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LASIK: Why Doing Better Is Important mivision • ISSUE 116 • SEP 16 miophthalmology 33 CreatingCreating vision LASIK: Why Doing Better withwith aa SMILE.SMILE. is Important ZEISSZEISS ReLExReLEx SMILESMILE Dr. DevinderRick Wolfe Chauhan LASIK has arguably become the safest It became evident that many LASIK and and most effective surgery of all time, but PRK patients, even those who had low it wasn’t always that way. It came about myopic ablations, had significantly reduced because of a confluence of technologies and night vision with halos. In Germany, where needs. José Barraquer developed the lamellar a night vision simulation is used in drivers’ refractive surgery in the 60s in Columbia. licence testing, some who had had PRK His procedure – myopic keratomileusis were denied the right to drive at night. (MKM) – involved the freezing, lathing and Quality of vision, particularly night vision, replacement of a corneal cap, which was is critical in military environments. Capt. much like the flap in modern LASIK, except (retired) Steven Schallhorn developed there was no hinge. It was not so long ago the United States Navy (USN) refractive In 1983, Dr. Trokel showed the excimer surgery program. I had the privilege of that we performed laser could be used to reshape the cornea. working with him at USN Medical Center PRK worked well, but slow recovery and San Diego as part of a RAN Reserve conventional laser postoperative pain were serious problems. exchange some years ago. Professor Ioannis Pallikaris first performed Other forces followed the USN lead in treatments that sadly excimer laser under a corneal flap in 1991 developing their own programs because at Crete University. This was pivotal for of remarkable efficiency gains following produced good visual refractive corneal surgery. Visual recovery surgery. A half a million procedures have mostly occurred quickly with no pain. now been performed in forces centres acuity, but were Without this development laser vision all over the USA. The USN has been correction would not have taken off to the responsible for excellent studies in visual diminished by a visual same extent. Professor Pallikaris coined quality after laser refractive surgery, which the term laser in-situ keratomileusis and its have shaped our thinking. acronym LASIK. The irony is that Crete result that was often Dr. Schallhorn put 105 USN personnel, has one of the world’s highest incidences who had had myopic PRK, many for of keratoconus, the natural enemy of the low corrections, through the Ginzberg poorer in other ways. LASIK procedure. Night Driving Simulator in Los Angeles. LASIK should aim Since then nearly 45 million LASIK He found 40 per cent were “significantly procedures have been performed (Source: worse” than before surgery and to improve vision in Market Scope, LLC St Louis MO USA) but staggeringly, every single one was “worse” //// INNOVATIONINNOVATION this represents only the tiniest proportion in the simulator than the preoperative visit! of the world’s ametropes. (Schallhorn SC Presentation 2004 ESCRS MADEMADE BYBY ZEISSZEISS every measurable and Munich Germany) Efficacy was very high in the early days of subjective way. LASIK and PRK and safety was also very Other studies of conventional ablation ReLEx SMILE is not approved in every country, e.g. in US FDA clinical study (IDE) is ongoing. e.g. in US FDA in every country, ReLEx SMILE is not approved ReLEx SMILE is not approved in every country, e.g. in US FDA clinical study (IDE) is ongoing. e.g. in US FDA in every country, ReLEx SMILE is not approved high. In one of the biggest published studies found worse night vision in 33 per cent3 and Hammond reported on 32,068 eyes treated 60 per cent4 of cases. Contrast sensitivity in the US Army Warfighter Refractive Eye was found to be worse than spectacle wear5 Surgery Program.1 While three cases of and others showed a permanent reduction of bacterial keratitis were reported (0.009 per contrast in low light.6-12 cent), loss of more than a line of BCVA was rd rd The problem related to the increase in MoveMove upto theto the 3 3Generation! Generation! seen in only 0.06 per cent with no case worse spherical aberration (SA) and other than 6/12. Not a single member had their higher order aberrations (HOA) induced As 3rdrd generation laser visionvision correctioncorrection beyondbeyond PRKPRK andand LASIK,LASIK, visual status downgraded. As 3 generation laser vision correction beyond PRK and LASIK, by the ablation. HOA are associated ® SMILESMILE isis redefiningredefining refractiverefractive surgery surgery as as we weknow know it. it.ReLEx TillTill now,now,SMILE PROBLEMS WITH LASIK with poor night vision with glare and ReLExfromReLEx ZEISS®® SMILESMILE is the fromfrom only ZEISS solution is the to only perform solution this totominimally performperform invasive, thisthis LASIK enjoyed enormous popularity halos13 and were increased in proportion 14-19 minimallyflaplessminimally procedure. invasive, flapless SMILE canprocedure. help