had abnormal topography in both eyes. One patient had abnormal topography in one eye. Only one patient was noted to have normal topography in both eyes and later developed ectasia in one eye in the absence of any known risk factors. The mean Randleman ectasia risk score was 4±3 (range: 1-8). The mean calculated percent tissue altered (PTA) was 38%±6% (range: 30%-47%). CONCLUSION: A majority of reported ectasia cases occurred in patients with subclinical keratoconus. These conditions may be exacerbated by SMILE and should be considered absolute contraindications to the procedure. Three patients were identified to have high risk based on the ERSS, and one patient exhibited a PTA ≥40%. We formulated a modification to the current calculation of PTA that takes into account the differences in tissue altered between SMILE and laser in situ keratomileusis (LASIK). More studies are needed to fully quantify the risk of ectasia. For now, we propose adopting the same exclusion criteria used for LASIK in the SMILE procedure until more specific metrics have been validated.

Neodymium:YAG laser posterior capsulotomy in eye with an intrastromal inlay.

We report intraoperative issues, patient outcomes, and lessons learned from inadvertently contacting a Kamra corneal inlay with a neodymium:YAG (Nd:YAG) laser during a routine capsulotomy procedure for posterior capsule opacification. We also present scanning electron microscopic and histopathologic images from a series of 4 inlays implanted in postmortem porcine eyes that were purposely contacted with an Nd:YAG laser. Our capsulotomy patient developed a clinically insignificant and transient corneal opacity accompanied by mild blanching on the inlay. Modeling this scenario in porcine corneas demonstrated the potential for carbon particle liberation into the overlying stroma, damage to the inlay body, and fusion of inlay nutrition holes.

Cataract Surgery in Patients with a Previous History of KAMRA Inlay Implantation: A Case Series.

INTRODUCTION: The visual outcome of cataract surgery in patients with a previous history of KAMRA inlay implantation is an emerging issue for which limited research exists. The purpose of this study is to describe postoperative visual outcomes in this patient population. METHODS: This is a case series with retrospective chart review. Seven patients underwent cataract surgery following KAMRA corneal inlay implantation. Visual acuity was assessed before and after cataract surgery. Keratometry was measured before and after KAMRA inlay implantation, and optical biometry was performed prior to cataract surgery. RESULTS: Postoperatively, uncorrected distance visual acuity (UDVA) was 20/20 in five (71%) patients and 20/40 or better in seven (100%) patients, corrected distance visual acuity (CDVA) was 20/20 or better in six (86%) patients and 20/25 in seven (100%) patients, and uncorrected near visual acuity (UNVA) was J1 in four (57%) patients, J2 or better in six (86%) patients, and J3 or better in seven (100%) patients. There was no significant change in keratometry after KAMRA inlay implantation. Biometry calculations accurately predicted intraocular lens (IOL) power after cataract surgery. Surgeons did not report a significant change in the surgical technique of cataract surgery. CONCLUSION: Patients who undergo cataract surgery with a previous history of KAMRA inlay implantation have good visual outcomes. Furthermore, intraocular lens (IOL) calculations accurately predict power, and there appears to be no significant change in surgical technique.

Stereoacuity after small aperture corneal inlay implantation.

PURPOSE: The aim of this study was to compare stereoacuity before and after KAMRA corneal inlay implantation for the correction of presbyopia. PATIENTS AND METHODS: This is a prospective study of 60 patients who underwent KAMRA inlay implantation. Patients were examined before and 6 months after surgery for stereoacuity, uncorrected distance visual acuity (UDVA), and uncorrected near visual acuity (UNVA). RESULTS: The mean stereoacuity before surgery was 29.5±28.1 arcsec (range: 20-200) and at 6 months was 29.8±26.4 arcsec (range: 20-200). The decline in stereoacuity was not statistically significant. At 6 months follow-up, UDVA was 20/25 or better in all 60 patients and UNVA was J2 (20/25) or better in 51 (85%) patients. CONCLUSION: There is no significant change in stereoacuity following KAMRA inlay implantation. The KAMRA inlay is a good treatment option for improving near vision in presbyopic patients while preserving stereoacuity and distance vision.

