Utilizing the latest Refractive Technologies in Classic LASIK
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1 Utilizing the latest Refractive Technologies in Classic LASIK A. John Kanellopoulos, MD Clinical Associate Professor NYU Medical School Director, Laservision.gr Institute, Athens, Greece
2 My Background Harvard Medical School-Cornea Fellow Cornell University-Cornea Fellow Medical Director- TLC Laser Eye Centers Director of Refractive Surgery, NYU Medical School, NY Laservision.gr Eye Institute, Athens, Greece Over Lasik procedures
3 Experience-Excimer Lasers Summit- Apex plus VISX-S2 and S3 Lasersight Nidek Alcon-Ladarvision B&L: Technolas 217 Wavelight: Allegretto-Wave
4 Key specifications that are important for the clinician: - the frequency of the flying spot treatment is 200 Hz - the spot size is 0.9 mm; - its active eye-tracking system involves an infrared camera and three individual illumination modules to sense the eye movement (by fixing on the pupilary reflex) with a detection frequency of 250 Hz and a reaction time 6 to 8 msec Maintenance issues
5 Experience-Microkeratomes B&L: ACS B&L: Hansatome Alcon:SKBM Moria:LSK Allergan: Amadeus Moria: One use Moria: M2 and M2 single use
6 Ideal MK specs: Good suction Smooth cut Reproducible flap size and thickness Low abrasion rate Comfortable for the pt Able to address extreme K s
7 One of the initial LASIK cases, 1993
8 Common problem with standard LASIK: goasting (large pupils, de-centered/small diameter ablations etc)
9 Effects of Corneal Curvature on Ablation Profile Round spot shape, even energy distribution, 96% energy absorption Elliptical spot shape, only 26% energy absorption per pulse Cornea The ALLEGRETTO Wave compensates for the reduced energy absorption in the periphery with more spots! Result: True, large optical zone and ability to create prolate cornea shape.
10 Effects of Corneal Curvature on Ablation Profile Round spot shape, even energy distribution, 96% energy absorption Elliptical spot shape, only 26% energy absorption per pulse Cornea The ALLEGRETTO Wave compensates for the reduced energy absorption in the periphery with more spots! Result: True, large optical zone and ability to create prolate cornea shape.
11 Prolate Ablation Prolate Cornea Shape Prolate Cornea Shape with the ALLEGRETTO Wave Oblate cornea shape with other refractive laser systems
12 -7D myopia corrected in same pt One eye (top) with the Allegretto-Wave The other eye (bottom) with the Technolas 217z
13 QuickTime and a DV/DVCPRO - NTSC decompressor are needed to see this picture.
14 Results Initial classic LASIK 520 cases: (presented originally at the winter ESCRS meeting in Barcelona, Spain ) Mean values: The mean pre-operative sphere was 4.75 D (-1.00 to 12.50) and the cylinder 1.25 (-0.25 to 3.75) UCVA improved from 20/200 to 20/25. At 3 months 87% of the eyes were 20/20, 47% 20/15 and 32% 20/ % of eye were within +/- 1D at 3 months.
15 Results-stability Day 1 Month 1 Month 2 Month 3 8/10 (20/25) 10/10 (20/20) 12/10 (20/16) 15/10 (20/13)
16 Results: standard -prolate LASIK Wavefront analysis showed a postoperative increase in coma of only 35% (mean coma of 6% pre-op to 9% post-op) 37% of eyes gained at least 1 line of BCVA No complications were noted in this limited group
17 Results in 520 consecutive cases myopic astigmatism
18 Hyperopic LASIK with the Allegretto-Wave and the M2 AAO 2003 A. John Kanellopoulos, MD Director, Laservision.gr Institute, Athens, Greece Clinical Associate Professor NYU, New York
19 The author(s) acknowledge no financial interest in the subject matter of this presentation.
20 Purpose of Study To evaluate the safety, efficacy and accuracy of hyperopic LASIK To determine the spherical nomogram adjustment To evaluate the wavefront pre- and postoperatively
21 Method 120 consecutive eyes, underwent LASIK for hyperopia or hyperopic astigmatism OZ: We evaluated pre- and post-operatively: refractive error,: UCVA and BCVA, high order aberrations at pre-op, 1 month, 3 months, 6 months and 1 year. These data are standard, non-wavefront guided treatments.
