Mississauga Lasik CE 2008 by Dr. Jeff Machat

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Mississauga Lasik CE 2008 by Dr. Jeff Machat

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Mississauga Lasik CE 2008 by Dr. Jeff Machat

  1. 1. Laser Refractive Surgery 2008 Dr. Jeffery J. MachatProperty  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  2. 2. I NEED MY GLASSES TO FIND MY GLASSES I JUST WANT TO WAKE UP AND BE ABLE TO SEE THE ALARM CLOCK ! Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  3. 3. 12 million North Americans have had Laser Vision Correction over the past 20 years Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  4. 4. EVERYONE THINKS THEY ARE SEVERE EVERYONE HAS THEIR OWN STORY, THEIR OWN REASON Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  5. 5. Research says... •  The number one issue that keeps patients from getting laser vision correction... FEAR Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  6. 6. TALKING TO CANDIDATES Ø  PRK/LASEK - laser pulses are applied on the front surface of the eye to correct your prescription CURVE from SPECSØ  LASIK - a flap is created of the protective layer of the cornea, the flap is lifted and the laser pulses are applied to an inner corneal layer BOOK ANALOGY Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  7. 7. IntraLase with CustomVue• Two parts to LASIK Procedure: Ø  Corneal Flap: IntraLase safest highest quality Ø Laser Ablation: CustomVue safest highest quality Ø Fear not price is the greatest deterrent to LASIKØ Both calm the natural FEAR of patients Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  8. 8. March 6th, 2000Zyoptix Custom Ablation Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  9. 9. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  10. 10. Patient: *************, ************* Patient ID: 0-343-91-63 Notes: OD Wavefront -4.49 DS +0.48 DC x 136° @ 12.5 mm (4.0 Pupil) 14-Dec-2001 20:26 Pupil (mm): 6.00 Hi Order: 8.7 % OS -4.14 DS +0.80 DC x 51° @ 12.5 mm (4.0 Pupil) 14-Dec-2001 20:27 Pupil (mm): 6.00 Hi Order: 6.2 % Analysis Eff. Blur (D): 4.25 Eff. Blur (D): 3.66 Acuity Map Rms Err.(µ): 5.52 Acuity Map Rms Err.(µ): 4.76 microns 90 microns 90 All Grid Spacing: 1 mm. 28.00 120 60 28.00 120 60 24.00 24.00 20.00 20.00 16.00 150 30 16.00 150 30 12.00 12.00 8.00 8.00 4.00 4.00 180 0 180 0 0.00 0.00 -4.00 -4.00 -8.00 -8.00 -12.00 -12.00 -16.00 -16.00 -20.00 -20.00 -24.00 -24.00 -28.00 -28.00 Bille Aberration Map Rms Err.(µ): 0.48 Bille Aberration Map Rms Err.(µ): 0.29 microns 90 microns 90 1.75 120 60 1.75 120 60 1.50 1.50 1.25 1.25 1.00 150 30 1.00 150 30 0.75 0.75 0.50 0.50 0.25 0.25 180 0 180 0 0.00 0.00 -0.25 -0.25 -0.50 -0.50 -0.75 -0.75 -1.00 -1.00 -1.25 -1.25 -1.50 -1.50 -1.75 -1.75 Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.   © Copyright 2001,VISX Inc.
