Doctors` Note - LASIK Ft. Worth

DOCTORS’ NOTE
FAL L /
W INTE R 2014
Texas Eye and Laser Center is committed to constantly improving communication with
our referring doctors and co-management partners. Because we share the common goal of
providing the best possible surgical outcomes and comprehensive postoperative care for our
patients, we are happy to introduce Doctors’ Note, a new quarterly newsletter for our referring
doctors and co-management partners. This newsletter is written to keep you up to date with
new clinical and surgical techniques as they evolve.
TEXAS EYE AND LASER CENTER NOW OFFERS
iFS™ Advanced Femtosecond
Laser Technology to Its LASIK Patients
Texas Eye and Laser Center is bringing the next
generation in laser vision correction technology to
the area with iFS™ Advanced Femtosecond Laser
for performing all-laser LASIK vision correction.
Coupled with the iFS technology is our custom
LASIK procedure with Laser Tracking and Iris
registration. Texas Eye and Laser Center is one
of only a few laser centers offering this in Dallas
and Ft. Worth.
We have always been committed to bringing the
safest and most advanced technology to its patients,
and with the addition of the iFS™ laser, we’re raising
the standards of laser vision correction yet again.
STAR S4 IR™ Excimer Laser
Laser Tracking and Iris Registration
iFS™ Advanced Femtosecond Laser
FOR MORE INFORMATION, PLEASE CONTACT TEXAS EYE AND LASER
CENTER AT (817) 540-6060 OR VISIT TEXASEYELASER.COM.
The Femtosecond Difference
by Perry Binder, M.D.
With the latest femtosecond laser technology, surgeons can make customizable,
stable, and safer flaps more quickly than ever.
Femtosecond technology now provides
surgeons with the ability to biomechanically
design the LASIK flap by controlling its shape
(diameter, hinge size, side-cut architecture,
elliptical or round) and thickness, while also
increasing safety and speed.
The technology has evolved tremendously since its
commercial introduction in 2001. Now, a
fifth-generation femtosecond laser (iFS
Advanced Femtosecond laser, Advanced
Medical Optics, AMO, Santa Ana, Calif.)
allows the flap to be created in less than
10 seconds.
SPEED
The increased speed allows surgeons to
use less energy per spot and to place the
spots and lines closer together. Less pulse
energy has the potential to decrease the
incidence of the opaque bubble layer (OBL).
In addition, faster flap creation means less
suction time on the eye, which contributes
to patient comfort. Arturo Chayet, M.D.,
Tijuana, Mexico, conducted the first two
clinical studies using the iFS laser. The first
series determined the optimal settings for
the laser, while the second series looked
at the clinical advantages of customizing
flap dimensions for a given patient. With
the iFS laser, the spot line separation can
be decreased from the current 8 to 9 microns and line separation to as low as 5 x
5 microns (although the software permits
even tighter placement). Thus flap lifts are
virtually effortless and the beds potentially
smoother than even those with the current
IntraLase FS system.
MECHANICAL STABILITY
OVAL-SHAPED FLAPS
The iFS uses new software that allows surgeons to customize the shape of the flap
based on the patient’s corneal diameter,
shape, and the excimer laser ablation profile.
The surgeon may choose the elliptical flap
option, which creates a larger stromal bed
area. While maintaining the vertical diameter,
the horizontal diameter is enlarged, pushing
the hinge away from the ablation zone. This
prevents the risk of hinge ablation or allows
the creation of a wider hinge, enhancing
flap stability. Perhaps the most interesting
and unique feature of the new iFS laser is
the ability to create an inverted “bevel-in”
side cut. The new iFS laser side cut can
be programmed from 30 to 150 degrees
(similar to a mechanical microkeratome).
