Emil William Chynn, MD, FACS, MBA Park Avenue LASEK 333 Park Avenue South, New York, NY
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1 Emil William Chynn, MD, FACS, MBA Park Avenue LASEK 333 Park Avenue South, New York, NY
2 Evolu&on of Refrac&ve Surgery RK, AK (Fyodorov Russia/Ukraine) PRK (Trokel & L Esperance, Columbia U) LASIK (Pallikaris, Greece) LASEK (Talamo, Abad & Azar, Mass Eye & Ear Intra- LASE, i- LASIK (Kurtz, USA) Epi- LASIK, epi- LASEK (Pallikaris, Greece)
3 Original Procedures: Incisional Chance favors the prepared mind Louis Pasteur Boy falls off bike/glasses shatter/corneal lacs- >no specs! Discovery/invention of RK Svyatoslav Fyodorov Hex K Antonio Medez (Mexico) Metal blade- >Diamond blade- >Guarded diamond blade Risks: perforation, infection Side- effects: starbursts, irregular astigmatism Unpredictability, overcorrection (PERK, Waring)
4 First move to the surface: PRK Excimer ( excited dimer ) laser, 193 nm IBM Labs, Armonk, NY (chip etching) Trokel (VISX) & L Esperance (Summit), Columbia US Patent #5,108,388 (1983/87/92), Claim 4: The method of changing optical properties of an eye by operating solely upon the anterior surface of the cornea of the eye (using) selective UV irradiation and attendant ablative photodecomposition of the anterior surface of the cornea in a volumetric removal of corneal tissue and with depth penetration into the stroma and to a predetermined curvature profile
5 PRK advantages/disadvantages Accuracy Myopia, hyperopia, astigmatism Stability Pain Delayed recovery Scarring
6 Move away from surface: LASIK Rapid recovery Nearly instantaneous results / wow effect Nearly painless Decreased risk of scarring Flap striae, partial flap, button- hole flap Debris, epithelial ingrowth, DLK Late trauma Ectasia (Speaker/$7mil, Niksarli/$5.6, DelloRusso/$15.3)
7 Safer Flaps: IntraLase/i- LASIK Fewer incomplete or button- hole flaps Thinner flaps Safer for thin corneas, high Rx, irregular astig/ff KC Persistent inflammation + photophobia DES Late flap trauma Iatrogenic KC
8 Move Back to the Surface LASEK remove epithelium en bloc using EtOH Epi- LASEK(IK) en bloc dissection using epi- keratome Advanced Surface Ablation (ASA) Flap- on vs. flap- off
9 Epi- LASEK (epi- LASIK)
10 ASA indica&ons (over LASIK) Irregular astigmatism/ FF KC Thin corneas / high Rx Highest Rx treated in NYC (2010) - 22 D ( = 350) Preop BCVA 20/60 OU - > Postop UCVA 20/40 OU Night vision concerns (glare from flap, large pupils) Contact sports / hazardous duty (Seals, etc) Anterior stromal opacities (scars, dystrophies?) Prior RK/AK Very special cases (pediatrics? dogs??)
11 Advantages of LASEK/epiLASEK Zero flap- related complications (vs. LASIK) 90% of all complications are flap- related Decreased Dry Eye Syndrome (vs. LASIK) caused by neurotrophic cornea/hypesthesia Decreased inflammation/pain (vs. PRK) Decreased risk of scarring (vs. PRK) Quicker recovery time (vs. PRK) Safer re- treatments of complicated (LASIK) cases
12 Sta&s&cal Trends (MarketScope)
13 Complicated LASIK enhancements Safer to re- treat surface/flap No increased depth/decreased stromal bed No added risk of ectasia No chance of epithelial ingrowth/corneal melt No risk of DLK No incomplete flaps No risk of recutting flaps
14 Enhancement procedure LASEK OU + MMC + CustomVue WaveFront (HD) LASEK safer than epi- LASEK on retreatments To prevent scarring: MMC mitomycin C (1 sec / sec. of ablation time) Vitamin C oral steroids (methylprednisolone) x 1 week PredForte (prednisolone acetate) QID, taper over mos UV protection CustomVue WaveFront Prevue Lens
15 PreVue Lens: useful in complex cases 1 LASIK retreatments UCVA close to 20/20 BCVA not 20/20 No objective improvement on manifest refraction Subjective complaints disproportionate Glare, halos, diplopia, ghosting Lawyers, legal considerations 1 Bansal, Chynn, Rubinfield, Refractive Surgery Complex Case Management, Cataract & Refractive Surgery Today, July 2008
16 Epithelial PreVue New Universal Way to PreVue Can be used with any laser platform (not just VISX) More accurate than PreVue Larger optical zone More realistic real- life trial Zero downside risk? turning lemons into lemonade Useful to: encourage/discourage enhancement pre- sell /justify WaveFront upgrade
17 A.F. 62 yo M s/p RK + AK CC: I can t see well far or near without glasses! Had multiple RK + AK incisions OU 28 years ago VA (distance): 20/80 OD, 20/100 OS, 20/60 OU VA (near): 20/100 OD, 20/80 OS, 20/80 OU Rx: x 80 OD x 95 OS Saw numerous LASIK surgeons who said: I wouldn t touch you with a 10- foot pole! If you get LASIK you will wind up with pizza slices!
