(Including PRK, LASIK, LASEK, WAVEFRONT ABERROMETRY, PRESBYOPIC LASIK, CONDUCTIVE KERATOPLASTY and BIOMECHANICAL CUSTOMISATION)
Editors Ashok Garg MS PhD FIAO (Bel) FRSM FAIMS ADM FICA
International and National Gold Medalist Medical Director Garg Eye Institute and Research Centre
235-Model Town, Dabra Chowk Hisar-125005, India
Ioannis G Pallikaris MD
Professor and Head Department of Ophthalmology University of Crete,
VEIC, P.O. Box 2208 Heraklion 71003, Crete, Greece
Guillérmo Avalos-Urzua MD
Chief Ophthalmic Deptt. Sagrado Corazon Hospital Medical Director Avalos Ophthalmic Institute and Ophthalmic Laser Clinic,
Terranova No. 676-101 Col Providencia, Guadalajara, Jal, Mexico CP 44630
Matteo Piovella MD
Founder and Director Centro Microchirurgia Ambulatoriale
Via Donizetti, 24, 20052 Monza, Italy
Jairo E Hoyos MD PhD
Medical Director Instituto Oftalmologico Hoyos
Rambla de Sabadell 62 10 08201, Sabadell, Barcelona, Spain
Roberto Pinelli MD
Scientific Director Instituto Laser Microchirurgia Oculare Crystal Palace,
Via Cefalonia 70 Brescia-25124, Italy
Cyres K Mehta MS FAGE FSVH FNRERF FSEC
Director and Consultant Ophthalmic Surgeon The Mehta International Eye Institute and Colaba Eye Hospital,
Seaside 147, Shahid Bhagat Singh Road Mumbai-400005, India
Foreword: Miguel Angelo Padilha
Jitendar P Vij
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Mastering the Techniques of Corneal Refractive Surgery
© 2006, Ashok Garg, Ioannis G Pallikaris, Jairo E Hoyos, Guillérmo Avalos-Urzua, Roberto Pinelli, Matteo Piovella, Cyres K Mehta
All rights reserved. No part of this publication and Interactive CD Rom should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
First Edition: 2006
9788180616181
Typeset at JPBMP typesetting unit
Printed at Replika Press Pvt. Ltd., 310 EPIP, HSIDC, Kundli, Sonepat (Haryana)
5To
My Respected Param Pujya Guru Sant Gurmeet Ram Rahim Singh Ji for his blessings and motivation.
My Respected Parents, teachers, my wife Dr Aruna Garg, son Abhishek and daughter Anshul for their constant support and patience during all these days of hard work.
My dear friend Dr Amar Agarwal, a renowned International Ophthalmologist for his constant support, guidance and expertise
—Dr Ashok Garg
All my colleagues at Vardinoyannion Eye Instutute of Crete (Greece)
—Dr Ioannis G Pallikaris
My parents, with gratitude for guiding me throughout my life and for giving me the opportunity to carryout my studies.
My friends, for trusting me.
The KMSG members, without them the scientific development of this group would not have been possible.
My sons, Jairo and Roberto for their support and their professional contributions.
—Dr Jairo E Hoyos
In loving memory of my father whom's example lay the footsteps for me to follow.
My wife with love and to my children may they achieve professional and personal fulfillment
—Dr Guillérmo Avalos-Urzua
India's Talented ophthalmologists, in the fervent hope that they may become increasingly devoted to refractive surgery
—Dr Roberto Pinelli
Michele, Mattia, Matilda and Barbara they know why…‥
—Dr Matteo Piovella
My parents for everything.
Vini my best friend
- A Bozkurt Sener md
- AcibademGoz
- Istanbul
- Turkey
- Alexander Hatsis md
- 2, Lincoln Ave
- Suite 401, Rockville Center
- New York, USA
- Amar Agarwal ms frcs frc ophth
- Consultant
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- AnnMarie Hipsley pt pfs phd
- Director of Research
- Global Vision Research Group Ltd.
