Introduction to Refractive Surgery Richard L. Nepomuceno, MD Diplomate, Philippine Board of Ophthalmology Cornea, External...
 
Errors of Refraction or Ametropia <ul><li>Problems in the focusing mechanism of the eye  </li></ul><ul><li>causes blurred ...
Emetropia <ul><li>NORMAL state of the eye  </li></ul><ul><li>light or image is focused on the retina </li></ul><ul><li>res...
Human Eye = Camera <ul><li>Cornea  =  outer lens of the camera </li></ul><ul><li>Pupil  =  aperture of the camera </li></u...
What affects focusing function of the eye? <ul><li>Shape of the cornea (steep, flat, oblong, irregular) </li></ul><ul><li>...
Types of Errors of Refraction <ul><li>Near sightedness or myopia ( minus ) </li></ul><ul><li>Far sightedness or hyperopia ...
Near Sightedness <ul><li>Far objects = blurred  </li></ul><ul><li>Near objects = clear </li></ul><ul><li>light is focused ...
Near Sightedness
Far  Sightedness <ul><li>Far objects = clear </li></ul><ul><li>Near objects = blurred </li></ul><ul><li>light is focused B...
Far  Sightedness
Astigmatism <ul><li>Both far and near objects appear blurred or have a shadow or double image </li></ul><ul><li>light is s...
Astigmatism
Presbyopia <ul><li>Difficulty in reading small prints </li></ul><ul><li>normal process due to aging </li></ul><ul><li>occu...
History of Vision Correction Surgery <ul><li>Dr. Jose Barraquer of Colombia (1949) </li></ul><ul><ul><li>Discovered that l...
History of Vision Correction Surgery <ul><li>Dr. Casimir Swinger (1985) </li></ul><ul><ul><li>nonfreeze keratomileusis </l...
Automated Lamellar Keratoplasty (ALK) <ul><li>For high myopes prior to Excimer laser </li></ul><ul><li>Flap is created by ...
Arrival of the Excimer Laser <ul><li>First used in human eyes in the late 80’s </li></ul><ul><li>Cool ultraviolet beam of ...
Photorefractive Keratectomy (PRK)
Photorefractive Keratectomy (PRK) <ul><li>First widely used procedure with the excimer laser (1987) </li></ul>
Photorefractive Keratectomy (PRK) <ul><li>Outer layer of cornea is removed then laser is applied </li></ul><ul><li>vision ...
PRK for Myopia
 
Photorefractive Keratectomy (PRK) <ul><li>No microkeratome involved </li></ul><ul><li>No flap created </li></ul><ul><li>Ul...
Photorefractive Keratectomy (PRK) HAZE
Laser In-situ Keratomilieusis (LASIK) Las er – performed with Excimer Laser I n situ – the cornea in its natural position ...
LASIK <ul><li>Started in 1991 </li></ul><ul><li>US Clinical Trials started in 1996 </li></ul><ul><li>FDA approval in 1999 ...
LASIK <ul><li>Thin outer corneal flap made with high speed blade </li></ul><ul><li>flap is lifted then laser is applied to...
LASIK
LASIK
LASIK
 
LASIK
LASIK
Laser Subepithelial Keratectomy (LASEK) <ul><li>Hybrid between PRK and LASIK </li></ul><ul><li>“Flap” of epithelium </li><...
Advantages of Excimer Laser <ul><li>Safe, quick and effective  if properly done </li></ul><ul><li>corrects near and far si...
Disadvantages of Excimer Laser Surgery <ul><li>Not ideal for very high degrees of errors </li></ul><ul><li>relatively expe...
Am I a good candidate? <ul><li>Stable refraction  (< 0.50 D) for at least one year </li></ul><ul><li>Ideal age  18 or 21 y...
Am I a good candidate? <ul><li>Surgically ideal eyes : </li></ul><ul><ul><li>Normal sized pupils < 7 mm at night </li></ul...
