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refractive Bonus Feature Why I Chose My Platform share what sets their device of choice apart from others on the market.

By Dan Z. Reinstein, MD, MA(Cantab), FRCSC, DABO, FRCOphth, FEBO; alaa el danasoury, md, frcs; paolo vinciguerra, md; Christopher L. Blanton, MD; Robert Ang, MD; and a. john kanellopoulos, md

MEL 80 Courtesy of Dan Z. Reinstein, MD, MA(Cantab), FRCSC, DABO, This device can provide superb clinical outcomes, even in the extremes of ametropia, and has optimal solutions for and therapeutic repair. By Dan Z. Reinstein, MD, MA(Cantab), FRCSC, DABO, FRCOphth, FEBO

There are a number of reasons why I chose the MEL 80 (Carl Zeiss Meditec; Figure 1) as my plat- form. These fall into two general categories: technology FRCOphth and applications. Technology. The MEL 80, a flying spot laser operating Figure 1. The MEL 80, a flying spot laser, operates at a at a repetition rate of 250 Hz, represented a quantum repetition rate of 250 Hz. leap in excimer laser technology when it was launched in 2002. The focus of its design was to maximize the MEL 80, and the user is able to change the fluence deliv- energy stability and reliability of the laser delivery ered in 2% steps, resulting in very high-accuracy energy system. This was achieved in several ways. The efficiency delivery. This 20-second process enables a calibration of the laser beam path is optimized by the use of only five check to be performed for every patient immediately mirrors and the fact that 90% of the beam path is through before treatment, thus optimizing outcomes. a vacuum tube. The laser system also includes closed-loop For the user, the product of all these features is a remark- energy regulation, resulting in an extremely consistent ably stable, consistent, and reliable laser. For example, in my energy fluence. Another unique feature of the MEL 80 is practice, the fluence setting value (selected during calibra- the patented beam shaper that guarantees the Gaussian tion) was between 0 and 2 (ie, within 4%) for 97% of treat- beam shape (achieved using a lenslet array much like those ments in the first 4 months of 2013. Additionally, service used in Hartmann-Shack wavefront sensors), and that visits are kept to a minimum; our center has required only does not require beam focusing as a regular maintenance five functional service visits and 14 preventive maintenance issue. Another patented feature, the cone for controlled visits in the past 3.5 years. Most important, we have never, atmosphere, ensures that the final part of the beam path— in 10 years of use, had to reschedule patients because of through air to the patient’s —is maintained as a consis- a technical failure with the MEL 80, and the device has tent environment by plume homogenization, as opposed to provided us with superb clinical outcomes, even in the straightforward plume extraction. extremes of ametropia (6.00 D to -12.00 D).1-3 Finally, the calibration process uses test phase cards Applications. With respect to applications, the MEL 80 with calibrated aluminium foil to test fluence, beam pro- has always included a wavefront-optimized aspheric file, and scanning mirror spot placement accuracy simul- profile as the standard base profile for , taneously. A display of the real-time energy variance and the hyperopic ablation profile has also been unsur- demonstrates how tightly fluence is controlled by the passed in stability and safety. Wavefront-guided treat-

