Emil	  William	  Chynn,	  MD,	  FACS,	  MBA	                            Park	  Avenue	  LASEK	  333	  Park	  Avenue	  Sout...
Evolu&on	  of	  Refrac&ve	  Surgery	    RK,	  AK	  	  (Fyodorov	  –	  Russia/Ukraine)	  	    PRK	  	  (Trokel	  &	  L Es...
Original	  Procedures:	  Incisional	    Chance	  favors	  the	  prepared	  mind 	  –	  Louis	  Pasteur	    Boy	  falls	 ...
First	  move	  to	  the	  surface:	  PRK	    Excimer	  ( excited	  dimer )	  laser,	  193	  nm	    IBM	  Labs,	  Armonk,...
PRK	  advantages/disadvantages	    Accuracy	    Myopia,	  hyperopia,	  astigmatism	    Stability	  	    Pain	    Dela...
Move	  away	  from	  surface:	  LASIK	    Rapid	  recovery	    Nearly	  instantaneous	  results	  /	   wow	  effect 	   ...
Safer	  Flaps:	  IntraLase/i-­‐LASIK	    Fewer	  incomplete	  or	  button-­‐hole	  flaps	    Thinner	  flaps	    Safer	  ...
Move	   Back	  to	  the	  Surface 	    LASEK	  –	  remove	  epithelium	  en	  bloc	  using	  EtOH	    Epi-­‐LASEK(IK)	  ...
Epi-­‐LASEK	  (epi-­‐LASIK)	  
ASA	  indica&ons	  (over	  LASIK)	    Irregular	  astigmatism/	  FF	  KC	    Thin	  corneas	  /	  high	  Rx	  	        ...
Advantages	  of	  LASEK/epiLASEK	    Zero	  flap-­‐related	  complications	  (vs.	  LASIK)	        90%	  of	  all	  compl...
Sta&s&cal	  Trends	  (MarketScope)	  
Complicated	  LASIK	  enhancements	    Safer	  to	  re-­‐treat	  surface/flap	    No	  increased	  depth/decreased	  stro...
Enhancement	  procedure	    LASEK	  OU	  +	  MMC	  +	  CustomVue	  WaveFront	  (HD)	    LASEK	  –	  safer	  than	  epi-­...
PreVue	  Lens:	  	           useful	  in	  complex	  cases1	    LASIK	  retreatments	    UCVA	  close	  to	  20/20	    ...
Epithelial	  PreVue 	   New	  Universal	  Way	  to	  PreVue	    Can	  be	  used	  with	  any	  laser	  platform	  (not	  ...
A.F.	  –	  62	  yo	  M	  s/p	  RK	  +	  AK	    CC: 	   I	  can t	  see	  well	  far	  or	  near	  without	  glasses! 	  ...
Surgical	  plan	    Enhance	  non-­‐dominant	  eye	  first	    Wait	  3	  months	  before	  enhancing	  second	  eye	   ...
SLE	  –	  1	  year	  postop	  
1	  year	  postop	    UCVA:                   	  20/20	  at	  distance	  (OU)               	          	           	     ...
LASEK	  of	  Granular	  Dystrophy	    22	  yo	  F	  –	  Hx	  Granular	  Dystrophy	  OU	  	    UCVA                   	  ...
Preop:	  Granular	  Dystrophy	  
1	  –year	  post	  LASEK	  for	  Granular	  
1-­‐year	  post-­‐LASEK	  for	  Granular	    UCVA              	  OD: 	  20/50	  	          	  (20/100	  preop)	         ...
Sze	  H.	  Wong,	  BS	                                                                      Lynnette	  P.	  Williams,	  MD...
 	  Study	  Popula&on:	  	  Characteris&cs	                                       n	  =	  93	  Patients	  (153	  Eyes)	  F...
Gain	  in	  VA	  at	  3	  months	                                             	      Postop	  UCVA	  vs.	  Preop	  Best	  ...
       Postop	  UCVA	  vs.	  Preop	  BCVA	                      (%)      	                           1-­‐Mo.	     2-­‐Mo.	...
Complica&ons                                      	  "   11/153	  (7	  %)	  of	  eyes	  had	  postop	  haze	  (tr	  to	  2...
CONCLUSION	    Extreme	  prescriptions	  may	  be	  safely	  and	  effectively	    treated	  with	  Advanced	  Surface	  A...
Summary:	   ASA 	  =	  LASEK	  +	  EpiLASEK	    10x	  safer	  than	  primary	  LASIK	  or	  i-­‐LASIK/   IntraLase?	    ...
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Current Trends in Refractive Surgery - Lecture given at Harvard by Emil Chynn, MD

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Dr. Chynn graduated from Harvard's ophthalmology program, which is probably the most famous in the world.

