Lasik and Beyond Lasik Wavefront Analysis and Customized Ablations

517 Pages·2001·37.3 MB·English

by  Prof. Benjamin Boyd

Editor-in-Chief:
BENJAMIN F. BOYD, M.D., F.A.C.S.
Editors:
SUNITA AGARWAL, M.S.;D.O.;F.S.V.H.
ATHIYA AGARWAL, M.D.;D.O.;F.R.S.H.
AMAR AGARWAL, M.S.;F.R.C.S.;F.R.C.Ophth
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Project Director: Andres Caballero, Ph.D
Production Manager: Kayra Mejia
Page Design and Typesetting: Kayra Mejia
Laura Duran
Art Design: Eduardo Chandeck
Spanish Translation: Prof. Juan Murube, M.D.
Sales Manager: Tomas Martinez
Marketing Manager: Eric Pinzon
Customer Service Manager: Miroslava Bonilla
International Communications: Joyce Ortega
©Copyright, English Edition, 2002 by HIGHLIGHTS OF OPHTHALMOLOGY
All rights reserved and protected by Copyright. No part of this publication may be reproduced, stored in retrieval
system or transmitted in any form by any means, photocopying, mechanical, recording or otherwise, nor the illustrations
copied, modified or utilized for projection without the prior, written permission of the copyright owner.
Due to the fact that this book will reach ophthalmologists from different countries with different training,
cultures and backgrounds, the procedures and practices described in this book should be implemented in a manner
consistent with the professional standards set for the circumstances that apply in each specific situation. Every effort
has been made to confirm the accuracy of the information presented and to correctly relate generally accepted practices.
The authors, editors, and publisher cannot accept responsibility for errors or exclusions or for the outcome of the
application of the material presented herein. There is no expressed or implied warranty for this book or information
imparted by it.
Any review or mention of specific companies or products is not intended as an endorsement by the authors or
the publisher.
Boyd, Benjamin F., M.D.; Agarwal, Sunita, M.S.; Agarwal, Athiya, M.D.; Agarwal, Amar, M.D.
"LASIK and Beyond LASIK - Wavefront Analysis and Customized Ablation"
ISBN Nº 9962-613-04-3
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EDITOR-IN-CHIEF
BENJAMIN F. BOYD, M.D., D.Sc. (Hon), F.A.C.S.
Doctor Honoris Causa
Immediate Past President, Academia Ophthalmologica Internationalis
Honorary Life Member, International Council of Ophthalmology
Editor-in-Chief and Author, HIGHLIGHTS OF OPHTHALMOLOGY, 25 Hard Cover Volumes and
the 15 million copies of HIGHLIGHTS OF OPHTHALMOLOGY Bi-Monthly Journal.
Recipient of the Duke-Elder International Gold Medal Award (International Council of Ophthal-
mology), the Barraquer Gold Medal (Barcelona), the First Benjamin F. Boyd Humanitarian Award and
Gold Medal for the Americas (Pan American), the Leslie Dana Gold Medal and the National Society for
Prevention of Blindness Gold Medal (United States), Moacyr Alvaro Gold Medal (Brazil), the Jorge
Malbran Gold Medal (Argentina), the Favaloro Gold Medal (Italy).
Recipient of The Great Cross Vasco Nuñez de Balboa Panama's Highest National Award.
EDITORS
DR. SUNITA AGARWAL, M.S.;D.O.;F.S.V.H. (Germany)
Pioneer in the world in the field of Laser Cataract Surgery. She heads Dr.Agarwal’s Eye Hospital at
Bangalore, India and Dr.Agarwal’s Eye Clinic at Dubai (UAE). She is an expert in the field of Lasik Laser
as she is in the field of cataract surgery under No Anesthesia. She has brought out for the first time in the world
the use of the Air Pump as a new method to prevent surge and also found out that the internal tube of the phaco
machine can lead to endophthalmitis . She practices at Dr.Agarwal’s Eye Hospital, 15 Eagle Street, Langford
town, Bangalore-560 025, India and at Dr.Agarwal’s Eye Clinic,Villa No.2, Roundhouse 3, Al Wasl Road,
Dubai Post box 9168, UAE.
DR. ATHIYA AGARWAL, D.O.;F.R.S.H. (London)
Excellent surgeon who trains ophthalmologists from all over the world in Lasik and Phaco.