- ACE Vision Group
- PO Box 328
- Blacklick Oh, 43004-0328
- USA
- Antonio A Marinho md phd
- Prof. of Ophthalmology
- University of Porto
- R. Crasto 708
- 4150-243, Porto, Portugal
- Ariadna Silva-Lepe md
- Terranova No. 676-101
- Col. Providencia
- Guadalajara, Jal.
- Mexico, CP 44630
- Ashish Doshi ms
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- Ashok Garg ms phd frsm
- Medical Director
- Garg Eye Institute and Research
- Centre, 235-Model Town
- Dabra Chowk, Hisar-125005, India
- Athiya Agarwal md do frsh
- Consultant
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- Barbara Kusa md
- Centre Microchirurgia
- Ambulatoriale, Via Donizetti
- 24 20052 - Monza, Italy
- C Banu Cosar md
- Sinpas Aqua City 1. Etap
- H Block D:13 A. Dudullu 80260
- Istanbul, Turkey
- Carlos Manrique-Lara md
- 26, South WillowPoint Circle
- The Woodlands
- Texas 77382, USA
- Carmen Martin-Marcos md phd
- Ophthalmologic Research Institute
- Ramon Castroviejo
- Zarracin 25-urb. La. Berzosa
- 28240-Hoyo de Manzanares
- Madrid, Spain
- Chaitra Jayadev doms
- Adityajyot Eye Hospital Pvt. Ltd.
- Wadala, Mumbai-400031, India
- Charalambos Siganos md phd
- Department of Ophthalmology
- University of Crete, Heraklion
- Crete, Greece
- Chris P Lohmann md phd
- Universitats-Augenklinik
- Franz-Josef-Strau B-Allee
- D-93042, Regensburg, Germany
- Cyres K Mehta ms fsvh fage
- Director and Consultant
- Mehta International Eye Institute
- Seaside, 147, Colaba Road
- Mumbai-400005, India
- Dan Z Reinstein md ma frcsc dabo
- Director
- London Vision Clinic
- 8, Devonshire Place, London
- W1G 6HP, UK
- Aditya Jyot Eye Hospital Pvt. Ltd.
- Wadala, Mumbai-400031, India
- David J Apple md
- Director and Professor of Ophthalmology
- John A Moran Eye Centre
- Department of Ophthalmology and Visual Sciences, 5th Floor
- University of Utah
- 50, North Medical Drive
- Salt Lake City, Utah-84132, USA
- Demetrio Pita-Salorio md
- Clinica Oftalmologica Simon Simon Eye Clinic
- Barcelona, Spain
- Dimitrii Dementiev md
- Chief and Medical Director
- Blue Eye Centro di
- Michrochirurgia Oculare Eye
- Clinic Arese 20020 (MI)
- Via Campo Gallo 21/10
- Milan, Italy
- Dipan Desai ms
- Director
- Desai Eye Hospital and Laser
- Center, 2nd Floor
- Anand Complex
- Opp. Shilp, CG Road
- Near Navrang Pura
- Ahmedabad-380009, India
- Dipti N Shah ms
- Sadhna Eye Care
- 275, Princess Building
- Next to Parsi Dairy Farm
- Opp. Marine Lines Station
- Mumbai-400002, India
- Emilio Balestrazzi md
- University of L Aquila
- S Salvatore Hospital-Coppito L
- Aquila, Italy
- Erika Eskina md
- Sphere Eye Clinic
- Moscow, Russia
- Eva Moreno md
- Clinica Moreno Alguacil
- San Pascual 47
- Aranjuez 28300, Spain
- Fabrizio I Camesasca md
- Deptt of Ophthalmology
- Istituto Clinico Humanitas
- Rozzano, Milano, Italy
- Federico Moreno md
- Clinica Moreno Alguacil
- San Pascual 47
- Aranjuez 28300, Spain
- Fernando Rodriguez-Mier md
- Instituto Oftalmologico Hoyos
- Rambla de Sabadell 62 10
- 08201 Sabadell, Barcelona, Spain
- Fernando Vaz md
- Porto, Portugal
- Francisco J Gutierrez-Carmona md phd
- Associate Professor
- Ophthalmologic Research Institute
- Ramon Castroviejo
- Zarracin 25-urb. La. Berzosa
- 28240-Hoyo de Manzanares
- Madrid, Spain
- Franco Bartoli md
- Refractive Laser Centre
- Corso Vittorio Emanuele 87
- 10100 Torino, Italy
- Frederic Hehn md
- Centre de La Vision
- Nations -Vision
- 23, Boulevard de l'europe
- 54500, Vandoeuvre, France
- George D Kymionis md phd
- Department of Ophthalmology
- University of Crete
- Heraklion, Crete, Greece
- GP Neatrour md
- Virginia Beach
- Virginia, USA
- Guillérmo Avalos-Urzua md
- Terranova No. 676-101
- Col. Providencia
- Guadalajara, Jal.
