supplement to eyeworld • may 2010 william trattler ...steven schallhorn, m.d. louis probst, m.d....

www.eyeworld.org

The News Magazine of the American Society of Cataract and Refractive Surgery

“ With the latest advancements inoptics, lens design, and biometrytechnology, we are continuing toincrease our success with premiumcataract surgery”

William Trattler, M.D.

Taking cataract and refractivesurgery to the next level

contributors

Farrell “Toby” Tyson, M.D.Elizabeth Davis, M.D.John Vukich, M.D.John Wittpenn, M.D.Steven Dewey, M.D.Roger Steinert, M.D.Marguerite McDonald, M.D.William Trattler, M.D.Robert Maloney, M.D.Stephen Lane, M.D.James Loden, M.D.Steven Schallhorn, M.D.Louis Probst, M.D.David Tanzer, M.D.COL Scott Barnes, M.D.

Supported by an educational grant from Abbott Medical Optics Inc.

S U P P L E M E N T T O E Y E W O R L D • M AY 2 0 1 0

Laser VisionCorrectionPages 10–15

Ocular SurfaceManagementPage 8–9

Refractive CataractSurgeryPages 2–7

2 ASCRS•ASOA Boston • Show Supplement — Taking cataract and refractive surgery to the next level

Update on next generation one-piece multifocal IOL

I think a one-piece IOL hasnumerous advantages, andnow we can add the Tecnismultifocal optic technology(Abbott Medical Optics Inc.,

Santa Ana, Calif.) to the list. Thisnew one-piece lens is easy to use,injectable through a smaller incision,and provides patients with relativepupil independence across all light-ing conditions.

Features and benefits The Tecnis multifocal lens is the firstand only approved wavefront-designed optic that rejuvenates visionby correcting spherical aberration toessentially zero. It is made of ahydrophobic acrylic material withthe lowest chromatic aberration andhighest optical throughput, thereby

“ Good

transmission of

light and image

focus

provide patients

with both good

reading vision and

improved contrast

sensitivity in

dimmer lights”Farrell C. “Toby” Tyson II, M.D.

in the clinical trial for the siliconeversion and I have three-year data onthat lens. I have been using thethree-piece acrylic since its releaseabout a year and a half ago and havehad excellent outcomes.

This lens takes surgeons from thethree-piece Tecnis multifocal plat-form to a one-piece platform. Many

surgeons are more comfortable with aone-piece design so now they canhave the benefits of the Tecnis multi-focal optic on their preferred plat-form.

Farrell C. Tyson II, M.D., is in practice at CapeCoral Eye Center, Cape Coral, Fla. He can bereached at 239-945-1054 or by email [email protected].

Surgeon finds new one-piece has relative pupil independence across

all lighting conditions so patients have improved reading in dim light

by Farrell C. “Toby” Tyson II, M.D.

Figure 1. Dr. Tyson finds the Tecnis lens offers the greatest amount of spherical aberrationcorrection

Figure 2. Spherical aberration correction results in improved image quality and contrastsensitivity especially in dimmer lighting situations

transmitting healthy blue light andreducing the incidence of glisteningsthat can reduce contrast sensitivity.

The one-piece lens design con-tributes to reliable lens centrationand reduction in cell migration.Traditionally one-piece lenses have atendency to move around in the bag.However, this lens is designed to staynicely in place as a result of three fix-ation points that come into contactwith the lens capsule. The 360-degreesquare edge creates an angled barrierthat helps prevent PCO, maintainingvisual quality and reducing the neces-sity for capsulotomy.

Just like the 3-piece TecnisMultifocal, this lens has relative pupilindependence across all lighting con-ditions as a result of the Tecnis multi-focal optic. I think this is one of thedifferentiating benefits of the tech-nology versus other single-piece mul-tifocal lenses. The diffractive ringsextend out to the periphery of thelens optic. As a result, when lightingconditions change there is not asmuch degradation in vision based onpupil size. In addition, the lens incor-porates 0.27 microns of sphericalaberration correction into the opticthat helps increase patient contrastsensitivity, which is important as justby being diffractive a little bit of con-trast is lost (Figure 1 & 2). Therefore,good transmission of light and imagefocus provide patients with bothgood reading vision and improvedcontrast sensitivity in dimmer lights.

Clinical experienceI have had a good experience withthis new lens. My one- and two-yearfollow-ups on the acrylic three-pieceplatform have been excellent, withno significant PCO. This is especiallykey because with a diffractive multi-focal a significant amount of readingvision could be lost very quickly withPCO. It is nice to have a lens that isgoing to reject PCO as long as possi-ble.

Recently I have been using thisone-piece version of the lens and ampleased with the results to date. I was

Refractive Cataract Surgery — Show Supplement • ASCRS•ASOA Boston 3

Large-scale comparison of visual outcomes of three presbyopic IOLs

world into a registry. The registry isfunded by Bausch & Lomb andadministered by SurgiVisionConsultants Inc.

The study included eyes with noprior surgery, mean Ks between 41.00and 46.50, and an axial length rangefrom 22 to 26.5 mm. Pre-op cornealastigmatism was ≤ 1.00 D. Analysisused the last reported post-op examin the one- to three-month interval.The eyes with good refractive out-comes were included in this survey topermit a comparison of visualacuities in eyes with similar refrac-tions. Spheroequivalents were limitedto ± 0.50 D and astigmatism to 0.75D. In the study, 2,641 received theCrystalens HD, 391 received theReStor +3 D, and 145 received theTecnis Multifocal.

ResultsOverall in the study we saw that allthe lenses provided adequate visionat all ranges. However, the TecnisMultifocal provided excellent visionat all distances and superior perform-ance at intermediate and near. TheCrystalens HD provided the bestaverage intermediate vision, whilethe ReStor +3 D and the TecnisMultifocal had similar average inter-mediate visual results as recorded inDataLink.

For UCVA at distance, 91% of theTecnis patients saw 20/30 or better,compared with 90% of the CrystalensHD patients and 86% of the ReStor+3 patients. For intermediate vision,87% of Tecnis patients saw 20/30 orbetter, compared with 84% ofCrystalens HD patients and 68% ofReStor +3 patients. For near vision,

“ The Tecnis

Multifocal delivers

on intermediate

vision as good as

ReStor +3 but also

provides excellent

near vision””

Elizabeth A. Davis, M.D.

99% of Tecnis patients achieved20/30, compared with 91% of ReStorpatients and 65% of Crystalenspatients. Further evaluation is neces-sary, but these results are promisingand confirm my personal clinicalfindings.

This study is indicative of realworld results as it evaluated the IOLdata collected from practicesthroughout the world for a widerange of patients. The Tecnis

Multifocal delivers on intermediatevision as good as ReStor +3 but alsoprovides excellent near vision. In thisregard, the Tecnis Multifocal providespatients with a good range of visionacross distance, intermediate, andnear distances.

Elizabeth Davis, M.D., is director of MinnesotaEye Laser and Surgery Center, Minnesota EyeConsultants, Bloomington, Minn. She can bereached at 800-393-8639 or by email [email protected].

Surgeon finds latest generation diffractive lens

provides excellent range of vision

by Elizabeth A. Davis, M.D.

Are all add powers the same?

by Elizabeth A. Davis, M.D.

My clinical experience has shown that the Tecnis Multifocal optic(Abbott Medical Optics Inc., Santa Ana, Calif.) has excellent func-tional performance. Outstanding quality of vision can be attrib-

uted to several features. The len’s aspheric anterior surface is designed tocorrect the average amount of corneal spherical aberration. In addition,the diffractive design, high ABBE number, and reading add (optical power+4.0 D) reduce chromatic aberrations.

Some surgeons might wonder why the +4.0 D reading add does nottranslate into the same close near focal point that is seen in patientsimplanted with the AcrySof IQ ReStor +4.0 multifocal IOL (Alcon, FortWorth, Texas). This theoretical difference may be explained in part by thefact that the diffractive rings are on the posterior surface of the Tecnisoptic and they are on the anterior surface of the ReStor IOL. A differencebetween the lenses in the A constant may also play a role.