  11. 11. • Wavefront Analogy:• Keratometry Topography• Refraction Wavefront Map Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  12. 12. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  13. 13. •  IntraLase added in Feb 2003 as a natural complement to Custom Ablation Platforms Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  14. 14. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.   * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser
  15. 15. IntraLaseÚ  Femtosecond laser–  (Nd:Glass) 1053 nm (near infrared)Ú  Each pulse of focused laser light lasts -13 approximately 10 seconds (100 femtoseconds) • In one second, light travels 7.5 times around the globe • In 100 femtoseconds, light travels across a human hair • Power = Energy/Time, extremely high power attained at relatively low energy Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.   * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser
  16. 16. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  17. 17. Pulsion FS Laser ™ Photodisruption A pulse of laser energy is focused to a precise spot inside the cornea 1 Micron A microplasma is created, vaporizingapproximately 1 micron of corneal tissueProperty  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.   * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser
  18. 18. Pulsion FS Laser ™ Photodisruption 2 to 3 MicronsAn expanding bubble of gas water is created separating the corneal lamellae Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.   * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser
  19. 19. Pulsion FS Laser ™ PhotodisruptionThe bi-products of photodisruption (CO2 water) areabsorbed by the mechanism of the endothelial pump, leaving a cleavage plane in the cornea Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.   * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser
  20. 20. Pulsion FS Laser ™ PhotodisruptionThousands of laser pulses are connected together in a raster pattern to create a cleavage plane Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.   * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser
  21. 21. Specific Indications•  Steep K s: above 46D  •  Flat K s: below 40D  •  Thin pachs•  Dry eye•  Small fissures•  Fear of blade Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  22. 22. Advantages•  Can cut a 110 micron flap consistently•  Can place hinge anywhere•  Easier for future re-cuts•  Reduced epithelial ingrowth•  Reduced incidence of flap slippage•  Reduced dry eye Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  23. 23. •  True Lamellar Flap•  Equally Smooth Stromal Bed•  Less induced Higher Order Aberrations•  More Tissue for Custom Ablation Treatments•  More Tissue for Larger Optical Zones Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  24. 24. Intra-op Safety: Loss of Suction •  Blade: serious complication, central buttonhole flap, vision may be permanently impaired, wait 3-12 months for repeat LASIK •  IntraLase: re-apply suction ring immediately, recenter and continue or restart flap from beginning Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.   •  IntraLase has added years to my life expectancy, especially with steep Ks, small orbits/narrow fissures and uncooperative patients
  25. 25. Post-op Safety•  Less need for enhancements, more stable•  Less flap displacement and less striae post-op•  Eliminates serious flap complications Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  26. 26. Post-op Safety•  Less epithelial ingrowth with IntraLase Flaps – 2 cases of grade 2 epithelial ingrowth out of 2000 cases, both following enhancements – Compared to 20 cases with last 2000 Hansatome Flaps Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  27. 27. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  28. 28. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  29. 29. CUSTOM ABLATION Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  30. 30. Custom Ablation •  Better Visual Results •  Greater Chance of 20/20 •  Greater Chance of Better than 20/20 •  Greater Chance of correcting Astigmatism •  Lower Chance of Losing BCVA •  Lower Chance of Night Glare •  Lower Chance of Enhancements Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  31. 31. Understanding CustomØ Wavefront approach is a completely different concept from standard refractive surgery planning Ø Optimizes cornea for light ray focusing on fovea not prescription or curvature Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  32. 32. Understanding Custom• Wavefront map:Ø Represents a refractive map of the entire visual system across the pupillary zoneØ That is, the prescription at each and every pointØ Details what correction would be required at each point in order to focus a light ray at that point on the fovea Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  33. 33. Higher Order Aberrations 2 nd sphere, cylinder LOA3 rd coma, trefoil HOA4 th spherical aberration Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  34. 34. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  35. 35. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  36. 36. SPHERICAL ABERRATION Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  37. 37. Effects of Spherical Aberrations Increasing Aberrations Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  38. 38. Wavefront • Wavefront treats higher order aberrations, the aberrations that spectacles do NOT correct, that is why vision potential EXCEEDS BSCVA i.e. 20/20 for most Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  •  Everyone BENEFITS from Wavefront but SOME benefit MORE than others
