IntraLase femtosecond laser vs mechanical microkeratomes in LASIK for myopia: a systematic review and meta-analysis

Resident surgical experience with lens and corneal refractive surgery: survey of the ASCRS Young Physicians and Residents Membership

A 43-question survey was e-mailed to all resident members of the American Society of Cataract and Refractive Surgery (ASCRS), ASCRS members in practice for 5 or fewer years, and residency program directors of 118 U.S. Accreditation Council for Graduate Medical Education-accredited ophthalmology programs (for distribution to their residents) in June 2010. Two hundred eighty-five of 2279 surveys sent were completed and returned, for a response rate of 12.5%. Most respondents (88.7%) had served as primary surgeon in more than 100 cataract surgeries. Fifty-two percent of respondents had not performed corneal relaxing incisions; 60% had no experience implanting a toric IOL. Twenty-two percent had experience implanting a presbyopia-correcting IOL. Over 75% had not performed any corneal refractive surgical procedures. Although basic cataract case numbers appear adequate, there are significant perceived deficiencies in current resident training models for surgical astigmatism management, implanting presbyopia-correcting IOLs, and corneal refractive surgery.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Femtosecond laser technology in corneal refractive surgery: a review

PURPOSE

To discuss current applications and advantages of femtosecond laser technology over traditional manual techniques and related unique complications in corneal refractive surgical procedures, including LASIK flap creation, intracorneal ring segment implantation, astigmatic keratotomy, presbyopic treatments, and intrastromal lenticule procedures.

METHODS

Literature review.

RESULTS

From its first clinical use in 2001 for LASIK flap creation, femtosecond lasers have steadily made a place as the dominant flap-making technology worldwide. Newer applications are being evaluated and are increasing in their frequency of use.

CONCLUSIONS

Femtosecond laser technology is rapidly becoming a heavily utilized tool in corneal refractive surgical procedures due to its reproducibility, safety, precision, and versatility.

Digital analysis of flap parameter accuracy and objective assessment of opaque bubble layer in femtosecond laser-assisted LASIK: a novel technique

Background:

The purpose of this study was to determine flap parameter accuracy, extent of the opaque bubble layer, and incidence of skip lines in femtosecond laser-assisted stromal in situ keratomileusis (LASIK) using the WaveLight^® FS200 laser and optoelectronic clinical measurements.

Methods:

Images from 101 flaps were automatically recorded during consecutive routine LASIK procedures performed using the WaveLight FS200 femtosecond laser and the EX500 excimer laser. Digital processing of these images was used to evaluate objectively the diameter of FS200-created flaps, by comparing planned versus achieved procedures and to evaluate the incidence and extent (area) of the opaque bubble layer.

Results:

The intended flap diameters were between 8.00 mm and 9.50 mm. The achieved flap diameters showed extremely high precision, and were on average −0.16 ± 0.04 mm smaller for a 8.00 mm intended flap diameter, −0.12 ± 0.03 mm smaller for a 8.50 mm flap, and up +0.06 ± 0.06 mm wider for a 9.50 mm flap. With an average flap area of 72.4 mm², the mean area of the opaque bubble layer (4.1 ± 4.3 [range 0–14.34] mm²) corresponded to a 6% opaque bubble layer-to-flap area. Specifically, 80% of the femtosecond-created flaps had an essentially zero opaque bubble layer (<2.7% of the flap area).

Conclusion:

In our clinical experience, flaps created using FS200 and this novel highly objective assessment technique demonstrate both precision and reproducibility. The incidence of opaque bubble layer was minimal.

Laser in-situ keratomileusis in patients with diabetes mellitus: a review of the literature

PURPOSE

A growing number of diabetic patients request laser in situ keratomileusis (LASIK) for elective vision correction each year. While the United States Food and Drug Administration considers diabetes a relative contraindication to LASIK surgery, there are several reports in the literature of LASIK being performed safely in this patient population. The purpose of this review was to examine whether diabetes should still be considered a contraindication to LASIK surgery by reviewing the ocular and systemic complications of diabetes, and examining the existing data on the outcomes of LASIK in diabetic patients.