The Tecnis Multifocal’s diffractive ring design makes vision pupil inde-pendent and also allows for good vision in all lighting conditions. The dif-fractive rings for the Tecnis Multifocal IOL fully extend to the optic periph-ery, unlike the ReStor multifocal IOL where the reading diffractive zonesare limited to the central 3.6 mm of the optic. As a result, reading visionmay be compromised with the ReStor multifocal IOL when the pupil isdilated in dim light.

In my personal clinical experience, I have had patients who wereimplanted with the ReStor +4.0 and the Tecnis and they have very differ-ent near points. Patients with the Tecnis multifocal have never had anissue with too close of a near point.

T he Tecnis Multifocal IOL(Abbott Medical OpticsInc., Santa Ana, Calif.)provides outstanding per-formance at all distances

and superior performance at interme-diate and near, according to a recentstudy of three presbyopic IOLs. Thestudy compared the visual outcomesat distance, intermediate, and nearfor the Tecnis Multifocal IOL,Crystalens HD (Bausch & LombSurgical, Aliso Viejo, Calif.), andReStor +3 (Alcon, Fort Worth, Texas).For the presbyopic IOL study, my col-league Guy Kezirian, M.D., and Iconducted an analysis of 3,177 eyesusing the data collected throughDataLink Inc., a repository of IOLdata not collected using a protocol,but reported by surgeons around the

The Tecnis Multifocal demonstrated excellent performance at near and intermediate


Next generation accommodative lens technology

Ihave found that second genera-tion accommodative IOLs pro-vide improved long-termaccommodation leading toenhanced near vision compared

to some first generation accommoda-tive lenses or multifocals. I think thesecond generation dual-optic accom-modative lens Synchrony (AbbottMedical Optics Inc., Santa Ana,Calif.) compares favorably to diffrac-tive multifocal IOLs currently in theU.S. market.

Features and functionality

The Synchrony IOL is a single-piece,dual-optic, silicone lens designed tomimic the natural lens (AbbottMedical Optics acquired Visiogen in2009). The lens has been in the U.S.as part of Phase III clinical trials for

than ReStor at 60 cm, 80 cm, 1 M,and 2 M; it was similar between thetwo IOLs at 40 cm and 4 M (Figure2). No Synchrony patient complainedof severe/very severe halos or glare.

My clinical experience as aninvestigator over the last three yearsconfirms the published results.Patients achieve excellent recovery ofintermediate and near vision. Theyreport near vision with few symp-toms of glare or halo. The mostimportant and subtle difference is thenatural ease that patients see upclose. While this may be hard toquantify, I know it when I see it. This

near vision is different than the nearvision with the previous generationof accommodative lenses, and thenatural facility of near vision seen inSynchrony patients is similar toyoung emmetropes.

John Vukich, M.D., is an assistant clinical pro-fessor at the School of Medicine and PublicHealth, University of Wisconsin, Madison. Hecan be reached at 608-282-2000 or by email [email protected].

References1. Ricardo Alarcón, M.D., Victor Bohorquez,M.D., Ivan Ossma, M.D., Andrea Galvis, M.D.2009 American Academy of OphthalmologyAnnual Meeting.

Surgeon says dual-optic lenses provide functional visual acuity

over a range of distances, including very natural near vision

by John A. Vukich, M.D.

Figure 2. Distance corrected visual acuity was better with Synchrony at 60 cm, 80 cm, 1 M,and 2 M than with ReStor. It was similar between the two IOLs at 40 cm (p = 0.23) and 4 M(p = 0.52)

Figure 1. Patients implanted with Synchrony showed better uncorrected vision at all distances

“ The natural

facility of near

vision seen in

Synchrony patients

is similar to young

emmetropes”John A. Vukich, M.D.

more than three years and is nowunder review. I was one of the origi-nal investigators and have patientfollow-up data of three years or more.The Synchrony has a 5.5-mm highplus anterior optic of +32 D, coupledwith a 6.0-mm negatively poweredposterior optic. These two lenses areseparated by a spring-activated mech-anism. The haptics separate the lens-es at a given distance under constric-tion of the capsule, and during relax-ation of the capsule following accom-modative effort, anterior movementof the positive anterior optic pro-duces increased power for near tasks.I think the lens is a significant stepforward in terms of the ability to usestandard thin lens optics in order tochange focal length. For example, thefocal distance can be changed byslightly moving a plus lens relative toa minus lens a certain distance andthat will provide a change in thefocal point.

Unlike first generation accom-modative lenses, the Synchrony fillsthe capsular bag and maintains therelative volume of the previous natu-ral human lenses. As a result, it morenaturally mimics the physiologicalstate of the relationship between theciliary body, the zonules, and thetranslated optomechanical move-ment that occurs during the accom-modative response.

The surgical technique forimplanting the Synchrony is standardcataract surgery with close attentionbeing paid to the anterior capsuloto-my. The capsulotomy must be wellcentered and small. It also needs tobe intact because it creates a mechan-ical system that will be under ten-sion. The lens is then insertedthrough a 3.8-mm incision using aninjector system that injects the poste-rior optic first, followed by the anteri-or optic. The post-op regimen is alsosimilar to standard cataract surgery.

Results

In a recent study conducted in SouthAmerica that compared Synchrony tothe ReStor multifocal (Alcon, FortWorth, Texas), Synchrony performedwell in terms of reading speed, con-trast sensitivity, and functional visualacuity over a range of distances1

(Figure 1). For distance visual acuityat one year, Synchrony was better


Avoiding glistenings

T he phenomenon of lensoptic glistenings hasincreasingly been reportedin AcrySof hydrophobicacrylic lenses (Alcon, Fort

Worth, Texas). Published studies haveshown the incidence of this compli-cation to range from 30% to 100%,1-3 with as many as one quarter show-ing some detriment to visual acuity.3It appears to occur when aqueousseeps into the lens polymer, causingthe acrylic molecules to shift awayfrom the water vacuoles.

During a five-year period from2003 to 2008, the AcrySof SA and SNIOLs were my most frequent choices,primarily for their ease of insertion.This made for efficient surgery—nomatter which nurse was scrubbed in

not had to choose between efficiencyand material clarity. The Tecnis 1-Piece loads very easily in the injectorand unfolds nicely in the eye. It ismade of the same acrylic material asthe Sensar AR40 lenses that Iimplanted in the past without anyglistenings, yet it has all the advan-tages of the latest generation of IOLdesign. For all these reasons, theTecnis 1-Piece has become my lens ofchoice for most cases.

John R. Wittpenn, M.D., is in private practicewith Ophthalmic Consultants of Long Island.Contact him at 631-941-3363 [email protected].

References1. Gunenc U, Oner FH, Tongal S, Ferliel M.Effects on visual function of glistening and fold-ing marks in AcrySof intraocular lenses. JCataract Refract Surg 2001;27(10):1611-4.

2. Moreno-Montañés J, Alvarez A, Rodríguez-Conde R, Fernández-Hortelano A. Clinical factorsrelated to the frequency and intensity of glisten-ing in AcrySof intraocular lenses. J Cataract

Refract Surg 2003;29(10):1980-4.

3. Christiansen G, Durcan FJ, Olson RJ,Christiansen K. Glistening in the AcrySofintraocular lens: Pilot study. J Cataract Refract

Surg 2001;27(5):728-33.

Surgeon finds peace of mind with IOL materials

that haven’t been associated with glistenings

by John R. Wittpenn, M.D.

Patient with monofocal acrylic IOL with significant glistenings and reduced quality of vision Source: William B. Trattler, M.D.

Grade 4+ glistenings in an AcrySof hydrophobic acrylic lens implanted in the left eye of anelderly patient

Source: John R. Wittpenn, M.D.

“ ... glistenings

have the potential

to negatively

affect visual

quality ...

I decided that

I would rather

implant lenses

that are not

subject to

glistenings”John R. Wittpenn, M.D.

to assist me, there were never anyproblems loading these lenses.