- Mexico, C.P. 44630
- Guillérmo L Simon-Castellvi md
- Clinica Oftalmologica Simon
- Simon Eye Clinic
- Barcelona, Spain
- Hetal R Solanki do
- Aditya Jyot Eye Hospital Pvt. Ltd.
- Wadala, Mumbai-400031, India
- Hijab Mehta ms doms fcps
- Aditya Jyot Eye Hospital Pvt. Ltd.
- Wadala, Mumbai-400031, India
- Hitendra Mehta ms
- Aditya Jyot Eye Hospital Pvt. Ltd.
- Wadala, Mumbai-400031, India
- Ioannis G Pallikaris md phd
- Prof. and Head
- Department of Ophthalmology
- University of Crete
- Heraklion, Crete, Greece
- J Agarwal ms
- Director
- Dr Agarwal's Eye Hospital Pvt. Ltd.
- 19, Cathedral Road
- Chennai-600086, India
- Jaime R Martiz md
- 26, South Willow Point Circle
- The Woodlands
- Texas 77382, USA
- Jairo E Hoyos md phd
- Instituto Oftalmologico Hoyos
- Rambla de Sabadell 62 10
- 08201 Sabadell
- Barcelona, Spain
- Jairo Hoyos-Chacón md
- Instituto Oftalmologico Hoyos
- Rambla de Sabadell 62 10
- 08201 Sabadell
- Barcelona, Spain
- Jean-Marc Legeais md phd
- Hôtel Dieu de Paris, Service d'
- Ophthalmologie, laboratoire
- Biotechnologie et oeil. 1 Place du
- Parvis Notre-Dame
- Paris, France 75004
- Jean-Pierre Timmermans dr sc, phd
- Department of Cell Biology and Histology, University of Antwerp
- Antwerp, Belgium
- Jes Mortensen md
- The Eye Department
- Orebro University Hospital
- SE-70185, Orebro, Sweden
- Jonathan Woolfson md
- TLC, The Windsor Laser Centre
- 3200, Deziel Drive Suite 208
- Windsor, Canada
- Jorge L Alió md phd
- Instituto Oftalmologico De
- Alicante, Avda. Denia 111, 03015
- Alicante, Spain
- Jose L Hernandez md
- Clinica Moreno Alguacil
- San Pascual 47
- Aranjuez 28300, Spain
- José M Simon-Castellvi md
- Clinica Oftalmologica Simon
- Simon Eye Clinic, Barcelona, Spain
- Joseph Colin md
- Hôpital Pellegrin-Tripode-
- Service d' Ophthalmologie Place
- Amilie Raba-Léon-33076
- Bordeauxcedex, France
- JT Lin phd
- 4532, Old Carriage Trail
- OVIEDO, Flourida 32765, USA
- Juan J Pérez-Santonja
- Instituto Oftalmologico
- De Alicante, Alicante, Spain
- Keiki R Mehta ms do fios
- Chairman and Medical Director
- Mehta International Eye Institute
- 147, Shahid Bhagat Singh Road
- Colaba Road, Mumbai-400005
- India
- Kumar Doctor ms dnb
- Director, Doctor Eye Institute
- Spenta Mansion, SV Road
- Andheri (West)
- Mumbai-400058, India
- Laure Gobin md
- Department of Ophthalmology
- University Hospital of Antwerp
- Antwerp, Belgium
- Leopoldo Spadea md
- University of L Aquila
- S Salvatore Hospital-
- Coppito L Aquila, Italy
- Liliana Werner md phd
