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Comparison of Corneal Wavefront Aberrations After Photorefractive Keratectomy and Laser in Situ Keratomileusis

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Comparison of Corneal Wavefront Aberrations After Photorefractive Keratectomy and Laser in Situ Keratomileusis Comparison of Corneal Wavefront Aberrations After Photorefractive Keratectomy and Laser In Situ Keratomileusis TETSURO OSHIKA, MD, STEPHEN D. KLYCE, PHD, RAYMOND A. APPLEGATE, OD, PHD, HOWARD C. HOWLAND, PHD, AND M. ALAA EL DANASOURY, MD, FRCSED c PURPOSE: To compare changes in the corneal wave- fractive keratectomy and laser in situ keratomileusis at front aberrations after photorefractive keratectomy and any postoperative point. For a 7-mm pupil, the post–laser laser in situ keratomileusis. in situ keratomileusis eyes exhibited significantly larger c METHODS: In a prospective randomized study, 22 total aberrations than the post–photorefractive keratec- patients with bilateral myopia received photorefractive tomy eyes, where a significant intergroup difference was keratectomy on one eye and laser in situ keratomileusis observed for spherical-like aberration, but not for coma- on the other eye. The procedure assigned to each eye and like aberration. This discrepancy seemed to be attribut- the sequence of surgery for each patient were random- able to the smaller transition zone of the laser ablation in ized. Corneal topography measurements were performed the laser in situ keratomileusis procedure. Before sur- preoperatively, 2 and 6 weeks, 3, 6, and 12 months after gery, simulated pupillary dilation from 3 to 7 mm caused surgery. The data were used to calculate the wavefront a five- to six-fold increase in the total aberrations. After aberrations of the cornea for both small (3-mm) and large surgery, the same dilation resulted in a 25- to 32-fold (7-mm) pupils. increase in the photorefractive keratectomy group and a c RESULTS: Both photorefractive keratectomy and laser 28- to 46-fold increase in the laser in situ keratomileusis in situ keratomileusis significantly increased the total group. For a 3-mm pupil, the proportion of coma-like wavefront aberrations for 3- and 7-mm pupils, and values aberration increased after both photorefractive kera- did not return to the preoperative level throughout the tectomy and laser in situ keratomileusis. For a 7-mm 12-month follow-up period. For a 3-mm pupil, there was pupil, coma-like aberration was dominant before sur- no statistically significant difference between photore- gery, but spherical-like aberration became dominant postoperatively. c Accepted for publication July 16, 1998. CONCLUSIONS: Both photorefractive keratectomy and From the Department of Ophthalmology, University of Tokyo School laser in situ keratomileusis increase the wavefront aber- of Medicine, Tokyo, Japan (Dr Oshika); LSU Eye Center, New Orleans, rations of the cornea and change the relative contribution Louisiana (Drs Oshika and Klyce); Department of Ophthalmology, School of Medicine, University of Texas Health Science Center at San of coma- and spherical-like aberrations. For a large pupil, Antonio, San Antonio, Texas (Dr Applegate); Neurobiology and Behav- laser in situ keratomileusis induces more spherical aber- ior Section, Cornell University, Ithaca, New York (Dr Howland); and El rations than photorefractive keratectomy. This finding Maghraby Eye and Ear Center, Abu Dhabi, United Arab Emirates (Dr El Danasoury). could be attributable to the smaller transition zone of the This work was supported in part by U.S. Public Health Service grants laser ablation in the laser in situ keratomileusis proce- EY03311 (Dr Klyce) and EY02377 (LSU Eye Center); EY08520 and dure. (Am J Ophthalmol 1999;127:1–7. © 1999 by EY08520-03S1 (Dr Applegate), and EY02994 (Dr Howland) from the National Eye Institute, National Institutes of Health, Bethesda, Mary- Elsevier Science Inc. All rights reserved.) land; a San Antonio Area Foundation Grant (Dr Applegate), a Kerr Foundation Grant (Dr Applegate); and an unrestricted research grant to the ITH ACCUMULATING EXPERIENCE AND CON- Department of Ophthalmology, University of Texas Health Science Center at San Antonio, Texas, from Research to Prevent Blindness, New York, New tinuing sophistication of techniques, the safety York. and efficacy of refractive surgery have dramat- Dr Klyce is a paid consultant to Computed Anatomy, manufacturers of W ically increased during recent years. In principle, refractive the Tomey TMS topographer. The other authors have no financial or proprietary interest in any methods or materials described within this surgical procedures focus on the elimination or reduction article. of spherical and cylindrical defocus, the most important Reprint requests to Tetsuro Oshika, MD, Department of Ophthalmol- ocular optical aberration to correct. On the other hand, ogy, University of Tokyo School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan; fax: 181-3-3817-0798; e-mail: oshika-tky@ much less attention has been directed to the higher order umin.ac.jp aberrations of the cornea. The human eye has a substantial 0002-9394/99/$20.00 © 1999 BY ELSEVIER SCIENCE INC.ALL RIGHTS RESERVED. 