I noticed some glistenings in thelens material early on. In somepatients the glistenings continued toworsen over time and in a few caseswere quite dense. In a recent retro-spective chart review of nearly 500eyes implanted with AcrySof IOLs inmy practice, about half had at least1+ glistenings. One percent of thelenses had dense glistenings, rated as4+.

Two cases in particular height-ened my concerns about glisteningsand eventually led me to stopimplanting AcrySof lenses.

The first was a 78-year-oldwoman with SA60 lenses in botheyes. The lens in one of her eyes hadno glistenings while the other haddense, 4+ glistenings that developedover several years. The eye with noglistenings had 20/20 best-correctedvisual acuity, while the eye with glis-tenings had 20/30 BCVA. The patientwas not complaining and I did notexplant the lens, but I was troubledby the imbalance between the twoeyes.

The second patient was a man inhis 60s who had an SA60 lensimplanted in the right eye. He had aprior retinal detachment with best-corrected acuity of 20/80 in the lefteye. When I first saw this patient, the“good eye” had a BCVA of 20/20. Theglistenings gradually worsened to 4+and the visual acuity deteriorated to20/30 in that eye, with no explana-tion other than the glistenings. Thispatient complained of difficulty withdriving and other night vision tasks,but I have been reluctant toexchange the lens because of thepotential for complications and thereduced acuity in the fellow eye.

In younger patients like this 60-year-old man or in those with premi-um, presbyopia-correcting IOLs, glis-tenings have the potential to nega-tively affect visual quality and acuity.Worse yet, we don’t know how theselens optics might continue to changeover the next 10 years. For my ownpeace of mind, I decided that I wouldrather implant lenses that are notsubject to glistenings.

With the introduction of theTecnis 1-Piece IOL (Abbott MedicalOptics Inc., Santa Ana, Calif.), I have


Pick your pump

Peristaltic vacuum pumpshave long been favored bycataract surgeons becausethey reduce the risk ofchamber instability. Pre-

programmed peristaltic safety fea-tures, such as advanced CASE andocclusion mode, modulate flow andvacuum to limit chamber shallowing.However, the safety of peristalticpumps is balanced by their reputa-tion for being a little less efficientthan venturi systems. With a venturipump, the vacuum is always “live”and therefore the potential for cham-ber shallowing or damage from acci-dental capsular contact always exists.

The WhiteStar Signature system(Abbott Medical Optics Inc., SantaAna, Calif.) is the first dual-pump sys-tem with a single cassette so that Ican switch between the two vacuum

styles on the fly, withthe touch of a singlebutton.

I was at first quiteskeptical of this con-cept. I imagined that itwould only be usefulfor surgeons with dif-ferent pump prefer-ences who wanted toshare a single device.Indeed, it is great formulti-surgeon loca-tions for this very rea-son. I continued usingmy normal peristalticpump settings andignored the venturicapabilities for awhile.

But because it is soeasy to switch fromperistaltic to venturi—and back again if oneis not comfortable—Igradually began to trythe venturi pump in more cases.

Today, my preference is to actual-ly use the venturi pump for theentire procedure in almost all cases. Iparticularly like venturi for densercataracts because of the lower powerprofile. For added safety, I use theDewey radius phaco tip(MicroSurgical Technolo gy, Redmond,Wash.), which is much less likely tobreak the capsule if it does come intocontact with it.

Pump comparison

I recently conducted a prospectivestudy in 104 eyes undergoing cataractsurgery to compare the effects of ven-turi and peristaltic vacuum. In alleyes, a perfect chop, bisecting thecataract, was required. In the first 52eyes, I used the venturi vacuum onthe first half of the cataract thenswitched to peristaltic for the secondhalf. In the next 52 eyes, I beganwith peristaltic and used venturi forthe second bisected half. Thesepatients were accumulated over afour-month period, with the limitingfactor being the elusive “perfect”chop.

cataracts seem to be emulsified withease, so I don’t see any significantdifference in clinical outcomes basedon vacuum styles.

Many surgeons opt to use bothvacuum styles within a single case,often beginning with peristaltic vacu-um and switching to venturi for thecortical cleanup and/or viscoelasticremoval at the end of the case. Theadditional shearing force that venturican apply at the lumen of the irriga-tion/aspiration tip evacuates vis-coelastic more efficiently, whether it’sa cohesive, dispersive, or supercohe-sive OVD.

The intraoperative versatility toswitch back and forth during a case isthe key to maximizing the advan-tages of each pump and to enhancingthe surgeon’s comfort with an unfa-miliar vacuum style. Whether youopt for an all-peristaltic, all-venturi,or combination approach, it is a greatbenefit to be able to adapt differentmodalities within a single device toyour own surgical technique.

Steven Dewey, M.D., is in private practice atColorado Springs Health Partners in ColoradoSprings, Colo. Contact him at 719-475-7700 [email protected].

Dual-pump system allows surgeon to switch vacuum

pumps on the fly, with just the touch of a button

by Steven Dewey, M.D.

“ Whether you opt

for an all-peristaltic,

all-venturi, or com-

bination approach, it

is a great benefit to

be able to adapt

different modalities

within a single

device to your own

surgical technique”Steven Dewey, M.D.

Combining both the first andsecond halves, the cataract extrac-tions performed with the venturipump required 20% less power com-pared to those performed with theperistaltic pump. Extraction with theventuri vacuum was also accom-plished in 14% less time inside theeye.

This is an interesting validationthat the faster rise time we get withventuri vacuum allows us to performthe surgery with just a little moreefficiency. I do not recommend goingfaster just for speed’s sake. But if theperformance of the surgery is basical-ly the same, then an improvement inefficiency that reduces the amount ofenergy going into the eye and limitsthe time in which a complication canhappen is at least theoretically advan-tageous. In this study, there were nocomplications in either group.

Besides efficiency and personalpreference, there may not be anystrong clinical reason to choose onevacuum style over the other. Usingthe WhiteStar Signature device, par-ticularly with Ellips transversalphaco, I see exceptionally clearcorneas post-op. Even the densest


Next generation transversal phaco

O ver the years, cataract sur-gery has become safer,with ongoing improve-ments in power modula-tion, pulse shaping, and

fluidics. Among the latest advances isthe new Ellips FX TransversalUltrasound handpiece, designed foruse with the WhiteStar Signature sys-tem (Abbott Medical Optics Inc.,Santa Ana, Calif.).

Transversal phaco blends the for-ward-and-back motion of longitudi-nal ultrasound with a lateral move-ment. The resulting elliptical cuttingpath increases the efficiency ofcataract removal because the tip issimultaneously cutting in multipledirections. From a practical stand-point, there are several advantages tothis blended approach. First, becauseboth the longitudinal and transversal

in clinical use. The ultrasound repeti-tion rate has been increased by about50%. The faster cutting frequencymakes nuclear removal even moreefficient. This is important not somuch for the sake of speed, butbecause it means I can use less powerand less balanced salt solution, mini-mizing endothelial cell damage. Theresult is a clear cornea in the immedi-ate post-op period and a healthiercorneal endothelium for the longterm.

It also makes the cataract extrac-tion feel very smooth, from the sur-geon’s perspective. For the chopping

techniques I use, it is ideal for thephaco tip to move through the nucle-us very smoothly and evenly so thatit doesn’t put pressure on the nucleusor zonules.

With Ellips, I think there is anoticeable difference in denser (3+)nuclei, and this is also true of EllipsFX. Harder nuclei can be choppedand the fragments emulsified muchmore smoothly than with a conven-tional handpiece. Ellips FX also has asignificantly larger stroke or cuttingpath. Although one might not noticethis difference in softer lenses, thethree-fold increase in the stroke pathgreatly facilitates removal of moreresistant material in dense cataracts.

In my opinion, where theWhiteStar Signature system excels isin marrying ultrasound and fluidicsadvancements for better followability,lower energy, and a more stable ante-rior chamber. When transversalphaco is combined with FusionFluidics and the versatility of havingboth peristaltic and venturi vacuumpumps on board, surgeons can maxi-mize post-op outcomes no matterwhat sort of case presents itself in theoperating room.

