Mississauga CE LASIK 2008 Dr. Jeff Machat

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Dr. Jeff Machat on Custom Vue LASIK, wavefront technology, Pulsion, IntraLase, Fourier by VISX, iris registration and cyclotorsional shift.

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Laser Refractive Surgery 2008:

Laser Refractive Surgery 2008 Dr. Jeffery J. Machat

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Research says...:

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PRK/LASEK - laser pulses are applied on the front surface of the eye to correct your prescription CURVE from SPECS LASIK - a flap is created of the protective layer of the cornea, the flap is lifted and the laser pulses are applied to an inner corneal layer BOOK ANALOGY TALKING TO CANDIDATES Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

IntraLase with CustomVue:

IntraLase with CustomVue Two parts to LASIK Procedure: Corneal Flap: IntraLase safest & highest quality Laser Ablation: CustomVue safest & highest quality Fear not price is the greatest deterrent to LASIK Both calm the natural FEAR of patients Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

March 6th, 2000 Zyoptix Custom Ablation:

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Wavefront Error 0-343-91-63 Patient ID: Notes: Physician: Patient: *************, ************* © Copyright 2001, VISX Inc. Operator: Mary Ann OD 14-Dec-2001 20:26 -4.49 DS +0.48 DC x 136° @ 12.5 mm (4.0 Pupil) Hi Order: Pupil (mm): 8.7 % 6.00 OS 14-Dec-2001 20:27 -4.14 DS +0.80 DC x 51° @ 12.5 mm (4.0 Pupil) Hi Order: Pupil (mm): 6.2 % 6.00 Eff. Blur (D): 4.25 Eff. Blur (D): 3.66 Acuity Map Bille Aberration Map microns 28.00 24.00 20.00 16.00 12.00 8.00 4.00 0.00 -4.00 -8.00 -12.00 -16.00 -20.00 -24.00 -28.00 0 30 60 90 120 150 180 microns 1.75 1.50 1.25 1.00 0.75 0.50 0.25 0.00 -0.25 -0.50 -0.75 -1.00 -1.25 -1.50 -1.75 0 30 60 90 120 150 180 Acuity Map Bille Aberration Map microns 28.00 24.00 20.00 16.00 12.00 8.00 4.00 0.00 -4.00 -8.00 -12.00 -16.00 -20.00 -24.00 -28.00 0 30 60 90 120 150 180 microns 1.75 1.50 1.25 1.00 0.75 0.50 0.25 0.00 -0.25 -0.50 -0.75 -1.00 -1.25 -1.50 -1.75 0 30 60 90 120 150 180 All Grid Spacing: 1 mm. Rms Err.(µ): 5.52 Rms Err.(µ): 4.76 Rms Err.(µ): 0.48 Rms Err.(µ): 0.29 Wavefront Analysis Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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IntraLase Femtosecond laser (Nd:Glass) 1053 nm ( near infrared ) Each pulse of focused laser light lasts approximately 10 -13 seconds (100 femtoseconds) In one second, light travels 7.5 times around the globe In 100 femtoseconds, light travels across a human hair Power = Energy/Time , extremely high power attained at relatively low energy * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Pulsion ™ FS Laser Photodisruption A pulse of laser energy is focused to a precise spot inside the cornea A microplasma is created, vaporizing approximately 1 micron of corneal tissue 1 Micron * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Pulsion ™ FS Laser Photodisruption An expanding bubble of gas & water is created separating the corneal lamellae 2 to 3 Microns * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Pulsion ™ FS Laser Photodisruption The bi-products of photodisruption (CO2 & water) are absorbed by the mechanism of the endothelial pump, leaving a cleavage plane in the cornea * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Pulsion ™ FS Laser Photodisruption Thousands of laser pulses are connected together in a raster pattern to create a cleavage plane * IntraLASIK proprietary software is designed exclusively for the Pulsion™ FS Laser Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Specific Indications:

Steep K ’ s: above 46D Flat K ’ s: below 40D Thin pachs Dry eye Small fissures “ Fear of blade ” Specific Indications Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Advantages:

Can cut a 110 micron flap consistently Can place hinge anywhere Easier for future re-cuts Reduced epithelial ingrowth Reduced incidence of flap slippage Reduced dry eye Advantages Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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True Lamellar Flap Equally Smooth Stromal Bed Less induced Higher Order Aberrations More Tissue for Custom Ablation Treatments More Tissue for Larger Optical Zones Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Intra-op Safety: Loss of Suction:

Blade: serious complication, central buttonhole flap, vision may be permanently impaired, wait 3-12 months for repeat LASIK IntraLase: re-apply suction ring immediately, recenter and continue or restart flap from beginning IntraLase has added years to my life expectancy , especially with steep Ks, small orbits/narrow fissures and uncooperative patients Intra-op Safety: Loss of Suction Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Post-op Safety:

Less need for enhancements, more stable Less flap displacement and less striae post-op Eliminates serious flap complications Post-op Safety Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Post-op Safety:

Less epithelial ingrowth with IntraLase Flaps 2 cases of grade 2 epithelial ingrowth out of 2000 cases, both following enhancements Compared to > 20 cases with last 2000 Hansatome Flaps Post-op Safety Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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CUSTOM ABLATION:

C USTOM A BLATION

Custom Ablation:

Custom Ablation Better Visual Results Greater Chance of 20/20 Greater Chance of Better than 20/20 Greater Chance of correcting Astigmatism Lower Chance of Losing BCVA Lower Chance of Night Glare Lower Chance of Enhancements Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Understanding Custom:

Wavefront approach is a completely different concept from standard refractive surgery planning Optimizes cornea for light ray focusing on fovea not prescription or curvature Understanding Custom Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Understanding Custom:

Wavefront map: Represents a refractive map of the entire visual system across the pupillary zone That is, the prescription at each and every point Details what correction would be required at each point in order to focus a light ray at that point on the fovea Understanding Custom Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Higher Order Aberrations:

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Effects of Spherical Aberrations:

Wavefront:

Wavefront Wavefront treats higher order aberrations, the aberrations that spectacles do NOT correct , that is why vision potential EXCEEDS BSCVA i.e. > 20/20 for most Everyone BENEFITS from Wavefront but SOME benefit MORE than others Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Advantages of CustomVue:

Vision potential for better than 20/20 Reduced risk of losing BCVA Less retreatments Preserves or Improves night vision Counters negative publicity Ability to treat patients with larger pupils Advantages of CustomVue Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Since March 2000, I have performed over 10,000 Custom LASIK procedures with: B&L Zyoptix System WaveLight Allegretto Wave Visx Star S4 with CustomVue Alcon LadarWave system Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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FOURIER WAVEFRONT ALGORHITHM:

FOURIER WAVEFRONT ALGORHITHM Taking Custom to a Higher Level

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Fourier is far more precise Zernike:

Data Resolution VISX 3 TIMES MORE POINTS:

Accuracy of Zernikes vs. Fourier:

Actual Physical Shape Measured Shape: Fourier Measured Shape: 4 th order Zernike Accuracy of Zernikes vs. Fourier Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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The Custom treatment is saved on a memory stick and then loaded into the laser Better Data IN = Better Clinical Outcomes OUT Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Beyond Zernike:

Beyond Zernike Visx Fourier is better than Zernicke If we obtain 240 spots it uses all 240 spots in the reconstruction, no averaging Visx CustomVue is the only laser platform that has switched from Zernike to the Fourier algorithm Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

IRIS REGISTRATION:

I RIS R EGISTRATION Taking Custom to the Highest Level

Iris Registration Conclusion :

Iris Registration Conclusion Optimizes Clinical Outcomes simply through alignment of Wavefront map and Laser ablation in all axes Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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It has always been recognized that it is important to align preoperative cylinder axis with the laser ablation axis for optimal results and safety Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Study Eyes Mean Degree Movement Other VISX Study, Chernyak, JCRS, 2004 51 2.2º + 2.0º excyclotorsion up to 10º Swami, Steinert et al, AJO, 2002 240 4.1º + 3.7º 8% with over 10º of movement Smith, Talamo, Assil, JCRS, 1994 50 - 25% over 7º of movement (up to 16º) Cyclotorsion Shift with Recumbent Position Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Iris Registration Compensation for Pupil Centroid Shift:

Iris Registration Compensation for Pupil Centroid Shift it is also critical to compensate for differences in pupil size between wavefront capture and laser delivery Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Compensation for pupil center shift with CustomVue:

Wavefront ablation is centered over the WaveScan pupil centroid (red), not the laser pupil centroid (purple) Iris outer boundary used as a FIXED reference Pupil under laser Compensation for pupil center shift with CustomVue Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Iris Registration Patient Identification:

Iris pattern is unique to each patient Confirm correct patient and eye being treated under the laser Iris Registration Patient Identification Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Iris Registration Advantages:

Cyclotorsional registration Wavefront Ablation Alignment Compensation for Pupil shift Iris Registration Advantages Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Iris Image Captured by the WaveScan:

Iris image is flattened to determine 24 unique reference points:

Iris Registration:

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Iris Registration Key Points:

Ability to measure and to compensate for ocular cyclotorsion Ability to align of Wavefront map and Laser ablation in all axes Ability to measure and compensate for pupil centroid shift Optimizing Clinical Outcomes !!! Iris Registration Key Points Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Custom Intralase 30 KHz Intralase 60 KHz IR Fourier Data Courtesy of Louis Probst, MD All Procedures Enhancement Rates 95-99% of procedures Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

Conclusion:

Conclusion Visual Acuity : More patients see 20/20 over conventional ablations with mechanical keratome flap creation Visual Quality : Fewer patients have night vision symptoms Safety : More patients gained lines of low contrast acuity Enhancements : Reduced retreatment rates Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

IntraLase with CustomVue:

Improving “ Quality of vision ” is now the objective with CustomVue Improving “ Safety ” is the objective with IntraLase and Iris Registration IntraLase with CustomVue provides the “ highest quality with the greatest safety ” to reduce patient FEAR IntraLase with CustomVue Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Custom LASIK with IntraLase Flaps:

Custom LASIK with IntraLase Flaps Better Visual Results Greater Chance of 20/20 Greater Chance of Better than 20/20 Greater Chance of correcting Astigmatism Lower Chance of Losing BCVA Lower Chance of Night Glare Lower Chance of Enhancements Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited.

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Property of Dr. Jeffery J. Machat. All rights reserved. Unauthorized use is prohibited. The information provided in this PowerPoint presentation is for your personal informational purposes only. It is not medical advice, medical diagnosis or treatment, or recommendation for medical care or treatment. All medical questions or concerns about a medical condition, care, diagnosis or treatment should be presented to a medical physician, health care provider, or health care professional. You acknowledge that your use of this information is at your sole risk, and that you assume and accept full responsibility for all risk associated with any reliance upon the information presented.

THANK YOU:

T HANK Y OU Jeffery J. Machat MD 2008