As the only member of his graduating class to specialize in Refractive Surgery, and now an recognized authority, Dr. Chynn is frequently invited back to Harvard to give updates on the State of the Art in Refractive Surgery.

This slide show presentation was given to 100 eye surgeons who flew in from across the country to learn the latest advances in glaucoma, retina, cataract surgery--and laser vision correction (from Dr. Chynn).

The title of his talk reflects the movement in the US and worldwide from leading surgeons that is called "Back to the Surface." This means that surgeons are moving away from LASIK and IntraLase, to avoid flap complications and the # 1 problem causing lawsuits (iatrogenic keratoconus, or KC), and back to the surface.

For some doctors, this means going back to the original procedure, PRK, which has a lot of pain, delayed healing, and scarring.

For Dr. Chynn, this means performing an Advanced Surface Ablation, which is either a LASEK or epiLASEK. These are more advanced than PRK because they do not hurt, healing and recovery is quick, and there is no haze or scarring.
For example, Dr. Chynn performs over 1,000 LASEKs and epiLASEKs per year--he performed his last PRK in 1999.

Obviously, he moved away from PRK to LASIK, then to IntraLase, and now back to the safer LASEK and epiLASEK procedures.

View the following slide show to find out more, and call us with your questions--better yet, come in and meet with our MDs!

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Current Trends in Refractive Surgery - Lecture given at Harvard by Emil Chynn, MD