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ments were coupled with wavefront-optimized (aspheric) 1. Reinstein DZ, Couch DG, Archer TJ. LASIK for hyperopic and presbyopia using micro-monovision with the Carl Zeiss Meditec MEL80. J Refract Surg. 2009;25:37-58. base profiles from the laser’s inception in 2002, allowing 2. Reinstein DZ, Archer TJ, Gobbe M. LASIK for myopic astigmatism and presbyopia using non-linear aspheric micro-monovision manifest refraction to be combined with higher-order with the Carl Zeiss Meditec MEL 80 platform. J Refract Surg. 2011;27:23-37. 3. Reinstein DZ, Carp GI, Archer TJ, Gobbe M. Transitioning from mechanical microkeratome to femtosecond flap creation: aberrations (HOAs). The Wavefront Supported Custom comparing experienced vs novice LASIK visual outcomes for the first 200 myopic procedures. J Cataract Refract Surg. Ablation (WASCA) aberrometer has been the highest- 2012;38:1788-1795. 4. Reinstein DZ, Carp GI, Archer TJ, Gobbe M. LASIK for the correction of presbyopia in emmetropic patients using aspheric abla- resolution wavefront sensor linked to an excimer laser tion profiles and a micro-monovision protocol with the Carl Zeiss Meditec MEL80 and VisuMax. J Refract Surg. 2012;28:531-541. until recently, as other providers are beginning to provide 5. Reinstein DZ, Archer TJ, Couch D, Schroeder E, Wottke M. A new night vision disturbances parameter and contrast sensitivity as indicators of success in wavefront-guided enhancement. J Refract Surg. 2005;21:S535-540. resolutions in a similar range. The 1,000-Hz eye tracker 6. Reinstein DZ, Archer TJ, Gobbe M. Combined and corneal wavefront data in the treatment of corneal provides a 4:1 tracking-frame-to-pulse ratio, resulting in irregularity and in LASIK or PRK using the Carl Zeiss Meditec MEL80 and CRS Master. J Refract Surg. 2009;25:503-515. 7. Reinstein DZ, Archer TJ, Gobbe M. Refractive and topographic errors in topography-guided ablation produced by epithelial an extremely low full-loop delay between 2 and 4 millisec- compensation predicted by three-dimensional Artemis very high-frequency digital ultrasound stromal and epithelial thickness onds. The eye tracker includes a sophisticated cyclotorsion mapping. J Refract Surg. 2012;28:657-663. 8. Reinstein DZ, Archer TJ, Gobbe M. Spot PTK for keratin plugging in incisions. Available at http://www. registration system that identifies the pupil, iris, limbus, youtube.com/watch?v=-H0l_kvHPvc&feature=youtube. and conjunctival vessels. It also allows manual centration by direct visualization of the position of the red helium- neon laser aiming beam so that it is simple to center the ablation on the corneal reflex of a coaxially fixating eye. Nidek EC-5000 The applications that stand out for the MEL 80 are This excimer laser has a 20-year history of excellent Presbyond and the options for clinical outcomes and satisfied patients and surgeons. therapeutic repair of previous refractive surgery compli- By Alaa El Danasoury, MD, FRCS cations. Laser Blended Vision1,2,4 is a solution for presby- opia that meets the goal of good binocular vision at all We began performing excimer at Magrabi distances, with no compromise in safety, contrast sen- Eye Hospitals and Centers as early as 1990 and had one sitivity, or night vision and with retention of functional of the first excimer laser systems worldwide. In 1993, we stereoacuity. Since developing the Laser Blended Vision acquired the first-generation Nidek EC-5000 excimer laser technique in 2003, my practice virtually eliminated the (Nidek Co., Ltd.; Figure 2), which was the state-of-the-art need for clear lens exchange and multifocal IOLs. excimer laser at the time, with its large ablation zone and In addition to wavefront-guided custom ablation,5 flexible transition zone. Since those early years, the platform the MEL 80 has a topography-guided custom ablation has undergone signficant change, and it remains at the algorithm,6 which improves on the original 1998 MEL 70 forefront of excimer laser technology today. For example, Topography Supported Customized (TOSCA) the current Navex Quest platform includes aspheric abla- topography-guided module. The topography-guided tion profiles and ocular wavefront-guided, topography- profile with the MEL 80 achieves excellent regularization of guided, and optimized prolate ablation (OPA) algorithms the with high refractive accuracy. The MEL 80 also to treat virtually any refractive surgery candidate based on has a versatile phototherapeutic keratectomy (PTK) mode7 his or her specific ocular characteristics and needs. that can be used for treating irregular astigmatism by per- Our group comprises 32 refractive surgeons at 26 centers forming transepithelial PTK. Finally, maximum versatility is and strives to be on the cutting edge of excimer technol- provided by the spot PTK joystick, which is essentially a 0.7- ogy. Over the years, we have evaluated other excimer mm microscalpel enabling extreme localization and control to determine the differences between platforms. However, of ablation; this feature can be applied in a wide variety of we have never felt the need to change our main platform unusual situations such as flap edge discontinuity after epi- (Nidek), as it provides all the modern aspects of laser vision thelial ingrowth, Salzmann nodules with scarring, anterior correction. The suite of technology in the Nidek excimer plat- basement membrane dystrophy, scarred radial keratotomy form includes automated cyclotorsion error correction and incisions, and lattice and other corneal dystrophies.8 a 1-kHz eye tracker. The Nidek platform differs from other platforms in three significant facets: (1) preoperative measure- Dan Z. Reinstein, MD, MA(Cantab), FRCSC, DABO, ment, (2) treatment planning, and (3) surgical treatment. FRCOphth, FEBO, practices at the London Vision Clinic, Preoperative measurement. The first step in successful London, and is affiliated with the Department of surgery is accurate preoperative measurements, and the , Medical College, New diagnostic tools included in the Nidek excimer laser are York, and the Centre Hospitalier National d’Ophtalmologie, outstanding. The OPD Scan III is a combination topog- Paris. Professor Reinstein states that he has financial interests rapher, aberrometer, pupillometer, autorefractor, and with Carl Zeiss Meditec and ArcScan Inc. He may be reached keratometer. It is a valuable tool for pre- and postopera- at e-mail: [email protected]. tive use in excimer laser and anterior segment surgery,