Am I a good candidate? <ul><li>Watch out for these health conditions : </li></ul><ul><ul><li>pregnant, about to get pregna...
Other Health conditions : <ul><li>Prescription Medicines that May Cause Problems : </li></ul><ul><ul><li>Accutane ( for ac...
Is It Painful <ul><li>No. The eyes are numbed with eyedrops </li></ul><ul><li>LASIK – slight pressure during suction </li>...
How Long does LASIK Take ? <ul><li>5-10 minutes </li></ul>
How Long will it take for my eyes to heal for LASIK? <ul><li>Compared to others, it is fast </li></ul><ul><li>Most postope...
When can I go back to work after LASIK <ul><li>Most patients can go back to work the following day. </li></ul><ul><li>If w...
How long will the correction last? <ul><li>Usually, LASIK, PRK, LASEK will correct distance vision permanently </li></ul><...
Excimer laser corneal refractive surgery does NOT prevent or reduce the risk of cataract, glaucoma and retinal  degenerati...
Excimer laser corneal refractive surgery does NOT prevent or treat the development of presbyopia.
Radial Keratotomy (RK) <ul><li>Myopia </li></ul><ul><li>Series of 4-8 radial microscopic incisions on surface of Cornea to...
Radial Keratotomy
 
Astigmatic Keratotomy (AK) <ul><li>Similar to RK </li></ul><ul><li>For astigmatism only </li></ul><ul><li>1-2 incisions al...
Astigmatic Keratotomy
 
Intacs Corneal Ring Segments <ul><li>FDA Approved 1999 </li></ul><ul><li><  3.0 D myopia w/  <  1.0D Astigmatism </li></ul...
Intacs Corneal Ring Segments
Intacs Corneal Ring Segments
 
Intraocular Lens Implant <ul><li>Placement of artificial plastic lenses inside the eye to correct errors of refraction </l...
Cataract Surgery
Clear Lens Extraction <ul><li>Remove lens as in cataract surgery </li></ul><ul><li>For patients > 40 y.o. </li></ul><ul><l...
Advantages of Lens Implant <ul><li>Artificial lenses are safe and effective </li></ul><ul><li>good for high degrees of err...
Disadvantages of Lens Implant <ul><li>Internal eye surgery </li></ul><ul><li>greater surgical risk </li></ul><ul><li>risk ...
Phakic Intraocular Lens (PIOL) Implants <ul><li>For extreme nearsightedness ( greater than -12D to -15D) / farsightedness ...
Phakic Intraocular Lens (PIOL) Implants
Bioptics <ul><li>Phakic IOL implant then LASIK </li></ul><ul><li>When neither technique alone works </li></ul><ul><li>Can ...
HYPEROPIA
PRK for Hyperopia
Laser Theramal Keratoplasty (LTK) <ul><li>FDA approval Jan 2000 </li></ul><ul><li>Holmium laser – deliver laser energy to ...
Laser Theramal Keratoplasty (LTK)
Conducktive Keratoplasty (CK) <ul><li>A special probe introduces electrical current to the peripheral cornea, shrinking th...
Conducktive Keratoplasty (CK)
Conducktive Keratoplasty (CK)
Presbyopia <ul><li>To date, there is still NO widely accepted, safe and effective permanent treatment for this condition <...
Surgery for Presbyopia <ul><li>Anterior Ciliary Sclerectomy (ACS) </li></ul><ul><li>Scleral Expansion Bands (SEBs) </li></ul>
VIDEO
 
What is best for you? Consider your personal preference and lifestyle.
