Introduction to Refractive Eye Surgery
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The document provides an introduction to refractive surgery. It discusses different vision conditions like myopia, hyperopia and presbyopia. It explains how these conditions can be corrected through glasses, contact lenses or refractive surgery options like LASIK and PRK. It addresses common myths about refractive surgery, discussing the safety, effectiveness and long-term outcomes of these procedures.
![INTRODUCTION TO REFRACTIVE SURGERY Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth London Vision Clinic, London, UK [email_address] General Medical Clinics, 3 rd September 2008](https://image.slidesharecdn.com/reinsteinintrotolasik-100622060016-phpapp01/85/Introduction-to-Refractive-Eye-Surgery-1-320.jpg)
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Introduction to Refractive Eye Surgery
- 1. INTRODUCTION TO REFRACTIVE SURGERY Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth London Vision Clinic, London, UK [email_address] General Medical Clinics, 3 rd September 2008
- 2. Why can’t I see well without my glasses?
- 10. Presbyopia Presbyopia Long/Short Sighted with Presbyopia Near vision is blurry
- 11. How can I correct my vision?
- 12. How Can I Correct my Vision? Glasses Contact Lenses Refractive Surgery
- 18. Myths in refractive surgery
- 20. History of refractive surgery It is still very new… Barraquer pioneered surgery in 1960
- 32. Myths in Refractive Surgery It hurts…
- 33. I don’t remember much about the procedure, mainly because it was so quick – less than 10 minutes. It was a similar sensation to when you close your eyes and then press firmly on them Sitting on the edge of the chair, my eyes doused in saline, I could read the vision chart on the wall opposite. When I sat up my first words were, “That’s amazing!”
- 34. Quick Procedure Your time in the clinic is brief and the procedure itself is over in a matter of minutes The procedure is brief and painless
- 35. The procedure is indeed painless The best thing about it is that it is over in about 10 minutes
- 37. Myths in Refractive Surgery If you move …
- 39. Myths in Refractive Surgery It cannot correct long-sightedness It cannot correct astigmatism
- 40. Who Is Suitable? -14.00 D +8.00 D -30.00 D +15.00 D Bioptics: Clear Lens Exchange & LASIK LASIK / PRK 0.00 D 0.00 D
- 41. Who is Suitable?
- 43. Myths in Refractive Surgery It does not work very well…
- 44. How To Get Good Outcomes
- 46. Myopia: Improved Contrast Sensitivity * * * *
- 47. Better Vision Than Glasses With Glasses Before LASIK Without Glasses After LASIK
- 50. Hyperopia: Improved Contrast Sensitivity * *
- 53. Advances: Super Vision Wavefront-guided refractive surgery: Correction of higher order aberrations Glasses or Contact lenses: Correction of lower order aberrations
- 54. Wavefront-Guided Treatment Refraction: -1.50 -0.75 x 163 No Glasses Vision With Glasses Before LASIK Without Glasses After LASIK
- 55. Myths in Refractive Surgery It cannot correct presbyopia
- 57. Problem With Multi-focality ReSTOR ReZoom Near Far Near Far Anschütz,Dausch,Klein,Joly (Meditec group, 1991) Avalos, Rozakis, Agarwal (PARM-technique, 1998) G.Tamayo (2000) Concentric distance near zones Diffraction design PROBLEM: Two Images Multi-focal Ablation Profiles Multi-focal IOLs
- 58. Visualization of Light Path for Multi-focal IOLs 2. Tecnis ZM900 (5 mm pupil) 4. ReZoom NXG1 (5 mm pupil) 5. ReSTOR SA60D3 (5 mm pupil)
- 59. Retinal Image with Multi-focal IOLs 2. Tecnis ZM900 3. Tecnis ZMA00 4. ReZoom NXG1 5. ReSTOR SA60D3
- 60. Optical Performance Multi-focal IOL 3 mm pupil 6 mm pupil ReSTOR ReZoom Tecnis ZM900
- 65. Case Example: Post CLE
- 71. Presbyopia Near Intermediate Distance Far Distance Right Eye Left Eye
- 72. Presbyopia: Ideal Solution Near Intermediate Distance Far Distance Right Eye Left Eye
- 73. Current Possible Depth of Field Increase Near Intermediate Distance Far Distance Right Eye Left Eye
- 74. Laser Blended Vision – Micro-Monovision Near Intermediate Distance Far Distance Dominant Eye Non-Dominant Eye “ Blend Zone”