She performs No anesthesia cataract surgery, Phakonit and Lasik Laser quite easily. Dr.Athiya is a very good
speaker and teaches routinely in various conferences nationally and internationally. She practices at
Dr.Agarwal’s Eye Hospital, 19 Cathedral Road, Chennai (Madras) – 600 086, India.
DR. AMAR AGARWAL, M.S.;F.R.C.S.;F.R.C.Ophth (London)
Started for the first time in the world "No anesthesia cataract surgery", "Phakonit (cataract removal
through a 0.9 mm incision)" and "Favit" a new technique to remove dropped nuclei. He is a very dynamic
speaker. He has a double FRCS to his credit. His parents Dr. J. Agarwal and Dr. Mrs.T.Agarwal, Sister
Dr.Sunita Agarwal, wife Dr.Athiya Agarwal and Brother-in-law Mr.Pankaj Sondhi help him in his aim to
perfection. He practices at Dr.Agarwal’s Eye Hospital, 19 Cathedral Road, Chennai (Madras) – 600 086,
India.
Dr.Agarwal’s Eye hospital at Chennai is the only eye hospital in the world built in the shape of an eye
and has been included in the Ripley’s Believe it or not series. Dr.Agarwal’s Eye Hospital is at Chennai (India),
Bangalore (India) and Dubai. The web site of the hospital is: http://www.dragarwal.com
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Contributing Authors
Agarwal, Amar, M.S.,FRCS;FRCOphth Avalos U., Guillermo, M.D. Carvalho, Luis A., PhD.
Medical Director, Chief, Department of Ophthalmology Institute of Physics
Dr. Agarwal's Group of Eye Hospital Hospital Sagrado Corazon; University of Sao Paulo, Brazil
Chennai, India Medical Director,
Clinica Laser Oftalmico Castro, Jarbas C., PhD.
Agarwal, J., FORCE;DO;FICS Guadalajara, Mexico Professor,
Chairman, Institute of Physics
Dr. Agarwal's Group of Eye Hospital, Belda, Jose I., M.D. University of Sao Paulo, Brazil
Chennai, India; Instituto Oftalmologico de Alicante
Bangalore, India; Alicante, Spain Cigales, Melania, M.D.
Dubai (UAE) Instituto Oftalmologico de Sabadell
Benelli, Umberto, M.D. Sabadell, Spain
Agarwal, Sunita, MS;DO;FSVH Department of Neurosciences
Medical Director; Section of Ophthalmology Coelho, Etelvino, M.D.
Dr. Agarwal's Group of Eye Hospital University of Pisa Director, Centro de Microcirugia
Bangalore, India Pisa, Italy Refrativa & Excimer Laser de
Minas Gerais
Agarwal, T.; FORCE;DO;FICS Border, Andrea D., O.D. Belo Horizonte, MG Brazil
Managing Director, Discover Vision Centers
Dr. Agarwal's Group of Eye Hospital, Kansas City, Missouri Coret, Andreu, M.D.
Chennai, India; Medical Director,
Bangalore, India; Instituto Oftalmologico de Barcelona
Dubai (UAE) Boyd, Benjamin F., M.D., F.A.C.S. Barcelona, Spain
Editor-in-Chief,
Alio, Jorge L., M.D. Highlights of Ophthalmology Int., Cummings, Arthur, MB, ChB Mmed
Director, Panama, Rep. of Panama (Ophth) FCS(SA), FRCS (Edin)
Instituto Oftalmologico de Alicante Wellington Ophthalmic Laser Clinic
Alicante, Spain Butler, Jason, M.D. Dublin, Ireland
Long Beach Laser Center
Attia, Walid, M.D. Long Beach, California Charles, Steve, M.D.
Instituto Oftalmologico de Alicante Clinical Professor
Alicante, Spain Carriazo E., Cesar, M.D. Department of Ophthalmology
Medical and Scientific Director University of Tennessee
Carriazo Ophthalmological Center, Center of Health Science
Colombia Memphis, Tennessee
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CONTRIBUTING AUTHORS
Chamon, Wallace, PhD. Hardten, David R., M.D. Lindstrom, Richard, M.D.