  1. 1. Emil  William  Chynn,  MD,  FACS,  MBA   Park  Avenue  LASEK  333  Park  Avenue  South,  New  York,  NY   dr@ParkAvenueLASEK.com    
  2. 2. Evolu&on  of  Refrac&ve  Surgery    RK,  AK    (Fyodorov  –  Russia/Ukraine)      PRK    (Trokel  &  L Esperance,  Columbia  U)      LASIK    (Pallikaris,  Greece)      LASEK    (Talamo,  Abad  &  Azar,  Mass  Eye  &  Ear      Intra-­‐LASE,  i-­‐LASIK    (Kurtz,  USA)      Epi-­‐LASIK,  epi-­‐LASEK    (Pallikaris,  Greece)  
  3. 3. Original  Procedures:  Incisional    Chance  favors  the  prepared  mind  –  Louis  Pasteur    Boy  falls  off  bike/glasses  shatter/corneal  lacs-­‐>no  specs!    Discovery/invention  of  RK  –  Svyatoslav  Fyodorov    Hex  K  –  Antonio  Medez  (Mexico)    Metal  blade-­‐>Diamond  blade-­‐>Guarded  diamond  blade      Risks:  perforation,  infection    Side-­‐effects:  starbursts,  irregular  astigmatism    Unpredictability,  overcorrection  (PERK,  Waring)  
  4. 4. First  move  to  the  surface:  PRK    Excimer  ( excited  dimer )  laser,  193  nm    IBM  Labs,  Armonk,  NY  (chip  etching)    Trokel  (VISX)  &  L Esperance  (Summit),  Columbia       US  Patent  #5,108,388  (1983/87/92),  Claim  4:       The  method  of  changing  optical  properties  of   an  eye  by  operating  solely  upon  the  anterior  surface  of   the  cornea  of  the  eye  (using)  selective  UV  irradiation   and  attendant  ablative  photodecomposition  of  the   anterior  surface  of  the  cornea  in  a  volumetric  removal   of  corneal  tissue  and  with  depth  penetration  into  the   stroma  and  to  a  predetermined  curvature  profile  
  5. 5. PRK  advantages/disadvantages    Accuracy    Myopia,  hyperopia,  astigmatism    Stability      Pain    Delayed  recovery    Scarring  
  6. 6. Move  away  from  surface:  LASIK    Rapid  recovery    Nearly  instantaneous  results  /   wow  effect    Nearly  painless    Decreased  risk  of  scarring      Flap  striae,  partial  flap,  button-­‐hole  flap    Debris,  epithelial  ingrowth,  DLK    Late  trauma    Ectasia  (Speaker/$7mil,  Niksarli/$5.6,  DelloRusso/$15.3)  
  7. 7. Safer  Flaps:  IntraLase/i-­‐LASIK    Fewer  incomplete  or  button-­‐hole  flaps    Thinner  flaps    Safer  for  thin  corneas,  high  Rx,  irregular  astig/FF  KC      Persistent  inflammation  +  photophobia    DES      Late  flap  trauma    Iatrogenic  KC  
  8. 8. Move   Back  to  the  Surface    LASEK  –  remove  epithelium  en  bloc  using  EtOH    Epi-­‐LASEK(IK)  –  en  bloc  dissection  using  epi-­‐keratome    Advanced  Surface  Ablation  (ASA)      Flap-­‐on  vs.   flap-­‐off    
  9. 9. Epi-­‐LASEK  (epi-­‐LASIK)  
  10. 10. ASA  indica&ons  (over  LASIK)    Irregular  astigmatism/  FF  KC    Thin  corneas  /  high  Rx       Highest  Rx  treated  in  NYC  (2010)  -­‐22  D  (600  –  250  =  350)     Preop  BCVA  20/60  OU  -­‐  >  Postop  UCVA  20/40  OU    Night  vision  concerns  (glare  from  flap,  large  pupils)    Contact  sports  /  hazardous  duty  (Seals,  etc)    Anterior  stromal  opacities  (scars,  dystrophies?)    Prior  RK/AK    Very  special  cases  (pediatrics?    dogs??)    
  11. 11. Advantages  of  LASEK/epiLASEK    Zero  flap-­‐related  complications  (vs.  LASIK)     90%  of  all  complications  are  flap-­‐related    Decreased  Dry  Eye  Syndrome    (vs.  LASIK)     caused  by  neurotrophic  cornea/hypesthesia      Decreased  inflammation/pain  (vs.  PRK)    Decreased  risk  of  scarring  (vs.  PRK)    Quicker  recovery  time  (vs.  PRK)      Safer  re-­‐treatments  of  complicated  (LASIK)  cases  
  12. 12. Sta&s&cal  Trends  (MarketScope)  
  13. 13. Complicated  LASIK  enhancements    Safer  to  re-­‐treat  surface/flap    No  increased  depth/decreased  stromal  bed    No  added  risk  of  ectasia    No  chance  of  epithelial  ingrowth/corneal  melt    No  risk  of  DLK    No  incomplete  flaps    No  risk  of  recutting  flaps  
  14. 14. Enhancement  procedure    LASEK  OU  +  MMC  +  CustomVue  WaveFront  (HD)    LASEK  –  safer  than  epi-­‐LASEK  on  retreatments    To  prevent  scarring:     MMC—mitomycin  C  (1  sec  /  sec.  of  ablation  time)     Vitamin  C     oral  steroids  (methylprednisolone)  x  1  week     PredForte  (prednisolone  acetate)  QID,  taper  over  mos     UV  protection    CustomVue  WaveFront—Prevue  Lens    
  15. 15. PreVue  Lens:     useful  in  complex  cases1    LASIK  retreatments    UCVA  close  to  20/20    BCVA  not  20/20      No  objective  improvement  on  manifest  refraction    Subjective  complaints  disproportionate    Glare,  halos,  diplopia,  ghosting    Lawyers,  legal  considerations    1Bansal,  Chynn,  Rubinfield,  Refractive  Surgery  Complex  Case   Management,  Cataract  &  Refractive  Surgery  Today,  July  2008  