Roger F. Steinert, M.D., is professor of ophthal-mology, professor of biomedical engineering,director of the Gavin Herbert Eye Institute, andchair of ophthalmology at the University ofCalifornia-Irvine (UCI). Contact him at [email protected] or 949-824-8089.

Surgeon finds latest modifications improve

efficiency and smoothness of transversal phaco

by Roger F. Steinert, M.D.

Ellips FX technology provides a larger stroke path and simultaneous blending of longitudinaland transversal motion for efficient cutting and faster lens removal

“ Although one

might not notice

this difference in

softer lenses, the

three-fold increase

in the stroke path

greatly facilitates

removal of more

resistant material in

dense cataracts”Roger F. Steinert, M.D.

“ Transversal phaco can be performed with

either a straight or curved phaco tip, while

other forms of lateral phaco require a bent

tip needle to accomplish their oscillating

movement”Roger F. Steinert, M.D.

modes are simultaneously incorporat-ed, I don’t have to switch back andforth between the two modes.

Additionally, transversal phacocan be performed with either astraight or curved phaco tip, whileother forms of lateral phaco require abent tip needle to accomplish theiroscillating movement. The curved orbent tip changes the surgeon’s angleof approach and can make mainte-nance of suction more challenging.With transversal ultrasound, the sur-geon can more easily maintain suctionwith a bent tip or get the benefits ofthe technology with the straight tiphandpiece that many prefer.

I have been using transversalphaco since it was introduced in 2007.Since I have found no disadvantages, Ihave it enabled for every case. I haveseen advantages in the speed and effi-ciency of surgery, especially for hardernuclei, and in the followability ofnuclear material. The elliptical move-ment also contributes to the overallstability of the chamber.

Key improvements

I have seen several key improvementsin the new version of Ellips, already


Dry eye management

Ihave found that high-qualitylubricating drops, on their ownor along with other therapeuticmeasures, can improve qualityof life and visual acuity in dry

eye patients. In patients preparing forrefractive or cataract surgery, it isdoubly important to stabilize the tearfilm before surgery and before obtain-ing pre-op measurements.

In my experience, a poor qualitytear film can significantly affecttopography, refraction, keratometry,and wavefront testing, possiblyreducing the accuracy of pre-opmeasurements. In refractive surgery,there is also a higher incidence ofepithelial defects, diffuse lamellar ker-atitis, slipped flaps, and enhance-ment in dry eyes. We have seen thatpatients with dry eyes who are poorcandidates for surgery can become

Benelli and colleagues random-ized 60 subjects with dry eye symp-toms to treatment for one monthwith Blink Tears or Systane.2 Patientswere seen at baseline and one monthafter beginning the drops. Tear osmo-larity was measured just before andfive minutes after drop instillation atboth visits. The researchers found sig-nificantly better impr ovement in tearfilm osmolarity with Blink (Figure 2).The Blink group had a correspondingimprovement in best-corrected visualacuity that was not seen in the othergroup.

Conclusions

Post-LASIK dryness presents a chal-lenging test for any lubricating drop,so the ability to actually improvethe post-surgical aberration profilewith a tear product is impressiveand is supported by the osmolaritydata we see being presented. Theunique viscoadaptive properties of

Blink Tears help to normalize thetear film, improving signs andsymptoms of dry eye and potentiallyimproving visual outcomes andpatient satisfaction with ophthalmicsurgery.

Marguerite B. McDonald, M.D., is clinical pro-fessor of ophthalmology at NYU LangoneMedical Center, New York, adjunct clinical pro-fessor of ophthalmology, Tulane UniversityHealth Sciences Center, New Orleans, La., and inprivate practice with Ophthalmic Consultants ofLong Island, Lynbrook, N.Y. Contact her at 516-593-7778 or [email protected].

References:1. McDonald MB. Efficacy of lubricating eye-drops for treatment of dry-eye syndrome andhigher-order aberrations in post-LASIK. Paperpresentation, American Society of Cataract andRefractive Surgery, Boston, April 2010.

2. Benelli U, Nardi M, Posarelli C, Albert TG.Tear osmolarity measurement using the TearLabOsmolarity System in the assessment of dry eyetreatment effectiveness. Cont Lens Anterior Eye

2010;33(2):61-7.

Surgeon finds advanced lubricating drops can

improve visual quality and tear film osmolarity

by Marguerite B. McDonald, M.D.

“ In patients

preparing for

refractive or

cataract surgery, it

is doubly important

to stabilize the tear

film before surgery

and before obtain-

ing pre-op

measurements”Marguerite B. McDonald, M.D.

good candidates with aggressive treat-ment and that patients benefit fromtopical cyclosporine treatment afterLASIK, whether they had dry eyes tostart with or not.

Comparing the options

There are many artificial tear prod-ucts available for patients to use butnot all offer the same degree of pal-liative relief and refractive clarity.

We conducted a double-masked,prospective study to evaluate theeffects of Blink Tears (Abbott MedicalOptics Inc., Santa Ana, Calif.) andSystane (Alcon, Fort Worth, Texas)after LASIK.1 Forty patients (80 eyes)were randomized to instill Blink Tearsin one eye and Systane in the othereye. Study visits were at baseline, oneweek, and one month. Outcomemeasures included higher-order aber-rations (HOA), corneal and conjuncti-val staining, drop preference, andvisual acuity.

We saw a statistically significantimprovement in post-op HOA in theBlink group compared to the Systanegroup. In fact, in the Systane group,the HOAs actually worsened with useof the tear (Figure 1). This may bepartly explained by the high viscosityof the original Systane formulation,which has a tendency to blur vision.

Both groups had very good visualoutcomes, with all eyes seeing 20/40or better at one week, but 80% of thepatients using Blink Tears achieved20/20 or better uncorrected vision,compared to 72% of the Systanegroup.

These findings are supported byother studies looking at the role oflubricant drops in tear film osmolari-ty. Traditional measures of dry eye,such as Schirmer’s testing, correlatepoorly with dry eye symptoms. Tearfilm osmolarity has the potential tobe more predictive of dry eye becauseit may be the link between lacrimalgland pathology and ocular surfacechanges. A number of papers havedocumented that with a reduction inaqueous secretions, such as one seesin dry eye or post-LASIK neurotroph-ic corneas, other tear constituentsbecome more concentrated.

With the TearLab OsmolaritySystem (TearLab Corporation, SanDiego, Calif.) a score of 300 indicatesmarginal dry eye, while 346 orgreater is severe.

Figure 1. HOA improved after installation of Blink and worsened post-installation of Systane.The difference between tears is significant

Figure 2. Blink Tears provides a greater improvement in tear film osmolarity than Systane

Ocular Surface Management — Show Supplement • ASCRS•ASOA Boston 9

Optimal ocular surface needed pre-op

New research shows that inorder to get the most accu-rate pre-op testing read-ings and the best post-opvisual results, ocular sur-

face problems must be identified andtreated first, and then patients shouldreturn for their pre-op testing proce-dures. Our research on the incidenceof dry eye in patients scheduled forcataract surgery, the ProspectiveHealth Assessment of CataractPatients’ Ocular Surface (PHACO)Study, demonstrated that dry eye isextremely common. Achieving thebest visual outcomes with cataractsurgery requires a careful evaluationof the ocular surface and initiatingtreatment to normalize the ocularsurface. Once dry eye has been treat-

using any types of eye drops. Patientson glaucoma drops were excluded.

Outcome measures included theincidence of dry eye as evaluated bygrade on ITF level, tear break up time(TBUT), ocular surface disease index(OSDI), corneal staining with fluores-cein, conjunctival staining with lis-samine, and a patient symptom ques-tionnaire. The interim study results,presented at the 2010 AmericanSociety of Cataract and RefractiveSurgery meeting, included 71 patients(142 eyes). The demographicsrevealed an even distribution ofmales and females, with a mean ageof 71. Twenty-five percent of patientshad a prior diagnosis of dry eye dis-ease.

