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1 March 3, 2010 SECO Updates in Corneal Refractive Laser Vision Correction Welcome! Eugene M. Smith, Jr., M.D. Surgeon & Medical Director LasikPlus Lasik Plus Vision Centers Atlanta, GA Education & Training COLLEGE: MEDICAL SCHOOL: Arizona Centre Eye & Facial Plastic Surgery, Tucson, AZ ASOPRS American Society of Oculo Facial Plastic & Reconstructive Surgery Approved Fellowship Preceptor: Robert M. Dryden MD, Assistant Clinical Professor, University of Arizona, Tucson, AZ Fellowship involved Diagnosis, Management and Treatment of complicated External Disease of the Face, Eyelids, Conjunctiva and Cornea Board Certification in Ophthalmology 1997 Authored Journal Articles & Book Chapters University of Hawaii Integrated Transitional Residency Program Honolulu, HI RESIDENCY: Medical College of Georgia, Augusta, GA Medical Doctor, M.D Fellowship: External Disease / Oculoplastic Surgery INTERNSHIP: US Air Force Academy, Colorado Springs, CO University of Georgia, Athens, GA B.S. Microbiology, 1986 Brown University School of Medicine, Dept Ophthalmology & Surgery, Providence, RI Fellowship: Cosmetic Plastic Surgery Plastic Surgery Center of the Pacific Honolulu, HI American Society of Cosmetic Surgery Approved Fellowship Preceptor: Robert S. Flowers, MD, Assistant Clinical Professor, Dept of Plastic Surgery, University of Hawaii, Honolulu, HI Fellowship involved full body cosmetic surgery with emphasis on cosmetic surgery of the eyes and face. American Board of Cosmetic Surgery Board Certification 1997 CoManaging Doctors Co Laser Vision Correction Cosmetic Plastic Surgery Thank you! 1

2 FLAPS: Which is better? Microkeratome vs. Femtosecond (IntraLase) Corneal Refractive Laser Vision Correction Thank you! FLAPS: Which is better? Microkeratome vs. Femtosecond (IntraLase) POLL QUESTION: In the hands of an experienced surgeon... Who believes a Microkeratome is as precise / accurate as Intralase (Femtosecond laser)? Thank you! POLL QUESTION: In the hands of an experienced surgeon... Who believes an experienced cataract surgeon can make as accurate incisions (size/shape), capsulorhexis, etc as a Femtosecond laser? POLL QUESTION: Experienced cataract surgeon versus Femtosecond laser Nagy Z, et al "Use of the femtosecond laser system in cataract surgery" AAO 2009; Abstract PA092 In one study presented at AAO, femtosecond laser incisions achieved perfect diameter accuracy in 100% of cases, while only 10% of surgeons' manual cuts were within 0.25 mm error 2

3 FLAPS: Is precision and accuracy important when making a LASIK flap? FLAPS: Is precision and accuracy important when making a LASIK flap? YES! Flap Shape Meniscus Consequences of the Bulge Button Hole The blade exits the cornea True Buttonhole 3

4 Flap Shape Planar Epithelial Ingrowth Consequences of a Meniscus Flap Accentuated Mudcrack Striae (Concentric compression of the thinnest flap area) meniscus planar BIOMECHANICS 4

5 ECTASIA RISK? LASIK 1:1000 1:8,000? PRK 1:100,000 1:500,000? Theoretically, SBK / LASIK affect on corneal strength approaches that of PRK as corneal flaps become smaller in diameter and thinner. Intralase flap video 5

6 LASIK Side Cut SIDE CUT: LASIK Side Cut SIDE CUT: ANGLE ANGLE DEPTH DEPTH FLAP COMPLICATIONS Intralase side sidecut illustration video 6

7 FLAP COMPLICATIONS Schallhorn SC, et al AJO April 2006: 0.3% TO 5.7%* 30 per 10, per 10,000 What constitutes a FLAP COMPLICATION? *100 of 10,000 = 1.0 % Button Hole IntraOperative IntraPartial Flap Button Hole Free Flap Corneal Abrasions? PostOperative PostDLK? Ectasia? Epithelial Ingrowth? Striae? DLK: Stages POLL QUESTIONS: DLK: Stages 1 2 Has anyone managed a patient with a large PostLASIK Post CORNEAL ABRASION? ABRASION? 7