Refractive Surgery Division Director of Refractive Surgery Medical Director,
Escola Paulista de Medicina Minnesota Eye Consultants; Phillips Eye Center for Teaching
University of Sao Paulo, Brazil Clinical Associate Professor of and Research;
Ophthalmology Clinical Professor,
Choudhry, Saurabh, D.O., FERC. University of Minnesota University of Minnesota,
Fellow, Dr. Agarwal's Eye Hospital, Minneapolis, Minnesota Minnesota, Minneapolis
Chennai, India
Haw, Weldon, M.D. Mahmoud M. Ismail, M.D., Ph.D.
Choudhry, Reena, M., DO.;FERC. Cornea & Refractive Surgery, University of Al-Azhar,
Fellow, Dr. Agarwal's Eye Hospital, Department of Ophthalmology, Cairo, Egypt
Chennai, India Stanford University School of Medicine
Stanford, California Manche, Edward E., M.D.
Davis, Elizabeth, A., M.D. Assistant Professor of Ophthalmology
Associate, Hoyos, Jairo E., M.D. Stanford University
Minnesota Eye Consultants, PA; Medical Director School of Medicine
Assistant Clinical Professor Instituto Oftalmologico de Sabadell Stanford, California
University of Minnesota Sabadell, Spain
Minneapolis, Minnesota Martiz, Jaime R., M.D.
Hoyos-Chacon, Jairo, M.D. Refractive Surgery Consultant;
Denning, James A., B.A., B.S. Instituto Oftalmologico de Sabadell The Laser Center, Houston, Texas;
Discover Vision Centers Sabadell, Spain Course Director & President
Kansas City, Missouri International Lasik Course
Katsanevaki, VJ, M.D. Houston, Texas
Doane, John F., M.D. Department of Ophthalmology
Discover Vision Centers University of Crete-Medical School McDonald, Marguerite, M.D.
Kansas City, Missouri Crete, Greece Director,
Southern Vision Institute
EuDaly, Lon S., O.D. Knorz, Michael C., M.D. New Orleans, Louisiana
Discover Vision Centers Klinikum Mannheim
Kansas City, Missouri Mannheim, Germany Morris, Scot, O.D.
Discover Vision Centers
Feinerman, Gregg, M.D. Koch, Paul S., M.D. Kansas City, Missouri
Medical Director, Koch Eye Associates
Feinerman Vision Institute, Warwick, Rhode Island Murube, Juan, M.D.
Long Beach Laser Center, Professor of Ophthalmology,
Long Beach, California; Krueger, Ronald, M.D. University of Alcala;
Assistant Clinical Professor, Medical Director, Chairman, Dept. of Ophthalmology,
University of California, Department of Refractive Surgery, Hospital Ramon y Cajal
Irvine, California The Cleveland Clinic Foundation Madrid, Spain
Cole Eye Institute
Gatell, Jordi, M.D. Cleveland, Ohio Narang, Sameer, M.S.
Instituto Oftalmologico de Barcelona Director, Narang Eye Clinic
Barcelona, Spain Lara, Elvira, O.D. Ahmedabad, Gujarat, India
Instituto Oftalmologico de Barcelona
Ginis, HS., BSc Barcelona, Spain Narang, Priya, M.S.
Department of Ophthalmology Director, Narang Eye Clinic
University of Crete-Medical School Lavery, Frank, MCh FRCSI FRCS Ahmedabad, Gujarat, India
Crete, Greece (Edin) DOMS
Wellington Ophthalmic Laser Clinic Narasimhan, Smita, M.B.B.S.,FERC
Gomez, Javier J., M.D. Dublin, Ireland Consultant, Dr. Agarwal's Eye Hospital,
Instituto Oftalmologico de Alicante Chennai, India
Alicante, Spain
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CONTRIBUTING AUTHORS
Nardi, Marco, M.D. Preetha R., M.B.B.S; FERC Simon-Castellvi, Jose Ma., M.D.
Associate Professor Fellow, Dr. Agarwal's Eye Hospital, Clinica Oftalmologica Simon,
Department of Neurosciences Chennai, India Barcelona, Spain
Section of Ophthalmology
University of Pisa Probst, Louis E., M.D. Simon-Castellvi, Sarabel, M.D.
Pisa, Italy Medical Director, Clinica Oftalmologica Simon,
TLC The Windsor Laser Eye Center, Barcelona, Spain
Nguyen, Kim, M.D. Windsor, Ontario, Canada
Long Beach Laser Center Slade, Stephen G., M.D.