Results

The average tear break up time in thesubgroup of patients presented atASCRS was just under 5 seconds. Thepercentage of eyes with a TBUT ofless than 5 seconds was just under60%. Three quarters of eyes had posi-tive corneal staining, and nearly 50%of eyes had central corneal staining.Just over 40% of eyes had aSchirmer’s score of ≤ 10, and justunder 20% of eyes had a Schirmer’sscore of ≤ 5.

Overall, we found that dry eyesigns are very common in patientsscheduled for cataract surgery (age 55or older) and that more than 50% ofeyes had very abnormal TBUTs. Justunder 50% of eyes had abnormalcentral corneal staining.

Many surgeons do not realize thenumber of people who are presentingwith dry eye. Often the primary focusis the cataract surgery and the discus-sion of the move on to presbyopicIOLs and getting ready for surgery.However, the rationale for identifyingdry eye prior to intraocular surgery iscompelling for several reasons. It willresult in better topography imagesand improved biometry (better Ks).In addition, there is the potential forreduced risk of infection, less cornealstaining, and a more comfortablepatient who will experience fasterhealing.

Therefore, it is imperative for sur-geons to take the time to look care-fully at the ocular surface to attainthe best readings and improved out-comes for their patients.

William B. Trattler, M.D., is director of theCornea Center For Excellence in Eye Care,Miami, Fla. Contact him at 305-598-2020 or byemail at [email protected].

For the best results, tear film should be in top shape

prior to lens selection and surgery, surgeon says

by William B. Trattler, M.D.

Two hundred patients were included in the PHACO Study, which found dry eye is common in pre-surgical patients

“ Overall, we

found that dry eye

signs are very

common in patients

scheduled for

cataract surgery

(age 55 or older)

and that more than

50% of eyes had

very abnormal

TBUTs”William B. Trattler, M.D.

ed and the corneal surface is healthy,patients may undergo biometry andkeratometry measurements for select-ing the intraocular lens.

I know that accounting for evensmall factors is necessary to end upon target. If a patient has dry eyewith a poor tear film, the keratome-try readings are likely to be off target,which can lead to inaccurate IOLreadings and an increased risk ofneeding an additional procedure toend up with a satisfactory visualresult.

Therefore we attempt to identifypatients who need ocular surfacetreatment prior to surgery. Thesepatients can be brought back into theoffice after their eyes have been treat-ed. At that time measurements canbe performed, and this will result inmore accurate and precise readings.

Dry eye incidence

The multicenter prospective PHACOstudy set out to determine the inci-dence and severity of dry eye inpatients at least 55 years of ageundergoing cataract surgery. The goalof the study is to include 10 sites and200 patients who are scheduled forsurgery and who are not currently

Fewer enhancements with femtosecond technology

Adopting all-laser LASIK inmy practice reduced myenhancement and compli-cation rates. Now it isextraordinarily rare to do

enhancements for patients who haveless than 4 D of myopia and who areunder the age of 40. I attribute thatin part to femtosecond technology.

The adoption of new technolo-gies over time has made a differencein the quality of my results. My phi-losophy is to adopt new technologiesthat provide improved results. In myopinion, it is worth the investmentbecause the best technology allowsthe surgeon to get better results.

Femtosecond benefits

The other advantage of femtosecondtechnology is reducing the rate of sig-

applanation of the eye. By better cen-tering the flap, night vision compli-cations can be reduced because a flapthat is perfectly centered on the pupilensures that the ablation doesn’toverlap onto the epithelium, maxi-mizing the regularity of the ablationand minimizing night vision issues.

Nomogram

We have also made an improvementto the method of flap centration thatwe call the IntraLase (Abbott MedicalOptics Inc., Santa Ana, Calif.)Centration Nomogram. This nomo-gram shifts the flap center nasallyand results in improved centration. Ifthe surgeon docks the IntraLase andcenters the flap on the pupil on thecomputer screen, it usually doesn’tquite end up centered on the pupil.Instead, it ends up slightly decen-tered temporally.

To use the centration nomogram,the IntraLase is docked and then thesurgeon looks at where the pupil is.

The surgeon clicks the cursor left orright to move the center of the abla-tion pattern onto the center of thepupil while counting the clicks andnoting which direction the move-ment is. Then the surgeon looks onthe nomogram for the line that corre-sponds to the number of clicks (rightor left). The nomogram gives thenumber of extra clicks to be doneand the direction. The effect of this isthat surgeons get an even more pre-cisely centered flap, which is betterfor night vision.

Surgeons can achieve betterresults with state-of-the-art wave-front-guided lasers and femotsecondtechnology. If they are still usingconventional lasers and microker-atomes, I think it is time to switch.

Robert K. Maloney, M.D., is director of MaloneyVision Institute, Los Angeles, Calif. He can bereached at 877-999-3937 or by email [email protected].

Surgeon says advanced technology and techniques lead to a

reduced incidence of enhancements and flap complications

by Robert K. Maloney, M.D.


Figure 1. Centration nomogram, left and right eye

Then Move:

11 or more clicks Right recenter the suction ring

10 Clicks Right 11 Extra Clicks Right





0 Clicks 6 Extra Clicks Right

2 Clicks Left 5 Extra Clicks Right




10 Clicks Left 1 Extra Click Right

12 Clicks Left 0 Extra Clicks

14 Clicks Left 1 Extra Clicks Left



20 Clicks Left 4 Extra Clicks Left21 or more clicks Left recenter the suction ring

Instructions:

1) Count horizontal and diagonal clicks. Ignore vertical clicks.

2) Round down in-between values (e.g. 3 clicks left reads the row for 2 clicks left)

3) Copyright Robert K. Maloney, 2007-2009. Permission is hereby given to any

surgeon to reproduce this for personal use

Maloney Vision Institute

Intralase Centration Nomogram

OSVersion 4

6/1/09

To Center on the Pupil, if you

move the cursor:Then Move:

11 or more clicks Left recenter the suction ring






0 Clicks 6 Extra Clicks Left

2 Clicks Right 5 Extra Clicks Left




10 Clicks Right 1 Extra Click Left

12 Clicks Right 0 Extra Clicks




20 Clicks Right 4 Extra Clicks Right21 or more clicks Right recenter the suction ring

Instructions:

1) Count horizontal and diagonal clicks. Ignore vertical clicks.

2) Round down in-between values (e.g. 3 clicks left reads the row for 2 clicks left)

3) Copyright Robert K. Maloney, 2007-2009. Permission is hereby given to any

surgeon to reproduce this for personal use

Intralase Centration Nomogram

Maloney Vision Institute

To Center on the Pupil, if you

move the cursor:

ODVersion 4

6/1/09

“ My philosophy

is to adopt new

technologies that

provide improved

results”Robert K. Maloney, M.D.

nificant flap complications in a cou-ple of areas.

Flap slipage: Flap slipage is muchless with femtosecond technology. Iattribute that to the fact that thebeds remain drier and stickier.

More perfect flaps: While suc-tion releases can still happen on thefemtosecond platform, when theyhappen they are of much less conse-quence. When a suction loss occurswith a mechanical microkeratome, anirregular flap or free cap results. Withfemtosecond technology, the flap isstill nicely attached to the cornea byresidual bridges of tissue, which allowthe surgeon to go back and simplyrepeat the femtosecond treatment onthe spot, achieving a superb flap evenin the setting of a suction release.

Flap centration: This has con-tributed significantly to our improvedresults. With the femtosecond laserwe can better center the flaps andadjust the position of the flap after

Laser Vision Correction — Show Supplement • ASCRS•ASOA Boston 11

In the early days of laser visioncorrection, we were striving forthe ideal outcome of 20/20uncorrected visual acuity. But itdidn’t take long to realize that

20/20 didn’t always mean happy.Poor quality of vision could leaveeven a 20/20 patient wildly dissatis-fied.

Quality of vision is directly relat-ed to higher-order aberrations (HOA).Modern conventional platformsinduce less HOAs than their predeces-sors. But a custom procedure thataddresses an individual patient’s actu-al aberrations is the best way to pro-vide consistently high quality ofvision.