- Assistant Professor
- John A Moran Eye Centre
- University of Utah
- 50, North Medical Drive
- Salt Lake City
- Utah 84132, USA
- Louis E Probst md
- Medical Director
- TLC, The Windsor Laser Centre
- 3200, Deziel Drive, Suite 208
- Windsor, Canada
- Lucio Buratto md
- Piazza della Republica
- 21, 20124, Milano, Italy
- Luigi Mosca md
- University of L Aquila
- S. Salvatore Hospital-
- Coppito L Aquila, Italy
- Marguerite B McDonald md
- Medical Director
- Southern Vision Institute
- New Orleans
- Lousiana, USA
- Maria C Arbelaez md
- Al Wattiyah, Romaila Building 106
- El-Maghraby Eye and Ear Centre
- P.O. Box. 513, PC 112 Rwui
- Muscat, Sultanate of Oman
- Maria Ceu Pinto md
- Porto
- Portugal
- Maria I Kalyvianaki md
- Department of Ophthalmology
- University of Crete
- Heraklion, Crete, Greece
- Maria T Iradier md
- Clinica Moreno Alguacil
- San Pascual 47
- Aranjuez 28300, Spain
- Marta Marsan md
- Instituto Oftalmologico Hoyos
- Rambla de Sabadell 62 10
- 08201 Sabadell
- Barcelona, Spain
- Marie-José Tassignon md phd
- Department of Ophthalmology
- Univeristy Hospital of Antwerp
- Antwerp
- Belgium
- Matteo Piovella md
- Centro Microchirurgia Ambulatoriale
- Via Donizetti 24
- 20052, Monza, Italy
- Melania Cigales md
- Instituto Oftalmologico Hoyos
- Sabadell (Barcelona), Spain
- Michael C Knorz md
- Klinikum Mannheim
- Theodor Kutzer Ufer 1–3
- Mannheim
- Germany
- Michiel Kritzinger md
- TLC, The Windsor Laser Centre
- 3200, Deziel Drive Suite 208, Windsor
- Ontario, Canada
- Nidhi Mathur dip nb
- Dr Agarwal's Eye Hospital
- 13 Cathedral Road
- Chennai, India
- Nilesh Kanjani ms
- Consultant
- Dr Agarwal's Eye Hospital Pvt.
- Ltd., 19, Cathedral Road
- Chennai-600086, India
- Patrick Schraepen md
- Department of Ophthalmology
- University Hospital of Antwerp
- Antwerp, Wilrijkstraat 10
- 2650, Edegem
- Belgium
- René Trau md
- Department of Ophthalmology
- University Hospital of Antwerp
- Antwerp, Belgium
- Rishi Mohan md dnb frcs
- Director
- MM EyeTec, 29 Link Road
- Lajpat Nagar-III
- New Delhi-110024, India
- Robert Montés-Micó md phd
- Instituto Oftalmologico De
- Alicante, Avda. Denia 111, 03015
- Alicante, Spain
- Roberto Pinelli md
- Director, Istituto Laser Microchirurgia Oculare
- Crystal Palace, Via Cefalonia
- 70, 25124, Brescia, Italy
- Romina Fasciani md
- University of L Aquila
- S Salvatore Hospital-Coppito L Aquila, Italy
- Ronald H Silverman md
- London Vision Clinic
- 8, Devonshire Place
- London, W1G 6HP,
- UK
- Aditya Jyot Eye Hospital Pvt. Ltd.