METHODS

A literature review was conducted through PubMed, Medline, and Ovid to identify any study on LASIK surgery in patients with diabetes mellitus. This search was conducted without date restrictions. The search used the Medical Subject Headings (MeSH(®)) term LASIK linked by the word "and" to the following MeSH and natural language terms: diabetes, diabetes mellitus, systemic disease, and contraindications. Abstracts for all studies meeting initial search criteria were reviewed for relevance. There were no prospective clinical studies identified. Three retrospective studies were identified. Key sources from these papers were identified, reviewed, and included as appropriate. An additional literature search was conducted to identify any study of ocular surgery on patients with diabetes using the MeSH terms refractive surgery, photorefractive keratectomy, radial keratotomy, cataract surgery, vitrectomy, and iridectomy linked by the word "and" to the following MeSH terms: diabetes, diabetes mellitus, and systemic disease. This search was conducted without date restrictions. Abstracts of studies meeting the initial search criteria were reviewed and articles deemed relevant to the subject were included in this review.

CONCLUSION

LASIK may be safe in diabetic patients with tight glycemic control and no ocular or systemic complications.

Laser in-situ keratomileusis in patients with diabetes mellitus: a review of the literature

Purpose

A growing number of diabetic patients request laser in situ keratomileusis (LASIK) for elective vision correction each year. While the United States Food and Drug Administration considers diabetes a relative contraindication to LASIK surgery, there are several reports in the literature of LASIK being performed safely in this patient population. The purpose of this review was to examine whether diabetes should still be considered a contraindication to LASIK surgery by reviewing the ocular and systemic complications of diabetes, and examining the existing data on the outcomes of LASIK in diabetic patients.

Methods

A literature review was conducted through PubMed, Medline, and Ovid to identify any study on LASIK surgery in patients with diabetes mellitus. This search was conducted without date restrictions. The search used the Medical Subject Headings (MeSH^®) term LASIK linked by the word “and” to the following MeSH and natural language terms: diabetes, diabetes mellitus, systemic disease, and contraindications. Abstracts for all studies meeting initial search criteria were reviewed for relevance. There were no prospective clinical studies identified. Three retrospective studies were identified. Key sources from these papers were identified, reviewed, and included as appropriate. An additional literature search was conducted to identify any study of ocular surgery on patients with diabetes using the MeSH terms refractive surgery, photorefractive keratectomy, radial keratotomy, cataract surgery, vitrectomy, and iridectomy linked by the word “and” to the following MeSH terms: diabetes, diabetes mellitus, and systemic disease. This search was conducted without date restrictions. Abstracts of studies meeting the initial search criteria were reviewed and articles deemed relevant to the subject were included in this review.

Conclusion

LASIK may be safe in diabetic patients with tight glycemic control and no ocular or systemic complications.

LASIK interface complications: etiology, management, and outcomes

PURPOSE

To describe the etiology, diagnosis, clinical course, and management of LASIK interface complications.

METHODS

Literature review.

RESULTS

Primary interface complications include infectious keratitis, diffuse lamellar keratitis, central toxic keratopathy, pressure-induced stromal keratopathy (PISK), and epithelial ingrowth. Infectious keratitis is most commonly caused by Methicillin-resistant Staphylococcus aureus (early onset) or atypical Mycobacterium (late onset) postoperatively, and immediate treatment includes flap lift and irrigation, cultures, and initiation of broad-spectrum topical antibiotics, with possible flap amputation for recalcitrant cases. Diffuse lamellar keratitis is a white blood cell infiltrate that appears within the first 5 days postoperatively and is acutely responsive to aggressive topical and oral steroid use in the early stages, but may require flap lift and irrigation to prevent flap necrosis if inflammation worsens. In contrast, PISK is caused by acute steroid response and resolves only with cessation of steroid use and intraocular pressure lowering. Without appropriate therapy PISK can result in severe optic nerve damage. Central toxic keratopathy mimics stage 4 diffuse lamellar keratitis, but occurs early in the postoperative period and is noninflammatory. Observation is the only effective treatment, and flap lift is usually not warranted. Epithelial ingrowth is easily distinguishable from other interface complications and may be self-limited or require flap lift to treat irregular astigmatism and prevent flap melt.

CONCLUSIONS

Differentiating between interface entities is critical to rapid appropriate diagnosis, treatment, and ultimate visual outcome. Although initial presentations may overlap significantly, the conditions can be readily distinguished with close follow-up, and most complications can resolve without significant visual sequelae when treated appropriately.