AAO Chicago 2010 LASIK/PRK following previous eye Surgery A. John Kanellopoulos, MD Associate Clinical Professor, NYU Medical School Director: Laservision.gr Eye Institute, Athens, Greece www.brilliantvision.com www.brilliantvision.com 1
LASIK Following Radial Keratotomy Special Concerns Treat epithelial inclusions and wound gapes prior to LASIK (re-suture if ness.) Careful surface marking Carefully handle flap to avoid tearing RK along incisions Thicker flaps Enhancements difficult Higher incidence of DLK? www.brilliantvision.com 2
LASIK following Radial Keratotomy PERK Study: 43% of eyes had a 1D hyperopic shift at 10 years Following LASIK 91% improvement or no change in BCVA 1 Following LASIK no loss of 2 lines in BCVA 2 1 Attia. Journal of Cataract and Refractive Surgery, 2001 2 Lindstrom. Ophthalmology, 2000 www.brilliantvision.com 3
LASIK following Radial Keratotomy Hyperopic shift/ Visual fluctuation may continue Ineffective for irregular astigmatism (except with wavefront-guided and/or topo-guided) www.brilliantvision.com 4
Enlarging myopic optical zone: Initially -10, 505µ LASIK: 4,5mmOZ, 125µ flap M2->plano ^BCVA 2 lines, but night halostopo-guided Tx to enlarge OZ to6mm and adjusting Q value to - 1,46Initially halos gone, Refraction: -1.25! Kanellopoulos MD www.brilliantvision.com
Enlarging optical zone-rk 10 year post-rk, Post-LASIK: +2,50-1,50Cyl, debilitating night vision. P topo-guided -0.50-0.50 marked improvement Kanellopoulos MD www.brilliantvision.com
50 y/o male, s/p RK for about 8 in USSR 1990 UCVA 20/40-, 20/40 +2.00-2.50 117 20/25 (8/10) +2.75-2.25 070 20/25- (7/10) Significant night glare (dec) www.brilliantvision.com 7
Pre-op www.brilliantvision.com 8
Post-op www.brilliantvision.com 9
46 y/o male 10 years s/p RK for 3.00 1.50 x? and subsequent hyperopic shift www.brilliantvision.com 10
46 y/o male 10 years s/p RK for 3.00 1.50 x? and subsequent hyperopic shift sc: 20/80 diplopia Rx +4.75 6.00 x 17 gives 20/25 LASIK with the Moria M2 and the Allegretto-wave Post-op 3 months: Sc 20/30! +1.25 1.50 x 40 20/25 www.brilliantvision.com 11
LASIK Following Penetrating Keratoplasty 39-70% of PK s are within 3D of emmetropia Mean cylinder following PK is 4-5 D Following LASIK 100% are within 3 D emmetropia 1 91% of eyes BCVA remained the same or improved 1 Contact lens remains standard of care 1 Donnenfeld. Ophthalmology, 1999 www.brilliantvision.com 12
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LASIK Following Penetrating Keratoplasty Special Concerns Avoid graft-host interface Flap adherence 5 minutes Increased postoperative corticosteriods Endothelial dysfunction and flap slippage 1 Keratoconus and progressive ectasia 1 Donnenfeld. ASCRS, 2001 www.brilliantvision.com 17
34 y/o male 2 years s/p Therapeutic PK for a CL-related ulcer Good cell counts: top= OD unaffected eye Bottom= OS eye with PK Rx 4.50 5.50 x 56 with the Allegretto-wave Post-op 3 months: Sc 20/30! +0.25 0.50 x 50 20/25 www.brilliantvision.com 18
LASIK Following Cataract Surgery No significant concerns with PC/IOL Careful with endothelial dysfunction around phaco wound site (flap slippage, poor adhesion)? PRK with AC/IOL Future of cataract surgery www.brilliantvision.com 19
LASIK and the Glaucoma Patient Absolute Contraindications Filtering/Valve Surgery -End stage disease Significant ON damage and/or Visual Field Loss Uncontrolled Glaucoma More than 2 Medications www.brilliantvision.com 20
