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LASIK and Beyond LASIK Wavefront Analysis and Customized Ablation_Boyd_2001

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CONTENTS
CHAPTER 18		lntraoperative Considerations	224
		Results (Pilot Study)	224
LASIK AFTER PREVIOUS		LASIK AFTER PKP	225
CORNEAL SURGERY		Performing Excimer Laser After PKP	226
CORNEAL SURGERY		Preoperative Considerations	226
		Preoperative Considerations	226
General Considerations After RK	215	Indications	227
General Considerations After RK	215	High Risk Cases & LASIK Contraindications	227
Residual Myopia After RK	215	High Risk Cases & LASIK Contraindications	227
Residual Myopia After RK	215	Preoperative Medications	227
Hyperopia After RK	216	Preoperative Medications	227
Hyperopia After RK	216	When to Operate	228
The Cornea After RK	216	When to Operate	228
The Cornea After RK	216	Intraoperative Considerations	229
LASIK AFTER RK	216	Intraoperative Considerations	229
LASIK AFTER RK	216	Conclusions	229
Preoperative Considerations	217	Conclusions	229
Preoperative Considerations	217	LASIK AFTER ALK	229
Contraindications	217	LASIK AFTER ALK	229
Contraindications	217	The Cornea After ALK	229
lntraoperative Considerations	217	The Cornea After ALK	229
lntraoperative Considerations	217	Performing LASIK After ALK	229
Results (Pilot Study)	218	Performing LASIK After ALK	229
Results (Pilot Study)	218	Preoperative Considerations	229
LASIK AFTER AK	218	Preoperative Considerations	229
LASIK AFTER AK	218	Intraoperative Considerations	230
The Cornea After AK	219	Intraoperative Considerations	230
The Cornea After AK	219	Conclusions	230
Performing LASIK After AK	219	Conclusions	230
Performing LASIK After AK	219	LASIK AFTER EPIKERATOPHAKIA	230
Preoperative Considerations	220	LASIK AFTER EPIKERATOPHAKIA	230
lntraoperative Considerations	220	LASIK AFTER CORNEAL TRAUMA	230
Results (Pilot Study)	220
LASIK AFTER PRK	220	FUTURE OF LASIK AFTER OTHER	230
The Cornea After PRK	220	CORNEAL SURGERIES
Performing LASIK After PRK	221
Preoperative Considerations	221	CHAPTER 19
Intraoperative Considerations	221
Postoperative Treatment	222	PEDIATRIC LASIK		Contents
Results (Pilot Study)	222
LASIK AFTER LTK	223	Patient Selection	234	Section 1
The Cornea After LTK	223	Patient Selection	234
The Cornea After LTK	223	Surgical Technique	234	Section 2
Performing LASIK After LTK	223	Surgical Technique	234
Performing LASIK After LTK	223	Ablation Parameters	234
Preoperative Considerations	223	Ablation Parameters	234
Preoperative Considerations	223	Results	235	Section 3
		Results	235

Section 4

SECTION IV

Section 5

LASIK COMPLICATIONS	Section 6
	Section 6
	Section 7

CHAPTER 20	CHAPTER 21
FIRST NON-INVASIVE TREATMENT FOR	PREVENTION AND MANAGEMENT
SUBLAMELLAR EPITHELIAL INGROWTH	OF LASIK COMPLICATIONS
AFTER LASIK BY LOCAL FREEZING

Subjects Index

Help ?

		Incidence - Relation to Multiple Variables	247
Sequence of Events	243	Classification	247
		Intraoperative Complications	247
Management Techniques Presently Available	243
		Early Postoperative Complications	250
The New Non-Invasive Method	243
		Late Postoperative Complications	253
Technique Step by Step	244

Results	245

			CONTENTS
	CHAPTER 22		CHAPTER 26
	FLAP COMPLICATIONS		INFLAMMATORY AND INFECTIOUS
Diminishing Complications with			COMPLICATIONS AFTER LASIK
Diminishing Complications with
New Microkeratomes		267	DIFFUSE LAMELLAR KERATITIS (DLK)
Classification of Complications		267	SYNDROME (SANDS OF SAHARA)	293
I)	Intraoperative	267	Causative Agents	293
II)	Early postoperative period	267	Clinical Findings	294
III) Late postoperative period		267	DLK Staging	294
Management of Variety of		267-73	Diagnosis &Differential Diagnosis	295-96
Flap Complications			Treatment	296
Sands of Sahara Syndrome		272	Prevention	296
Dry Eye Syndrome		273	Conclusions	297
Epithelial Ingrowth		273	INFECTIOUS KERATITIS
The Hansatome (“Down-Up”)			INFECTIOUS KERATITIS
Microkeratome		274	FOLLOWING LASIK	297
Main Advantages and Disadvantages		274	Clinical Findings	297
Cleaning of the Instrument		275	Causative Organisms	299
PEARLS TO ASSIST WITH THE MAKING			Diagnosis & Differential Diagnosis	300
OF A GOOD FLAP		275	Treatment	301
			Prognosis	302
	CHAPTER 23		Prevention	303