1 PII S0002-9394(98)00288-8 amount of aberrations.1–3 These naturally occurring higher than 490 mm by ultrasonic pachymetry, keratoconus, or order aberrations, combined with the aberrations induced keratoconus suspect by videokeratography, active ocular by refractive surgery, can affect the visual performance disease, systemic disease likely to affect corneal wound after surgery. healing (for example, connective tissue disease), and After refractive corneal surgery for myopia, the asphericity inability to achieve the strict follow-up example, schedule of the cornea typically reverses (that is, less curvature in the that was given to the patients before surgery. There was no central cornea than in the peripheral cornea). This would be upper age limit in this trial; however, presbyopic patients expected to increase the spherical aberration of the cornea, who preferred undercorrection of one eye (monovision) which might diminish the quality of the retinal image. were not enrolled in the study, therefore emmetropia was Previous studies have indicated that higher order corneal the refractive goal in all eyes. All patients signed an aberrations increase after radial keratotomy4–6 and photore- informed consent in their native language as approved by fractive keratectomy.7–9 The increases in wavefront aberra- El Maghraby Health Corporation Research Committee. tions after radial keratotomy were shown to depend on the The study protocol was approved by the Human Investi- magnitude of refractive correction,6 and they were correlated gation Committee in El Maghraby Eye and Ear Center. to a decrease in contrast sensitivity.10 However, the changes The Nidek EC-5000 excimer laser (Nidek Co, Gama- in optical quality of the cornea after laser in situ kerato- gori, Japan) was used for all eyes. The laser system mileusis have not been well studied, and no data are parameters were: wavelength, 193 nm; pulse repetition available on the influence of laser in situ keratomileusis rate, 30 Hz; fluence, 140 mJ/cm2; ablation depth between procedures on corneal aberrations. We conducted the 0.20 and 0.26 mm per scan (mean, 0.25 mm) in polymeth- current prospective study to compare the amount of ylmethacrylate and between 0.48 and 0.62 mm per scan wavefront aberrations of the cornea after photorefrac- (mean, 0.60 mm) on the cornea; no aspiration air flow; tive keratectomy and laser in situ keratomileusis. ablation zone diameter of 5.5 mm; and transition zone diameter of 7.0 mm in photorefractive keratectomy proce- dures and 6.5 mm in laser in situ keratomileusis procedures. PATIENTS AND METHODS The shaping system of the beam involved a rectangular cross-sectional beam of up to 2 mm by 9 mm and an FORTY-FOUR EYES OF 22 PATIENTS WITH BILATERAL MYOPIA expanding diaphragm. Beam delivery was achieved by were enrolled in a prospective randomized study. Patient linear scan of 10 overlapped rectangular cross-sectional age ranged from 19 to 45 years (26.7 6 5.9 years; mean 6 beams, combined with rotation of the rectangle by 120 standard deviation). Every patient received photorefrac- degrees on completion of each scan. The astigmatism tive keratectomy on one eye and laser in situ keratomileu- correction combined the opening diaphragm with an sis on the other eye. All patients had both eyes operated on opening slit with the long axis aligned with the flattest during the same surgical session. The procedure assigned to corneal meridian and was performed after the spherical each eye and the sequence of surgeries for each patient correction in all spherocylindrical ablations. were randomized using a random number table. Photorefractive keratectomy was performed by mechan- The mean preoperative spherical equivalent refraction ical scraping of the epithelium from the central 8.0 mm of was 23.23 6 0.63 diopters (range, 22.50 to 25.00 the cornea with a No. 69 beaver blade without damaging diopters) in photorefractive keratectomy eyes and the Bowman layer. The patient fixated a blinking green 23.44 6 0.72 diopters (range, 22.25 to 25.50 diopters) in diode light coaxial with the laser beam. Topical diclofenac laser in situ keratomileusis eyes. There was no statistically sodium 0.1% (Naclof, Ciba Vision Ltd, Hettlingen, Swit- significant difference in the baseline manifest refraction zerland) was applied four times daily for 3 days, topical between the two groups. Eleven eyes (50%) of each group, tobramycin 0.3% (Tobrex, Alcon-Couvreur, Belgium) was which underwent the combined spherical and astigmatic applied four times daily for 1 week, and topical fluoro- ablation, had a refractive cylinder of 0.50 or more. The metholone 0.1% (Flucon, Alcon-Couvreur) was used four mean preoperative refractive cylinder was 0.44 6 0.57 times daily initially, then tapered over 4 months. No diopters (range, 0 to 2.25 diopters) in the photorefractive contact lenses or patches were used. keratectomy group and 0.38 6 0.40 diopters (range, 0 to The Automated Corneal Shaper, sequence number 332, 1.50 diopters) in the laser in situ keratomileusis group. adjustable ALK style (Chiron Vision, Irvine, California) was Patients selected for the study met inclusion criteria used in all laser in situ keratomileusis procedures.
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