22 Method WaveFront evaluated prior to surgery Dilated pupil to 7mm (not cycloplegic, 1 drop Mydriacyl 1%)) Pre-op, Day 1, Week 1, month 1 and Month 3 Data
23 Results: Results: Mean values: The pre-op sphere was D (+1.00 to ) and the cylinder 1.25 (0 to 3.75) UCVAimproved from 20/100 to 20/25. At 6 months 88% of the eyes were 20/20, 17% 20/ % of eye were within +/- 0.75D of the refractive goal at 6 months. and 1 year
24 Results: RMSH increased by 45%. 47% of eyes gained at least 1 line of BCVA. No complications were noted in this limited group. There was a mean regression in the spherical correction noted between the 1 st month
25 Results at 12 months 120 consecutive cases hyperopia and mixed astigmatism
26 Results: Safety 12 months QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.
27 Case example:
28 Case example: Pre-op RE: x 167 and BCVA 6/10 3m post standard LASIK : x 19 UCVA 9/10 In topographic terms all of the cylinder corrected, of importance the effective ablation zone on topography is exactly the one planned with the laser: 6.5mm
29 Same patient: Orbscan measurements: pre-op above and postop below
30 Conclusion Hyperopic LASIK utilizing the ALLEGRETTO- WAVE excimer laser and the M2 microkeratome appears to be safe and effective in the correction of hyperopia and hyperopic astigmatism. It has demonstarted in our clinical practice the ability to induce little higher order aberrations
31 Conclusion Refraction appears to stable at 12 months The postoperative results at day one were very impressive, possibly deriving from the smooth ablation pattern of corneal stroma bed and/or the smooth microkeratome pass. Very significant improvement in BCVA postoperatively
32 Placement of the keratome
33 Folding of flap, even moisture on stromal bed
34 My technique Irrigation very important Squeeze out excees fluid and Striae with moist Weck-cell milky drop (predforte 1%) to delineate gutter width, centration and striae
35 2 observation interval Flap is evaluated with build-in slit-lamp
36 My technique 1 Drop of Alcaine Betadine scrub and drape eyelids Aspirating speculum Lubricate blade and rotating parts with Alcaine!!!
37 Placement of the M2 Push down untill good suction, then lift
38 Microkeratome pass Observe patient anxiety and squeeze
39 My technique Fold flap onto itself to minimize Dehydration and exposure (minimal manipulation) Even bed hydration very dry technique (hinge ½ most moist)
40 ABLATION: Check parameters! (last chance to avoid error) Intraoperative moistute eq if needed
41 Irrigation of flap and careful wipe (remove fluid from interface)
42 My technique Irrigation very important Squeeze out excees fluid and Striae with moist Weck-cell Suspension-opaque drop (predforte 1%) to delineate gutter width, centration and possible striae