- 75. Contact Lens Monovision Near Intermediate Distance Far Distance Dominant Eye Non-Dominant Eye “ Blend Zone” “ Blur Zone”
- 76. Correcting Presbyopia: Contact Lens Monovision Dominant eye: mainly corrected for distance Non-dominant eye: mainly corrected for near Brain merges two images to see near and far without glasses ~60% Patients Tolerate
- 77. Correcting Presbyopia: Laser Blended Vision Brain merges two images to see near and far without glasses Dominant eye: mainly corrected for distance Non-dominant eye: mainly corrected for near ~97% Patients Tolerate
- 80. Safety and refractive surgery You could end up blind.. If something goes wrong there is nothing that can be done…
- 81. Risks: Surgical Information Pack
- 82. Risks
- 84. Safety: All Risks Combined -8.00 D Preop -8.00 D UCVA Hand movements BSCVA 20/16 Postop Situation 1 UCVA 20/25 (little blurry) BSCVA 20/16 Postop Situation 2 UCVA 20/25 (little blurry) BSCVA 20/25 (lose 2 lines) 0.1% chance Enh to 20/16
- 86. Complication Rate – Prof Reinstein FLAP COMPLICATIONS Eyes out of 12,977 % Lose 2 Lines Free Cap 1 (0.01%) 0.0000000% Thin Flap 2 (0.02%) 0.0000000% Incomplete Flap (no ablation) 6 (0.05%) 0.0000000% Corneal Perforation 0 (0.00%) 0.0000000% Blindness (total loss of vision) 0 (0.00%) 0.0000000% Corneal scarring reducing vision 0 (0.00%) 0.0000000% Inflammation with decrease of vision 1 (0.01%) 0.0000000% Infection 0 (0.00%) 0.0000000% Epithelial Ingrowth (requiring further surgery) 21 (0.19%) 0.0000000% Need for corneal transplantation 0 (0.00%) 0.0000000% Keratectasia 0 (0.00%) 0.0000000% LASER COMPLICATIONS Eyes out of 12,977 % Lose 2 Lines Visually sig. decentrations 0 (0.00%) 0.0000000% Laser parameter data entry error 3 (0.03%) 0.0000000%
- 88. Safety: Myopia up to -12.00 D Safety: Lines Change BSCVA
- 89. Safety: Hyperopia up to +7.25 D Safety: Lines Change BSCVA
- 90. Long term safety and refractive surgery Advances in diagnostic tools
- 92. Topography Screening for Keratoconus
- 93. Pentacam Screening for Keratoconus
- 95. Advances: Artemis Cornell University Bio-Acoustic Lab 1991-1998 Ron Dan
- 97. Artemis - LASIK
- 99. Probability Model of the Inaccuracy of Residual Stromal Thickness Prediction to Reduce the Risk of Ectasia after LASIK
- 101. Conclusions
- 103. Thank You Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth London Vision Clinic, London, UK [email_address]
- 104. LASIK in Corneal Graft: Pre-Op
- 105. LASIK in Corneal Graft: Post-Op
- 106. Topography Guided LASIK in Corneal Graft Post-Graft 1 Year Post-LASIK Manifest -1.25 -7.00 x 92 -2.75 -1.25 x 120 BSCVA 20/40 20/25+2 UCVA 20/200 20/63-2 Intended -1.50 -1.00 x 92
- 107. Topography Guided LASIK in Corneal Graft Post-Graft 1 Year Ablation Difference Rx -1.25 -7.00 x 92 BSCVA 20/40 UCVA 20/200 Int -1.50 -1.00 x 92 Rx -2.75 -1.25 x 120 BSCVA 20/25+2 UCVA 20/63-2
- 108. What questions should your patient ask to select a skilled surgeon? S afety T echnology E xpertise E xperience R esults “ Do not pass go” – 8 questions
- 117. Outcomes: Comparison with Spectacles and Contact Lenses
- 122. What does it mean to see well?
- 123. Vision testing Quality of vision is not only being able to read black letters on a white background
- 124. Vision Testing Quality of vision = Visual Acuity Contrast Sensitivity Aberrations = Quality of the optics of the eye
- 125. Vision Testing Good Quality of vision = 1. Good Visual Acuity : small letters on the chart 2. High Contrast Sensitivity 3. Low level of aberrations : Low order aberrations can be corrected with glasses and contact lenses High order aberrations cannot be corrected with glasses and contact lenses
- 126. How can I correct my vision?
- 127. How Can I Correct my Vision? Glasses Contact Lenses Refractive Surgery
- 128. History of Glasses
- 134. Vision with Glasses Riding at night was the most unpleasant because of the glare and ghosting from the glasses Riding in the rain totally smeared the lenses Glasses don’t have full peripheral vision , so you are not fully aware of people coming up behind you
- 139. What are the advantages of refractive surgery?