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including and phakic IOL implantation. The OPD Scan III includes corneal disease screening soft- ware, a useful adjunct to the surgeon’s clinical impression. Comparison of corneal topography and internal aberra- tion maps allows the surgeon to select the most appropri- ate treatment for each patient. Additionally, the difference in the pupil center (line of sight) and corneal vertex are plotted on all maps to aid ablation centration. Advanced treatment planning software allows us to separate lower- order aberration (LOA) corrections (sphere and cylinder) from HOA corrections for greater flexibility of treatment. We can choose to correct some or all of the HOAs based

Courtesy of Alaa El Danasoury, MD, FRCS on the clinical picture. Figure 2. The Nidek EC-5000 excimer laser provides all of the Treatment planning. The OPA profile provides an modern aspects of laser vision correction. unmatched physiologic prolate shape over the mesopic pupillary area,1 potentially improv- ing postopera- tive visual quality (Figures 3 and 4).2 For treatment planning with this profile, the surgeon can modify the target spherical aberration and tai- lor it to presbyopic patients. Currently, we target -0.30 μm

Courtesy of Alaa El Danasoury, MD, FRCS spherical aberration Figure 3. Preoperative corneal topography of an eye that subsequently underwent LASIK for -6.50 D in both , which of myopia using a Nidek Quest laser with an OPA profile (left). The postoperative map (right) shows a increases depth of prolate corneal shape over the entire mesopic pupil. focus and improves near vision by approximately 0.75 D; this can be combined with mini- monovision (0.75 D of myopia) in the nondominant eye. Surgical treatment. During treatment, there is auto- mated compensation for cyclotorsion; however, with the Nidek excimer focusing slit beam, as opposed to the focus- ing spot beam used in many other platforms, the surgeon can detect any head tilt during ablation. This is significantly more effective with slit illumination. During ablation, the laser arm moves to follow the eye’s movements, as opposed to only the laser optics. This leads to more accurate delivery of laser energy to achieve the intended correction. Operation of the Nidek laser is exceptionally cost-

Courtesy of Alaa El Danasoury, MD, FRCS effective. We operate in 26 locations in six countries and Figure 4. Mean spherical aberration for a 6-mm pupil in eyes that have a total of 19 Nidek platforms and two other systems. received OPA (purple) compared with eyes that received classic As the director of refractive surgery, I can appreciate the myopic LASIK treatment (light blue). OPA eyes maintained their longevity of the Nidek laser cavity and the significantly negative spherical aberration values, whereas eyes with classic lower maintenance cost with these systems compared with myopic treatment had induced positive spherical aberrations. others. An additional advantage is the lack of a per-click

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fee with the Nidek EC-5000. The Nidek platform has given us a 20-year history of excellent clinical outcomes, satisfied patients, and consequently satisfied surgeons.

Alaa El Danasoury, MD, FRCS, is Chief of Cornea and Refractive Surgery Service at Magrabi Eye Hospitals and Courtesy of Schwind eye-tech-solutions Centers, Saudi Arabia, Gulf Region & Egypt. Dr. El Danasoury did not provide financial disclosure information. He may be reached at e-mail: [email protected].