8 FLAP COMPLICATIONS Schallhorn SC, et al AJO April 2006: 0.3% TO 5.7%* 30 per 10, per 10,000 *100 of 10,000 = 1.0 % Partial Flaps Vertical gas breakthrough: Response: Post Op result: 1 size/location: small, at flap periphery flap lifted with manual dissection in this area 20/20 on POD#1 and beyond Aborted 2nd eye (bilateral case scheduled): TOTAL: 3 (0.03%) LOSS OF BCVA 0 Abrasions (Vis Sig) DLK > Stg II Ectasia TOTAL Flap Comp with loss BCVA > 2 lines ABORTED 2 nd eye (bilateral case sched) Higher COST Hardware purchase ($250k?) Higher Ongoing Maintenance costs ($45k/yr) Higher cost per flap: $150 $450? Femtosecond (IntraLase) ADVANTAGES 0 Caution with corneal scars: post RK Transient Light Sensitivity and interface inflammation may occur if energy set too high Not readily portable (roll(rollon/roll on/rolloff is difficult) 1st 10k IL PRECISE CONTROL of FLAP PARAMETERS: Diameter, Thickness, Shape (PLANAR (PLANAR), ), Sidecut angle Side EXTREMELY LOW FLAP COMPLICATION RATE: Experienced surg: LESS THAN 1:10,000? LOW RISK of need to ABORT PROCEDURE: Experienced surg: LESS THAN 1:10,000? LOWER RISK OF ECTASIA? Femtosecond (IntraLase) DISADVANTAGES Last 10k MK Button Holes IntraLase Cases requiring action different from normal procedure (First 10,000 cases): Suction Loss (during flap creation): 2 Response: immediate repeat creation of flap Post Op result: 20/20 for both cases on POD #1 and beyond 1st 10k MK Free Flaps Microkeratome: DISADVANTAGES Higher FLAP COMPLICATION RATE? Partial Flaps, Button Holes, DLK, Abrasions, Epithelial Ingrowth: (1:1000 1:5000?) UNABLE TO VARY FLAP PARAMETERS: ABORT PROCEDURE: Diameter, Thickness, Shape (Meniscus (Meniscus), ), sidecut Partial Flaps, Button Holes, Large ABRASIONS Higher RISK of LOSS OF BEST CORRECTABLE VISION? 8

9 Microkeratome: ADVANTAGES INEXPENSIVE PORTABLE (easy to carry to different locations) Which EXCIMER laser is BEST? Hardware ($50k vs. $300k) Maintenance costs $30 per flap May use with Corneal Scars (post RK) Low Complication rate in hands of EXPERIENCED SURGEON (1:3,000 (1:3,000?)?) surgeons often say... In my hands a microkeratome is safer than the IntraLase... FDA Data of Approved CONVENTIONAL Lasers % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 99.7% 87.3% 97% 58.6% 93.7% 56.9% LEADING LASER SYSTEMS LASER CONVENTIONAL ABERROMETER WAVEFRONT 85.4% 53.1% 84.4%47.4% VISX 20/40 or better 20/20 or better STAR S 4 CUSTOMVUE ALLEGRETTO WaveLight Optimized Wavelight Wavefront Guided ALCON LADARWAVE CUSTOMCORNEA B&L B&L WAVESCAN LADARVision TECHNOLAS ZYWAVE ZYOPTIX VISX LADAR LSX Nidek LASIK and PRK for low to moderate myopia (less than 7D) and low to moderate astigmatism (less than 4D). Source: Which one? Which excimer laser is best? IRB Approved* Multicenter Trial at LasikPlus Moderator: Dr. Dan Durrie 3 centers Can we use ONE laser for everyone? Minneapolis Washington, D.C. Atlanta Dr. Matthew Sharpe Dr. Neil Wills Dr. Eugene Smith 180 eyes (60 eyes of 30 patients in 3 centers) Contralateral eye study (eyes matched ) Contra eyes randomized to receive: WLO, WFG, VISX S4, CV, B&L, Zy *IRB granted authority by FDA to ensure safe and effective research. 9

10 IRB Approved* Multicenter Trial at LasikPlus Moderator: Dr. Dan Durrie Study has been accepted for presentation and publication at ASCRS 2011 Spring meeting (March 29, 2011) San Diego, CA. CONCLUSIONS No single laser is best for all treatments WaveLight Optimized results and CustomVue results are equal in most cases. Wavelight Optimized is usually better than conventional treatments Wavelight Optimized is preferred to Custom in some situations. Custom is preferred to WLO in some situations. We now use VISX and Wavelight systems *IRB granted authority by FDA to ensure safe and effective research. LasikPlus Lasik Plus No single Excimer is the best for every patient. No single treatment delivery (Custom vs. Optimized vs. Conventional) is best for every pt. LEADING LASER SYSTEMS VISX Sometimes: Custom treatment is preferred Wavefront Optimized treatment is preferred Conventional treatment is preferred LASER STAR S 4 CUSTOMVUE ALCON (WAVELIGHT) WaveLight Optimized Wavefront Guided Topography Guided 2001 Most common Atypical Mycobacterium Now rare due to use of 4th Generation fluroquinolones: Moxifloxacin or Gatifloxacin 2011 Most common Methicillin Resistant Staphalococus Aureus (MRSA) Also MRSE Add POLYTRIM 14 to + 6, Astig 6 D 8 to +4, Astig 3.5 D 14 to + 6, Astig 6 Corneal Topography Infections TREATMENT RANGE Pentacam vs. Orbscan *TRUST STUDY 10