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LASIK and the Glaucoma Patient Special Concerns Epithelial Sloughing: Discontinue topical meds pre-op Oral CAIs Nerve Fiber Layer Analysis(HRT, GDx) Post-operative IOP Measurement Mean Decrease in IOP is 4.3 mm Hg 1 Beware of low IOP and progressive ON damage (interface fluid-maloney Ophathalmology2002) 1 Danasoury. Journal ofrefractive Surgery, 2001 www.brilliantvision.com 22
LASIK Following Retinal Detachment Pre-LASIK vitreoretinal consultation Avoid LASIK in high buckles-risk of poor suction/ irregular flap Treatment of asymptomatic holes controversial Avoid silicone oil eyes www.brilliantvision.com 23
LASIK after Previous PRK Central keratometry/ Orbscan Consider Epithelial hyperplasia (If suspected plan for thicker flap) Increased postoperative steroids www.brilliantvision.com 24
LASIK after Previous LASIK Relift flap if possible (unless limited by thin cornea) Undercorrect consecutive ametropia 1 1 Jacobs. Journal of cataract and refractive surgery, 2001 www.brilliantvision.com 25
LASIK after Previous LASIK New flap should be larger and deeper than the original flap or narrower and thinner (the same MK will cut a thinner consecutive flap on a thinner cornea) Posterior flap ablation when residual stromal bed not adequate (not possible with flying-spot excimers) Personal preference: minimum cornea thickness> 400nm 35<K s<49 www.brilliantvision.com 26
Artisan/Verisyse www.brilliantvision.com 27
OD Bioptics 6 months postop 20/20 www.brilliantvision.com 28
WG enhancement-poor result Pre : Post: www.brilliantvision.com 29
Same pt other eye RMSH improved from 1,2 to 0.36 (!) LCS improved from C3 to C7 (!) www.brilliantvision.com 30
Topography guided www.brilliantvision.com 31
Enlarging myopic optical zone: Initially -10, 505µ LASIK: 4,5mmOZ, 125µ flap M2->plano ^BCVA 2 lines, but night halostopo-guided Tx to enlarge OZ to6mm and adjusting Q value to - 1,46Initially halos gone, RE -1.25 www.brilliantvision.com 32
Post-trauma irregular astigmatism Old K perf, s/p CE, IOL,s/p LASIK for +2.00 now -1,50-250 160 irregularbcva 20/40+Topo-guided, Q adjustment to -0.3 Postop: UCVA 20/30, BCVA 20/25 www.brilliantvision.com 33
Post-surgery irregular astigmatism Complicated CE-Aphakia-Artisan IOL-in an old LASIK pt P -350 90 BCVA 20/60 Postop +0.50-0.50 90 UCVA 20/25 www.brilliantvision.com 34
Centering optical zone-hyperopia Initially: +3.50-3.00 180, plasik:+1.00-1.25 70 UCVA 20/40 BCVA 20/25 ptopog: plano -0.25 UCVA 20/20 www.brilliantvision.com 35
Enlarging optical zone-rk 10 year post-rk, Post-LASIK: +2,50-1,50Cyl, debilitating night vision. P topo-guided -0.50-0.50 marked improvement www.brilliantvision.com 36
Enlarging optical zone-hyperopia S/p LASIK for +4.50, now +1.00 and night vision down C3, s/p topo-guided CS=C7 www.brilliantvision.com 37
Post-keratitis irregular astigmatism Patient with old severe Cornea ulcer and paracentral flattening -3.50-2.00 irregular cyl UCVA 20/200 to 20/25 BSCVA from 20/40- to 20/25 www.brilliantvision.com 38
Re-centering OZ, smoothing irregularities (Loss of K sliver in recuts) www.brilliantvision.com 39
Topo-guided epi LASIK with the Moria EpiK and Wavelight Eye-Q laser improve -2.50-4.50 cyl 6 months 20/20-, +0.75-0.50 cyl www.brilliantvision.com 40
How do we select topo- or wave- guided? www.brilliantvision.com 41
OD Topo-wavefronts OS PRE POST www.brilliantvision.com 42
Clinical Case Treatment Results Corneal topography pre- and post-enhancement Pre-enhancement Post-enhancement Difference 43
Patient 2 75y/o male s/p PRK in the Pseudophakic OS has now significant haze, irregular hyperopic astigmatism UCVA 20/200 BSCVA 20/50 with +2.50 2.75 @ 22 Significant superficial and anterior stromal haze exists He is referred for a cornea graft 44 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 44
