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Dr Trevor Gray Ophthalmologist Eye Institute Clinical Senior Lecturer University of Auckland 9:30 - 9:55 Improving Vision

Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

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Page 1: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

Dr Trevor GrayOphthalmologist

Eye Institute

Clinical Senior Lecturer

University of Auckland

9:30 - 9:55 Improving Vision

Page 2: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

VISION CORRECTIONCOMMON QUESTIONS

Dr Trevor Gray

Clinical Senior Lecturer in Ophthalmology, University of Auckland

Cornea & Cataract Specialist, Greenlane Hospital

Vision Correction Specialist, Eye Institute

Degree of Refractive Surgery Lecturer, Sydney Eye Hospital

RANZCO Part II Exam Course Lecturer in Cataract & Refractive Surgery, Dunedin

Past President: Cornea & Contact Lens Society of NZ

Page 3: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

OBJECTIVES

Confident & knowledgeable

Patient-focused advice

Assist patients with realistic expectations

Page 4: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

MOST COMMON QUESTIONSHow does it work?What treatment is best for me?

Can it correct astigmatism?How do I know if I’m suitable?Does it wear off after 10 years?

Can it get me out of reading glasses? (50+yrs)Can it go wrong?Cost?

Page 5: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

HOW DOES IT WORK? - EXCIMER LASERPrecision & safety

<1mm laser beam

0.00025mm removed in 12 billionths of a second

No tissue damage – vapourizes what it strikes

>29yrs proven corneal safety

Human hair

Laser plume Laser etching

Page 6: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

PHOTOREFRACTIVE KERATECTOMY= PRK

1987 Germany Dr Theo Seiller

Rapid demise of incisional radial keratotomy (RK)

Page 7: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

LASIK

1989 PRK

1987

Page 8: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

Page 9: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

LASIK LASER VISION CORRECTION

“State of the art 2016”1. Femtosecond laser flap LASIK

2. Wavefront–guided excimer laser corneal reshaping

Page 10: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

WHAT IS A FEMTOSECOND?

• 10-15 second• 1 billionth of 1 millionth of a second• Femtosecond:Second = Second:32 million years• Light travels across a human hair in 100fs

Human hair

Page 11: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

A pulse of laser energy is focused to a precise location inside the cornea

A microplasma is created, vaporizing approximately 1 micron of corneal, lens, capsule tissue

1 Micron

Page 12: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

Thousands of laser pulses are connected together to define a resection plane in cornea, capsule or lens

Page 13: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

FEMTOSECOND LASIK FLAP

Page 14: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

WAVEFRONT-GUIDED LASIK

Page 15: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

IRIS REGISTRATIONIris Registration – matching pre- and intra-op:

Limbus

Pupil margin

Iris details

WaveScan Reference MarksCyclotorsionRotation Indicator

Prominent Iris Landmarks

Page 16: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

Page 17: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

Page 18: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

SURFACE LASER VISION CORRECTION= PRK

Excellent in low myopes (<-3D)

Trauma risk

Police

Armed Forces

Contact sports

Excellent outcomes

Negligible scarring or regression

Slower visual recovery (4-14d)

Page 19: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

PRK OR LASIK?

With permission

Page 20: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

Page 21: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

WHAT IF I’M NOT SUITABLE FOR LASER?Re-examine CL tolerance issues…

Consider Orthokeratology (hard CL worn at night)

If above unsuccessful, consider surgical options

With permission

Page 22: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

OTHER SURGICAL OPTIONS

In my experience… Implantable Contact Lenses (ICL) – pre-presbyopic 20-45yrs

Refractive lens exchange (RLE) – presbyopic >45yrs

ICL

Lens

Cornea

ICL Vault

ICL

Page 23: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

IMPLANTABLE CONTACT LENSICL (Implantable Contact Lens)

-20 to +10 D Sphere, 6 D Cyl

No dry eye, reversible

>1000 ICLs personally

Page 24: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

REFRACTIVE LENS EXCHANGEor Refractive Cataract Surgery

• Highly accurate• High definition vision• Rapid return to ‘normal’ life in presbyopic patients

Page 25: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

IMAGE-GUIDED CATARACT SURGERY

Page 26: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

VISION CORRECTION SCALE …

+12 +6 +3 0 -3 -6 -9 -12 -15 -18 -21

ICLLASIK

PRK

Page 27: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

CAN IT CORRECT ASTIGMATISM? YES – “Iris Recognition”

Astig >6D

+ Higher order aberrations

Refractive lenticule extraction (ReLEx flex) and wavefront-optimized Femto-LASIK: comparison of contrast sensitivity and

high-order aberrations at 1 year. Graefes Arch Clin Exp Ophthalmol. May 2013;251(5):1437-42

Page 28: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

AM I SUITABLE?1 hour assessment of ocular health and focus85% suitable to consider LVC

LASIK or PRK

Unsuitable Keratoconus

Pellucid marginal degeneration

Unstable refraction

Herpes simplex keratitis / scarring

Others…

No cost, no obligation exam’

keratoconus

Page 29: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

WEAR OFF AFTER 10YRS?

NO

Permanent change to corneal curvature Normal vision for age…

No crystal ball…

Modern LASIK more stable than 10-15yrs ago

CustomVue laser in situ keratomileusis for myopia and myopic astigmatism using the Visx S4 excimer

laser: Efficacy, predictability, and safety. J Cataract Refract Surg. Mar 2006;32(3):475-9

Page 30: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

GET RID OF READING GLS?Maybe…

Presbyopia normal aging

Blended-Vision = “Social Vision” Dominant – dist

Non-dominant – near

CL trial before

(also cataract surgery)

Multifocal IOLs

Page 31: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

CAN IT GO WRONG? YESVery rarely vision-threatening

Similar risk to driving home today…

Some “complications” are normal Early dry eyes

Early night blurring/halos

iLASIK approved technology for US Navy fighter pilots

NASA

Page 32: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

COST?

$2850 per eye All pre-op & post-op care

1+ year post-op care

Health care professionals “mates-rates”

No cost, no obligation 1hr assessment

Page 33: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

THANK [email protected]

Page 34: Dr Trevor Gray - GP CME North/Sun_plenary_0930... · Wavefront guided Yes No Iris registration Yes No Auto centration Yes No Astig auto-alignment Yes No High astigmatism Yes No Low

[email protected]

LASIK VS SMILELASIK SMILE

Vision improvement Faster Slower

Wavefront guided Yes No

Iris registration Yes No

Auto centration Yes No

Astig auto-alignment Yes No

High astigmatism Yes No

Low Myopia Yes No

Hypermetropia Yes No

Optic zone size Larger Smaller

Easy enhancement Yes No

Flap security Less More

Dry eye <6mths Yes (more) Yes (less)

Dry eye >6mths Yes (mild) Yes (mild)


ASTIG M.E

ASTIG M.E

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