  16. 16. Epithelial  PreVue   New  Universal  Way  to  PreVue    Can  be  used  with  any  laser  platform  (not  just  VISX)    More  accurate  than  PreVue     Larger  optical  zone     More  realistic   real-­‐life  trial    Zero  downside  risk?     turning  lemons  into  lemonade    Useful  to:     encourage/discourage  enhancement     pre-­‐sell /justify  WaveFront  upgrade  
  17. 17. A.F.  –  62  yo  M  s/p  RK  +  AK    CC:   I  can t  see  well  far  or  near  without  glasses!    Had  multiple  RK  +  AK  incisions  OU  28  years  ago    VA  (distance):  20/80  OD,  20/100  OS,  20/60  OU    VA  (near):  20/100  OD,  20/80  OS,  20/80  OU    Rx:  +3.25  –  2.25  x  80  OD          +  4.50  –  4.75  x  95  OS    Saw  numerous  LASIK  surgeons  who  said:     I  wouldn t  touch  you  with  a  10-­‐foot  pole!     If  you  get  LASIK  you  will  wind  up  with  pizza  slices!  
  18. 18. Surgical  plan    Enhance  non-­‐dominant  eye  first    Wait  3  months  before  enhancing  second  eye    Maximum  scarring  prophylaxis    Stress  patient  compliance    Frequent  post-­‐op  visits/SLE  to  check  for  scarring    Slow  taper  of  topical  steroids  
  19. 19. SLE  –  1  year  postop  
  20. 20. 1  year  postop    UCVA:  20/20  at  distance  (OU)          20/25  at  near  (OU)      Rx:  OD:  +0.50  –  0.75  x  13          OS:  -­‐0.75  –  1.25  x  123      SLE:    clear      CC:     I  can  see  near  and  far  like  when  I  was  30,   which  is  good  as  I  just  married  a  30-­‐year-­‐old  and  am   having  my  tubes  reconnected  to  try  to  have  kids!  
  21. 21. LASEK  of  Granular  Dystrophy    22  yo  F  –  Hx  Granular  Dystrophy  OU      UCVA  OD:  20/100            OS:  20/80              OU:    20/70      BSCVA:  OD:  -­‐1.75  –  1.50  x  170  (20/80)        OS:  -­‐1.00  –  0.50  x  5  (20/70)        OU:  20/60  
  22. 22. Preop:  Granular  Dystrophy  
  23. 23. 1  –year  post  LASEK  for  Granular  
  24. 24. 1-­‐year  post-­‐LASEK  for  Granular    UCVA  OD:  20/50      (20/100  preop)        OS:  20/40    (20/80  preop)      OU:    20/30    (20/70  preop)      BSCVA:  OD:  -­‐.75  –  0.50  x  160  (20/30)  (20/80  pre)        OS:  -­‐.50  –  0.50  x  15  (20/30)  (20/70  pre)        OU:  20/25        (20/60  pre)  
  25. 25. Sze  H.  Wong,  BS   Lynnette  P.  Williams,  MD   Emil  W.  Chynn,  MD,  FACS,  MBA  The  authors  have  no  financial  interest  in  the   Presented  at  ASCRS,  2011  subject  ma4er  of  this  poster.    
  26. 26.    Study  Popula&on:    Characteris&cs   n  =  93  Patients  (153  Eyes)  Female   47  %  Male   53  %  Age  (mean  ±  SD;  range)   31.4  ±  8.3  (19  -­‐  66)  Eyes  With  Extreme  Myopia  (SE  ≥  -­‐9)   72  %  Eyes  With  Extreme  Hyperopia  (SE  ≥  +6)   4  %  Eyes  With  Extreme  Astigmatism  (cyl  ≥  -­‐3)   31  %  LASEK  Eyes   83  %  Epi-­‐LASIK  Eyes   17  %  WaveFront  Eyes   61  %  Rx  Range   -­‐22.00  to  +7.50  Preop  Corneal  Thickness   554  ±  39  µm  Ablation  Thickness     125  ±  36  µm  Postop  Corneal  Thickness   429  ±  50  µm  
  27. 27. Gain  in  VA  at  3  months     Postop  UCVA  vs.  Preop  Best   Corrected  Visual  Acuity  (BCVA)   100  %  of  eyes  had  postop  UCVA  >  preop  UCVA!   Extreme  Myopic  Eyes   Extreme   Extreme   Hyperopic  Eyes   Astigmatic  Eyes   Number  of        Lines  Gained   8.42   3.58   6.68   LogMAR         Gained   1.51   0.77   1.08  
  28. 28.   Postop  UCVA  vs.  Preop  BCVA   (%)   1-­‐Mo.   2-­‐Mo.   3-­‐Mo.   Postop         UCVA  ≥   40   57   72  Preop  BCVA  Postop  UCVA        >  Preop  BCVA   18   25   34  Postop  UCVA        =  Preop  BCVA   22   32   38  
  29. 29. Complica&ons  "   11/153  (7  %)  of  eyes  had  postop  haze  (tr  to  2+)  "   3/153  (2%)  of  eyes  lost  ≥  1  line  of  BCVA  due  to   postop  haze  "   1/153  (0.7%)  of  eyes  lost  ≥  2  lines  of  BCVA  due   to  postop  haze      
  30. 30. CONCLUSION    Extreme  prescriptions  may  be  safely  and  effectively   treated  with  Advanced  Surface  Ablation,  combined   with  adjunctive  treatments  to  prevent  scarring    72%  eyes:  3-­‐mo.  postop  UCVA  ≥  preop  BCVA      Further  studies  are  needed  to  determine  whether   extremely  hyperopic  eyes  are  more  likely  to  lose  BCVA     and  how  to  avoid  this  loss
  31. 31. Summary:   ASA  =  LASEK  +  EpiLASEK    10x  safer  than  primary  LASIK  or  i-­‐LASIK/ IntraLase?    Definitely  safer  in  complicated  enh  (RK,  AK,  PK)    Need  steroids  +  MMC  to  prevent  scarring    Slower  healing  /  patient  compliance    Combine  safety  of  PRK  with  comfort  of  LASIK    Can   Return  to  the  Surface      revitalize  Refractive  Surgery?      (still  0%  penetration  of  candidate  population)  
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