1. El Danasoury AM. NIDEK optimized prolate ablation for the treatment of myopia with and without astigmatism. J Refract Surg. 2009;25(Suppl):S136-S141. 2. El Danasoury AM, Holladay J, Waring GO 3rd, Pieger S, Bains HS. A contralateral, randomized comparison of optimized prolate ablation and conventional LASIK for myopia with the NIDEK excimer laser platform. J Refract Surg. 2012;28(7):453-461. Figure 5. The Schwind Amaris 750S is distinguished by several features, including its tracking system and centration. Schwind Amaris The laser’s tracking system and centration can track eye movements in six dimensions. By Paolo Vinciguerra, MD Courtesy of Paolo Vinciguerra, MD After more than 25 years’ experience with excimer laser cornea-based refractive surgery, my current laser system is the Schwind Amaris 750S (Schwind eye-tech-solutions; Figure 5). I have chosen this as my excimer laser for a number of reasons, including the responsiveness of the company to feedback, the features offered by this refractive platform, and the excellent clinical results it provides. Figure 6. For a therapeutic ablation, such as this one in I have found that Schwind is a responsive, flexible compa- a patient with Acanthamoeba corneal infection, built-in ny that consistently aims to improve this device’s hardware pachymetry can provide real-time feedback. and software. The reaction of Schwind’s research and devel- opment team to my feedback is always reliable and precise. A variety of features distinguish the Schwind Amaris 750S from other refractive laser platforms on the market. The laser’s tracking system and centration can track eye movements in six dimensions. The system determines the visual axis, tracks it, and automatically centers the ablation of LOAs on this axis. By contrast, HOA ablation is centered on the pupil center, from which it has been Courtesy of Paolo Vinciguerra, MD calculated. This makes a difference in outcomes; post- operative maps show better centration of the refractive ablation, and results are no longer sensitive to the angle kappa (the distance between the pupil center and the visual axis). Additionally, postoperative coma is much lower than with other laser platforms I have used. Figure 7. Same patient as Figure 6: Postoperative result and The Schwind Amaris 750S features an integrated optical difference maps. coherence tomography (OCT) device that can measure in real time. This provides feedback after a myopic ablation, postoperative corneal maps show between the planned and obtained ablation that is espe- a prolate cornea (Figure 8). It can be difficult to determine cially useful in retreatments and therapeutic ablations whether these eyes have been treated or not. At a recent (Figures 6 and 7). Perhaps most impressive is the prolate ophthalmic congress, I showed participants side-by-side shape of after treatment with this system. Even OCT images of untreated eyes and other patients after

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A Courtesy of Paolo Vinciguerra, MD Figure 8. Even after a myopic ablation, postoperative corneal maps show a prolate result. B

treatment with the Schwind Amaris 750S (Figure 9). No one was able to detect which patient had been treated. Other advantages of the laser include its large optical zone size and its speed. Most cases performed with the Schwind Amaris 750S are completed within 60 seconds from the start of ablation. This platform also enables the surgeon to treat highly irregular corneas with little difficulty.

Paolo Vinciguerra, MD, is the Chairman of the Department of Ophthalmology, Istituto Clinico Humanitas, Milan, Italy. Dr. Vinciguerra is a member of the CRST Europe Editorial Board. He may be reached at e-mail: paolo.vinciguerra@ C humanitas.it. Star S4 IR Wavefront-guided, iris-registered excimer laser delivery provides maximal treatment of HOAs with meticulous placement of the axis of astigmatism. By Christopher L. Blanton, MD Courtesy of Paolo Vinciguerra, MD

