Emil William Chynn, MD, FACS, MBA Park Avenue LASEK 333 Park

Emil William Chynn, MD, FACS, MBA Park Avenue LASEK 333 Park Avenue South, New York, NY [email protected] Evolu&on of Refrac&ve Surgery —  RK, AK (Fyodorov – Russia/Ukraine) —  PRK (Trokel & L’Esperance, Columbia U) —  LASIK (Pallikaris, Greece) —  LASEK (Talamo, Abad & Azar, Mass Eye & Ear —  Intra-­‐LASE, i-­‐LASIK (Kurtz, USA) —  Epi-­‐LASIK, epi-­‐LASEK (Pallikaris, Greece) Original Procedures: Incisional —  “Chance favors the prepared mind” – Louis Pasteur —  Boy falls off bike/glasses shatter/corneal lacs-­‐>no specs! —  Discovery/invention of RK – Svyatoslav Fyodorov —  Hex K – Antonio Medez (Mexico) —  Metal blade-­‐>Diamond blade-­‐>Guarded diamond blade —  Risks: perforation, infection —  Side-­‐effects: starbursts, irregular astigmatism —  Unpredictability, overcorrection (PERK, Waring) First move to the surface: PRK —  Excimer (“excited dimer”) laser, 193 nm —  IBM Labs, Armonk, NY (chip etching) —  Trokel (VISX) & L’Esperance (Summit), Columbia —  US Patent #5,108,388 (1983/87/92), Claim 4: “The method of changing optical properties of an eye by operating solely upon the anterior surface of the cornea of the eye (using) selective UV irradiation and attendant ablative photodecomposition of the anterior surface of the cornea in a volumetric removal of corneal tissue and with depth penetration into the stroma and to a predetermined curvature profile” PRK advantages/disadvantages —  Accuracy —  Myopia, hyperopia, astigmatism —  Stability —  Pain —  Delayed recovery —  Scarring Move away from surface: LASIK —  Rapid recovery —  Nearly instantaneous results / “wow effect” —  Nearly painless —  Decreased risk of scarring —  Flap striae, partial flap, button-­‐hole flap —  Debris, epithelial ingrowth, DLK —  Late trauma —  Ectasia (Speaker/$7mil, Niksarli/$5.6, DelloRusso/$15.3) Safer Flaps: IntraLase/i-­‐LASIK —  Fewer incomplete or button-­‐hole flaps —  Thinner flaps —  Safer for thin corneas, high Rx, irregular astig/FF KC —  Persistent inflammation + photophobia —  DES —  Late flap trauma —  Iatrogenic KC Move “Back to the Surface” —  LASEK – remove epithelium en bloc using EtOH —  Epi-­‐LASEK(IK) – en bloc dissection using epi-­‐keratome —  “Advanced Surface Ablation” (ASA) —  “Flap-­‐on” vs. “flap-­‐off” Epi-­‐LASEK (epi-­‐LASIK) ASA indica&ons (over LASIK) —  Irregular astigmatism/ FF KC —  Thin corneas / high Rx —  Highest Rx treated in NYC (2010) -­‐22 D (600 – 250 = 350) —  Preop BCVA 20/60 OU -­‐ > Postop UCVA 20/40 OU —  Night vision concerns (glare from flap, large pupils) —  Contact sports / hazardous duty (Seals, etc) —  Anterior stromal opacities (scars, dystrophies?) —  Prior RK/AK —  Very special cases (pediatrics? dogs??) Advantages of LASEK/epiLASEK —  Zero flap-­‐related complications (vs. LASIK) —  90% of all complications are flap-­‐related —  Decreased Dry Eye Syndrome (vs. LASIK) —  caused by neurotrophic cornea/hypesthesia —  Decreased inflammation/pain (vs. PRK) —  Decreased risk of scarring (vs. PRK) —  Quicker recovery time (vs. PRK) —  Safer re-­‐treatments of complicated (LASIK) cases Sta&s&cal Trends (MarketScope) Complicated LASIK enhancements —  Safer to re-­‐treat surface/flap —  No increased depth/decreased stromal bed —  No added risk of ectasia —  No chance of epithelial ingrowth/corneal melt —  No risk of DLK —  No incomplete flaps —  No risk of recutting flaps Enhancement procedure —  LASEK OU + MMC + CustomVue WaveFront (HD) —  LASEK – safer than epi-­‐LASEK on retreatments —  To prevent scarring: —  MMC—mitomycin C (1 sec / sec. of ablation time) —  Vitamin C —  oral steroids (methylprednisolone) x 1 week —  PredForte (prednisolone acetate) QID, taper over mos —  UV protection —  CustomVue WaveFront—Prevue Lens PreVue Lens: 1