Comparison and analysis of FDA reported visual outcomes of the three latest platforms for LASIK: wavefront guided Visx iDesign, topography guided WaveLight Allegro Contoura, and topography guided Nidek EC-5000 CATz.

PURPOSE: To compare and analyze the differences in visual outcomes between Visx iDesign Advanced WaveScan Studio™ System, Alcon Wavelight Allegro Topolyzer and Nidek EC-5000 using Final Fit™ Custom Ablation Treatment Software from the submitted summary of safety and effectiveness of the US Food and Drug Administration (FDA) data. METHODS: In this retrospective comparative study, 334 eyes from Visx iDesign, 212 eyes from Alcon Contour, and 135 eyes from Nidek CATz platforms were analyzed for primary and secondary visual outcomes. These outcomes were compared via side-by-side graphical and tabular representation of the FDA data. Statistical significance was calculated when appropriate to assess differences. A P-value <0.05 was considered statistically significant. RESULTS: The mean postoperative uncorrected distance visual acuity (UDVA) at 12 months was 20/19.25±8.76, 20/16.59±5.94, and 20/19.17±4.46 for Visx iDesign, Alcon Contoura, and Nidek CATz, respectively. In at least 90% of treated eyes at 3 months and 12 months, all three lasers showed either no change or a gain of corrected distance visual acuity (CDVA). Mesopic contrast sensitivity at 6 months showed a clinically significant increase of 41.3%, 25.1%, and 10.6% for eyes using Visx iDesign, Alcon Contoura, and Nidek CATz, respectively. Photopic contrast sensitivity at 6 months showed a clinically significant increase of 19.2%, 31.9%, and 10.6% for eyes using Visx iDesign, Alcon Contoura, and Nidek CATz, respectively. CONCLUSION: FDA data for the three platforms shows all three were excellent with respect to efficacy, safety, accuracy, and stability. However, there are some differences between the platforms with certain outcome measurements. Overall, patients using all three lasers showed significant improvements in primary and secondary visual outcomes after LASIK surgery.

Short-term visual result after simultaneous photorefractive keratectomy and small-aperture cornea inlay implantation.

PURPOSE: To report the short-term results of simultaneous photorefractive keratectomy (PRK) and small-aperture cornea inlay implantation (KAMRA) surgery in treating presbyopia. METHODS: Simultaneous PRK and KAMRA inlay surgery was performed on 21 patients from July 2015 to March 2016. Follow-up exams were conducted at 1, 3, and 6 months postoperatively. Our patients were also divided preoperatively into three categories: myopic, hyperopic, and emmetropic. Over the 6-month period, the main outcome measures were uncorrected near visual acuity (UNVA), changes in best-corrected distance visual acuity, and mean spherical equivalent refraction. RESULTS: At 6-month follow-up, 83% (10/12) of patients had a monocular UNVA of 20/40 or better, and 75% had a binocular UNVA of 20/40 (J5) or better. At 6 months, the overall mean refractive spherical equivalent (MRSE) was -0.60 D (±0.42 standard deviation [SD], range: -1.38 to -0.13) with a mean change of -0.43 D (±1.19 SD, range: -1.5 to 2.63) compared to preoperative data. Overall, 91% (10/11) of patients were within a ±0.5 D range of our target -0.75 D for KAMRA use. One-hundred percent (5/5) of the hyperopes, 50% (1/2) of emmetropes, and 100% (4/4) of myopes met the targeted range. At 6 months, the MRSE for the hyperopic subgroup (n=5) was 0.33 D (±0.20 SD), the MRSE for the emmetropic subgroup (n=2) was -1.19 D (±0.19 SD), and the MRSE for the myopic subgroup (n=4) was -0.66 D (±0.36 SD). CONCLUSION: Based on preliminary results and a small sample size, it seems that simultaneous PRK and KAMRA is effective and predictable. There are multiple advantages in performing simultaneous PRK and KAMRA including a shorter recovery time and less steroid use than the two surgeries performed separately.