Pre-operative Topography: Topolyzer 45 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 45
Pre-operative Topography: Oculyzer 46 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 46
Pre-operative Wavefront Map Non available K haze 47 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 47
48 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 48
Wavefront Ablation Profile Non available 49 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 49
Topography Ablation Profile 50 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 50
OcuLink Ablation Profile 51 51
Wavefront Optimized TM Ablation Profile 52 52
Treatment: 50 microns PTK at 7mm OZ Topolyzer-guided treatment (due to the haze a nd irregularity was anticipated to be more accurate than the Oculyzer-guided Tx UVA CCL 3 mw/cm2 + 0.1% riboflavin 30 minutes 53 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 53
At 3 m UCVA 20/40, -0.50-0.75 @ 62: 20/25 54 54
Summary-Custom Q Q adjustment may be an effective and tissue sparing primary treatment and re-treatment approach It may not change unwanted Zernickes as in wavefront-guided It appears to improve the most predictable factor in night vision problems: Cornea asphericity or spherical aberration C12 It appears to optimise mesopic and scotopic visual quality www.brilliantvision.com 55
DSEAK with anterior scarring treated with PTK/PRK www.brilliantvision.com
Post PTK/PRK
Anterior K clarity before and after
Topo-guided PRK Kanellopoulos MD www.brilliantviion.com
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Over the last 7 years we have treated over 800 cases of KCN and ectasia with CXL J Cornea August 2007 CXL followed 6 months later by a partial tprk Kanellopoulos MD www.brilliantvision.com 61
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Multifocals: Restor. Technis, Acrylisa
Multifocal IOL-unhappy pt Trial with toric contact lens prior to laser enhancement Macula OCT-subclinical ERM may complicate pt satisfaction by reducing contrast sensitivity PCO-collection of lens epithelial cells on IOL steps?- when to perform YAG capsulotomy Centration of IOL on optical axis (specially in hyperopes)? Option to remove the IOL after first eye if anticipation of problem for the second? Perhaps bilateral implantation may be prefferble? Prof. Kanellopoulos, MD
Customised bioptics with topography-guided laser refractive enhancements (tglre). Purpose: To evaluate the safety, efficacy and clinical parameters of tglres. Setting: The Laservision.gr Institute, Athens, Greece. Methods: 31 eyes of 18 consecutive patients that had underwent previously one of the following procedures: Multifical, toric, accommodating or phakic IOL implantation, DSEK, lamellar or penetrating keratoplasty were treated with tglre PRK or LASIK and were evaluated pre- and 6 months post-operatively for: age, UCVA, BSCVA, refraction, topography, endothelium (ECC), and possible complications. Results: There were 21 LASIK and 10 PRK tglre. The mean age was 57 years (27 to 78) and mean values pre- and post-op were respectively: UCVA: 20/50, 20/25, BSCVA: 20/40, 20/25, Spherical equivalent reduction from 2.2 to 0.6 diopters, ECC: 1850, 1650, Follow-up: 5.5 montsh (3 to 38). No complications were encountered in his small group. Conclusions: tglre appear to be a safe and effective step in the bioptics visual rehabilitation of this variable group of cases. Prof. Kanellopoulos, MD
Thank you www.brilliantvision.com Thank you Kanellopoulos MD www.brilliantvision.com 66