THANK YOU
 
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Fatima refractive surgery lecture

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Fatima refractive surgery lecture

  1. 1. Introduction to Refractive Surgery Richard L. Nepomuceno, MD Diplomate, Philippine Board of Ophthalmology Cornea, External Disease & Refractive Surgery Fatima Medical Center . St. Lukes Medical Center . Capitol Medical Center East Avenue Medical Center . Manila Central University Cardinal Santos Medical Center . Manila Doctors Hospital
  2. 3. Errors of Refraction or Ametropia <ul><li>Problems in the focusing mechanism of the eye </li></ul><ul><li>causes blurred vision because light or image is not focused on the retina </li></ul>
  3. 4. Emetropia <ul><li>NORMAL state of the eye </li></ul><ul><li>light or image is focused on the retina </li></ul><ul><li>resulting in clear and sharp vision. </li></ul>
  4. 5. Human Eye = Camera <ul><li>Cornea = outer lens of the camera </li></ul><ul><li>Pupil = aperture of the camera </li></ul><ul><li>Lens = inner lens of the camera </li></ul><ul><li>Retina = film of the camera </li></ul>
  5. 6. What affects focusing function of the eye? <ul><li>Shape of the cornea (steep, flat, oblong, irregular) </li></ul><ul><li>Shape and thickness of the crystalline lens </li></ul><ul><li>Length of the eyeball </li></ul>
  6. 7. Types of Errors of Refraction <ul><li>Near sightedness or myopia ( minus ) </li></ul><ul><li>Far sightedness or hyperopia or hypermetropia ( plus ) </li></ul><ul><li>Astigmatism </li></ul><ul><li>Mixed types </li></ul><ul><li>Presbyopia (reading glasses) </li></ul>
  7. 8. Near Sightedness <ul><li>Far objects = blurred </li></ul><ul><li>Near objects = clear </li></ul><ul><li>light is focused IN FRONT of the retina </li></ul><ul><li>Due to : </li></ul><ul><ul><li>long eyeball </li></ul></ul><ul><ul><li>steep cornea </li></ul></ul><ul><ul><li>thick lens </li></ul></ul><ul><ul><li>combination of the above </li></ul></ul>
  8. 9. Near Sightedness
  9. 10. Far Sightedness <ul><li>Far objects = clear </li></ul><ul><li>Near objects = blurred </li></ul><ul><li>light is focused BEHIND the retina </li></ul><ul><li>Due to: </li></ul><ul><ul><li>short eyeball </li></ul></ul><ul><ul><li>flat cornea </li></ul></ul><ul><ul><li>thin lens </li></ul></ul><ul><ul><li>or combination of above </li></ul></ul>
  10. 11. Far Sightedness
  11. 12. Astigmatism <ul><li>Both far and near objects appear blurred or have a shadow or double image </li></ul><ul><li>light is split and falls at different location from the retina </li></ul><ul><li>due to corneal shape (football instead of basketball) </li></ul>
  12. 13. Astigmatism
  13. 14. Presbyopia <ul><li>Difficulty in reading small prints </li></ul><ul><li>normal process due to aging </li></ul><ul><li>occurs around age 40 </li></ul><ul><li>due to weakening of the crystalline lens to focus near objects </li></ul><ul><li>people with normal vision or far sighted will need reading glasses </li></ul><ul><li>near sighted people will have to remove their distance glasses </li></ul>
  14. 15. History of Vision Correction Surgery <ul><li>Dr. Jose Barraquer of Colombia (1949) </li></ul><ul><ul><li>Discovered that lamellar (layered) corneal surgery could reshape the cornea to enhance focus </li></ul></ul><ul><ul><li>Keratomileusis – a microkeratome(blade) removes a disc of the front portion of the cornea. Freezes and reshapes it, then puts it back. </li></ul></ul>