FOLDS AND STRIAE OF THE DISC

POST LASIK

Definition	277
Treatment of:	280
Folds
Striae
Surgical Technique	280

CHAPTER 24

TREATMENT OF FLAP STRIAE

SURGICAL TREATMENT		284
Massaging the Flap Using:		284
a)	A Spatula over a Contact Lens	284
b)	Direct Massaging	285
Appearance of the Cornea After Treatment		285
Outcome		286

CHAPTER 25

KERATECTASIA INDUCED BY

MYOPIC LASIK

Corneal Stromal Changes	287
Induced by LASIK
Corneal Evaluation Using the	288
Orbscan Topography System
How the Orbscan Helps Evaluating High
Risk Cases for LASIK and FFK	291

CHAPTER 27

PREVENTION AND MANAGEMENT OF LASIK COMPLICATIONS

INTRAOPERATIVE COMPLICATIONS	307
Flap Complications	307
Ablation Complications	309
POSTOPERATIVE COMPLICATIONS	311

CHAPTER 28

VITREORETINAL COMPLICATIONS OF

REFRACTIVE SURGERY

Preoperative Evaluation	317
Indications for Prophylaxis of Retinal
Breaks and Degenerations	317
Theoretical Mechanisms Resulting in
Retinal Breaks and Detachment	318
Anterior Chamber Shallowing	318
Vitreoretinal Complications of PRK & LASIK	319
Retinal Detachment After PRK	319
Retinal Detachment After LASIK	319
Macular Hemorrhage	320
Nerve Fiber Layer Damage	321
Endophthalmitis	321
Dislocated Intraocular Lenses	321

Contents

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Subjects Index

Help ?

CONTENTS

SECTION V

BEYOND CONVENTIONAL LASIK

Corneal Custom Ablation Guided by Wavefront Mapping

CHAPTER 29		CHAPTER 32
REFINING CUSTOM ABLATION		WAVEFRONT ANALYSIS AND
THROUGH WAVEFRONT MAPPING		CUSTOM ABLATION
Wavefront Analysis	325	Promising Achievements	339
Mapping a Profile of the Whole Eye	325	Principle of Wavefront Analysis	339
Development of Wavefront Technology	325	Availability of Technology	340
The Mechanisms of Wavefront Devices	328	Custom Intraocular Lens	340
Benefits of Wavefront Analysis	329	Goal in Mind	340
Linking Diagnostic Information from	329
Wavefront Mapping to Laser Treatment		CHAPTER 33
Wavefront Analysis in Conjunction	331
with Corneal Topography		THE ROLE OF DIFFERENT ABERRATIONS
Personalized LASIK Nomograms	331	IN WAVEFRONT ANALYSIS
		IN WAVEFRONT ANALYSIS

CHAPTER 30

COMPUTERIZED CORNEAL

TOPOGRAPHY AND ITS IMPORTANCE TO

WAVEFRONT TECHNOLOGY

Corneal Topography and Wavefront Analysis	333
Current Status of Custom Ablation	334

CHAPTER 31

CUSTOMIZED CORNEAL ABLATION THROUGH WAVEFRONT MAPPING The Quest for Bionic or Super Vision

Promising New Technology	337
Attaining Bionic or Super Vision	337
Generating the Wavefront Map	337
Wavefront Analysis & Corneal Topography	338

What Do We Mean by Wavefront Sensing Analysis?

What do we Understand as an Aberration of the Optical System?

How Do Different Aberrations Affect Vision in Humans?

Do Aberrations Contribute to Sight in Any Positive Way?