The purpose of excimer laser surgery for vision correc- tion is to provide each eye with optimal . The more precise the laser, the more likely we are to achieve this outcome. How can we determine which platform is most precise? This may vary from surgeon to surgeon, but I prefer to look at US Food and Drug Administration (FDA) results Figure 9. Side-by-side OCT images show how difficult it is to and phase 4 clinical trial outcomes. tell treated from untreated eyes in three examples (A–C). In a study published in the Journal of Cataract & Refractive Surgery, Abbott Medical Optics Inc.’s (AMO’s) wavefront- have continuously improved the Star S4 IR’s level of preci- guided platform, the Star S4 IR (Figure 10), provided 94% sion. Several studies have documented high levels (20/16 or of eyes with 20/20 or better and 74% of eyes with 20/16 or better) of visual acuity with low enhancement rates.2-4 better UCVA.1 Since the laser gained FDA approval, multiple These results have been achieved with the Star S4 IR advances in refractive surgery have occurred, including iris in a variety of settings including large corporate laser registration and the advent of the femtosecond laser, which centers, small individual private practices, and the

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1. Jabbur NS, Kraff C; for the Visx Wavefront Study Group. Wavefront-guided laser in situ using the WaveScan system for correction of low to moderate myopia with astigmatism: 6-month results in 277 eyes. J Cataract Refract Surg. 2005;31:1493-1501. 2. Schallhorn SC, Venter JA. One-month outcomes of wavefront-guided LASIK for low to moderate myopia with the Visx Star S4 laser in 32,569 eyes. J Refract Surg. 2009;25:S634-S641. 3. Tanzer DJ, Brunstetter T, Zeber R, et al. A prospective evaluation of laser in situ keratomileusis in US Naval avia- tors. J Cataract Refract Surg. 2013. In press. 4. Blanton CL. Customizing LASIK flaps with 150 kHz femtosecond technology. Paper presented at: the American Society of Cataract & Refractive Surgery Annual Meeting; March 25-29, 2011; San Diego, CA. Technolas 217P This reliable platform expands the refractive surgery market to the presbyopic age group.

Courtesy of Christopher L. Blanton, MD By Robert Ang, MD Figure 10. AMO’s wavefront-guided platform, the Star S4 IR excimer laser. Choosing an excimer laser for one’s practice is an extremely important decision because it is an expensive military; in short, they are highly reproducible, and, in piece of equipment. It will take many years to recoup this my experience, unsurpassed. The combination of wave- investment, so the practice has to live with the decision for front-guided, iris-registered excimer delivery under a at least 5 years. femtosecond flap provides maximal treatment of HOAs I have had a Technolas 217 system (now Bausch + Lomb with meticulous placement of the axis of astigmatism Technolas) ever since I started in private practice 12 years delivered to a consistently dry stromal bed. This is the ago. At that time, wavefront-guided treatment was the recipe for precise results. hottest topic in refractive surgery, and the Bausch + Lomb In addition to iris registration, the Star S4 IR offers variable Zyoptix system was the best on the market. Many years have spot scanning. Variable beam sizes and repetition rates con- passed, and many companies have introduced other lasers serve tissue and optimize treatment times. ActiveTrak eye with numerous innovations. However, I have stuck with tracking captures all three dimensions of intraoperative eye Technolas, and I now use the Technolas 217P (Figure 11) for movements, with no dilation required, and its automatic the reasons detailed below. First, I am happy with the sur- centering locates and sets the treatment center to the cen- gical results achieved with this laser. I get spot-on refractive ter of the pupil. outcomes using the personalized aspheric program (com- The AMO platform is dedicated to the principle of bined wavefront and aspheric treatment). Rarely will I get wavefront-guided treatment of refractive errors with a focus a refractive surprise of more than 0.75 D, and my enhance- on detecting, measuring, and fastidiously treating all aber- ment rate over 12 years is less than 1%. Patients are happy rations. Using a Fourier-based algorithm, the aberrometer because their vision is stable, and our hospital manage- calculates thermally sensitive delivery of excimer laser pulses ment staff is happy because we do not need to absorb a designed to create a smooth, swift treatment that attempts significant amount of costs doing touch-ups. The second to eliminate all aberrations. This information drives the reason I prefer the Technolas 217P is familiarity. I know excimer laser delivery, eliminating transcription errors and the system and how to use the laser. I also know and trust providing compensation of the cyclorotation that occurs the Bausch + Lomb Technolas application specialists, who when patients go from standing to a supine position. provide efficient technical service. During the past 12 years, Last, the Star S4 IR comes with a dedicated team of not once was my laser nonfunctional for more than 1 day. technicians, engineers, clinical and business development I have never had to cancel , and this has enabled personnel, and medical monitors, all whom are dedicated me to provide consistent service to my patients. to helping users optimize clinical results for their patients. Last but most important of all, we upgraded from the Coupled with its aforementioned features and study out- Technolas 217z100 to the Technolas 217P because we can comes, this comprehensive platform stands apart from oth- perform Supracor, a presbyopic LASIK algorithm that can ers on the market. treat refractive errors and presbyopia in a single procedure. Now we can attract an additional population of patients. Christopher L. Blanton, MD, is in private practice at Whereas before we could offer only reading for Inland Eye Lasik, in Ontario, California. Dr. Blanton states presbyopic patients older than 40 years of age, now, as long that he is a consultant for Abbott Medical Optics Inc. He as they qualify based on standard LASIK parameters, we may be reached at e-mail: [email protected]. can offer them Supracor LASIK.

