August 2014

 

COVER FEATURE

 

Keratorefractive surgery

LASIK results continue to improve


by Lauren Lipuma EyeWorld Staff Writer

 
   

In this study, the majority of eyes test with better than 20/20 corrected vision preoperatively, demonstrating how high the bar is set for postoperative outcomes.

Three months after Custom IntraLase LASIK, more than 95% of eyes tested with an uncorrected vision better than 20/20.

When the preoperative best corrected distance visual acuity (BDVA) is compared to the postoperative uncorrected distance visual acuity (UDVA), improvement is evident at all levels of vision.

Source (all): Louis Probst, MD

Experts discuss LASIK outcomes in the modern refractive era

More than 15 years after the Food and Drug Administration approved LASIK, results of the refractive procedure continue to improve. According to 3 top LASIK providers, refractive surgeons have been evolving their techniques in response to improved technology and are providing increasingly better outcomes for patients.

LouProbst, MD, national medical director of TLC Laser Eye Centers, Chicago; Steven Schallhorn, MD, in practice in San Diego; and Kerry Solomon, MD, Carolina Eyecare Physicians, Charleston, S.C., discussed recent improvements in the refractive procedure, current outcomes, and the future of LASIK surgery. The surgeons focused on trends in the major factors that they use to measure the success of the procedurepostoperative visual acuity, the incidence of complications and side effects, and patient satisfaction. The physicians agreed that there are technological and human components that have contributed to increases in visual acuity and patient satisfaction and decreases in complications and side effects. Technological advances in the field have made the procedure safer and more effective, with physicians learning how to better use those technologies to their advantage.

The technology-human interface

Custom ablations with systems such as the CustomVue (Abbott Medical Optics, AMO, Santa Ana, Calif.) have allowed for safer surgeries and more refined ablation profiles, according to Dr. Probst. These have incorporated features such as iris registration, adjustment for centroid shift, and improved eye trackers. In addition, the use of femtosecond lasers to create the LASIK flap has virtually eliminated serious flap complications. The IntraLase system (AMO) has essentially eliminated epithelial ingrowth and flap striae seen previously with the microkeratome, Dr. Probst said. Those things translate into a safer procedure, but I think that the planar flap has translated into better optics, and that has resulted in incremental improvements in visual acuity after the procedure, he said. With these technological innovations, surgeons are able to provide more precise custom procedures and better select their refractive goals. Surgeons can also use the technologies available to refine their patient selection, becoming more conservative with some groups of patients and more liberal with others. Patients with dry eye or certain levels of hyperopia may not be treated now, said Dr. Schallhorn, or may undergo therapy to get their conditions under control before surgery. Conversely, patients with large pupils who were formerly excluded can now be treated. Weve gotten better at triaging who the best candidates are, and we have other modalities available to patientsviable contact lenses and phakic lenses that were not available 10 years ago, Dr. Solomon said. So even though we had LASIK approved in the upper range, we didnt have any alternatives. Today, we have alternatives. For higher myopes, for example, were more likely to proceed with a phakic IOL. For hyperopes, were more likely to proceed with a refractive lens procedure. Those subtle improvementsand they have been subtlehave gradually improved the outcomes year to year, Dr. Probst said.

Benchmarks of success

Today, surgeons are striving for higher postoperative visual acuity than beforeand are achieving it. In the original FDA trials, 60% of patients were in the 20/20 range. Today, the numbers have improved: 60% are 20/15 or better and 90% to 95% are 20/20, according to Dr. Solomon.

Today almost everyone is on the money or awfully close, he said.

The fact that were achieving vision better than [20/20] could speak to the quality of the ablations and the quality of the surgery. The eye has the potential to see better than 20/20, its just a question of whether or not we can optimize patients visual systems, he said. Back in the early days of refractive surgery, we were happy if patients could see 20/20, and we considered that to be a victory, Dr. Probst said. In the whole modern refractive eraand I think this will translate to cataract surgery toowhat we find is that 20/20 is not a very ambitious benchmark for a postoperative outcome.

I think in our society, the laser vision correction deal is that you have no problems, that youve paid your money, and that youre going to have better vision than youve ever had before. What we want to do is have people seeing better than they were beforethat should be our benchmark. With the current technology, we can do that in the vast majority of people, he said. The physicians agreed that patient satisfaction is the final measure. The bottom line, according to Dr. Schallhorn, is what the patients think about their LASIK results. It is critical to maximize visual acuity and minimize side effects and complications to have a successful refractive business. Side effects such as dry eye and poor night vision due to glare or halos are correlated to the postoperative residual refractive error, he said, so focusing on achieving the best possible uncorrected visual acuity is key to reducing these effects. One suggestion that Dr. Probst made for increasing patient satisfaction is to demonstrate to patients how their vision has improved postoperatively. To hear the numbers and to hear that youre seeing better than 20/20, you walk out of the clinic feeling like youve got a superpower of some sort. This is a way that we can use our advanced outcomes to increase our patient satisfaction, he said.

Future of refractive surgery

Drs. Probst, Solomon, and Schallhorn agreed that outcomes will continue to improve and that refractive surgeons will see new technologies become available in the coming years. In Europe, eye trackers are more advanced than in the U.S., Dr. Probst said, and can account for eye rotation.

There are improvements in aberrometers and the iDesign unit [Abbott Medical Optics], he said. That should allow a higher resolution wavefront map, which could be translated into better procedures. Femtosecond lasers continue to become faster and more precise, and that will result in smoother beds and faster procedures, which will be less traumatic on the eye. I think were going to see our procedures get more refined, less invasive, and more accurate, said Dr. Solomon. New refractive procedures are on the horizon, he added, such as all femto-based intrastromal ablations like the SMILE procedure (Carl Zeiss Meditec, Jena, Germany). The refractive landscape will continue to change as new procedures emerge and existing ones evolve. I see a progressive march toward better outcomes with the surgery, Dr. Schallhorn said. I think medicine in general, and certainly these procedures, move in one directionto improve the outcomes; weve certainly seen that over the last 10 years or so, and well continue to see that.

Editors note: Dr. Probst has no financial interests related to his comments. Dr. Schallhorn has financial interests with AMO and Carl Zeiss Meditec. Dr. Solomon has financial interests with Bausch + Lomb (Bridgewater, N.J.), AMO, and Alcon (Fort Worth, Texas).

Contact information

Probst
: 708-562-4682
Schallhorn: scschallhorn@yahoo.com
Solomon: kerry.solomon@carolinaeyecare.com

LASIK results continue to improve LASIK results continue to improve
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