useful in complex cases —  LASIK retreatments —  UCVA close to 20/20 —  BCVA not 20/20 —  No objective improvement on manifest refraction —  Subjective complaints disproportionate —  Glare, halos, diplopia, ghosting —  Lawyers, legal considerations 1Bansal, Chynn, Rubinfield, Refractive Surgery Complex Case Management, Cataract & Refractive Surgery Today, July 2008 “Epithelial PreVue” New Universal Way to PreVue —  Can be used with any laser platform (not just VISX) —  More accurate than PreVue —  Larger optical zone —  More realistic “real-­‐life” trial —  Zero downside risk? —  turning lemons into lemonade —  Useful to: —  encourage/discourage enhancement —  “pre-­‐sell”/justify WaveFront upgrade A.F. – 62 yo M s/p RK + AK —  CC: “I can’t see well far or near without glasses!” —  Had multiple RK + AK incisions OU 28 years ago —  VA (distance): 20/80 OD, 20/100 OS, 20/60 OU —  VA (near): 20/100 OD, 20/80 OS, 20/80 OU —  Rx: +3.25 – 2.25 x 80 OD + 4.50 – 4.75 x 95 OS —  Saw numerous LASIK surgeons who said: —  “I wouldn’t touch you with a 10-­‐foot pole!” —  “If you get LASIK you will wind up with pizza slices!” Surgical plan —  Enhance non-­‐dominant eye first —  Wait 3 months before enhancing second eye —  Maximum scarring prophylaxis —  Stress patient compliance —  Frequent post-­‐op visits/SLE to check for scarring —  Slow taper of topical steroids SLE – 1 year postop 1 year postop —  UCVA:
20/20 at distance (OU)
20/25 at near (OU) —  Rx: OD: +0.50 – 0.75 x 13
OS:
-­‐0.75 – 1.25 x 123 —  SLE: clear —  CC: “I can see near and far like when I was 30, which is good as I just married a 30-­‐year-­‐old and am having my tubes reconnected to try to have kids!” LASEK of Granular Dystrophy —  22 yo F – Hx Granular Dystrophy OU —  UCVA
OD: 20/100
OS: 20/80 OU: 20/70 —  BSCVA:
OD: -­‐1.75 – 1.50 x 170 (20/80) OS: -­‐1.00 – 0.50 x 5 (20/70) OU: 20/60 Preop: Granular Dystrophy 1 –year post LASEK for Granular 1-­‐year post-­‐LASEK for Granular —  UCVA
OD: 20/50 OS: 20/40 OU: 20/30 (20/100 preop) (20/80 preop)
(20/70 preop) —  BSCVA:
OD: -­‐.75 – 0.50 x 160 (20/30) (20/80 pre) OS: -­‐.50 – 0.50 x 15 (20/30) (20/70 pre) OU: 20/25 (20/60 pre) Sze H. Wong, BS Lynnette P. Williams, MD Emil W. Chynn, MD, FACS, MBA The authors have no financial interest in the subject ma4er of this poster. Presented at ASCRS, 2011 Study Popula&on: Characteris&cs n = 93 Patients (153 Eyes) Female 47 % Male 53 % Age (mean ± SD; range) 31.4 ± 8.3 (19 -­‐ 66) Eyes With Extreme Myopia (SE ≥ -­‐9) 72 % Eyes With Extreme Hyperopia (SE ≥ +6) 4 % Eyes With Extreme Astigmatism (cyl ≥ -­‐3) 31 % LASEK Eyes 83 % Epi-­‐LASIK Eyes 17 % WaveFront Eyes 61 % Rx Range -­‐22.00 to +7.50 Preop Corneal Thickness 554 ± 39 µm Ablation Thickness 125 ± 36 µm Postop Corneal Thickness 429 ± 50 µm Gain in VA at 3 months Postop UCVA vs. Preop Best Corrected Visual Acuity (BCVA) 100 % of eyes had postop UCVA > preop UCVA! Extreme Myopic Eyes Extreme Hyperopic Eyes Extreme Astigmatic Eyes Number of Lines Gained 8.42 3.58 6.68 LogMAR Gained 1.51 0.77 1.08 Postop UCVA vs. Preop BCVA (%) 1-­‐Mo. 2-­‐Mo. 3-­‐Mo. Postop UCVA ≥ Preop BCVA 40 57 72 Postop UCVA > Preop BCVA 18 25 34 Postop UCVA = Preop BCVA 22 32 38 Complica&ons "   11/153 (7 %) of eyes had postop haze (tr to 2+) "   3/153 (2%) of eyes lost ≥ 1 line of BCVA due to postop haze "   1/153 (0.7%) of eyes lost ≥ 2 lines of BCVA due to postop haze CONCLUSION —  Extreme prescriptions may be safely and effectively treated with Advanced Surface Ablation, combined with adjunctive treatments to prevent scarring —  72% eyes: 3-­‐mo. postop UCVA ≥ preop BCVA —  Further studies are needed to determine whether extremely hyperopic eyes are more likely to lose BCVA and how to avoid this loss
Summary: “ASA” = LASEK + EpiLASEK —  10x safer than primary LASIK or i-­‐LASIK/
IntraLase? —  Definitely safer in complicated enh (RK, AK, PK) —  Need steroids + MMC to prevent scarring —  Slower healing / patient compliance —  “Combine safety of PRK with comfort of LASIK” —  Can “Return to the Surface” revitalize Refractive Surgery? (still 0% penetration of candidate population)