43 Attempt to compensate for irregular hydration state of the flap during the procedure (excimer, procedure speed)
44 Is the flap back in place?
45 1 observation interval Flap is evaluated with build-in slit-lamp
46 Why Wavefront? Necessary tool in today s refractive practice Large (usually light-colored) pupils High astigmatism Enhancements (decentrations) Enhancing monovision
47 Purpose of Study To evaluate the safety, efficacy and accuracy of wavefront-guided LASIK To determine the spherical nomogram adjustment To evaluate the wavefront pre- and postoperatively
48 Method 105 consecutive cases treated Refractive errors: to D Average refraction: D Astigmatism: 0.00 to D Average astigmatism: D Average age: 29.5 yrs
49 Method WaveFront evaluated prior to surgery (4 scans) Dilated pupil to 7mm (not cycloplegic, 1 drop Mydriacyl 1%)) Pre-op, Day 1, Week 1, month 1 and Month 3 Data
50 Ten pearls in my technique Wavefront monitoring essential for refractive surgery Pt expectations Understand the technology (surgeon-staff) Aberration indices that REALLY matter Preoperative measurements RE Preoperative planning mesopic-scotopic pupil Preoperative wave evaluation #, quality Wavefront-guided OZ Preoperative LASIK planning Consistent flap, tracker, excimer energy
51 Conclusion WaveFront-guided LASIK with the ALLEGRETTO-WAVE (a 0.9mm flying-spot and 200Hz) and the M2 appears to be safe and very effective for correction of myopic astigmatism It has demonstarted in our clinical practice the ability to significantly reduce higher order aberrations
52 Conclusion Improving the quality of vision (Contrast sensitivity) The postoperative results at day one were very impressive, possibly deriving from the smooth ablation pattern of corneal stroma bed and/or the smooth microkeratome pass. Very significant improvement in BCVA postoperatively
53 Wavefront-guided retreat in symptomatic LASIK eyes AAO 2003 A. John Kanellopoulos, MD Clinical Associate Professor NYU Medical School Director, Laservision.gr Institute, Athens, Greece
54 The author(s) acknowledge no financial interest in the subject matter of this presentation.
55 Co-workers John Agapitos, OD Mary Chalikia, OD Marianthi Chriridou, O.D. Part of a Wavelight study with: Prof. Theo Seiler, M.D., Ph.D., Michael Mrochen, Ph.D., Arthur Cummings, M.D., Matthias Maus, M.D.
56 Methods: 26 consecutive symptomatic eyes p LASIK Pre-, and post-operative refraction, Total and high order aberrations (RMSH), cornea and flap thickness, Low contrast sensitivity (LCS) and possible complications. Follow-up was 3-7 months (4.5) Pupil size
57 Inclusion Criteria RE within +/ W-G treatment had to be > 6mm OZ RMSH > 0,4 at 6mm pupil At least one of the below indications: small OZ, decentered ablation, irregular astigmatism, night vision problems, under- or over- correction
58 Surgical technique All cases re-lift Intra-operative subtraction pachymetry Treated 6, 6.5 and 7mm Ozs Utilized the average of 4 reproducible WFs
59 Method WaveFront evaluated prior to surgery Dilated pupil to 7mm (not cycloplegic, 1 drop Mydriacyl 1%)) Pre-op, Day 1, Week 1, month 1 and Month 3 Data
60 Results: 22 eyes treated The mean values were: RE: sphere: 0,92D (plano to 1.50) cylinder: -0.85D (0 to 1,75). UCVA improved from 20/25 to 20/18. There was no loss of BCVA in any case. The RMSH decreased from 0.62 to LCS improved by 55%.
61 Sample study cases 45 y/o male s/p LASIK for -5 OD : plano, BCVA 20/25+, LCS C4 OS: -0.50, BCVA 20/25+ LCS C5 WG enhancement OU, 6.5mm OZ Post-op: OD UCVA 20/20, LCS C6 OS UCVA 20/20, LCS C5
62 Pre and post-op data
63 Original OD: IRREGULAR BCVA 20/60 to 20/25
64 Original OS: IRREGULAR BCVA 20/50 to 20/25
65 QuickTime and a DV - PAL decompressor are needed to see this picture.
66 Conclusion WaveFront-guided LASIK with the ALLEGRETTO-WAVE (a 0.9mm flyingspot and 200Hz) and the M2 appears to be safe and very effective for correction of myopic astigmatism It has demonstarted in our clinical practice the ability to significantly reduce higher order aberrations
67 Conclusion Improving the quality of vision (Contrast sensitivity) The postoperative results at day one were very impressive, possibly deriving from the smooth ablation pattern of corneal stroma bed and/or the smooth microkeratome pass. Very significant improvement in BCVA postoperatively
68
69 Thank You
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