Numerous studies have demon-strated the advantages of custom cor-rection. Steve C. Schallhorn, M.D.,has shown that wavefront-guided sur-

Surgeon says wavefront-guided surgery provides excellent visual out-

comes now and is the ideal platform for even better results in the future

by Stephen S. Lane, M.D.

Revising outcome expectations

Figure 1. Wavefront-guided treated patients were able to identify and detect hazards faster post-op in night driving simulator testing

Source: Steve Schallhorn, M.D.

“ Custom wave-

front-guided abla-

tion gives us the

ability to offer each

patient an individu-

alized treatment

with the potential

to provide the ideal

correction for his or

her visual system”Stephen S. Lane, M.D.

gery with a femtosecond laser flapproduces better visual acuity (88% vs.68% 20/16 or better) and better con-trast acuity than conventional abla-tion with a mechanical microker-atome.1 In our own clinic, wavefront-guided ablations have produced con-sistently better results than conven-tional surgery.

Night-driving simulations pro-vide perhaps the best evidence thatcorrecting higher-order aberrations isimportant. In another study conduct-ed by Dr. Schallhorn, subjects whounderwent LASIK for moderatemyopia with either a custom or con-ventional ablation were tested on anight driving simulator pre-op andsix months after surgery.2

Performance loss—or a reduction inthe ability to detect and identify sim-ulated roadside hazards—was signifi-cantly worse with conventional treat-ment. In fact, wavefront-guidedpatients actually performed betterafter surgery and were able to detecta hazard 20 feet earlier than pre-op,while the conventional group’s abili-ty to detect hazards declined signifi-cantly (Figure 1).

We are rapidly reaching a pointat which nearly all patients achieve20/20 or better vision post-op. In thefuture, we will focus more attentionon the subtleties of the procedure,further improving quality of vision,and reducing the potential for rarecomplications like ectasia.

As the sophistication of diagnos-tic and laser technology increases,our understanding of the impact ofHOAs and the ideal HOA profile willgrow as well. Custom wavefront-guid-ed ablation gives us the ability tooffer each patient an individualizedtreatment with the potential to pro-vide the ideal correction for his orher visual system.

Steven S. Lane, M.D., is adjunct professor ofophthalmology, University of Minnesota, and isin private practice with Associated Eye Care inStillwater, Minn. Contact him at 651-275-3000or [email protected].

References1. Schallhorn SC. “Evidence that Custom CorneaReally is Better.” 2006 American Academy ofOphthalmology/International Society ofRefractive Surgery presentation.

2. Schallhorn SC, Tanzer DJ, Kaupp SE, MaladySE. Comparison of Night Driving PerformanceAfter Wavefront-Guided and Conventional LASIKfor Moderate Myopia. Ophthalmology 2009;116(4):702-9.

Evaluating femto features

by James C. Loden, M.D.

Since I began performing bladeless LASIK several years ago, I worry alot less about potential flap complications, and I am able to offer cus-tom LASIK, rather than PRK, to people with thinner corneas or deep

ablations.But as femtosecond laser technology expands, it is important to realize

that not all femtosecond lasers are alike. Having used both the IntraLaseiFS (Abbott Medical Optics Inc., Santa Ana, Calif.) and Ziemer (Port,Switzerland) platforms, I can attest to the fact that there are differences interms of cost, convenience, complications, and surgical ease of use. Hereare the five qualities I look for in a femtosecond laser.

Reproducibility. The lack of “surprises” is the major reason to switchto a femtosecond laser. When you program the flap depth or hinge width,you should get exactly what you expect.

Low rate of complications. A femtosecond laser must be compatiblewith custom, all-laser LASIK and the patient expectations associated withthat. If you have to cancel surgery due to complications more than once ortwice a year, that’s too often.

Customizability. A customizable femtosecond laser gives me the free-dom to choose the flap profiles I want for particular types of cases (e.g.,myopes, hyperopes, narrow fissures) without having to compromise for thelimitations of the technology. The iFS laser allows me to make the verticalor slightly inverted side cuts (90-degree to 120-degree) I prefer, as well asthe slightly elliptical shape I occasionally use for very narrow fissures.

Simplicity. One should be able to easily place the suction ring on mosteyes. Centration should be straightforward and easy to maintain. IntraLaselasers use the same type of docking cone and suction ring for every patient,limiting the need to switch things around depending on the case.

Visibility. Not being able to see the flap as you make it significantlylimits the safety of flap creation. With the IntraLase laser I can watch theprogression of the raster pass and confirm there is adequate meniscusthroughout the procedure. If there is any problem, I can see it in real time,stop, and re-applanate or abort the procedure as needed.

For all the reasons outlined above, I find the IntraLase iFS best meetsmy expectations for smooth, predictable surgery, and a custom, all-laserexperience for the patient.

James C. Loden, M.D., is in private practice at Loden Vision Centers in Nashville, Tenn. Contacthim at 615-859-3937 or [email protected].


L aser vision correction hascome a long way since thefirst excimer laser approvalsin 1996. We are now at apoint where it is reasonable

to assume that the majority ofpatients can actually achieve betterthan 20/20 uncorrected acuity. Yet wecan still look forward to ongoingrefinements at every stage of thetreatment.

Better diagnostic devices. Ourgoal is simple: to select patients whowill do well and avoid those withvalid risk factors. In the past, patientswith certain conditions or pre-opcharacteristics have often been treat-ed—or denied treatment—based onthe surgeon’s anecdotal experiencewith similar patients. A great deal ofwork is being done right now to bet-ter predict ectasia and other compli-

cations so that we can move awayfrom anecdote-based decision mak-ing.

Advanced aberrometry. Thenext generation of aberrometers willhave a broader dynamic range andwill capture hundreds more datapoints for higher resolution and bet-ter spot quality. The result will be amore accurate representation of thetrue wavefront (Figure 1). We willalso be moving toward aberrometersthat perform multiple measurementsat once, so that wavefront aberrome-try, topography, autorefractometry,pupillometry, and keratometry can allbe captured with a single buttonpush.

Flap improvements.Femtosecond lasers have alreadyimproved the consistency, biome-chanical stability, and predictabilityof flaps, but there is ongoing researchinto the tremendous potential of thistechnology. The latest femtosecondlasers, for example, make it possibleto customize the shape and side-cutangle of the flap (Figure 2). In thefuture, surgeons will continue tolearn more about how to leveragethis customizability to improve out-comes.

Better alignment and registra-tion of the treatment. Iris registra-tion has made a huge difference inthe accuracy and precision withwhich the excimer laser treatment isapplied to the cornea, but we canexpect further advancements inlasers’ ability to accurately identifythe limbus. We may also see active,real-time cyclo-alignment and cyclo-adjustment that would further reduceerrors.

Refined algorithms. As aberrom-etry improves, laser algorithms canbe refined to predict and addresshigher-order aberrations more direct-ly. Optimized algorithms attempt tocorrect for average spherical aberra-tion, but future wavefront algorithmswill be better able to incorporate thepatient’s actual pre-op aberrationsand expected interactions amongthose aberrations into the treatmentalgorithm. Age, corneal curvature,and many other parameters may alsobe built into the algorithms.

Topography-guided ablationsare exciting because they offer thepotential to treat unusual or highlyaberrated corneas that can’t beaddressed with current technology.

Surgeon says advancements in patient selection, wavefront aberrometry, flap-making

technology, and treatment algorithms will continue to improve LASIK outcomes

by Steven C. Schallhorn, M.D.

The future of laser vision correction

“ The next genera-

tion of aberrometers

will have a broader

dynamic range and

will capture hun-

dreds more data

points for higher

resolution and bet-

ter spot quality”Steven C. Schallhorn, M.D.