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was also one of the first surgeons to perform LASIK in the United States. At the time, I used Bausch + Lomb’s Automated Corneal Shaper microkeratome to create the flap and the Visx Star S3 to perform the ablation; later, I

Courtesy of Robert Ang, MD upgraded to the Visx Star S4 (now Abbott Medical Optics Inc.). Through the years, I have used other excimer lasers including the Technolas 217B, 217C, and 217Z and the LadarVision (Alcon). In 2001, I became one of the first surgeons to use the WaveLight 200-Hz Allegretto Wave excimer laser (Alcon). I have since upgraded lasers, first to the 400-Hz Allegretto Wave Eye-Q laser and most recently to the WaveLight EX500 excimer laser in combination with Figure 11. The Technolas 217P is used to perform Supracor. the WaveLight FS200 femtosecond laser (both by Alcon; Figure 12). The prospect of using this customized technol- We are currently conducting a Supracor study in ogy at an early time in the history of refractive surgery was myopic presbyopes, and early results show promising one of the key reasons of relocating my practice from Park outcomes.* Likewise, our clinical experience indicates Avenue, New York City, to Europe. We have published that pseudophakic presbyopic and post-LASIK patients results with these lasers for myopia, myopic astigmatism, and who have become presbyopic can undergo Supracor hyperopia in more than 20 articles and book chapters.1-24 for presbyopia correction. Further, Supracor has In my experience, WaveLight is the only platform on the increased hospital revenues in two ways. One, presby- market that can offer a multitude of customized excimer laser opic LASIK treatments have made up for the decreasing treatments for patients with myopia, myopic astigmatism, and census of young LASIK patients and allowed the hos- hyperopia. The main treatment for myopia is the wavefront- pital to charge more for this premium treatment. Two, optimized signature treatment for the WaveLight technology; while marketing Supracor as a presbyopic treatment, this is basically a myopic ablation that delivers more spots in we are incidentally attracting patients who have cata- the periphery of the optical zone to reduce spherical aberra- racts and choose to undergo cataract surgery with us. tion, one of the main factors causing night vision problems in The Technolas 217P has provided me with a reliable PRK and LASIK patients (Figure 13). excimer laser platform that can provide safe and accurate In patients with significant astigmatism or any type LASIK treatments, and it has expanded our market to the of irregularity, I employ topography-guided treatments presbyopic age group. We look forward to using the next- with the WaveLight platform. WaveLight was the pio- generation Technolas 317* excimer laser in the near future. neer of topography-guided treatments in 2003, and it *Editor’s note: The Supracor procedure for myopic presby- is interesting that, even today, this is a foreign language opes and the Technolas 317 laser are pending receipt of the to most other laser platforms. With the WaveLight Conformité Européenne (CE) Mark. Supracor for post-LASIK platform, topography-guided treatment is not just one and pseudophakic patients is under clinical evaluation. entity, as four separate topographers and/or Scheimpflug tomographers can be used to supply diagnostic data. We Robert Ang, MD, is Senior Consultant at the Asian Eye currently use the Oculyzer II, a version of the Pentacam Institute in the Philippines. Dr. Ang states that he has HR (Oculus Optikgeräte GmbH) incorporated into the financial interest in AcuFocus, Inc.; Allergan, Inc.; and WaveLight system, to obtain topographic images and Bausch + Lomb Technolas. He may be reached at e-mail: perform customized topography-guided treatments in [email protected]. patients with more than 1.50 D of astigmatism and in all hyperopes to address angle kappa, which we use in combination with flash CXL-LASIK Xtra, a technique we introduced in 2007. WaveLight Refractive Suite Wavefront-guided treatment is also available with This laser pursues excellence through a high level of the WaveLight platform. Used in conjunction with the safety, customization, and durability. Analyzer II diagnostic device, this platform uses the By A. John Kanellopoulos, MD Tscherning principle, a type of analysis that uses visible light and does not extrapolate data from infrared diag- I started performing LASIK in Europe in 1994 with the nostic beams as Hartmann-Shack wavefront analyzers Summit excimer laser (Summit Technology, Inc.), and I do. The Tscherning analyzer is difficult to use, and it does