- Wadala, Mumbai-400031, India
- RR Sasikanth md
- Dr Agarwal's Eye Hospital
- 13 Cathedral Road, Chennai, India
- S Natarajan ms
- Chairman and Medical Director
- Aditya Jyot Eye Hospital Pvt. Ltd.
- Plot No. 153, Road No. 9
- Major Parmeshwaran Road
- Opp. SIWS College, Gate No. 3
- Wadala, Mumbai-400031, India
- Sarabel Simon-Castellvi md
- Clinica Oftalmologica Simon
- Simon Eye Clinic
- Barcelona, Spain
- Sonika Doshi ms
- Dr. Agarwal's Eye Hospital Pvt.
- Ltd., 19, Cathedral Road
- Chennai-600086, India
- Soosan Jacob md dnb ferc
- Dr. Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- Sunita Agarwal ms do psvh
- Dr. Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- 15, Eagle Street, Langford Town
- Bangalore, India
- Suresh K Pandey md
- Assistant Professor
- John A. Moran Eye Centre
- Deptt. of Ophthalmology and Visual Sciences
- University of Utah
- 50, North Medical Drive
- Salt Lake City, Utah-84132, USA
- Intraocular Implant Unit
- Sydney Eye Hospital
- Save Sight Institute
- University of Sydney
- GPO Box 1614,
- Sydney, NSW-2000, Australia
- T Agarwal force do fics
- Director
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- Theokliti G Papadaki md
- Department of Ophthalmology
- University of Crete
- Heraklion
- Crete, Greece
- Thierry Vandorselaer md
- Department of Ophthalmology
- University Hospital of Antwerp
- Antwerp, Belgium
- Vidushi Sharma md frcs
- Scholar
- Sydney Eye Hospital
- Save Sight Institute
- University of Sydney
- GPO Box 1614
- Sydney, NSW-2000
- Australia
- Vikentia J Katsanevaki md phd
- Vardinoyannion Eye Institute
- University of Crete
- Greece
- Vishwas Varma do
- Dr Agarwal's Eye Hospital
- 13 Cathedral Road
- Chennai, India
- Vivek Kadambi md doms ms
- Director
- Kadambi Laser Vision Clinic and Research Foundation Pvt Ltd.
- 157, Defence Colony
- 4th Main Road
- Indiranagar
- Bangalore-560038, India
José Barraquer, regarded as the forefather of refractive surgery may not have foreseen in the early sixties that his keratomileusis was the beginning of so long a chain of consequences responsible for the tremendous development of the armamentarium of refractive solutions by means of manipulation of the cornea.
Barraquer was followed in continuous movement by Fyodorov's anterior radial keratotomy in 1977 and its introduction into the United States by Leo Bores in 1978, by Kaufman and McDonald's epikeratophakia in 1980, by the advent of Trokel and Seller's excimer laser radiation removing corneal tissues in animal experiments in 1983 and by the introduction of Ruiz's keratomileusis-in-situ in 1987, all of them fostering the tremendous development in research, technique, methods and management of complications in refractive surgery in the last forty years.
This ongoing evolutionary process has overcome new challenges and has so drastically and speedily changed this area of ophthalmic surgery that most surgeons find it hard to follow closely and quickly absorb all the innovations. Exploring and manipulating areas previously undreamed of in ophthalmology, the 21st century surgeon perplexes at the thought that, not too long ago, so much was ignored about the embryology, histology, anatomy and physiology of the cornea.
Today, such delicate structure has been unveiled by researchers, who irrepressibly seek ways to reshape it and bring light beams to meet the retina. Such encounter is the perfect conjunction of the external environment with the visual phenomenon which is processed inside, granting the brain with the best vision possible.
The search for refractive surgical solutions is clearly not restricted to the reshaping of the cornea. The other advances are the refractive lensectomy and its replacement by monofocal, bifocal, multifocal or accommodative intraocular lenses and the implantation of IOLs in phakic eyes. All of these options have advantages and disadvantages, but we know that the unyielding quest for the vision that is as nearly perfect as possible will never cease. As men attempt to achieve immortality and resemblance to their creator, ophthalmologists strive at a breathtaking pace to correct the defects of the visual device, amazed at the power they now bear in their own hands.