Figure 1. With much greater resolution, advanced aberrometers will be able to moreprecisely map the true wavefront

Figure 2. Elliptical flaps allow for the creation of a wide hinge without ablating overthe hinge area. They may also protect more corneal nerves, improving corneal sen-sation, and reducing dry eye symptoms after surgery

Eyes with corneal scars, grosslydecentered ablations, and othercorneal pathologies would benefitfrom a topography-guidedapproach—and any surgeon with afew such patients in his or her casefiles welcomes therapeutic solutionsfor these challenging eyes. But for thevast majority of normal eyes, weshould continue to treat based on thewavefront, which measures the totaloptical path and corrects for all theeye’s aberrations, not just the cornealones. Topography-guided correctionsrely on manually entered, subjective-ly derived manifest refractions—astep backward in the treatment ofeyes that could otherwise benefitfrom customized, precise correctionbased on objective wavefront data.

While purely topography-guidedablations will likely be a niche toolfor abnormal eyes, the ability to

influence wavefront-guided ablationswith topographical information haspowerful implications for all eyes.The advanced aberrometers of thefuture will likely be able to importtrue topographic data from hundredsof points on the cornea and integratethat into the wavefront. This wouldallow the laser to compensate for thecosine effect in a much more sophis-ticated manner, without giving upthe higher-order corrections weachieve with wavefront-guided abla-tions.

With all of the advances outlinedhere, the future looks bright for con-tinued improvements in patient satis-faction and refractive surgery out-comes.

Steven C. Schallhorn, M.D., is global medicaldirector of Optical Express. Contact him at619-920-9031or [email protected].

Advanced aberrometry

Flap improvements


We are at a great pointin the evolution oflaser refractive surgery.Custom treatmentswith iris registration,

correction for centroid shift andcyclotorsion, fourier-based algo-rithms, and femtosecond laser flapshave all improved the consistencyand quality of visual results. Despitethese gains, however, our post-opacuity testing hasn’t changed all thatmuch.

The classic approach to post-opvisual acuity testing has been to aimfor what we called “20/happy.” Werecognized that not every patientcould be 20/20—nor did they neces-sarily need that to be satisfied withthe procedure. Even as outcomes andpatient satisfaction have risen overthe years, I feel that pushing to testacuity much beyond 20/20 would be

counterproductive and might makepatients feel they had somehowfailed our vision test.

Recent data have challenged myassumptions. Last year, SteveSchallhorn, M.D., and Jan Venter,M.D., reported that 71.6% of morethan 32,000 myopic eyes could see20/16 or better uncorrected after laservision correction.1 Schallhorn report-ed that satisfaction with the proce-dure continued to increase with eachline of uncorrected acuity.2 DavidTanzer, M.D., also reported excellentresults. In more than 300 eyes treatedwith myopic LASIK with a STAR S4 IRexcimer laser (Abbott Medical OpticsInc., Santa Ana, Calif.) and anIntraLase femtosecond laser (AbbottMedical Optics Inc.), nearly 30% were20/10 and 84% were 20/12.5 onemonth after surgery3 (Figure 1).

These results demonstrated to methat patients were achieving betteroutcomes than we thought, even ifwe weren’t measuring those out-comes. I decided to start tracking out-comes better than 20/20 in my ownpractice, and we are gradually makingthat shift throughout TLC.

We now use a more controlledand standardized backlit LCD moni-tor that can display ETDRS charts. Wealso make sure that eyes are welllubricated prior to testing.

We still celebrate the achieve-ment of 20/20 before asking thepatient to attempt the smaller lines.We are currently analyzing data for astudy, but so far, the vast majority ofour patients are indeed seeing betterthan 20/20. Telling them so seems tohave a very positive impact on theirsatisfaction and on word-of-mouthreferrals.

Other reasons to test beyond20/20 include the opportunity toplace your practice in the best lightwith regard to the competition andthe ability to continue improvingoutcomes. Even if your 20/20 rate isgreat and your patients are highlysatisfied, you may discover that somenomogram tweaks or increased pre-op lubrication could raise your 20/16or 20/10 rates.

With today’s refractive surgerytechnology, refractive surgeons canproduce dramatically better resultsthan we achieved in the early days oflaser vision correction. We no longerneed to be afraid of testing moreaggressively because we can actuallydeliver the results that patients want.

Measuring our success—and ourpatients’ success—promotes the pro-cedure, drives business, and contin-ues to drive improvements in out-comes.

Louis E. Probst, M.D., is the medical director ofTLC Laser Eye Centers. Contact him at 608-249-6000.

References1. Schallhorn SC, Venter JA. One-month out-comes of wavefront-guided LASIK for low to

LASIK results have improved dramatically and it is time

for post-op measurements to catch up, surgeon says

by Louis E. Probst, M.D.

Measuring beyond 20/20

Figure 1. In a study by David Tanzer, M.D., 322 eyes with pre-op refractive error ranging from

–0.34 D to –8.62 D underwent LASIK with the STAR S4 IR excimer laser and the IntraLase FS60

or iFS femtosecond laser. At 1 month, nearly 30% were 20/10 and 84% were 20/12.5 or better

“ Measuring our

success—and our

patients’ success—

promotes the

procedure, drives

business, and

continues to drive

improvements in

outcomes”Louis E. Probst, M.D.

moderate myopia with the VISX STAR S4 Laserin 32,569 eyes. J Refract Surg 2009; 25:S634-41.

2. Schallhorn SC. Patient satisfaction with laservision correction as performed by a large corpo-rate provider. Paper presentation, RefractiveSubspecialty Day, AAO, Oct. 23, 2009.

3. Tanzer DJ. Bringing LASIK to the next levelwith advanced femtosecond technology: A clini-cal comparison. Paper presentation, ESCRS,Barcelona, Spain, Sept. 15, 2009.

Getting to the best refraction

by Steven C. Schallhorn, M.D.

Comparing the wavefront refraction to the manifest refraction is a criti-cal step in designing a custom laser vision treatment. This compari-son is best facilitated by performing the wavefront exam first and

then using it to guide the manifest refraction. Even when carefully done, the wavefront and manifest refractions can

be different from one another. This is because they are fundamentally dif-ferent measures. The manifest refraction is a measure of the sphere, cylin-der, and axis needed for a patient to achieve the best possible subjectivevision through trial and error.

A wavefront refraction, by contrast, is a completely objective, automat-ed measurement of a patient’s sphere, cylinder, and axis errors extractedfrom the overall ocular aberrations. There can be a coupling effect betweenlower- and higher-order aberrations that cannot be duplicated with aphoropter that corrects only for lower-order aberrations.

I have found that with modern aberrometers like the WaveScan (AbbottMedical Optics Inc., Santa Ana, Calif.), the cylinder value and axis in nor-mal, untreated eyes are very accurate and therefore, I have never needed toadjust the wavefront cylinder. When the manifest cylinder doesn’t matchthe wavefront, the patient will typically see better when presented with theaberrometry-derived cylinder correction.

From a clinic flow perspective, it is also more efficient to obtain thewavefront refraction first. With modern aberrometers, wavefront refractionsare highly accurate and can reduce the time spent performing the manifestrefraction significantly. Starting out closer to your goal can also limit theneed for repeated exams.

Steven C. Schallhorn, M.D., is global medical director of Optical Express. Contact him at 619-920-9031or [email protected].


Some Army centers are usingwavefront-guided technolo-gy while others favor thewavefront-optimized plat-form. With the availability

of two excellent platforms, I neededto decide which was the best for oursoldiers at Fort Bragg. Recent evalua-tions comparing the outcomes ofwavefront-guided and wavefront-optimized LVC in Army personnelhave shown that while both tech-nologies produced good results atabout six to nine months, the wave-front-guided LVC eyes experienced asignificantly faster recovery thanwavefront-optimized LVC eyes.

When I set out to evaluate theLVC platforms I critically analyzedobjective clinical studies that werepresented to the FDA as well as cor-

Our military data evaluation con-firmed the WFG laser used for surfaceablation procedures showedimproved results in a shorter periodof time. At one month and threemonths a significant difference in thenumber of patients who had 20/15and 20/20 UCVA outcomes wasnoted. At one month, 47% of WFGeyes reached 20/15 and 92% reached20/20, compared to 25% and 72% ofWFO eyes, respectively. At threemonths, 76% of WFG eyes reached20/15 and 100% were at 20/20, com-pared to 55% and 91% of WFO eyes.Finally, at six months, the resultsbecame closer yet still pointed towardbetter outcomes with the WFG plat-form (Figure 1).

