Mississauga Lasik CE 2008 by Dr. Jeff Machat

1. Laser Refractive
Surgery
2008
Dr. Jeffery J. Machat
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2. I NEED MY GLASSES TO FIND MY GLASSES
I JUST WANT TO WAKE UP AND BE ABLE
TO SEE THE ALARM CLOCK !
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3. 12 million North Americans have had Laser
Vision Correction over the past 20 years
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4. EVERYONE THINKS THEY ARE SEVERE
EVERYONE HAS THEIR OWN STORY, THEIR
OWN REASON
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5. Research says...
•
The number one issue that
keeps patients from getting laser
vision correction...
FEAR
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6. TALKING TO CANDIDATES
Ø PRK/LASEK - laser pulses are
applied on the front surface of the eye
to correct your prescription CURVE
from SPECS
Ø 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
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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
LASIK
Ø Both calm the natural FEAR of patients
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8. March 6th, 2000
Zyoptix Custom Ablation
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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
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© Copyright 2001,VISX Inc.

11. • Wavefront Analogy:
• Keratometry
Topography
• Refraction
Wavefront Map
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12. Property
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13. • IntraLase added in Feb 2003 as a natural
complement to Custom Ablation Platforms
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14. Property
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* IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser

15. IntraLase
Ú 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
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* IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser

16. Property
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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, vaporizing
approximately 1 micron of corneal tissue
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* IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser

18. Pulsion FS Laser ™
Photodisruption
2 to 3 Microns
An expanding bubble of gas water is created
separating the corneal lamellae
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* IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser

19. Pulsion FS Laser ™
Photodisruption
The bi-products of photodisruption (CO2 water) are
absorbed by the mechanism of the endothelial pump,
leaving a cleavage plane in the cornea
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* IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser

20. Pulsion FS Laser ™
Photodisruption
Thousands of laser pulses are connected together
in a raster pattern to create a cleavage plane
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* IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser

21. Specific Indications
• Steep K s: above 46D
• Flat K s: below 40D
• Thin pachs
• Dry eye
• Small fissures
• Fear of blade
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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
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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
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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
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• IntraLase has added years to my life
expectancy, especially with steep
Ks, small orbits/narrow fissures and
uncooperative patients

25. Post-op Safety
• Less need for
enhancements, more
stable
• Less flap
displacement and less
striae post-op
• Eliminates serious
flap complications
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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
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27. Property
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28. Property
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29. CUSTOM ABLATION
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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
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31. Understanding Custom
Ø 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
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32. Understanding Custom
• Wavefront map:
Ø Represents a refractive map of the entire
visual system across the pupillary zone
Ø That is, the prescription at each and every
point
Ø Details what correction would be required at
each point in order to focus a light ray at
that point on the fovea
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33. Higher Order Aberrations
2 nd sphere, cylinder
LOA
3 rd coma, trefoil
HOA
4 th spherical aberration
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34. Property
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35. Property
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36. SPHERICAL ABERRATION
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37. Effects of Spherical
Aberrations
Increasing Aberrations
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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
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• Everyone BENEFITS from
Wavefront but SOME benefit
MORE than others

39. Advantages of
CustomVue
Ø Vision potential for better than 20/20
Ø Reduced risk of losing BCVA
Ø Less retreatments
Ø Preserves or Improves night vision
Ø Counters negative publicity
Ø Ability to treat patients with larger pupils
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40. Routine Lasik
Custom Lasik
Total Degree of
Spherical Aberration
Pre-op
Post-op
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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
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42. Ø Visx CustomVue with
IntraLase Flaps is our
procedure of choice
today
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43. FOURIER
WAVEFRONT
ALGORHITHM
Taking Custom to a Higher Level
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44. WAVEFRONT IS 25 TIMES MORE
PRECISE THAN STANDARD
REFRACTIONS TREATMENTS
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45. Fourier is far more precise Zernike
Standard Wavefront
ZERNIKE - BL
FOURIER - VISX
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46. Data Resolution
VISX 3 TIMES MORE POINTS
Zernike
Shape
Fourier
Shape
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47. Accuracy of Zernikes vs. Fourier
Actual Physical Shape Measured
Shape:
4th order
Zernike
Measured
Shape:
Fourier
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48. Better Data IN = Better Clinical Outcomes OUT
The Custom treatment is
saved on a memory stick and
then loaded into the laser
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49. Variable Spot Scanning 0.6mm
to 6.5mm
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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
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Zernike to the Fourier algorithm

51. IRIS REGISTRATION
Taking Custom to the Highest Level
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52. Iris Registration
Conclusion
• Optimizes Clinical
Outcomes
• simply through
alignment of
• Wavefront map and
Laser ablation
• in all axes
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53. Property
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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
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55. Property
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Jeffery
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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 excyclotorsion
Swami, 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)
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57. • Error Induced from Cyclotorsional
Movements in an eye with 1.00 diopter of
cylinder
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58. Iris Registration Compensation for
Pupil Centroid Shift
Ø it is also critical
to compensate
for differences
in pupil size
between
wavefront
capture and
laser delivery
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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
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60. Iris Registration
Patient Identification
Ø Iris pattern is
unique to each
patient
Ø Confirm correct
patient and eye
being treated
under the laser
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61. Iris Registration
Advantages
Ø Cyclotorsional registration
Ø Wavefront Ablation
Alignment
Ø Compensation for Pupil shift
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62. Iris Image Captured by
the WaveScan
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63. Iris image is flattened to determine
24 unique reference points
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64. Iris Registration
Torsional Angle
Compensation
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65. Ø More precise and accurate
means to register the
Ablation to the Wavefront
map
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66. Iris Registration Key Points
1. Ability to measure and to compensate
for ocular cyclotorsion
2. Ability to align of Wavefront map and
Laser ablation in all axes
3. Ability to measure and compensate for
pupil centroid shift
Ø Optimizing Clinical Outcomes !!!
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67. All Procedures Enhancement Rates
Custom Fourier IR
95-99% of
procedures
Intralase Intralase
30 KHz 60 KHz
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Data Courtesy of Louis Probst, MD

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
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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
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70. Warm caring people providing Reassurance,
Safety and Results !
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71. Incredibly exciting technology that
Changes Lives !
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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
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73. The information provided in this PowerPoint presentation is
for your personal informational purposes only. It is not
medical advice, medical diagnosis or treatment, or
recommendation for medical care or treatment. All medical
questions or concerns about a medical condition, care,
diagnosis or treatment should be presented to a medical
physician, health care provider, or health care professional.
You acknowledge that your use of this information is at your
sole risk, and that you assume and accept full responsibility for
all risk associated with any reliance upon the information
presented.
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74. THANK YOU
Jeffery J. Machat MD
2008
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