  15. 16. History of Vision Correction Surgery <ul><li>Dr. Casimir Swinger (1985) </li></ul><ul><ul><li>nonfreeze keratomileusis </li></ul></ul><ul><li>Dr. Luis Ruiz </li></ul><ul><ul><li>Automated Lamelar Keratoplasty (ALK) - automated microkeratome to reshape the cornea directly on the eye </li></ul></ul>
  16. 17. Automated Lamellar Keratoplasty (ALK) <ul><li>For high myopes prior to Excimer laser </li></ul><ul><li>Flap is created by microkeratome </li></ul><ul><li>Second pass with microkeratome to remove corneal tissue </li></ul><ul><li>Less precise, higher complications than LASIK </li></ul><ul><li>High percentage need additional procedures to achive desired results </li></ul>
  17. 18. Arrival of the Excimer Laser <ul><li>First used in human eyes in the late 80’s </li></ul><ul><li>Cool ultraviolet beam of light to vaporize tissue with great precision, w/o harming adjacent tissue </li></ul>
  18. 19. Photorefractive Keratectomy (PRK)
  19. 20. Photorefractive Keratectomy (PRK) <ul><li>First widely used procedure with the excimer laser (1987) </li></ul>
  20. 21. Photorefractive Keratectomy (PRK) <ul><li>Outer layer of cornea is removed then laser is applied </li></ul><ul><li>vision improves as surface heals after 4 to 7 days </li></ul><ul><li>discomfort present during healing </li></ul><ul><li>can cause corneal scarring </li></ul>
  21. 22. PRK for Myopia
  22. 24. Photorefractive Keratectomy (PRK) <ul><li>No microkeratome involved </li></ul><ul><li>No flap created </li></ul><ul><li>Ultimate visual results similar to LASIK </li></ul><ul><li>Longer recovery period (> 2 weeks) </li></ul><ul><li>Complications similar to LASIK; Haze </li></ul>
  23. 25. Photorefractive Keratectomy (PRK) HAZE
  24. 26. Laser In-situ Keratomilieusis (LASIK) Las er – performed with Excimer Laser I n situ – the cornea in its natural position on the eye K eratomileusis – carving the cornea to reshape it
  25. 27. LASIK <ul><li>Started in 1991 </li></ul><ul><li>US Clinical Trials started in 1996 </li></ul><ul><li>FDA approval in 1999 </li></ul>
  26. 28. LASIK <ul><li>Thin outer corneal flap made with high speed blade </li></ul><ul><li>flap is lifted then laser is applied to sculpt cornea </li></ul><ul><li>corneal flap is then returned </li></ul><ul><li>immediate visual improvement </li></ul><ul><li>almost no discomfort </li></ul><ul><li>early adjustment can be done </li></ul>
  27. 29. LASIK
  28. 30. LASIK
  29. 31. LASIK
  30. 33. LASIK
  31. 34. LASIK
  32. 35. Laser Subepithelial Keratectomy (LASEK) <ul><li>Hybrid between PRK and LASIK </li></ul><ul><li>“Flap” of epithelium </li></ul><ul><li>ZERO “flap” complications of LASIK </li></ul><ul><li>Slightly faster recovery than PRK </li></ul><ul><li>Less incidence of haze than PRK </li></ul><ul><li>Results similar to PRK and LASIK </li></ul>
  33. 36. Advantages of Excimer Laser <ul><li>Safe, quick and effective if properly done </li></ul><ul><li>corrects near and far sightedness and astigmatism </li></ul><ul><li>removes or decrease need for glasses or contact lenses </li></ul><ul><li>long lasting result </li></ul><ul><li>external eye surgery </li></ul><ul><li>US - FDA approved </li></ul>
  34. 37. Disadvantages of Excimer Laser Surgery <ul><li>Not ideal for very high degrees of errors </li></ul><ul><li>relatively expensive </li></ul><ul><li>presence of surgical risk </li></ul><ul><li>not reversible </li></ul><ul><li>glare, halo or night vision problems </li></ul><ul><li>delayed healing or scarring </li></ul><ul><li>no 100% guarantee </li></ul>