The data from some Army centersusing the WFO system suggested thateven though they eventually didwell, a number of patients were tak-ing longer to recover, especially withcylinder correction. We hadn’t expe-rienced this delay in our WFG plat-form at Fort Bragg and because ofthese excellent early results, wedecided to continue using the WFGplatform to treat our soldiers.

One benefit noted in the WFOplatform was that it was slightlyfaster (3 sec/per D versus 4–7 sec/perD depending on the amount of cylin-

der) than the WFG platform.However, this increased speed did nottranslate into a clinically relevantincrease in patient volume, as the 15second savings per eye meant wecould only treat 1.5 more eyes perday using the WFO platform.

A longer, more in-depth study iswarranted to confirm these findings.However, when we evaluated the ret-rospective military data from severalcenters, it demonstrated that at onemonth patients were ahead withWFG, and at three months the gapwas narrowing somewhat. Yet, it wasnot until six months that the resultswere similar.

In summary, through criticalevaluation we noted that the clinicaltrials and the TLC LASIK studies indi-cated the WFG LVC produced a simi-lar or better outcome than the WFOprocedure and in some cases, at anearlier post-op time. When we ana-lyzed our own data, the resultsshowed that WFG therapy showedexcellent results with a faster recov-ery time than the WFO platform withthe same type of procedure. As aresult we have continued with WFGtherapy in our soldiers at Fort Bragg.

COL Scott D. Barnes, M.D., is chief of refrac-tive surgery, U.S. Army at Ft. Bragg, N.C. Hecan be reached at [email protected].

Surgeon finds outcomes, including excellent visual

quality and faster results, make the difference

by COL. Scott D. Barnes, M.D.

Comparing wavefront-guided and wavefront-optimized LVC

“ Our military

data evaluation

confirmed the WFG

laser used for

surface ablation

procedures showed

improved results in

a shorter period of

time”COL. Scott D. Barnes, M.D.

Figure 1. The results showed that wavefront-guided correction provided excellent results with a faster recovery time than conventional andwavefront-optimized corrections

porate laser center data (TLC), main-tained a healthy suspicion, and thenevaluated the platforms based on theresults obtained at some of our largerArmy refractive centers. Finally, I hadto be willing to change my “opinion”based on facts if necessary. I evaluat-ed the wavefront-optimized (WFO)Allegretto (Alcon, Fort Worth, Texas),which has a treatment based onsphere, cylinder, and axis, withoutspecifically addressing multiple high-er-order aberrations, and the wave-front-guided (WFG) STAR S4 laser(Abbott Medical Optics Inc., SantaAna, Calif.), which is designed toreduce or eliminate all HOA and hasa wavefront treatment basis.

The results of LASIK clinical trialsshowed that on myopic treatments aswell as hyperopic treatments the bestoutcomes were seen with the WFGplatform. In the corporate industry,we looked at the TLC data to seewhat results they have achieved withregard to quality of vision. The TLCLASIK data demonstrated morepatients achieved 20/16 by threemonths post-op with the WFG plat-form. In fact, with myopia less thanor equal to –4 D, twice as manypatients achieved 20/16 or betterwith the WFG platform compared tothose with the WFO platform.

Military PRK — WFG vs. WFO


Ithink premium LASIK with afemtosecond laser represents thebest refractive surgical proce-dure performed today. The mili-tary clinical results are out-

standing with 100% of patientsreaching 20/20, 97% reaching 20/16,and 72% reaching 20/12 uncorrectedvisual acuity (UCVA) at two weeks,according to preliminary results fromthe LASIK Naval Aviators Study(Figure 1).

In terms of functional vision, noinduced aberrations are evident andimprovement in low contrast visualacuity is clear. No complaints havebeen voiced by aviators, and 100% ofour aviators have returned to flightstatus, as expected, two weeks aftermyopic LASIK and four weeks afterhyperopic or mixed astigmatic LASIK.Satisfaction is incredibly high in all

Evidence-based medicine is used to

develop Navy standards for LVC

by David J. Tanzer, M.D., CAPT, MC (FS), USN

Majority of military personnel have WFG LVC

Figure 1. One hundred percent of patients reached 20/20, 97% reached 20/16, and 72%reached 20/12 uncorrected visual acuity (UCVA) at two weeks, according to preliminaryresults from the LASIK Naval Aviators Study

Figure 2. A significant gain is seen in low contrast visual acuity following LVC

“ Satisfaction is

incredibly high in

all service mem-

bers, with 100% of

aviators saying

they would recom-

mend LASIK to

fellow aviators”David J. Tanzer, M.D.

service members, with 100% of avia-tors saying they would recommendLASIK to fellow aviators.

I have found that U.S. warfighterLVC has been overwhelmingly suc-cessful in the military in all types ofjobs and has shown tremendousoperational benefits.

Military refractive surgery

Within the Department of Defense atotal of 25 warfighter refractive sur-gery centers (Army: 12, Navy: 7, AirForce: 6) completed more than312,000 refractive surgery proceduresover the past 10 years. LVC has beenallowed for all aspects of militaryservice, including aviation, specialoperations, and support personnel. Itis also approved for NASA astronauts.All surgery is done on a voluntarybasis.

Only one Department of Defensemedical disability retirement hasbeen recorded (one medical board in156,000 patients treated yields animpressive incidence rate of0.000007%). This one medical boardwas a result of quality of vision com-plaints, despite the individual having20/20 UCVA. It has been proventhrough the military’s vast experiencethat LVC is extremely safe and veryeffective for our warfighters.Evidence-based medicine has drivenrefractive surgery standards and poli-cies in the U.S. military.

Data

The LASIK in U.S. Naval AviatorsStudy is ongoing. To date, more than200 aviators, including over 50 pilotsin actual control of aircraft, are in thestudy, which is being conducted atthe Naval Medical Center San Diego,the primary treatment facility, and atthe Naval Medical CenterPortsmouth. Both wavefront-guidedand wavefront-optimized lasers areused; however, more than 90% ofcases have been wavefront-guided,and all of the aviators have theirLASIK flaps created with a femtosec-ond keratome.

Treatment has ranged from +3.4D to –7.6 D MRSE. For UCVA, 100%of former myopes are 20/20 uncor-rected by two weeks, and at fourweeks, 97% are 20/16 or better, 86%are 20/12 or better, and 26% are20/10 or better (Figure 1). In terms ofefficacy, 95% of the myopic aviators

are as good or better uncorrected atfour weeks compared to what theywere pre-op best corrected. I havefound the procedure results in exqui-site refractive stability. At one week,our average post-op refractive error isplano sphere and that fluctuates byapproximately 0.05 D out to threemonths. A significant gain is seen inlow contrast visual acuity followingLVC (Figure 2). Patients have no sig-nificant complaints of post-op glare,haze, halo, or sharpness of visioncompared to pre-op habitual correc-tions (vision with glasses).

High satisfaction

Patient satisfaction is outstanding atthree months post-op. Using a ques-

tionnaire, aviators are surveyed ontheir overall satisfaction at threemonths post-op. Ninety-eight percentindicated they felt their vision wasbetter than they expected, and 80%felt it was much better. Ninety-eightpercent also indicated that they feltLASIK helped their effectiveness as anaval aviator, and 85% felt it wasvery helpful. Further, 99% indicatedthey would definitely recommendLASIK treatment to a fellow navy avi-ator.

David J. Tanzer, M.D., CAPT, MC (FS), USN, isthe program director of the Navy RefractiveSurgery Center, department of ophthalmology,Naval Medical Center San Diego. He can bereached at [email protected].

This supplement was produced by EyeWorld under an educational grant from Abbott Medical Optics Inc.

Copyright 2010 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect

those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS.

supplement to eyeworld • may 2010 william trattler ...steven schallhorn, m.d. louis probst, m.d....

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