practices Moreover, to attract SMILE new helpshelps over the years after its development, but to the attempted correction. SA was it eventually became evident there were increased by a factor of up to 36.620 and, practicespatientpractices groups attract and new differentiate patient groups from and other set clinics. themselves apartapart problems. Seiler, in 1998, reported three in one study where the measurement was from other clinics. from other clinics. highly myopic post LASIK eyes developing for a 7mm pupil, the factor SA increase www.zeiss.com/relex-smile central steepening, which she correctly was three hundred fold.21 HOA www.zeiss.com/relex-smilewww.zeiss.com/relex-smile interpreted as corneal ectasia.2 magnitude is proportional to the radius 34 miophthalmology mivision • ISSUE 116 • SEP 16 aberrometry to reduce them or to reduce aberrometry as in WFG, the corneal induction. A WFO treatment only seeks to topography is used to calculate the ablation induce as little SA as possible and is not a pattern. I think TG provides all the customised treatment. advantages of WFG customisation without some of the difficulties. Most surgical platforms developed WFG capability. Early outcomes were mixed but all TG treatments were mainly used for induced less HOA and SA than conventional treatment of very irregular corneas. treatment. Some had poorer results in Early reports36, 37 detailed successful managing SA.22 The Wavelight platform, in corneal regularisation and improved vision one of the early studies,23 demonstrated most following corneal trauma, keratoplasty, encouraging results with only an increase on central islands and other laser ablation HOA by a statistically insignificant factor of problems, such as decentred zones and Figure 1. Top left shows right eye topography following a 1.4 and only a doubling of SA. small optic zones. Since then other grossly decentred PRK for high myopia (original refraction applications of TG such as keratoconus unknown). BCVA was 6/15. Bottom left is final result with This was a turning point for LASIK, when treatment have been used in association 6/7.5 BCVA. Right is the difference map showing both vision was routinely improved rather than with corneal collagen cross-linking.38 steepening of the flat area and flattening of the steep area routinely diminished in some way. achieved under TG control. As an example of TG ablation, a Schallhorn had done much work on grossly decentred PRK ablation is depicted WFG LASIK and PRK in the USN. He in Fig. 1. Following TG ablation the patient authored an official American Academy achieved 6/7.5 in this eye. The difference of Ophthalmology meta-analysis of WFG map on the right shows simultaneous 23 treatments in 2008. He found of WFG flattening of the steeper area and steepening over conventional, less induced HOA, and of the flatter area. The performance of the with the Wavelight platform a reduction TG software on the Wavelight platform can HOA in those eyes with preop HOA over produce amazing results. 0.3μ. He also found less halo and glare, better contrast sensitivity and similar or ALCON WaVELIGHT TG LASIK - better refractive accuracy and UCVA with CONTOURA Figure 2. The WaveLight EX500 excimer laser. WFG treatments. TG LASIK for untreated ametropic eyes is not new and several reports of satisfactory of the aperture so with a poor ablation, There are several difficulties with WFG outcomes exist.39-47 vision can rapidly deteriorate as the treatments. They require an expensive pupil dilates. aberrometer with which treatment is We have been using this modality in determined. Often an adequate acquisition conjunction with the newer EX500 The realisation that LASIK was far from is not possible and the whole process takes excimer laser in virgin eyes undergoing perfect, despite excellent uncorrected visual considerable staff time. Many surgeons don't refractive surgery. We feel it has all the acuity (UCVA) and near instant visual bother for these reasons, claiming WFO advantages of WFG over WFO, in that recovery, was of concern to many, not least treatments are quite adequate. WFO ablation the treatment is truly customised. An of all consumers. Many clinicians were patterns were developed to address these additional advantage is that it is combined looking for ways to do better, while others problems. They don’t consider pre-existing with the Q adjustment facility. were in denial. LASIK could have had a HOA but aim to compensate for the induced bleak future without a vast improvement. As a requirement for FDA registration SA of conventional treatments. of the Alcon Wavelight platform for THE SOLUTION WFO treatments are certainly better than performing TG treatments on irregular The error of conventional ablation profiles corneas, results of surgery on normal conventional treatments. Eight studies,24-31 should have been blindingly obvious, but it ametropic eyes had to be presented first. though show WFG superior to WFO and took some years to understand.
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