Comparative analysis of the performance of two different platforms for femtosecond laser-assisted cataract surgery.

PURPOSE: To analyze and compare the intraoperative and postoperative outcomes of cataract surgery performed with two different femtosecond laser platforms. METHODS: Randomized controlled prospective intraindividual comparative study including 90 eyes of 45 patients aged between 61 and 86 years. All eyes underwent bilateral cataract surgery assisted with femtosecond laser technology. Eyes were randomized to one of two different femtosecond laser platforms: Catalys Precision system (Abbott Medical Optics Inc., Santa Ana, CA, USA) (Catalys group), and LenSx system (Alcon-LenSx Inc., Aliso Viejo, CA, USA) (LenSx group). Several intraoperative parameters and changes in corrected distance visual acuity and corneal endothelial density were evaluated and compared. RESULTS: The LenSx group showed a significantly higher cumulative dissipated energy and phacoemulsification power needed compared to the Catalys group (P≤0.043). Likewise, a longer patient interface preparation time, more severe perception of pressure by patient, and more cases of subconjunctival hemorrhage were found in the LenSx group (P≤0.014). A complete capsulotomy was achieved in more cases in the Catalys group compared to the LenSx group (P=0.002). Regarding corneal incisions, no statistically significant differences were found between groups (P≥0.071). The same occurred for postoperative corrected distance visual acuity (P≥0.48), endothelial cell density changes (P≥0.14), and the incidence of corneal edema or flare (P≥0.399). CONCLUSION: Cataract surgery with the two evaluated femtosecond laser platforms is a safe procedure, with reduced phaco time and energy, and preservation of corneal endothelium integrity. However, both systems differ in the performance of capsulotomy and the procedure of docking, with an advantage of the Catalys over the LenSx system.

Six-month visual outcomes for the correction of presbyopia using a small-aperture corneal inlay: single-site experience.

OBJECTIVE: The objective of this study was to describe 6-month postoperative efficacy and safety outcomes after monocular KAMRA corneal inlay implantation in emmetropic presbyopic patients. STUDY DESIGN: This study followed a retrospective chart analysis. SETTING: This study was performed at Hoopes Vision in Draper, UT, USA. SUBJECTS AND METHODS: Fifty-seven patients met the inclusion criteria of this study and underwent KAMRA corneal inlay implantation following the approval of the United States Food and Drug Association between May 2015 and April 2016 at a single site. Surgery involved femtosecond laser-created corneal pockets of various depths. Efficacy, safety, and patient satisfaction reports were analyzed at 3 and 6 months. RESULTS: At 6 months follow-up, the monocular uncorrected near visual acuity (UNVA) was Jaeger (J) 4 (20/32), the mean uncorrected distance visual acuity was 20/25, and the mean corrected distance visual acuity was 20/20. At 6 months, 71% of patients with a pocket depth of ≥250 µm had a UNVA of 20/20 or better, whereas only 22% of patients with a shallow pocket depth of <250 µm had a UNVA of 20/20 or better. There was no statistical difference in UNVA at 6 months between virgin eyes and post-LASIK eyes. One patient had an explant and five patients underwent inlay recentration, all of which resulted in improved visual acuity. At 6 months, 72% of patients reported some level of satisfaction, 26% of patients reported being "not dependent" on reading glasses, and 62% of patients reported being able to do most things in bright light without reading glasses. CONCLUSION: For patients with emmetropic presbyopia, the KAMRA inlay is a viable treatment option resulting in improved UNVA. Increased pocket depth may be associated with better postoperative outcomes. Safety rates are high, while explantation and recentering rates are low. Overall, patient satisfaction of the KAMRA inlay is good.