- 140. Convenience for Outdoor Activities
- 141. Golf: Michael Hoey … my vision is probably better than 20/20 and it has made an outrageous difference to me on the golf course I feel I can read greens a lot better I was playing against the best players in the world and I couldn’t see where my ball was finishing
- 143. Diving If you take part in any water sports and suffer from poor eyesight, the benefits of refractive surgery are enormous Your time in the clinic is brief and the procedure itself is over in a matter of minutes The procedure is brief and painless
- 144. Diving I don’t think it would be exaggerating to call it a life changing moment
- 145. They are the crack gun cops who guard Tony Blair, ready to respond in a split second with a precision shot to rub out anyone deemed to threat his life. Trouble is, some of them don’t exactly have 20/20 vision… Some workers will become more productive following the operation
- 147. Results for the Met Police
- 149. Visual Acuity Improvement Dark blue columns are the vision levels achieved after LASIK Red columns are the level of vision without glasses before LASIK Light blue columns representing the vision of ‘normal’ eyes in the population
Editor's Notes
- Complete 1 day results
- Add picture of eye tracker and speculum
- Not only is the quantity of vision (20/20 etc) improved with the MEL80, but the contrast sensitivity is also slightly improved This is a huge advance from the previous generation lasers where the contrast sensitivity was worse after surgery Refractive surgery is now starting to be able to compete with glasses vision!
- Not only is the quantity of vision (20/20 etc) improved with the MEL80, but the contrast sensitivity is also slightly improved This is a huge advance from the previous generation lasers where the contrast sensitivity was worse after surgery Refractive surgery is now starting to be able to compete with glasses vision!
- This slide demonstrated how higher order aberrations affect the vision Before surgery, the E is very blurry, mainly due to the myopic refraction Once the refraction has been treated, the E is much clearer Once the aberrations have been treated as well, the E is crisp
- Multifocal (and accommodative) intra-ocular lenses have also been designed and are being used
- In presbyopia, the loss of accommodation means that the near vision in both eyes becomes blurred, leaving the patient needing reading glasses.
- The ideal solution would be to increase the depth of field so that both eyes could see clearly at both distance and near.
- So far, the non-linear aspheric profiles have been able to increase the depth of field, but not enough to give the patient clear vision at all distances.
- So, in order to give the patient good reading vision, the non-dominant eye is shifted towards myopia. This results in one eye being clearly focused for distance vision, but only slightly blurred at near, and the other eye being clearly focused for near vision, but only slightly blurred at distance. However, the increased depth of field in each eye means that there is a region where the range of clear vision overlaps – know as a blend zone. The result is that good binocular near and distance vision can be achieved with a lower degree of anisometropia than traditional monovision – which we refer to as micro-monovision. Therefore, much less suppression is required and there is no dissociation between the eyes.
- In traditional monovision, the depth of field in each eye is comparatively smaller, meaning that the near eye needs to be more myopic for the patient to read comfortably, leaving a gap between the range of vision of the two eyes and replaces the “ blend zone ” with a “ blur zone ” .
- 98% of myopic patients could see 20/20 at distance and J5 (newsprint) at near
- 95% of hyperopic patients could see 20/20 at distance and J5 (newsprint) at near
- Update numbers
- The Artemis is commercially available from Ultralink LLC in St Petersburg, FL. It is an FDA approved device, based on 50 MHz ultrasound high-speed arc-scanning that produces high resolution, real-time imaging. It was specifically designed as a refractive surgical tool capable of imaging and measuring the whole anterior segment, or the whole cornea in one scan sweep. Three dimensional data sets can be obtained by multi-meridional scanning. 3D data acquisition takes 3 minutes total per eye. One of it’s major features is infrared eye position control to enable the surgeon to know exactly from where on the eye or cornea a scan plane was taken.
- Legend from publication: Geometrically corrected horizontal B-scans through the visual axis of a cornea before (A above) and 4 months post-LASIK (B - below). The epithelial and posterior corneal boundaries are clearly visualized from one end of the corneal scan to the other, spanning a 9-mm diameter of cornea. Post-LASIK the extra interface produced by the interface between the stromal component of the flap and posterior residual stroma is clearly visualized along it's entire trajectory; The keratome entrance point, with a small separation in the cut ends of Bowman's layer under the epithelium is evident (E); A small irregularity in the smoothness of the keratome track is evident (I); The flap is noted to be thinner (T) nasally than temporally; The keratome track is noted to stop abruptly within the nasal stroma to produce the flap hinge (H).
- In November 2006, we published a probability model for the inaccuracy of RST prediction in the Journal of Refractive Surgery. These papers outline a method to predict the risk of the keratectomy being excessively deep for individual cases and for a population of refractive surgery patients.
- Add article (pdf)
- Add evening standard pic