Effects of laser repetition rate on corneal tissue ablation for 193-nm excimer laser light

Thermal Load During Corneal Excimer Laser Ablation: Impact of Different Ablation Parameters

PURPOSE

To characterize the impact of different ablation parameters on the change in peak corneal temperature during corneal excimer laser ablation.

METHODS

Forty-two ablations were performed (21 on polymethylmethacrylate [PMMA] and 21 on porcine eyes) simulating photorefractive keratectomy (PRK), transepithelial PRK, and laser in situ keratomileusis (LASIK) treatments. Each ablation was recorded using infrared thermography. The change in peak corneal temperature was analyzed with respect to varying ablation parameters.

RESULTS

Excellent correlation between the temperature rise in PMMA and porcine eyes was found. The change in peak corneal temperature was significantly higher in myopic than in hyperopic corrections, ranging from 6 °C for hyperopic corrections to 16 °C for a -18.00 diopters (D) correction. The change decreased with larger optical zones. Of all analyzed metrics, the refractive correction together with the maximum slope of the treatment showed the best coefficient of determination. Transepithelial ablations led to a higher change in peak corneal temperature than pure stromal ablations. Isothermal lines as a function of the refractive correction and optical zone diameter were calculated with a hypersurface model. If keeping the change in peak corneal temperature below 8 °C is the limit, only 3.00 to 4.00 D can be treated (6.5 mm or larger optical zone); for 10 °C, a maximum of 7.00 D (7 mm or larger optical zone) can be treated and for 12 °C, 10.00 D can be treated (6 mm or larger optical zone).

CONCLUSIONS

The effect of different parameters on change in peak corneal temperature during corneal laser ablation could be quantitatively evaluated. Cooling the cornea may aid in avoiding thermal denaturation. This is particularly important for transepithelial ablations, which further increase the thermal load due to the extra ablation of the epithelium. [J Refract Surg. 2020;36(10):667-676.].

Comparison between aberration-free transepithelial photorefractive keratectomy and small incision lenticule extraction for correction of myopia and myopic astigmatism

PURPOSE

To evaluate the clinical outcomes of small incision lenticule extraction (SMILE) and aberration-free transepithelial photorefractive keratectomy (AF t-PRK) in patients with low to moderate myopic astigmatism, including visual acuity, refractive outcomes, astigmatic vector analysis and corneal aberrometric changes.

METHOD

This retrospective comparative case series study involved 110 right eyes of 110 patients who underwent either SMILE (55 eyes) or AF t-PRK (55 eyes). Visual acuity, manifest refractive error and corneal higher-order aberrations (HOAs) were measured and analyzed at baseline, 1 month and 3 months after operation. The safety and efficacy indices, and vector parameters were also compared.

RESULT

1 month postoperatively, the mean uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA) and spherical equivalent refraction (SE) were better after SMILE than AF t-PRK (logMAR UDVA,  - 0.03 ± 0.07 and  - 0.006 ± 0.07, P = 0.050; logMAR CDVA,  - 0.06 ± 0.07 and  - 0.03 ± 0.07, P = 0.043; SE,  - 0.04 ± 0.25 and 0.15 ± 0.26, P < 0.001). However, these parameters were comparable between the groups at 3 months after surgery. Residual astigmatism ≤ 0.25 diopters was observed in 74.5% and 90.9% (P = 0.023) of the eyes at one month and in 87.3% and 85.5% (P = 0.781) of the eyes at 3 months after SMILE and AF t-PRK, respectively. There were no significant differences between the groups in any of the vector parameters at 1 month or 3 months after surgery. Coma and total HOAs after SMILE were significantly higher than AF t-PRK (1 month coma, 0.49 ± 0.23 and 0.29 ± 0.15, P < 0.001; 1 month total RMS HOAs, 0.65 ± 0.20 and 0.54 ± 0.14, P = 0.001; 3 months coma, 0.50 ± 0.22 and 0.30 ± 0.17, P < 0.001; 3 months total RMS HOAs, 0.68 ± 0.20 and 0.55 ± 0.17, P < 0.001).

CONCLUSION

In this study, both SMILE and AF t-PRK were effective and comparable for correction of low to moderate myopic astigmatism. AF t-PRK group induced less coma and total HOAs than SMILE.

Differential Laser-Induced Perturbation Spectroscopy for Analysis of Mixtures of the Fluorophores l-Phenylalanine, l-Tyrosine and l-Tryptophan Using a Fluorescence Probe

Quantitative detection of common endogenous fluorophores is accomplished using differential laser-induced perturbation spectroscopy (DLIPS) with a 193-nm UV fluorescence probe and various UV perturbation wavelengths. In this study, DLIPS is explored as an alternative to traditional fluorescence spectroscopy alone, with a goal of exploring natural fluorophores pursuant to biological samples and tissue analysis. To this end, aromatic amino acids, namely, l-phenylalanine, l-tyrosine and l-tryptophan are mixed with differing mass ratios and then classified with various DLIPS schemes. Classification with a traditional fluorescence probe is used as a benchmark. The results show a 20% improvement in classification performance of the DLIPS method over the traditional fluorescence method using partial least squares (PLS) analysis. Additional multivariate analyses are explored, and the relevant photochemistry is elucidated in the context of perturbation wavelengths. We conclude that DLIPS is a promising biosensing approach with potential for in vivo analysis given the current findings with fluorophores relevant to biological tissues.