Mastering the Techinques in Corneal Refractive Surgery derives from a mighty concentrated effort by Garg, Pallikaris, Hoyos, Avalos, Pinelli, Piovella and Mehta to bring together a select group of exponents in the field of refractive surgery in order to discuss techniques and procedures constantly questioned in contemporary ophthalmology. It is mandatory to speak of contemporaneousness once the evolution of means and methods for the practice of our specialty involves technology in continuous and overwhelming velocity of transformation.
In sixty-one chapters divided in four sections, the work exposes the essence of what present-day refractive surgeons consider important and indicates the direction of their thinking.
The first section provides knowledge of how to deal with the different technology at our disposal, not only to treat but, most importantly, to precisely and correctly evaluate perspective candidates to refractive surgery. A comprehensive knowledge of the available technology and sound surgical indications are major requirements to avoid complications.12
The second section exposes the reader to various techniques by thoroughly describing the main approaches to refractive surgery which have proven most effective in the hands of experienced surgeons.
The third section focus on how to prevent and manage complications. The authors share valuable information and insights leading the attentive reader to improvement in results.
The fourth and last section is an enticing journey through new perspectives of corneal refractive surgery, anticipating what may well be a reality in the near future.
Two to three decades ago a skeptic and frightened but also curious and inquisitive ophthalmic community watched the raids of intrepid surgeons on the cornea, cutting it, burning it and excising tissue from its surface with lasers. These are but remote images, now replaced by state-of-the-art technology which provides detailed examinations of the corneal structure as well as sophisticated evaluation of aberrations.
Most of us have witnessed already strides in ophthalmology which have perplexed us but the full impact of successful evolution has yet to be realized—the day will come when limitations to visual potentiality will no longer exist.
I heartily congratulate my prestigious colleagues Dr Ashok Garg, and co-editors who collaborated in the devising, elaboration and execution of this encompassing work which provides a substantial and opportune update in corneal refractive surgery and grants us the means to meet with the challenge of keeping abreast of the dynamic changes we can already envisage.
Dr Miguel Angelo Padilha md fbcs
Professor and Director of the Department of Ophthalmology
Brazilian College of Surgeons
Rua Visconde de Silva, 52/5th Floor
Ed. Colégio Brasileiro de Cirurgiões
Botafogo, 22271-090
Rio de Janeiro, Brazil
tel. (55) 21 - 2539.2847
fax (55) 21 - 2527.9994
13Preface
The promise of non-spectacle vision correction has been a cherished dream for ophthalmologist for a long time. Since 1953 when Prof. T. Sato first proposed an In Situ Method for Flattening of the Corneal Curvature by partial thickness incisions Corneal Refractive Surgery has come a long way over the years. Many new modalities have been used to reshape the cornea each having its merits and demerits. In last one-decade tremendous progress has been made in corneal refractive surgery specially from Keratomileusis, Radial Keratotomy and PRK to LASIK, LASEK, Presbyopia LASIK, Conductive keratoplasty, Wavefront aberrometry and Corneal biomechanical customisation. The next generation of Laser Refractive Surgery is certainly biomechanical customisation.
A team of well known International corneal refractive surgeons have contributed their skill in the form of chapters in this Mega International Book in a most lucid and simplified way for the benefit of ophthalmologists who are keen to do clinical practice in corneal refractive surgery. Sixty-one chapters of this book are divided into four sections covering all aspects from Refractive media of the eye, Preprocedure evaluation, Various techniques, Complications management, Recent advances and hope for the future.
Our special thanks to Sh JP Vij (CMD), Mr Tarun Duneja (General Manager, Publishing) and whole staff of publishing House M/s Jaypee Brothers Medical Publishers Pvt. Ltd. who took keen interest and published this high quality Mega International Book in a short time.
With the development of newer technique specially biomechanical customisation, aberrometry and better diagnostic technology the corneal refractive surgery shall meet the expectations of the future.
Editors