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The ability to use all of these custom options to achieve excellent, stable results with few maintenance issues has made us true believers in the WaveLight plat- form. In addition to using the equipment, our center has adopted a WaveLight philosophy: pursuing excellence through the use of a multitude of diagnostic devices; performing surgery with a high level of safety and cus- tomization; and the ability to work overtime and endure hard, everyday clinical use. n

A. John Kanellopoulos, MD, is the Director of

Courtesy of A. John Kanellopoulos, MD the LaserVision.gr Eye Institute in Athens, Greece, Figure 12. The WaveLight Refractive Suite, including the and is a Clinical Professor of Ophthalmology at FS200 femtosecond laser (left) and the integrated EX500 New York University School of Medicine. He is excimer laser (right). also an Associate Chief Medical Editor of CRST Europe. Dr. Kanellopoulos states that he is a consultant to Alcon/WaveLight and Avedro, Inc. He may be reached at tel: +30 21 07 47 27 77; e-mail: [email protected].

1. Kanellopoulos AJ, Pe LM, Kleiman L. Moria M2 single use microkeratome head in 100 consecutive LASIK procedures. J Refract Surg. 2005;21(5):476-479. 2. Kanellopoulos AJ. Topography-guided custom retreatments in 27 symptomatic eyes. J Refract Surg. 2005;21(5):S513-S518. 3. Kanellopoulos AJ, Conway J, Pe LH: Lasik for hyperopia with the WaveLight excimer laser. J Refract Surg. 2006;22(1):43-47. 4. Kanellopoulos AJ, Pe LH. Wavefront-guided enhancements using the WaveLight excimer laser in symptomatic eyes previ- ously treated with LASIK. J Refract Surg. 2006;22(4):345-349. 5. Basmak. H, Sahin A, Yildirim N, Papakostas TD, Kanellopoulos AJ. Measurement of angle kappa with synoptophore and Orbscan II in a normal population. J Refract Surg. 2007;23(5):456-460. 6. Kanellopoulos AJ. Post-LASIK ectasia. Ophthalmology. 2007;114(6):1230. 7. Alio JL, Rodriguez AE, Mendez MC, Kanellopoulos AJ. Histopathology of epi-LASIK in eyes with virgin corneas and eyes with previously altered corneas. J Cataract Refract Surg. 2007;33(11):1871-1876. 8. Hafezi F, Kanellopoulos AJ, Wiltfang R, Seiler T. Corneal collagen crosslinking with riboflavin and A to treat induced keratectasia after laser in situ keratomileusis. J Cataract Refract Surg. 2007;33:2035-2040. 9. Kanellopoulos AJ, Binder PS. Collagen cross-linking (CCL) sequential topography-guided PRK: a temporizing alternative for to penetrating keratoplasty. Cornea. 2007;26(7):891-895. 10. Kanellopoulos AJ. Comparison of sequential vs same-day simultaneous collagen cross-linking and topography-guided PRK for treatment of keratoconus. J Refract Surg. 2009;25(9):S812-S818. 11. Krueger RP, Kanellopoulos AJ. Stability of simultaneous topography-guided photorefractive keratectomy and riboflavin/ Courtesy of A. John Kanellopoulos, MD UVA cross-linking for progressive keratoconus: case reports. J Refract Surg. 2010;26(10):S827-S832. Figure 13. The scattergram from a recently published paper on 12. Kanellopoulos AJ, Skouteris V. Secondary ectasia due to forceps injury at childbirth: management with combined topography-guided partial PRK and collagen cross-linking (Athens Protocol) and subsequent phakic IOL implantation. J Refract using the refractive suite in low, moderate, and high myopia. Surg. 2011;27(9):635-636. 