Principles for the Study and Diagnosis of Aberrations

CHAPTER 34

341

341 Contents

Section 1

343

Section 2

343

Section 3

344

Section 4

Section 5

REFRACTION EVALUATION SYSTEMS		Section 6
REFRACTION EVALUATION SYSTEMS
FOR WAVEFRONT ANALYSIS		Section 7
What is Wavefront Technology?	347	Subjects Index
What is Wavefront Technology?	347
Current Ocular Refraction Evaluation		Help ?
Systems	349	Help ?
Systems	349
Phoroptor and Autorefractors	349
Corneal Topography	349
20/10 Perfect Vision Wavefront System	349
Other Wavefront Sensing Devices	349
How the Visx 20/10 Wavefront	351
System Works
How to Read a Wavefront Map	353
The Shortcomings of Shack-Hartmann	355
Wavefront Analysis
Clinical Examples	357-69

xii

		CONTENTS
CHAPTER 35		Technical Development of PALM	399
		Technique
ZYOPTIX
PERSONALIZED LASER VISION		CHAPTER 38
CORRECTION		CUSTOMIZED ABLATIONS IN LASIK
		CUSTOMIZED ABLATIONS IN LASIK
Performing Zyoptix Treatment	373
Orbscan II (Elevation Topography)	374	Present Role of Customized Ablations	401
The Zywave Aberrometer	374	Present Role of Customized Ablations	401
Bausch & Lomb Technolas 217z	375	Technique of TopoLink	402
Excimer Laser		Examples of Uses of TopoLink	402
Zyoptix Patient Case	377	Results of TopoLink in Repair Procedures	407
		The Bausch & Lomb Aberrometer	409
CHAPTER 36		Wavefront-Deviation Guided LASIK	411
ZYOPTIX		CHAPTER 39
		CHAPTER 39
Preoperative Procedure	379	WAVEFRONT MEASUREMENTS
Zywave Aberrometer	380	OF THE HUMAN EYE WITH
Elevation Topography (Orbscan)	386	OF THE HUMAN EYE WITH
Elevation Topography (Orbscan)	386	HARTMANN-SHACK SENSOR
Zylink	386	HARTMANN-SHACK SENSOR
Zylink	386
Preparing the Laser	389
Treatment	391	Principles of Eye Aberration	413
Advantages & Disadvantages	391	Principles of Eye Aberration	413
Advantages & Disadvantages	391	Measurements with the Hartmann-Shack
Clinical Cases	391-3	Measurements with the Hartmann-Shack
Clinical Cases	391-3	Sensor	Contents
		Sensor	Contents
CHAPTER 37		Present Technologies for Optimizing	417
LASIK – PALM		Visual Acuity through Refractive	Section 1
LASIK – PALM		Surgery	Section 2
		A Look into the Future of Refractive Surgery	Section 2
The PALM Gel	396	A Look into the Future of Refractive Surgery	417
The PALM Gel	396		Section 3
The PALM Procedure	398		Section 3
			Section 4
	SECTION VI		Section 5
LASIK IN PRESBYOPIA			Section 6
LASIK IN PRESBYOPIA

Section 7

CHAPTER 40

PRESBYOPIA

Surgical Correction - Current Trends

Surgery for Management of Presbyopia	427
through MONOVISION
The LADARVision Laser for	427
Myopia and Presbyopia
Hyperopia and Presbyopia	427
Emmetropia with Presbyopia	428
Description of Operations on the Sclera to	428
Improve Presbyopia

CHAPTER 41

PRESBYOPIA

Theories of Accommodation	436
Treatment with Optical Devices	437
Surgical Methods	438
SCLERAL TECHNIQUES	439
Anterior Ciliary Sclerotomy (ACS)	439
(Thornton’s Technique)
Scleral Expansion Band - Schachar´s Technique	439
INTRACORNEAL TECHNIQUE	441
Intracorneal Implants	441
INTRAOCULAR TECHNIQUES	441
LASER TECHNOLOGY TECHNIQUES	444

Subjects Index

Help ?

xiii

CONTENTS

SECTION VI I

ALTERNATIVES TO LASIK

CHAPTER 42

NO ANESTHESIA CATARACT /

CLEAR LENS EXTRACTION

NUCLEUS REMOVAL TECHNIQUES	451
Karate Chop	451
Soft Cataracts	452
Agarwal Chopper	452
Step by Step Technique	452-57
NO ANESTHESIA CLEAR LENS	458
EXTRACTION
Step by Step Technique	458-62

CHAPTER 43

PHAKONIT AND LASER PHAKONIT

Three Basic Styles of Phakic IOL'S	471
ANTERIOR CHAMBER PHAKIC IOL'S	472
THE ARTISAN LENS	472
Step by Step Technique	473-80
THE NU-VITA ANTERIOR	481
CHAMBER LENS
Step by Step Technique	481-82
POSTERIOR CHAMBER PLATE LENSES	485
THE BARRAQUER PRE-CRYSTALLINE LENS 485
Step by Step Technique	485-91
THE POSTERIOR CHAMBER	492
FOLDABLE PLATE PHAKIC LENS
(The Implantable Contact Lens)	492
Step by Step Technique	492-97