18 Surgical plan Enhance non- dominant eye first Wait 3 months before enhancing second eye Maximum scarring prophylaxis Stress patient compliance Frequent post- op visits/sle to check for scarring Slow taper of topical steroids
19 SLE 1 year postop
20 1 year postop UCVA: 20/20 at distance (OU) 20/25 at near (OU) Rx: OD: x 13 OS: x 123 SLE: clear CC: I can see near and far like when I was 30, which is good as I just married a 30- year- old and am having my tubes reconnected to try to have kids!
21 LASEK of Granular Dystrophy 22 yo F Hx Granular Dystrophy OU UCVA OD: 20/100 OS: 20/80 OU: 20/70 BSCVA: OD: x 170 (20/80) OS: x 5 (20/70) OU: 20/60
22 Preop: Granular Dystrophy
23 1 year post LASEK for Granular
24 1- year post- LASEK for Granular UCVA OD: 20/50 (20/100 preop) OS: 20/40 (20/80 preop) OU: 20/30 (20/70 preop) BSCVA: OD: x 160 (20/30) (20/80 pre) OS: x 15 (20/30) (20/70 pre) OU: 20/25 (20/60 pre)
25 Sze H. Wong, BS Lynnette P. Williams, MD Emil W. Chynn, MD, FACS, MBA The authors have no financial interest in the subject ma4er of this poster. Presented at ASCRS, 2011
26 Study Popula&on: Characteris&cs n = 93 Patients (153 Eyes) Female 47 % Male 53 % Age (mean ± SD; range) 31.4 ± 8.3 (19-66) Eyes With Extreme Myopia (SE - 9) 72 % Eyes With Extreme Hyperopia (SE +6) 4 % Eyes With Extreme Astigmatism (cyl - 3) 31 % LASEK Eyes 83 % Epi- LASIK Eyes 17 % WaveFront Eyes 61 % Rx Range to Preop Corneal Thickness 554 ± 39 µm Ablation Thickness 125 ± 36 µm Postop Corneal Thickness 429 ± 50 µm
27 Gain in VA at 3 months Postop UCVA vs. Preop Best Corrected Visual Acuity (BCVA) 100 % of eyes had postop UCVA > preop UCVA! Extreme Myopic Eyes Extreme Hyperopic Eyes Extreme Astigmatic Eyes Number of Lines Gained LogMAR Gained
28 Postop UCVA vs. Preop BCVA (%) 1- Mo. 2- Mo. 3- Mo. Postop UCVA Preop BCVA Postop UCVA > Preop BCVA Postop UCVA = Preop BCVA
29 Complica&ons " 11/153 (7 %) of eyes had postop haze (tr to 2+) " 3/153 (2%) of eyes lost 1 line of BCVA due to postop haze " 1/153 (0.7%) of eyes lost 2 lines of BCVA due to postop haze
30 CONCLUSION Extreme prescriptions may be safely and effectively treated with Advanced Surface Ablation, combined with adjunctive treatments to prevent scarring 72% eyes: 3- mo. postop UCVA preop BCVA Further studies are needed to determine whether extremely hyperopic eyes are more likely to lose BCVA and how to avoid this loss
31 Summary: ASA = LASEK + EpiLASEK 10x safer than primary LASIK or i- LASIK/ IntraLase? Definitely safer in complicated enh (RK, AK, PK) Need steroids + MMC to prevent scarring Slower healing / patient compliance Combine safety of PRK with comfort of LASIK Can Return to the Surface revitalize Refractive Surgery? (still 0% penetration of candidate population)
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