11 What is the most important reason for Topography? Most important reason for Topography:: Topography To identify signs of INTRINSIC CORNEAL WEAKNESS forme fruste KERATOCONUS PELLUCID MARGINAL DEGENERATION Young pt: Usually INFERIOR cornea (temporal, nasal or superior also possible) Usually Bilateral (may be asymmetric) Paracentral thinning with Para protrusion in area of thinning Pach: THIN Retinoscopy: scissoring ATR Astigmatism Prevalence (1:2,000?) Rabinowitz (1999) Kylce Groden Randleman I:S difference Age Asymmetry Posterior float Posterior shape Manifest age 40+ INFERIOR Bilateral (may be asymmetric) Peripheral band of thinning with protrusion above band Pach: NORMAL ATR Astigmatism Prevalence (1:20,000? 50,000?) *TYPICAL FEATURES of CORNEAL ECTATIC DISEASES Ectasia Risk Factor Analysis Ectasia Risk Factor Analysis PELLUCID MARGINAL DEGENERATION (PMD)* KERATOCONUS (KC)* Rabinowitz (1999) Kylce Groden Randleman Orbscan versus Pentacam 11

12 Normal Keratoconus Pellucid Marginal Degeneration advanced KC PMD asymmetric Lobster Claw PMD Pellucid Marginal Degeneration 12

13 FF PMD? CLASSIC KC FFKC? FFKC? KC 31 yo FFKC? 13

14 KC PMD FFKC progression to KC FF PMD? LOBSTER CLAW KISSING FISH FF PMD LOBSTER CLAW 14

15 MUSTACHE / KISSING FISH / KEYHOLE MUSTACHE / KISSING FISH / KEYHOLE FFPMD? kissing fish fish mouth 0.5 D FFPMD? Fat Lobster Claw? SCALE 1.5 D FFPMD? 15

16 EARLY LOBSTER CLAW FF KC vs FF PMD? VERTICAL D QUESTIONS? My The End! cell phone: CoMgt: Co Thank You! 16

17 References References and CoManagement Co Information Ocular TRUST Study LASIK COMPLICATION RATES FDA: 1 5% of cases Glare and sensitivity to light: 1.7% of patients Visual fluctuations: 2.6% of patients Halos around light sources: 3.5% of patients Report vision worse than before LASIK: 3.0% of pts LASIK SUCESS RATES AAO/Soloman review of 64 LASIK studies since 2000 ASCRS 2008 worldwide Satisfaction rate 95.4% Low to Moderate myopia AAPECS (Am. Assoc of Profess. Eyecare Spec) Low to High myopia 94% 20/40 or better High myopia 89% 20/40 or better 55.3% 20/20 or better 92.6% 20/40 or better LCAV MultiMulticenter trial 99% 20/40 or better LASIK SUCESS RATES 93.3% 20/20 or better 100% 20/40 or better ASCRS 2008 worldwide Satisfaction rate 95.4% 55.3% 20/20 or better 92.6% 20/40 or better 17

18 CoManagement Program LCA Multiple laser systems allows customized patient treatments Unbeatable results (> 93% 20/20 or better) Best value for patients (Best price guarantee for same technology and same service/acuity plan) SAME PRICE FOR COMGT AND OUR PATIENTS Payment plan = 20% of price paid by patient Primary care referrals: We refer patients to our list of Comanaging doctors Lifetime Acuity Plan Surgeon Accessibility (Cell #: ) CoManagement Program Facility Fees CoManagement Fee = 20%, amount depends on acuity plan patient chooses and price paid (insurance plan may change the price) Most patients choose lifetime acuity plan CoManagement Program Initial Contact: Shanon: CoManagement Tracy: Coordinator, or Atlanta Area Director Credentialing Packet Fill out the EXAM FORM and FAX to Shannon Please send form even if not entirely complete Many tests will be repeated on treatment day (MR or CR, Orbscan, Pachymetry, Pupil diameters, K values, etc.) If needed, consult with Dr. Silver, Dr. Wright, Dr. Wild or Dr. Smith. Schedule Patient (Shannon or Tracy) 18