CHAPTER 45

Phakonit to Correct Refractive Errors	463	LASIK vs PHAKIC LENS IMPLANTATION
TECHNIQUE OF PHAKONIT	454	TO CORRECT MYOPIA
FOR CATARACTS
Surgical Technique Step by Step	464-66	Surgical Technique:	499
PHAKONIT IN CLEAR LENS	467	Surgical Technique:	499
EXTRACTION		Ophtec Artisan Myopia Implant
Surgical Technique Step by Step	468	Surgical Technique: LASIK	503
		The Study: Ophtec Artisan Myopia	507
CHAPTER 44		Implant vs. LASIK
		Results	508
PHAKIC IOL's - SURGICAL
MANAGEMENT OF HIGH MYOPIA		CHAPTER 46
		CHAPTER 46
Limitations of LASIK in Very	469	INTACS TM
High Myopia		INTACS TM
High Myopia		REFRACTIVE CORRECTION WITH AN
The Important Role of Phakic	469	REFRACTIVE CORRECTION WITH AN
Intraocular Lenses		INTRACORNEAL DEVICE
Contributions of Phakic IOL's	469	Surgical Procedure	514
Advantages Over Corneal	470	Surgical Procedure	514
Refractive Surgery		Clinical Outcomes	514
Limitations of Phakic IOL's	470	Safety Assurance and Further Indications	519

Contents

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Subjects Index

Help ?

xiv

Contents

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Subjects Index

Help ?

Zyoptics, Personalized Laser Visual Correction

UNDERSTANDING REFRACTIVE LASERS

Chapter 1

UNDERSTANDING REFRACTIVE LASERS

Benjamin F. Boyd, M.D., F.A.C.S.

Therapeutic Principles of Excimer

Lasers

The most significant advance in the past three years has been the emergence of the excimer laser and its rapid rise to dominate refractive corneal surgery. The excimer laser is a source of energy that is very difficult to control and apply to the human eye with the assurance of safety.

Harnessing this laser to safely perform corneal surgery has been a major technical achievement.

The argon fluoride (ArF) 193 nanometer excimer laser is a pulsed laser that has wide potential because it can create accurate and very precise excisions of corneal tissue to an exact depth with minimal disruption of the remaining tissue. Fig. 1-1 presents the comparative mechanisms of the excimer laser vs various other lasers commonly used in ophthalmology.

Figure 1-1 Comparative Mechanisms of the Various Lasers Used in Ophthalmology

(1) The argon and krypton lasers employ a thermal mechanism whereby the laser

(L) heats the chorioretinal photocoagulated tissue and produces scarring (arrow). Retina (R), choroid (H) and pigment epithelium (E). (2) The YAG laser works by photodisruption of tissues, creating small acoustical explosions that produce openings (arrow) such as we make in posterior capsulotomy (P). A plasma screen of ions (+ and -) is created. (3) Excimer ultraviolet laser works by photoablation. Small amounts of tissue (T), essentially the stroma in cases of LASIK, are removed from the cornea (C - arrow) with each pulse. (After Boyd´s

"Atlas of Refractive Surgery").

Contents

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Subjects Index

Help ?

LASIK AND BEYOND LASIK

Chapter 1

Ophthalmic excimer lasers use ultraviolet radiation at a wavelength of 193 nanometers. It is a wavelength that practically does not heat the tissue but actually breaks interand intramolecular bonds. The molecules in the area of ablation explode away from the surface (Fig. 1-2).

The concept of ablative surgery is that by removing small amounts of tissue from the anterior surface of the cornea (Fig. 1-3) a significant change of refraction can be attained. The effect in myopes is achieved by flattening the anterior dome of the central cornea over a 5 mm disc shaped area.

ADVANCES IN EXCIMER LASER TECHNOLOGY

Scanning Lasers

As pointed out by Peter McDonnell, M.D.,

Professor and Chair, Department of Ophthal-

Figure 1-2: Excimer Laser - Effects on the

Tissue

The high intensity energy of ultraviolet light from an excimer laser during tissue ablation breaks inter and intramolecular bonds, causing the molecules of the area of ablation to explode away from the surface. Please observe that there is minimal disruption of the remaining surrounding tissue.

(After Boyd´s "Atlas of Refractive Surgery").

mology, University of California, Irvine, and Professor of Ophthalmology and Director of Refractive Surgery at the Doheny Eye Institute, University of Southern California at Los Angeles, in most parts of the world broad beam lasers still predominate in the laser market (Fig. 1-3). Recently, however, scanning or flying spot lasers have gained attention. Instead of using an iris diaphragm to control a broad beam, some scanning lasers use a small slit that is scanned across the corneal surface (Fig. 1-4). Flying spot is another type of scanning laser. Instead of a slit that scans the surface , flying spot lasers (Fig. 1-5) have a small circular or elliptical spot perhaps 1 mm to 2 mm in diameter that is moved across the surface of the cornea by computercontrolled galvanometric mirrors.