  35. 38. Am I a good candidate? <ul><li>Stable refraction (< 0.50 D) for at least one year </li></ul><ul><li>Ideal age 18 or 21 years old and above </li></ul><ul><li>Degree of correction* : </li></ul><ul><ul><li>Myopia (-0.75 to -12D) </li></ul></ul><ul><ul><li>Hyperopia (+6D) </li></ul></ul><ul><ul><li>Astigmatism (6D) * depends on patient, surgeon, machine, procedure </li></ul></ul>
  36. 39. Am I a good candidate? <ul><li>Surgically ideal eyes : </li></ul><ul><ul><li>Normal sized pupils < 7 mm at night </li></ul></ul><ul><ul><li>Nomal corneal thickness (> 500 u m ) </li></ul></ul><ul><ul><li>Stucturaly normal eye (not irregularly shaped like keratoconus, etc) </li></ul></ul><ul><ul><li>Healthy pressure within the eye </li></ul></ul><ul><ul><li>Generaly Health eyes ( eye diseases or injuries that could interfere) </li></ul></ul>
  37. 40. Am I a good candidate? <ul><li>Watch out for these health conditions : </li></ul><ul><ul><li>pregnant, about to get pregnant or breast feeding if female </li></ul></ul><ul><ul><li>Collagen Vascular Diseases – Cornea has collagen </li></ul></ul><ul><ul><li>Glaucoma or Cataracts </li></ul></ul><ul><ul><li>Certain corneal dystrophies </li></ul></ul><ul><ul><li>Herpetic keratitis </li></ul></ul><ul><ul><li>Diabetic retinopathy </li></ul></ul><ul><ul><li>Lupus, diabetes, rheumatoid arthritis must be controlled an identified </li></ul></ul>
  38. 41. Other Health conditions : <ul><li>Prescription Medicines that May Cause Problems : </li></ul><ul><ul><li>Accutane ( for acne) – may cause severe dry eye and decreased night vision </li></ul></ul><ul><ul><li>Oral Prednisone – may lower resistance to infections </li></ul></ul><ul><li>UNREALISTIC expectations </li></ul>
  39. 42. Is It Painful <ul><li>No. The eyes are numbed with eyedrops </li></ul><ul><li>LASIK – slight pressure during suction </li></ul><ul><li>After surgery : </li></ul><ul><ul><li>Some FB sensation a few hours after LASIK </li></ul></ul><ul><ul><li>Some scratchiness for 2- 4 days for PRK </li></ul></ul>
  40. 43. How Long does LASIK Take ? <ul><li>5-10 minutes </li></ul>
  41. 44. How Long will it take for my eyes to heal for LASIK? <ul><li>Compared to others, it is fast </li></ul><ul><li>Most postoperative discomfort and visual side effects are minor </li></ul><ul><li>Watery sensation a few hours after surgery </li></ul><ul><li>Rarely any significant discomfort the following day </li></ul><ul><li>Good vision the following day. </li></ul><ul><li>Vision improves for 2-6 months until stable </li></ul>
  42. 45. When can I go back to work after LASIK <ul><li>Most patients can go back to work the following day. </li></ul><ul><li>If work environment very dusty, wait about 48 hours </li></ul>
  43. 46. How long will the correction last? <ul><li>Usually, LASIK, PRK, LASEK will correct distance vision permanently </li></ul><ul><li>Eyesight changes slightly over time </li></ul><ul><li>Not because the procedure was unstable but because our eyes change </li></ul><ul><li>Enhancement procedures are normal (5-10%) </li></ul>
  44. 47. Excimer laser corneal refractive surgery does NOT prevent or reduce the risk of cataract, glaucoma and retinal degeneration or detachment.
  45. 48. Excimer laser corneal refractive surgery does NOT prevent or treat the development of presbyopia.