Centration axis in refractive surgery

The human eye is an asymmetric optical system and the real cornea is not a rotationally symmetrical volume. Each optical element in the eye has its own optical and neural axes. Defining the optimum center for laser ablation is difficult with many available approaches. We explain the various centration approaches (based on these reference axes) in refractive surgery and review their clinical outcomes. The line-of-sight (LOS) (the line joining the entrance pupil center with the fixation point) is often the recommended reference axis for representing wavefront aberrations of the whole eye (derived from the definition of chief ray in geometrical optics); however pupil centration can be unstable and change with the pupil size. The corneal vertex (CV) represents a stable preferable morphologic reference which is the best approximate for alignment to the visual axis. However, the corneal light reflex can be considered as non-constant, but dependent on the direction of gaze of the eye with respect to the light source. A compromise between the pupil and CV centered ablations is seen in the form of an asymmetric offset where the manifest refraction is referenced to the CV while the higher order aberrations are referenced to the pupil center. There is a need for a flexible choice of centration in excimer laser systems to design customized and non-customized treatments optimally.

Safety, efficacy, predictability and stability of laser in situ keratomileusis (LASIK) with a 1000-Hz scanning spot excimer laser

PURPOSE

To evaluate the safety, efficacy, predictability and stability of laser in situ keratomileusis (LASIK) with a 1000-Hz scanning spot excimer laser (Concept System 1000; WaveLight GmbH, Erlangen, Germany).

METHODS

LASIK was performed on twenty eyes with myopia or myopic astigmatism (mean spherical equivalent refraction: -3.97±1.72 dioptres (D); mean cylinder: -0.84±0.77 D) using a microkeratome for flap creation and the Concept System 1000 for photoablation. Patients were examined preoperatively as well as 1, 3 and 6 months after the treatment. Manifest sphere and cylinder, uncorrected (UCDVA) and best corrected (BCDVA) distance visual acuity, corneal topography and pachymetry were analysed.

RESULTS

We observed no adverse events that might have been associated with the use of a repetition rate of 1000 Hz. All eyes maintained or had improved BCDVA at 6 months after treatment when compared to preoperative values. Six months after LASIK, UCDVA was 20/20 or better in 85% and 20/25 or better in 100% of the eyes. The spherical equivalent refraction was within ±0.50 D in 95% of the eyes at 6 months after surgery. The refraction stayed stable over time; 95% of the eyes changed<0.5 D postoperatively.

CONCLUSION

LASIK with the prototype 1000-Hz excimer laser was safe, efficient and predictable. The postoperative refraction was stable over time. There were no specific clinical side-effects that might be associated with the use of such a high repetition rate.

Real-time measurement of ArF excimer laser corneal tissue ablation rates using cross-correlation of laser waveforms

The current popularity of excimer laser refractive surgery suggests a need for continued research and refinements to further improve clinical outcomes. A fundamental limitation of current clinical systems is the lack of real-time feedback specifically addressing the laser-tissue interactions as directly related to laser ablation rates. This paper reports data to assess the feasibility of a novel approach that holds promise as a real-time feedback scheme based on comparison of the incident and reflected laser pulse waveforms, as quantified using a cross-correlation algorithm. The approach is evaluated for ablation of bovine cornea over a range of clinically relevant laser fluences. A linear relationship was observed between several cross-correlation metrics and the directly measured corneal ablation rate, yielding an average RMS predictive error of 3.9% using a 25-shot average reflected waveform. Assessment of the cross-correlation approach for single-shot ablation data revealed a brief transient corresponding to the first few laser pulses, which is attributed to a slight hydration gradient near the surface of the de-epithelialized cornea. Clinical refractive data are necessary to assess the precision of this approach for actual refractive surgery.

Effect of air-flow on the evaluation of refractive surgery ablation patterns

An Allegretto Eye-Q laser platform (Wavelight GmbH, Erlangen, Germany) was used to study the effect of air-flow speed on the ablation of artificial polymer corneas used for testing refractive surgery patterns. Flat samples of two materials (PMMA and Filofocon A) were ablated at four different air flow conditions. The shape and profile of the ablated surfaces were measured with a precise non-contact optical surface profilometer. Significant asymmetries in the measured profiles were found when the ablation was performed with the clinical air aspiration system, and also without air flow. Increasing air-flow produced deeper ablations, improved symmetry, and increased the repeatability of the ablation pattern. Shielding of the laser pulse by the plume of smoke during the ablation of plastic samples reduced the central ablation depth by more than 40% with no-air flow, 30% with clinical air aspiration, and 5% with 1.15 m/s air flow. A simple model based on non-inertial dragging of the particles by air flow predicts no central shielding with 2.3 m/s air flow, and accurately predicts (within 2 μm) the decrease of central ablation depth by shielding. The shielding effects for PMMA and Filofocon A were similar despite the differences in the ablation properties of the materials and the different full-shielding transmission coefficient, which is related to the number of particles ejected and their associated optical behavior. Air flow is a key factor in the evaluation of ablation patterns in refractive surgery using plastic models, as significant shielding effects are found with typical air-flow levels used under clinical conditions. Shielding effects can be avoided by tuning the air flow to the laser repetition rate.

Testing a model for excimer laser-ablation rates on corneal shape after refractive surgery

We have tested whether a recent model [Appl. Phys. Lett.95, 174105 (2009)APPLAB0003-695110.1063/1.3254236] that considers the angular dependence of laser-ablation rates, including reflection losses and geometrical dependence of incident fluence, and the effect of plume absorption can have significant effects for refractive surgery patients. We have developed a mathematical procedure and deduced equations that show that this model can significantly influence postsurgical corneal parameters (radius and asphericity) and, thus, should be considered in ablation algorithms in order to achieve a better emmetropization and an effective correction of eye aberrations.