The
purpose for making a more vertical flap
edge was initially based on a pig eye study
that measured how much force it took to
dislocate a flap. When the walls are more
perpendicular it is more difficult to move
that flap. Studies conducted independently
and most recently by Prof. John Marshall
and Prof. Dr. Michael Knorz prove that the
140- to 150-degree bevel-in side cut is an
essential component to a biomechanically
stable cornea, Prof. Knorz’ comparative
study concluded that flaps created with
the iFS laser, utilizing a 140-degree side
cut, required three times as much force to
dislodge than those created with a modern
microkeratome.
Side-cut architecture with
the iFS femtosecond laser may also decrease
the incidence of epithelial in-growth, which
is common after enhancing
a microkeratome flap, but
it’s much less common after
enhancing a femtosecond
flap. Femtosecond lasers
have many clinical applications. In addition to flapmaking capabilities, surgeons
also have the ability to create
channels for the implantation
of intracorneal ring segments,
wedge resections, corneal tattooing,
limbal stem cell transplantation, lamellar
and full thickness corneal transplants,
retinal keratoplasty, corneal biopsies,
and IntraLase Enabled Keratoplasty
(IEK) patterns.
The iFS laser enables the surgeon to change
the shape of a flap from round to a 12%
oval, in which the vertical meridian is 12%
shorter than the horizontal meridian. This
shape is beneficial in hyperopic ablations for
preventing the excimer laser from ablating
the hinge. With a circular flap, the surgeon
would have to decrease the hinge’s arc
length from a width of 45° to 30° in order to
move the hinge away from the path of the
ablation. The tradeoff is that a hinge with
a shorter width can decrease the strength
and stability of the flap. By choosing an
oval shape, the surgeon can maintain the
same hinge angle or even increase it without
crossing the ablation’s path. The oval flap
shape can be made with either a nasal or
a temporal hinge. Long-time contact lens
wearers who have significant blood vessels
in the cornea’s vertical meridian may also
benefit from this option, because the surgeon
can avoid cutting across those vessels and
inducing bleeding in the interface.
There is some preliminary anecdotal evidence that creating an oval flap severs fewer
nerves and corneal lamellae. Preserving
these tissues would contribute to stronger corneal biomechanics and reduce the
symptoms of dry eye as well as the risk of
corneal ectasia.
This state-of-the-art technology truly represents a significant advance in the field of
refractive surgery.
iFS™ Advanced
Femtosecond Laser
TO LEARN MORE ABOUT FEMTOSECOND LASER TECHNOLOGY,
PLEASE CONTACT TEXAS EYE AND LASER CENTER AT (817) 540-6060
OR VISIT TEXASEYELASER.COM.
(817) 540-6060
TexasEyeLaser.com
© 2013 Stubenbordt Consulting, Inc. • ALL RIGHTS RESERVED
2
Update: Pterygium Removal
A pterygium is a wedge-shaped, benign, fibrovascular growth pterygium excision include discomfort, infection, bleeding,
extending from the conjunctiva onto the cornea. Pterygia scarring, and recurrence. The risk of infection is less than
1%. Patients are given topical antibiotics postoperatively
for prophylaxis. In addition, subconjunctival hemorrhages
are commonly seen afterward since the lesions are vascular,
so it is a good idea to make this known to patients prior
to the procedure so that it does not take them by surprise
if it occurs. Scarring may sometimes be seen, whether on
the cornea or in the form of pyogenic granuloma within the
healing conjunctiva. Topical steroids are given to patients
postoperatively in order to temper healing and help to
reduce scarring. A brief inquiry into whether or not the
patient has a history of keloid formation may be a useful
part of counseling.
are most common in persons from areas near the equator
and are frequently found in people who spend much of their
time outdoors. As a result of prolonged ultraviolet exposure,
conjunctival tissue undergoes a transformation via elastotic
degeneration and slowly creeps onto the corneal surface.
The benign pterygium rarely undergoes further transformation
into a malignant lesion representing conjunctival squamous
cell carcinoma.
Many times, patients are unbothered by pterygia. Other
times, patients may come to the office seeking treatment
for reasons ranging from facial aesthetics to loss of vision.
