I found this article in one of our industry newsletters. All of its “points” are “on point” and will hopefully help to dispell many of the misconceptions about these amazing procedures.

by Maxine Lipner Senior EyeWorld Contributing Editor

What patients are really thinking about when it comes to LASIK options

Mythology can be a powerful thing. Unfortunately, when it comes to LASIK there are some myths that have evolved over the last decade or so that are just plain confusing and may ultimately be keeping potential patients at bay. EyeWorld asked several leading practitioners to share some of the key misconceptions that they’ve recently come across.
Louis E. Probst, M.D., national medical director, TLC Laser Eye Centers, pegs cost as the top misconception for prospective patients. “The average price for LASIK from an industry perspective is pretty close to $2,000 per eye, and that has been shown by Market Scope,” Dr. Probst said. Cut-rate advertisements, however, give patients the impression that the rate is in the $1,000 range. “Patients do understand that what they got from their cursory analysis isn’t the state-of-the-art LASIK that they want for their eyes,” he said.
He commonly comes across patients who have done internet searches who worry that night glare and dry eyes after LASIK are significant concerns. Many perspective patients are not differentiating between the old technology and custom LASIK. “The reality is that since we have started using custom treatments, and that has been over 5 years now, night glare is not a significant factor and is not related to pupil size,” Dr. Probst said. He pointed to studies done by Mihai Pop, M.D., and Steven Schallhorn, M.D., which clearly show that pupil size is not correlated with night vision disturbances. Likewise, Dr. Probst finds that dry eye was a much worse issue with mechanical microkeratomes than with the current femtosecond laser. “Now that we are so conscious of the risk of dry eye, we use lubricating drops, like Restasis (cyclosporine, Allergan, Irvine, Calif.), which is extremely effective when started pre-operatively, and now that we use the femtosecond laser, which makes thinner, slightly smaller flaps than mechanical micokeratomes, the incidence of dry eye has become a small concern,” Dr. Probst said. Many fall victim to the idea that LASIK is not an effective treatment for high myopia. “I think that patients often think that if they’re anything greater than –6 that they’re essentially “blind” and there’s no way that their prescription could be treated,” Dr. Probst said. “Of course that’s not true.”

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Dry eye has been a major topic of discussion as it relates to patient candidacy for laser vision correction. While it may seem like a simplistic issue it is actually very complex. Numerous attempts to formulate an artificial tear with a composition similar to that of biological tears has been extremely elusive. This is because the natural tear film has three distinct layers: an aqueous layer sandwiched between an inner mucus layer, and an outer oil layer. The inner mucin layer is created by secretions from goblet cells located on the surface of the eye. This layer smoothes out the characteristically rough surface of the eye. The middle layer is the water or aqueous layer and is primarily secreted by the lacrimal gland located just above the outer aspect of the each eye. Finally there is an outer oil layer that helps to keep the tear film from evaporating too quickly. This is created by 45 vertically-oriented meibomian glands found behind the row of lashes on the upper and lower eyelids. One can actually have a large amount of aqueous production and still have dry eyes due to a poor oil or mucin layer causing the tear film to break up too quickly.

Usually, the normal blink rate is approximately 15 times per minute but when we concentrate on driving or stare at a computer screen for a period of time our blink rate may decrease to as little as 5 times per minute. Therefore, if the tear breakup rate is quicker than the blink rate, it won’t allow for the tear film to coat the surface of the eye and patients will not have clear vision.

Goblet cells may take several weeks to completely recover from the manipulation and drops that are used around the time of LASIK. Most of the attention for dry eye therapy, however, is focused on the other two elements, namely: water and oil. While much attention has been given to the use of Restasis (Cyclosporin) (Allergan Pharmaceuticals), unless there is inflammation of  the lacrimal glands causing decreased water production, it is unlikely to provide a significant benefit.

The greatest number of questions from people looking into laser vision correction are related to the longevity of the procedure and dry eye. In all but the rarest of cases, people who wear contact lenses for hours a day are not at significant risk for dry eye post-operatively. Their dry eye may be related to irritation from the contact lens or solution used in their care. Read the rest of this entry »

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The following article is timely because one of the great concerns of any refractive surgeon is our ability to accurately predict which of our patients might be at risk for problems in the future. Most surgeons who have been involved with PRK and LASIK for some time have encountered at least one or two patients who prior to treatment had corneal scans that were normal in appearance only to return 5 to 6 years later with loss of best corrected vision and apparent corneal ectasia. One can only speculate whether eye rubbing, elevated intraocular pressure (either naturally or subsequent to steroid response) or some other factor was contributory or whether the corneal pathology would have occurred regardless of whether they were treated or not. Although we may never have a reliable method to completely eliminate this unfortunate sequelae, it is comforting to know there is now a method for stalling the progression of corneal weakening and potentially rehabilitating these patients without having to rely completely on the use of gas permeable contact lenses.

            This article discusses several options for the treatment of post kerato-refractive ectasias with emphasis on collagen cross-linking of the cornea. Cross-linking is a new minimal invasive surgical treatment that utilizes a solution of riboflavin (Vitamin B 2), a photosensitizing agent and Ultraviolet-A (UV-A, 365nm). The riboflavin, when activated by approximately 30 minutes of illumination with UV-A light, augments the collagen cross-links within the body of the cornea (i.e. stroma) increasing its strength by more than 300%. This increase in corneal strength has been shown to arrest the progression of keratoconus in numerous studies performed around the world.  FDA trials investigating the safety and efficacy of this process are currently being conducted at a number of centers across the U.S.