13. Kanellopoulos AJ, Binder PS. Management of corneal ectasia after LASIK with combined, same-day, topography-guided partial transepithelial PRK and collagen cross-linking: The Athens Protocol. J Refract Surg. 2011;27(5):323-331. not produce reliable wavefront data in 100% of patients; 14. Kanellopoulos AJ. Long term results of a prospective randomized bilateral eye comparison trial of higher fluence, shorter duration however, the surgeon is able to directly visualize in the ultraviolet A radiation, and riboflavin collagen cross linking for progressive keratoconus. Clin Ophthalmol. 2012;6:97-101. 15. Kanellopoulos AJ. The management of cornea blindness from severe corneal scarring, with the Athens Protocol (transepithelial human visual spectrum, view raw data on the retina, topography-guided PRK therapeutic remodelling, combined with same-day, collagen cross linking). Clin Ophthalmol. 2012;6:87-90. and have a direct understanding of how these data are 16. Kanellopoulos AJ. Topography-guided hyperopic and hyperopic astigmatism femtosecond laser-assisted LASIK: long term experience with the 400 Hz eye-Q excimer platform. Clin Ophthalmol. 2012;6:895-901. used in generating the wavefront. This gives me confi- 17. Kanellopoulos AJ. Long term safety and efficacy follow-up of prophylactic higher fluence collagen cross-linking in high dence in using this information to improve eyes with a myopic laser-assisted in situ keratomileusis. Clin Ophthalmol. 2012;6:1125-1130. 18. Kanellopoulos AJ, Khan J. Topography-guided hyperopic LASIK with and without high irradiance collagen high degree of primary HOAs and to treat patients with cross-linking: initial comparative clinical findings in a contralateral eye study of 34 consecutive patients.J Refract Surg. previous excimer laser refractive surgery who have visual 2012;28(Suppl):S837-840. 19. Kanellopoulos AJ, Asimellis G. Digital analysis in flap parameter accuracy and objective assessment of opaque bubble layer problems attributed to wavefront aberrations. in femtosecond laser assisted LASIK. A novel technique. Clin Ophthalmol. 2013;7:343-351. Finally, the WaveLight technology can use a combination 20. Kanellopoulos AJ, Asimellis G. Long term bladeless LASIK outcomes with the FS200 femtosecond and EX500 excimer laser workstation: the refractive suite. Clin Ophthalmol. 2013;7:261-269. of diagnostic data from axial length interferometry, topog- 21. Kanellopoulos AJ, Spadea L. Point/counterpoint: my ideal ablation pattern for combined CXL treatments. Cataract & Refrac- raphy, and wavefront analysis that, when combined and tive Surgery Today Europe. March 2013. analyzed, can produce a ray-tracing customized treatment 22. Kanellopoulos AJ, Asimellis G. Three dimensional LASIK flap thickness variability: topographic central, paracentral and peripheral assessment, in flaps created by a mechanical microkeratome (M2) and two different femtosecond lasers (FS60 and that takes into account all of the factors mentioned above, FS200). Clin Ophthalmol. 2013;675-683. the expected tissue interaction, and whether the case will 23. Kanellopoulos AJ, Asimellis G. Essential opaque bubble layer elimination with novel LASIK flap settings in the FS200 femtosecond laser. Clin Ophthalmol. 2013;7:765-770. be performed with LASIK or PRK. The published data so far 24. Kanellopoulos AJ, Asimellis G. FS200 femtosecond laser LASIK flap digital analysis parameter evaluation: comparing two seem promising with this customized technique. different types of patient interface applanation cones. Clin Ophthalmol. 2013;7:1103-1108.

26 Cataract & Refractive Surgery Today Europe july/august 2013