If a patient is experiencing inflammatory symptoms such as
chronic redness, foreign body sensation, or pain,
then it may be worthwhile for the patient to undergo
a trial of topical medications. Typically, lubricants
are prescribed to the patient. NSAIDs and/or
steroids may be used judiciously. Sometimes the
symptoms may become more severe, particularly
if the pterygium is relatively large and elevated.
Patients may complain of dryness and poor vision. Patients
may state that they have become contact-lens intolerant
because the contact lens abuts the abnormal tissue. If
the pterygium becomes large enough, it may also cause
increased “with-the-rule” or irregular astigmatism as it flattens
the cornea either from the nasal or temporal aspect. Thus,
the patient may experience a slow decline in vision as the
tissue grows. In some cases, a pterygium may grow large
enough to actually block the visual axis. Patients may solely
be bothered by the cosmetic aspect of having chronic and
unsightly red eye that may draw negative attention.
Recurrence rates have been cited between 30% and 50%
with bare scleral techniques versus only 5-12% using
adjunctive methods like intraoperative or preoperative
mitomycin C application, conjunctival autografts, and
amniotic membrane grafts. The technique favored by the
surgeons utilizes either conjunctival autografts or amniotic
membrane transplantation with the usage of mitomycin
C intraoperative application to the residual conjunctival
tissues. In addition, we prefer the use of fibrin glue versus
the older method of suturing the grafts in place. In our
hands, our recurrence rate is routinely less than 10%. Also,
the procedure itself is far more comfortable and convenient
because of the suture-free technique employed. As far as
It is important for the doctor and patient
to evaluate and discuss whether surgical
intervention is necessary.
postoperative discomfort is concerned, patients generally
complain of moderate foreign body sensation and irritation,
which tend to improve with time and heal in approximately
two weeks. All pterygia are sent as laboratory specimens
to verify that they are benign in nature.
If you have a patient who suffers from pterygium, please
do not hesitate to have the patient contact our office at
(817) 540-6060 for a consultation.
It is up to the doctor and patient to discuss and decide whether
or not surgical intervention is necessary. The main risks of
(817) 540-6060
TexasEyeLaser.com
© 2013 Stubenbordt Consulting, Inc. • ALL RIGHTS RESERVED
3
Ft. Worth
Hurst
3405 Locke Avenue, Suite 100
Ft. Worth, TX 76107
To Arlington
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No
30
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wy
Dr
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Wes
West F
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To Fort Worth
W Vickery
Rd
Rd
Hurstview Dr
ood
arw
WH
osed
WR
ood
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WH
Photo Ave
Smiley
Lovell Ave
Trinity
MONTGO MERY
Locke Ave
Brown Trail
To Weatherford
1872 Norwood Drive, Suite 200
Hurst, TX 76054
To Euless
121
183
1872 Norwood Drive, Suite 200
Hurst, TX 76054
(817) 540-6060
TEXASEYELASER.COM
LASIK and the FAA
A pilot’s vision is the most important sense he or she possesses. Their safety, and that of their
passengers, depends on how well they see. LASIK has been approved for NASA astronauts and
military pilots. Pilots considering LASIK should understand the benefits as well as the risk. Our
surgeons can discuss LASIK with pilots during a personal complimentary LASIK consultation; we
can also evaluate patient candidacy. Most patients that have LASIK see 20/20 or better and often
have improved contrast sensitivity and night vision.
The FAA expects that a pilot will not resume piloting aircraft
until his or her own treating health care professional determines:
•
The postoperative condition has stabilized.
•
There have been no significant adverse effects or
complications.
•
The person meets the appropriate FAA vision standards.
If these determinations are favorable and if otherwise
qualified, the pilot may immediately resume piloting but
must ensure that:
• The treating health care professional documents his or her
determinations in the pilot’s health care treatment record.
•
•
A copy of that record is immediately forwarded to the
Aerospace Medical Certification Division in Oklahoma City.
A personal copy is retained.
The pilot may continue flight duties unless informed otherwise by the FAA or another disqualifying condition occurs.