  39. 39. Advantages of CustomVueØ Vision potential for better than 20/20Ø Reduced risk of losing BCVAØ Less retreatmentsØ Preserves or Improves night vision Ø Counters negative publicity Ø Ability to treat patients with larger pupils Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  40. 40. Routine Lasik Custom Lasik Total Degree ofSpherical Aberration Pre-op Post-op Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  41. 41. • Since March 2000, I have performed over 10,000 Custom LASIK procedures with: • BL Zyoptix System • WaveLight Allegretto Wave • Visx Star S4 with CustomVue • Alcon LadarWave system Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  42. 42. Ø Visx CustomVue with IntraLase Flaps is our procedure of choice today Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  43. 43. FOURIER WAVEFRONT ALGORHITHMTaking Custom to a Higher Level Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  44. 44. WAVEFRONT IS 25 TIMES MORE PRECISE THAN STANDARD REFRACTIONS TREATMENTS Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  45. 45. Fourier is far more precise Zernike Standard Wavefront ZERNIKE - BL FOURIER - VISX Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  46. 46. Data Resolution VISX 3 TIMES MORE POINTS ZernikeShapeFourierShape Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  47. 47. Accuracy of Zernikes vs. FourierActual Physical Shape Measured Shape: 4th order Zernike Measured Shape: Fourier Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  48. 48. Better Data IN = Better Clinical Outcomes OUT The Custom treatment is saved on a memory stick and then loaded into the laser Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  49. 49. Variable Spot Scanning 0.6mm to 6.5mm Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  50. 50. Beyond Zernike •  Visx Fourier is better than Zernicke•   If we obtain 240 spots it uses all 240 spots in the reconstruction, no averaging•  Visx CustomVue is the only laser platform that has switched from Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.   Zernike to the Fourier algorithm
  51. 51. IRIS REGISTRATIONTaking Custom to the Highest Level Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  52. 52. Iris Registration Conclusion •  Optimizes Clinical Outcomes•  simply through alignment of•  Wavefront map and Laser ablation•  in all axes Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  53. 53. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  54. 54. Ø It has always been recognized that it is important to align preoperative cylinder axis with the laser ablation axis for optimal results and safety Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  55. 55. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  56. 56. Cyclotorsion Shift with Recumbent Position Mean Degree Study Eyes Movement Other VISX Study,Chernyak, JCRS, 51 2.2º + 2.0º up to 10º 2004 excyclotorsionSwami, Steinert 8% with over et al, 240 4.1º + 3.7º 10º of AJO, 2002 movement Smith, Talamo, 25% over 7º Assil, 50 - of movement JCRS, 1994 (up to 16º) Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  57. 57. •  Error Induced from Cyclotorsional Movements in an eye with 1.00 diopter of cylinder Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  58. 58. Iris Registration Compensation for Pupil Centroid ShiftØ it is also critical to compensate for differences in pupil size between wavefront capture and laser delivery Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  59. 59. Compensation for pupil center shift with CustomVue Ø Wavefront ablation is centered over the WaveScan pupil centroid (red), not the laser pupil centroid (purple)Ø Iris outer• boundary• used as a• FIXED Pupil under• reference laser Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  60. 60. Iris Registration Patient Identification Ø Iris pattern is unique to each patientØ Confirm correct patient and eye being treated under the laser Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  61. 61. Iris Registration Advantages Ø Cyclotorsional registrationØ Wavefront Ablation AlignmentØ Compensation for Pupil shift Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  62. 62. Iris Image Captured by the WaveScan Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  63. 63. Iris image is flattened to determine 24 unique reference points Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  64. 64. Iris Registration Torsional AngleCompensation Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  65. 65. Ø  More precise and accurate means to register the Ablation to the Wavefront map Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  66. 66. Iris Registration Key Points 1.  Ability to measure and to compensate for ocular cyclotorsion2.  Ability to align of Wavefront map and Laser ablation in all axes3.  Ability to measure and compensate for pupil centroid shiftØ Optimizing Clinical Outcomes !!! Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  67. 67. All Procedures Enhancement Rates Custom Fourier IR 95-99% of procedures Intralase Intralase 30 KHz 60 KHz Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  Data Courtesy of Louis Probst, MD
  68. 68. Conclusion •  Visual Acuity: More patients see 20/20 over conventional ablations with mechanical keratome flap creation •  Visual Quality: Fewer patients have night vision symptoms •  Safety: More patients gained lines of low contrast acuity •  Enhancements: Reduced retreatment rates Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  69. 69. IntraLase with CustomVue • Improving Quality of vision is now the objective with CustomVue• Improving Safety is the objective with IntraLase and Iris Registration• IntraLase with CustomVue provides the highest quality with the greatest safety to reduce patient FEAR Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  70. 70. Warm caring people providing Reassurance, Safety and Results ! Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  71. 71. Incredibly exciting technology that Changes Lives ! Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  72. 72. Custom LASIK with IntraLase Flaps •  Better Visual Results •  Greater Chance of 20/20 •  Greater Chance of Better than 20/20 •  Greater Chance of correcting Astigmatism •  Lower Chance of Losing BCVA •  Lower Chance of Night Glare •  Lower Chance of Enhancements Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  73. 73. The information provided in this PowerPoint presentation isfor your personal informational purposes only. It is notmedical advice, medical diagnosis or treatment, orrecommendation for medical care or treatment. All medicalquestions or concerns about a medical condition, care,diagnosis or treatment should be presented to a medicalphysician, health care provider, or health care professional.You acknowledge that your use of this information is at yoursole risk, and that you assume and accept full responsibility forall risk associated with any reliance upon the informationpresented. Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  
  74. 74. THANK YOU Jeffery J. Machat MD 2008 Property  of    Dr.  Jeffery  J.  Machat.  All  rights  reserved.  Unauthorized  use  is  prohibited.  

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