Contents

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Subjects Index

Help ?

Advantages of Scanning Lasers

Scanning lasers (Figs. 1-4 and 1-5) have several potential advantages over broad beam

2 SECTION I

Figure 1-3 (above): Concept of Broad Beam Laser Application for Refractive Surgery

The most common type of excimer laser is the broad beam laser (L1). The method of application uses a widening diaphragm or pre-shaped ablatable mask (M) through which the laser beam (L2) passes. To produce more ablation of the cornea in the center (C) than in midperiphery (P), the thinner central portion of the mask allows the laser to ablate the central cornea longer. As the disk is ablated in a peripheral direction (arrows), the cornea is shaped accordingly in a desired gradient fashion.(After

Boyd´s "Atlas of Refractive Surgery").

UNDERSTANDING REFRACTIVE LASERS

Figure 1-4 (below): Concept of the Scanning

Type Laser for Refractive Surgery

Another type of excimer laser uses a scanning laser beam. The laser beam (L1) strikes a moving mask (M-arrow) which has a slit through which the beam passes (L2) in a predetermined fashion. More ablation occurs centrally (C) and less peripherally (P) to achieve the desired corneal reshaping. (After Boyd´s "Atlas of Refractive Surgery").

Contents

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Subjects Index

Figure 1-5 (left): Concept of the "Flying Spot" Scanning Laser Application for Refractive

Surgery

Help ?

A third type of excimer laser application is known as the "flying spot". A small laser beam (L) moves across the cornea (arrow) in a predetermined, computer driven pattern to ablate more tissue centrally (C) than in the mid-periph- ery (P). This type of laser application is very flexible with regard to the type of ablation pattern that can be applied. (After Boyd´s "Atlas of Refractive Surgery").

LASIK AND BEYOND LASIK

Chapter 1

lasers (Fig. 1-3). The postoperative corneal surface may be smoother, resulting less often in a healing response which can progress to corneal haze or opacity. A higher quality of vision and improved visual acuity may also result from the smoother and more uniform corneal surface when using scanning lasers.

McDonnell emphasizes that another possible advantage of scanning technology is increased flexibility in the ablation profile or algorithm. The profile can produce aspheric rather than only spherical ablations (Figs. 1-6 and 1-7). Larger diameters of ablation can be made. The possibility of using topographical maps of the cornea to guide the ablation is a distinct advantage, which will allow for more flexibility in treating astigmatism. Some patients do not have perfect symmetry of the cornea, particularly those with surgically induced astigmatism after penetrating keratoplasty or cataract surgery, or those with keratoconus. Broad beam lasers do not take the asymmetry of irregular astigmatism into account; they treat all corneas the same. The scanning technology allows the possibility of a customized ablation that is unique for every cornea (Fig. 1-7).

Figure 1-6: Flexibility of the "Flying Spot" Scanning Laser May Provide Customized Ablation

The "Flying Spot" type excimer laser has an advantage over other broad beam and slit scanning lasers by providing increased flexibility in the ablation profile. The profile can be altered to provide aspheric as well as spherical ablations. The mid-peripheral cornea (red shaded area-P) can be treated with the laser (L) to produce a different curvature than that of the central cornea (D - blue line shaded area). This allows the possibility of a customized ablation unique for every cornea. A lamellar corneal flap (B) is retracted. (After Boyd´s "Atlas of Refractive Surgery").

(Note from the Editor in Chief: this flexibility of ablating different profiles in the same cornea is being utilized by some surgeons to create or "sculpt" the so-called "multifocal cornea" which is a significant step forward when it works but of increased risk to the patient's quality of vision when even a minor error in the sculpting occurs. This procedure is experimental).

It may even be possible to improve upon the naturally occurring corneal surface, with improvement in best corrected visual acuity, bringing patients who are 20/20 with correction preoperatively to 20/15 uncorrected postoperatively. We still need more experience to know more definitively whether scanning lasers can actually fulfill their early promise.

Contents

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Subjects Index

Help ?

Currently Available Scanning Lasers

Several companies are now working on developing scanning lasers. Chiron (now a division of Bausch & Lomb) has the Technolas laser.

Autonomous Technologies, recently purchased by Summit, the company that manufactured one of the first broad beam lasers, also manufactures a superior quality scanning laser. This indicates

4 SECTION I

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