  46. 49. Radial Keratotomy (RK) <ul><li>Myopia </li></ul><ul><li>Series of 4-8 radial microscopic incisions on surface of Cornea to change curvature </li></ul>
  47. 50. Radial Keratotomy
  48. 52. Astigmatic Keratotomy (AK) <ul><li>Similar to RK </li></ul><ul><li>For astigmatism only </li></ul><ul><li>1-2 incisions along periphery of cornea </li></ul><ul><li>For pure astgmats </li></ul><ul><li>May be combined with LASIK, PRK, LASEK, Cataract extraction. </li></ul>
  49. 53. Astigmatic Keratotomy
  50. 55. Intacs Corneal Ring Segments <ul><li>FDA Approved 1999 </li></ul><ul><li>< 3.0 D myopia w/ < 1.0D Astigmatism </li></ul><ul><li>2 small plastic ring segments placed on periphery of cornea </li></ul><ul><li>Removable </li></ul>
  51. 56. Intacs Corneal Ring Segments
  52. 57. Intacs Corneal Ring Segments
  53. 59. Intraocular Lens Implant <ul><li>Placement of artificial plastic lenses inside the eye to correct errors of refraction </li></ul>
  54. 60. Cataract Surgery
  55. 61. Clear Lens Extraction <ul><li>Remove lens as in cataract surgery </li></ul><ul><li>For patients > 40 y.o. </li></ul><ul><li>Disadvantage : intraocular surgery,no accomodation, risk of Retinal Detachment </li></ul>
  56. 62. Advantages of Lens Implant <ul><li>Artificial lenses are safe and effective </li></ul><ul><li>good for high degrees of errors </li></ul><ul><li>minimal visual distortions </li></ul><ul><li>near immediate result </li></ul><ul><li>lifetime effect </li></ul><ul><li>no maintenance </li></ul><ul><li>reversible and adjustable (some types) </li></ul>
  57. 63. Disadvantages of Lens Implant <ul><li>Internal eye surgery </li></ul><ul><li>greater surgical risk </li></ul><ul><li>risk of late retinal detachment </li></ul><ul><li>risk of late corneal damage </li></ul><ul><li>relatively expensive </li></ul>
  58. 64. Phakic Intraocular Lens (PIOL) Implants <ul><li>For extreme nearsightedness ( greater than -12D to -15D) / farsightedness (greater than +4D to +6D ) </li></ul><ul><li>Advantage : maintains accomodation </li></ul><ul><li>Disadvantage : may develop cataracts;endophthalmitis </li></ul>
  59. 65. Phakic Intraocular Lens (PIOL) Implants
  60. 66. Bioptics <ul><li>Phakic IOL implant then LASIK </li></ul><ul><li>When neither technique alone works </li></ul><ul><li>Can correct more than 30D of myopia </li></ul>
  61. 67. HYPEROPIA
  62. 68. PRK for Hyperopia
  63. 69. Laser Theramal Keratoplasty (LTK) <ul><li>FDA approval Jan 2000 </li></ul><ul><li>Holmium laser – deliver laser energy to periphery of cornea </li></ul><ul><li>For Hyperopia (0.75 to 2.5 D) </li></ul><ul><li>Takes months to stabilize </li></ul><ul><li>In time, the effect wears off in a substantial number of cases </li></ul>
  64. 70. Laser Theramal Keratoplasty (LTK)
  65. 71. Conducktive Keratoplasty (CK) <ul><li>A special probe introduces electrical current to the peripheral cornea, shrinking the collagen to tighten the cornea and make it steeper centrally </li></ul><ul><li>FDA approved 2002 </li></ul>
  66. 72. Conducktive Keratoplasty (CK)
  67. 73. Conducktive Keratoplasty (CK)
  68. 74. Presbyopia <ul><li>To date, there is still NO widely accepted, safe and effective permanent treatment for this condition </li></ul>
  69. 75. Surgery for Presbyopia <ul><li>Anterior Ciliary Sclerectomy (ACS) </li></ul><ul><li>Scleral Expansion Bands (SEBs) </li></ul>
  70. 76. VIDEO
  71. 78. What is best for you? Consider your personal preference and lifestyle.
  72. 79. THANK YOU
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