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    Cataract & Refractive (page 5)

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    Is LASIK losing its popularity?
    Moving away from cataract complications, we are continuously being reminded that cataract surgery is becoming more and more like refractive surgery. However, with innovations in IOLs yielding impressive lenses and with the promise of more innovations to come, should we perhaps be looking at this in another way? Might refractive surgery be morphing into cataract surgery by becoming more of a lens-based procedure?

    Although LASIK remains the gold standard for refractive corrections, more surgeons and patients are considering the long-term outcomes of corneal ablation and instead opting for the safer, and reversible approach, i.e. lens implantation.

    "The number of lens implantations is naturally much lower than that of ablation procedures simply because it is an intraocular surgery. Despite this, I do believe that phakic IOLs have evolved significantly in recent years and are no longer associated with the complications that they once were. Now, I implant IOLs in around 5 to 10% of my refractive surgery patients," commented Professor Dick.

    "…iris registration has signified a
    major development in the field of
    refractive surgery, the use of which
    has been more widespread this year"

    Although it doesn't appear as though any procedure is going to knock LASIK from the number one spot just yet, this year has witnessed very few innovations in ablation surgery. Rather, according to Dr Vergés, 2007, has been a year of learning more about the capabilities of newer technologies, such as premium IOLs, femtosecond lasers and wavefront-guided ablations. "I personally learned that the degree of optical aberration does not necessarily dictate visual quality. For example, a patient with some degree of aberration could have better vision than another who has no aberration. This proves that a better optical condition does not always equal better visual quality. We need to learn more about this mechanism," said Dr Vergés.

    Following on from this, Dr Amar Agarwal feels that he and his team of co-workers have unveiled a previously unidentified refractive entity, which may go some way to explain Dr Vergés' thoughts. Specifically, Dr Agarwal has presented a new refractive entity — aberropia. This proposed condition results from a net negative effect of higher-order aberrations, which results either from the inadequacy of helpful aberrations or because only detrimental aberrations are present in the eye, thus resulting in visual deterioration, even after wavefront-guided LASIK.5

    Dr Agarwal therefore suggests that this residual refractive error can be corrected either by changing the way the aberrations interact or by bringing the total wavefront error down to zero.


    Michael Knorz, MD on the other hand suggests eradicating residual ametropia with the bioptics combination approach.6 Based on his experience, Dr Knorz has increased the rate of spectacle-independence in his cataract and refractive lens exchange patients implanted with a multifocal IOL from 85-90% to 99%, by including a wavefront-guided LASIK enhancement in his treatment approach.

    New technology gets the thumbs up
    In terms of new technologies, this year has been somewhat quieter than previous years, in the area of refractive surgery technology launches. Worthy of note was Schwind's launch of the new AMARIS excimer laser, which received its debut at this year's ESCRS congress. This new system combines a 1,050 Hz turbo eye tracker (5D eye tracker), accurate ablations via the "TotalTech Laser", which has a true pulse laser frequency of 500 Hz, and two automatically adapted fluence values. A control mechanism is able to dynamically adapt the distribution of laser pulses in order to reduce significant corneal heating and online pachymetry provides continuous measurement of corneal thickness. Three-month results with the new system so far have demonstrated excellent visual acuity results and high predictability.

    "For me, iris registration has signified a major development in the field of refractive surgery, the use of which has been more widespread this year. Not only does it assist with the treatment of spherical aberration, but also astigmatism, coma and other aberrations, to provide a truly customized wavefront-guided treatment," said Professor Dick. "This is a terrific innovation and, in my opinion, it is a must for all refractive surgeons. More and more of my patients are now opting for wavefront-guided treatments," he added.

    "I have been a little frustrated and
    disappointed by wavefront-guided
    laser technology. I perform surface
    ablations and I do not see better
    results with wavefront, as other
    surgeons suggest"

    Dr Vergés also believes his practice has benefited from the ocular response analyser (ORA) technology (Reichert), which has allowed him to study corneal biomechanics.

    "I have to admit, I have been a little frustrated and disappointed by wavefront-guided laser technology. I perform surface ablations and I do not see better results with wavefront, as other surgeons suggest," said Dr Vergés. "In my experience, wavefront-guided surgery is better in patients with a RMS higher than 0.4, but it does not improve 'normal' patients with some degree of aberration. I have also been disappointed by the laser treatment of presbyopia. In my opinion, the results are not very encouraging," he conceded.

    The rebirth of surface ablations
    Elsewhere, the rebirth of surface ablation procedures and the increasing popularity of sub-Bowman's keratomileusis (SBK), the continued evolution of the phakic and multifocal IOLs, the growing evidence of the safety and efficacy of intracorneal implants and corneal cross-linking as well as the advancement of new techniques with femtosecond laser technology have all contributed to the myriad of options available to today's refractive surgeon.

    "I have personally been very surprised by the good results that I have obtained with surface ablation, using the Epi-K (Moria), i.e. Epi-LASIK. Based on my experience so far, we have been able to control pain and obtain rapid visual recovery with this technology," said Dr Vergés. "This is very interesting because people are afraid of traditional PRK, but this is completely new and different," he added.

    Dr Vergés has recently added corneal rings and cross-linking to his practice for his keratoconus and corneal ectasia patients. "These are real innovations and have helped our patients significantly," he enthused.

    Elsewhere, Dr Kuchynka has introduced posterior lamellar keratoplasty (PLK) this year. He believes that it offers advantages over traditional penetrating keratoplasty (PK), including lower postoperative astigmatism and faster visual rehabilitation. "The modification of PLK, i.e. the small incision deep lamellar endothelial keratoplasty (DLEK), has made the surgical procedure easier. In fact, by the end of February 2008, the Eye Bank of Prague will be shipping pre-cut donor tissue directly to surgeons for simple trephination," he noted.

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    Jorge L. Alio, MD, PhD

    Jorge L. Alió, MD, PhD is Professor & Chairman of Ophthalmology and the Medical Director of VISSUM, Instituto Oftalmologico de ...

    Carlos Verges, MD, PhD
    Carlos Vergés, MD, PhD is Professor and Head of the Department of Ophthalmology at C.I.M.A. Universidad Politécnica de Cataluña, ...
    Professor Alessandro Franchini
    Alessandro Franchini, MD works in the Optical Physiopathological Department at the University of Florence, Eye Institute - Azienda ...
    Pavel Kuchynka, MD

    Pavel Kuchynka, MD is Professor of Ophthalmology at the Vinohardy Teaching Hospital, Prague, Czech Republic. He may be reached by ...

    Professor H. Burkhard Dick, MD, PhD

    Professor H. Burkhard Dick, MD is Chairman of the University Eye Hospital Bochum, Bochum, Germany. He may be reached by E-mail: ...

    Christoph Faschinger, MD

    Christoph Faschinger, MD is a Clinical Professor at the Medical University of Graz, Clinic of Ophthalmology, Graz, Austria. He may be ...

    Fedra Pavlou
    Fedra Pavlou is the Editor-in-Chief of Ophthalmology Times Europe. She may be reached by Tel: +44 (0)1244 393 420 or E-mail:

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