Long Beach, California Sasikanth, RR., MD The Laser Center,
Dr. Agarwal's Eye Hospital Houston, Texas
Oliveira, Canrobert, M.D. Chennai, India
Director, Hospital de Olhos de Brasilia Viera de Carvalho, Luis A., PhD.
Brasilia, DF Brazil Schor, Paulo, PhD, M.D. Professor,
Bioengineering Division University of Sao Paulo
Pallikaris, Ioannis G., M.D. Escola Paulista de Medicina Brazil
Department of Ophthalmology University of Sao Paulo
University of Crete-Medical School Sao Paulo, Brazil Waring, George, M.D.
Crete, Greece Professor of Ophthalmology
Emory University;
Parul, Goel, M.S., F.E.R.C. Shalaby, Ahmad, M., M.D. Co-Founder
Consultant, Dr. Agarwal's Eye Hospital, Instituto Oftalmologico de Alicante Emory Vision Correction Center
Chennai, India Alicante, Spain Atlanta, Georgia
Perez-Santoja, Juan J., M.D. Simon-Castellvi, Cristina, M.D. Werner, Leonardo P., M.D.
Refractive Surgery and Cornea Unit Clinica Oftalmologica Simon, Department of Ophthalmology,
Alicante Institute of Ophthalmology Barcelona, Spain São Geraldo Eye Hospital,
Miguel Hernandez University Federal University of Minas Gerais
School of Medicine Simon-Castellvi, Guillermo L., M.D. and the "Instituto Vizibelli"
Alicante, Spain University of Barcelona, Belo Horizonte, Minas Gerais, Brazil
Faculty of Medicine,
Peters, Tim, M.D. Dept. of Ophthalmology; Wilson, Steven E., M.D.
Nationwide Vision Laser & Eye Center, Chief Anterior Segment Surgeon, Chair, Department of Ophthalmology,
Clinical Lecturer, Clinica Oftalmologica Simon, and Professor of Vision Research
University of Arizona Barcelona, Spain University of Washington
Phoenix, Arizona Seattle, Washington
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Contents
SECTION I - LASIK
FUNDAMENTAL PRINCIPLES OF DIAGNOSIS, CORNEAL MAPPING,
MECHANISM OF ACTION OF EXCIMER LASERS
CHAPTER 1 CHAPTER 3
UNDERSTANDING REFRACTIVE LASERS EVALUATION OF THE LASIK FLAP BY
CONFOCAL MICROSCOPY
Therapeutic Principles of Excimer Lasers 1
Advances in Excimer Laser Technology 2
Scanning Lasers 2 Frequent Problems With the Flap 61
Eye Tracking Systems 6 What is Confocal Microscopy? 61
How the Corneal Tissues are Affected in Confocal Microscopy Procedure 62
LASIK vs Incisional Keratotomy 6 Results 62
The Importance of Confocal Microscopy to the
CHAPTER 2 Sands of Sahara’s Syndrome 63
How to Prevent Sands of Sahara Syndrome 63
FUNDAMENTALS ON
CHAPTER 4
CORNEAL TOPOGRAPHY
Introduction: Human Optics and the PREDICTIVE FORMULAS FOR LASIK
Normal Cornea 9
Instruments to Measure the Corneal Surface 10 The Predictive Formulas Main Components 65
Causes of Artefacts of the Corneal Developing Individualized Predictive Formulas 65
Topography Map 14 The Healing Pattern of the Cornea 65
Understanding and Reading Corneal Topography15 Excimer Laser Ablation Nomograms for:
Topographic Scales 16 Photorefractive Keratectomy 66
Computer Displays: Presentation of LASIK 66
Topographic Information 16 Predictive Formulas for LASIK with: 67
Special Software Applications and Displays 23 VISX S2 SmoothScan 68
ATLAS OF CORNEAL TOPOGRAPHY 31-42 Chiron Technolas 116 69
TOPOGRAPHERS NOW AVAILABLE 43 Technolas 217 Excimer Laser 70
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CONTENTS
SECTION II - LASIK
HIGHLIGHTS OF SURGICAL INSTRUMENTATION (MICROKERATOMES)
AND SURGICAL TECHNIQUES
CHAPTER 5 CHAPTER 9
MICROKERATOMES LIMITATIONS AND
CONTRAINDICATIONS OF LASIK
Different Mechanical Components 78-80
Applanation Lenses 80 Preoperative Evaluation 127
Tonometer 80 Special Cases 134
