FEMTO-LASIK and BEYOND - Carl Zeiss, Inc.

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24 Ophthalmology WORLD REPORT International Refractive User Symposium Kuala Lumpur, Malaysia VisuMax in Keratoplasties Dr Khaled Ben Amor on “Keratoplasties with VisuMax” “Even in DLK, the results of femtosecond laser are very nice optically and we have much more success rate with the technique.” Keratoplasties with VisuMax: : Dr Ben Amor shared his experiences about the keratoplasty with VisuMax which according to him is “the obligation of the VisuMax, much beyond refractive surgery”. Discussing the advantages of the VisuMax he said that it offered a curved corneal interface and a planar cut. He then showed the high performance optics in ZEISS that was the key to optimum cut. He shared videos showing how it was easy to lift a donor graft and those for keratoconus hydrops, corneal scarring, bullous keratopathy and adherent leucoma. Dr Ben Amor also discussed the advantages of the femto penetrating keratoplasty due to the regular side cut. “Better centration and better donor recipient fit give a nice optical result better than that with a manual keratoplasty,” he said. Deep lamellar keratoplasty (DLK): He explained the principle approach in a DLK which required the separation of the endothelium from the stroma by injecting a bubble. In manual DLK, the bubble layer is seen in around 52% cases which necessitate desiccation of the rest of the stroma. According to him, Femto DLK ensures precision during surgery. Dpt Dense central corneal scarring (Dr. Burjor P. Banaji, India) “The cut can easily be lifted and then a big bubble is injected which works in 75% of cases. It is much easier to take off the remaining stroma. So, you have a complete Descemet barring which is very important. This happens in 90% of the Femto DLK cases versus 60% in manual DLK,” Dr Ben Amor added. Dr Burjor P. Banaji on “Challenging Cases Corrected with Topography-Linked LASIK” Clinical experiences: Dr Banaji shared his experiences with topography-guided LASIK in some “weird” cases he has done over the past few years, which otherwise would be very difficult if not impossible to treat with the standard modalities of LASIK. He showed the topographical picture of a corneal central island. He shared another case of multiple prior corneal surgeries. He then shared interesting results in a patient who had dense corneal scarring after a lacerating full thickness injury to the cornea many years ago and was complaining of haloes, scatter and distortion of images. The refraction was -8D spherical with -5D cylindrical and BCVA was approximately 6/36. The scar was right in the center of the pupil and the corneal thickness was almost 600μm. “We smoothened the bed and about 4-5 months later lifted the flap and corrected the residual error again with a topography guided treatment,” he specified. He showed the large 10D shift in the center of the pupil that was causing debilitating symptoms and how just smoothing it with topography brought down the dioptric shift by 6D, thus abating the symptoms. LASIK was planned as the patient was still severely myopic. The pre-op refraction was -8D/-5D and post-op it miraculously was -0.75D. “I could not have done it with anything other than a topography-guided treatment,” added Dr Banaji. Further, he discussed a post-op cataract case, which was referred to him in not very distant past. A well-centered multifocal IOL was given and there was a residual astigmatism.“Confirm that your central rim and the lights are like a bull’s eye, one within the other when the patient is asked to look into the microscope after the procedure. Then you see that your lens is centered properly. You will often need to decenter your lens nasally for that to happen. When you look at your eye postoperatively, that ring should, if you have done your job properly, never be in the center of our pupil,” he explained. He attributed the astigmatism to an LRI that “had done something very naughty to the cornea”. The patient was not only having an asymmetrical astigmatism, it was non-orthogonal. “Post-op the patient was very happy and the topography has worked very well,” he said in delight.
June 2012 Supplement 25 Conclusion: Dr Banaji supported that ZEISS had the best refractive outcome among all topography-guided systems. He referred to the topography-guided treatment as “ZEISS’ hidden jewel” and called it an “Optical success for Carl Zeiss”. Topography assisted ablation with Carl Zeiss Meditec MEL 80 and CRS-Master (Dr Ruben Lim-Bon-Siong, Philippines) Dr Ruben Lim Bon Siong on “Topography- Guided Refractive Surgery: For the Sins of Our Past and Present” “It is not the end of the road when a flap complication occurs. There are topography-guided procedures that can help these kinds of problems.” a) Change in Snellen lines of BCVA (N=48) Topography-guided refractive surgery: Dr Lim Bon Siong spoke of the topographically customized systems that aim to correct an irregular corneal surface. He shared the published results of topography-guided ablation with MEL 80 and CRS-Master by Dan Reinstein. The results were of 48 eyes in 32 patients who underwent the procedure for small optic zones, decentered ablations, decentration after radial keratotomy, high myopia after deep lamellar keratoplasty, irregular astigmatism due to wound gape following cataract surgery and irregular astigmatism due to scars. The median follow-up was 7.7 months (1 month to more than 1 year) and the mean preop spherical equivalent was -1.12D ± 1.97D with a mean preoperative cylinder of -1.34D ± 1.65D. “All patients had good topographies. LASIK, LASIK-enhancements, or PRK were done and treatments were centered on the corneal vertex. “It is a very safe procedure. None of the patients lost more than 2 lines after the procedure.” Speaking about the accuracy, he said, “79% of patients were within +/- 1D and 63% within +/- 0.5D. All these patients had an improvement of least 2 lines or more. This was very significant compared to the pre-op. It is very stable. All patients had improved contrast sensitivity.” Clinical cases: Dr Lim Bon Siong discussed clinical experiences including cases of a central island, post-LASEK corneal scar, lost cap and incomplete flap. Additionally, he discussed a case of a 22-year-old male Filipino who underwent LASIK with XP microkeratome and ended in an incomplete flap with subsequent haze in the left eye. The preoperative refraction of OS was -3.25-0.50 x 170 (20/20). Three months after the the flap complication, the UCVA was 20/200 with refraction of +6.50 -2.00 x 170 and BCVA 20/30. In this patient a transepithelial PTK was done with ablation depth of 50µm and a diameter of 8mm b) Accuracy c) UCVA improvement d) Stability
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