During this treatment riboflavin solution is applied and absorbed through the layers of the cornea 1) through either intact (but disrupted) epithelium or 2) following manual epithelial debridement. The benefits of the former method are greater patient post-op comfort, visual rehabilitation, and lower incidence of visually significant cornea haze. However, the riboflavin solution has difficulty crossing through intact epithelium so the epithelium must be disturbed in some way (e.g. anesthetic, detergent) to allow the riboflavin to penetrate. While ongoing research protocols are being conducted to determine which of these two methodology delivers the best long term effect, it would seem that the best method to serve the post-LASIK patient would be via a third alternative, namely by lifting the corneal flap to deliver the riboflavin to the corneal bed. Recalling the mechanism of action of hyperopic ALK performed in the early 90’s, we learned that following its creation, the corneal flap offers very little structural support for the corneal and merely drapes over the supporting corneal bed. This is why regardless of how thick a flap is, national protocols call for a minimal residual bed of 250 microns of tissue when performing LASIK (although upward for 300 microns may be preferable); they don’t say 410 microns if there is a 160 micron flap or 350 microns if there is an 100 micron flap. It would make sense therefore that lifting the flap and cross linking of the residual stromal bed would be preferable to either of the two delivery methods currently being investigated. This method would directly target the corneal tissue affected and allow for the comfort of a trans-epithelial procedure approach while provide the effectiveness of the epithelium-off procedure. An even greater benefit to this approach is that if subsequent kerato-refractive refinement is considered via PRK in the LASIK flap, the tissue to be treated will not have been treated in the cross-linking process. Unfortunately, a photo-toxicity effect on the cornea endothelium (i.e. the inner lining of the cornea that provides the pump functioning of the cornea to keep it from spontaneously swelling) from UV-A has been calculated to occur in corneas < 400 microns in thickness so unless this issue can be circumvented, cross-linking by lifting the LASIK flap is not currently a viable treatment option.

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Here is a somewhat technical but interesting article which supports something I have been saying for years. It is far too simplistic for a LASIK surgeon to say that they won’t operate on a patient whose cornea measures less than 500 microns (1/2mm) in thickness. Since the cornea flap drapes over the bed post-operatively and doesn’t lend any structural support to the cornea, all support comes from the amount of tissue remaining following flap creation and laser sculpting. And since older keratome devices use to make 160 micron flaps compared with the 100 to 110 micron flaps we now routinely make with the IntraLase all-laser LASIK procedure, it makes intuitive sense that a patient with a 100 micron flap in a 480 micron cornea (380 micron bed) would have more remaining support than a patient who has a 160 micron flap created with a microkeratome on their 500 micron cornea (340 micron bed) This assumes, of course, that no other pathology is noted on the patient’s color scans

LASIK ON THIN CORNEAS?

No association found between GGT, post-LASIK ectasia in eyes with normal corneal shape

By Cheryl Guttman Krader Reviewed by Steven C. Schallhorn, MD

E-mail: steveschallhorn@opticalexpress.com

Dr. Schallhorn Is a consultant to Abbott Medical OptiCS

San Diego-Findings from a retrospective analy­sis including 81,715 consecutive LASIK-treated eyes provide no evidence after 12 to 24 months of follow-up that a “thin cornea” increases the risk for postoperative ectasia, acccording to Steven C. Schallhorn, MD.

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Dr. Cory M. Lessner and Millennium Laser Eye Centers are featured in this episode of the reality TV show Vive la Vie!.

Dr. Cory M, Lessner, performs LASIK eye surgery in one of the members of the show.  Watch the video!

Cory Lessner, MD
Medical Director and CEO
Millennium Laser Eye Centers
Sunrise, Fla.

Life isn’t always fair. Many myopic patients have accepted their
vision impairment as a matter of course, assimilating their contact
lenses or eyeglasses into their persona from an early age. But the
presbyopic hyperope, who never had to wear vision aids and now
needs them to see clearly at any distance, might have difficulty
coming to terms with his need for vision correction. As a 49-yearold-
emmetrope, I know the feeling. It’s difficult to see the food on
my plate in a romantic setting, my Blackberry is getting harder to
read despite maxing out the font, and I’m close to needing
“cheaters” to read and write the treatment calculation on my
patient’s LASIK charts. Perhaps this is why, despite being slightly
less accurate than their myopic counterparts’ treatments, my hyperopic
patients overall seem elated with their treatment outcomes.

Speed and Accuracy Improve Outcomes

I’ve performed about 3200 hyperopic LASIK procedures with
various excimer laser platforms on approximately 1800 patients
since the FDA approved these treatments a decade ago. In
December 2003, my center was one of the first in the nation to
install the Wavelight Allegretto 200Hz following its approval, and I
was immediately impressed by its speed and accuracy. It wasn’t
uncommon for patients to sit up and immediately see the time on
their wristwatches or be able to read a magazine in the hallway 5
minutes later, while waiting to be discharged. In June 2008, we
upgraded to the Allegretto WAVE Eye-Q (400 vs. former 200 Hz)
cutting the treatment times in half and improving accuracy even
further. With the standard default treatment zone utilized on most
patients, it takes only 5 seconds per diopter for hyperopic treatments
(3s/D for myopes). A 6D treatment that takes more than a
minute on some of the other available excimer laser platforms takes
only 30 seconds on the Allegretto.

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