Guidelines for Microkeratome Use 80 LASIK after IOL Implantation 134
Astigmatism Inductions by Hinge Ablation 86 Bilateral Simultaneous vs. Sequential Surgery 134
Free Cap 87 LASIK after RK 134
The Main Microkeratomes: 87-99 Alternatives to LASIK 135
Outline PRK 135
Description Refractive Lensectomy 135
How to Use Them Phakic Intraocular Lens 136
Thermokeratoplasty (LTK) 136
CHAPTER 6
AUTOMATIC CORNEAL SHAPER
CHAPTER 10
Note from the Editor-in-Chief 101
Different Components & Instrumentation 101-3 LASIK SURGICAL TECHNIQUE
Surgical Technique Step by Step 104-5
Troubleshooting 105 Patient Selection 139
Care, Handling & Sterilization 107 PREOPERATIVE PREPARATION 140
The Patient 140
CHAPTER 7 The Instruments 140
The Laser 140
DOWN UP LASIK The Keratome 141
The Surgeon 142
Setting up of the Hansatome 109 PREPARATION IN OPERATING ROOM 142
Care, Maintenance & Sterilization 112 Draping 142
Troubleshooting 114 Speculum 142
Surgical Technique Step by Step 114 Positioning the Patient 143
Advantages & Disadvantages 114 THE LASIK PROCEDURE 143
Marking 143
CHAPTER 8 Placement of the Suction Ring 143
The Microkeratome Cut 144
Laser Ablation 145
ALL LASER LASIK With the
Replacing the Flap 146
Pulsion FS Laser
Intraoperative Bleeding in LASIK 148
Postoperative Care 150
Preoperative Evaluation 119
Home Care Instructions 150
Surgical Logistics 120
Surgical Technique Step by Step 120-4
Postoperative Care 125
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CONTENTS
CHAPTER 11 Maintain Consistent Hydration 153
Perform the Appropriate Ablation 154
PEARLS IN LASIK TECHNIQUE Prevent and Remove Debris from
Beneath the Flap 155
Properly Align the Flap 156
Patient Counseling 151
Achieve Good Flap Adhesion 157
Achieving Adequate Exposure 151
Avoid and Treat Loose Epithelium 157
Achieve and Confirm Adequate Suction 152
Conclusion 158
Create a Complete Flap 153
SECTION III
LASIK IN COMPLEX CASES
CHAPTER 12 Compound Myopic Astigmatism 188
Simple Hyperopic Astigmatism 188
Compound Hyperopic Astigmatism 188
LASIK FOR HYPEROPIA
Mixed Astigmatism 189
Negative Cylinder Ablation to Treat
Technique, Safety and Efficacy 161
Mixed Astigmatism 189
Hyperopic Correction using the Excimer Laser 162
Positive Cylinder Ablation to Treat
Patient Selection and Preoperative Considerations163
Mixed Astigmatism 190
Technique 164
Bitoric Ablation to Treat Mixed Astigmatism190
Clinical Results 164
Results of Lasik in Mixed Astigmatism 192
Secondary Hyperopia 165
Conclusion 192
Hyperopia with Astigmatism 165
CHAPTER 15
CHAPTER 13
RELASIK
LASIK FOR IRREGULAR ASTIGMATISM
Procedure 195
Results 196
Etiology of Irregular Astigmatism 169
Discussion 198
Diagnosis 170
Clinical Classification 170 CHAPTER 16
Corneal Topography Patterns 170
1. Irregular astigmatism with defined pattern 170 LASIK AFTER RK AND PRK
2. Irregular astigmatism with undefined
Results of LASIK After RK and PRK 201
pattern 171
RK Group 202
Preoperative Evaluation 171
PRK Group 203
Treatment of Irregular Astigmatism 175
Discussion 204
Surgical Techniques with Excimer Laser 175
Automated Anterior Lamellar Keratoplasty 184
CHAPTER 17
Intracorneal Ring Segments (INTACS) 184
Other Non-Surgical Procedures 184
LASIK AFTER PENETRATING
Contact Lens Management 184
KERATOPLASTY
Eligible Patients 208
CHAPTER 14
Timing of Surgery 208
Surgical Technique 209
LASIK IN MIXED ASTIGMATISM
Postoperative Treatment 209
Risks and Possible Complications 210
Classification 187
Results 210
Simple Myopic Astigmatism 187
Conclusions 212
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