Editors Ashok Garg MS, PhD, FIAO (Bel), FRSM, ADM, FAIMS, FICA
International and National Gold Medalist Chairman and Medical Director Garg Eye Institute and Research Centre
235-Model Town, Dabra Chowk, Hisar-125005 (India)
JT Lin PhD
Technical Director, New Visionul Inc.
Room 826, No. 144, Section 3 Min-Chuan East Road Taipei, Taiwan 105
Christopher J Rapuano MD
Co-Director, Cornea Service and Refractive Surgery Deptt., Wills Eye Institute Prof Jefferson Medical College Of Thomas Jefferson University Philadelphia, PA 19170
A John Kanellopoulos MD
Director, Laservision gr. Institute
Mesogeion 2 Str Athens Tower Building B 11527 Athens, Greece
Frederic Hehn MD
Chief and Medical Director Centre de La Vision, Nations-Vision
23, Boulevard de l'europe 54500, Vandoeuvre, France
Cyres K Mehta MS, FSVH, FAGE
Director and Consultant Mehta International Eye Institute
Seaside, 147, Colaba Road, Seaside 147, Colaba Road, Mumbai– 400005, India
Jorge L Alio MD, PhD
Chairman and Professor of OphthalmologyInstituto Oftalmologico De Alicante
Avda. Denia 111, 03015 Alicante Spain
Frank Jozef Goes FD
Medical Director
Goes Eye Centre, W Klooslaan 6 B2050 Antwerp Belgium
Jerome Jean Bovet MD
Consultant Ophthalmic Surgeon FMH Clinique de L'oeil, 15
Avenyue Du Bois-de-law Chapelle CH-1213, Onex Switzerland
Roberto Pinelli MD
Director, Istituto Laser Microchirurgia Oculare Crystal Palace,
Via Cefalonia 70, 25124, Brescia Italy
Bojan Pajic MD
Chief of the Cornea and Refractive Surgery Department Klinik Pallas
Louis Giroud-Str. 20 147, Colaba Road 4600 Olten Switzerland
Foreword Emanuel Rosen
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Mastering Advanced Surface Ablation Techniques
© 2008, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication 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 editor and the publisher.
First Edition: 2008
9788184482188
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset
4Dedicated to
My Respected Param Pujya Guru Sant Gurmeet Ram Rahim Singh Ji for his blessings and motivation. My respected parents, teachers, my wife Aruna Garg, son Abhishek and daughter Anshul for their constant support and patience during all these days of hard work.
My dear friend Amar Agarwal, a renowned International Ophthalmologist for his constant support, guidance and expertise.
— Ashok Garg
To Mayca, Jorge, Fernando and Maria Lucia and most especially to my beloved wife Maria, for the hours that were taken from our family life to make this book possible.
— Jorge L Alio
My wife, Jeanette and my sons Alex and Tao, who have been giving me constant support and love.
— JT Lin
My wife, Rita, for the support in my Professional Career and to my four grandchildren—Stephanie, William, Louise and Vincent – with the hope that at least one of them will become an ophthalmologist—as their father and their Daddy did.
— Frank Jozef Goes
My wounderful wife, Sara, a terrific partner at home and at work and to my children, Michael, Patrick, Daniel and Megan, who never stop reminding me what is important in life.
— Christopher J Rapuano
Yveric, Luc and Fanny Laur. Silvio Korol, who was not only a teacher but also an intellectual guide and a friend.
— Jerome Bovet
My parents, the endless and willing teachers and my family: my wonderful wife Nathalie, and our children: Alexander, Angelina and Konstantine.
— A John Kanellopoulos
I dedicate this book to India's Talented ophthalmologists, in the fervent hope that they may become increasingly devoted to refractive surgery.
— Roberto Pinelli
My wife, Marie Laurence and my children Thibaut, David, Carole and Lola.
— Frederic Hehn
To my son Valentin Aleksandar.
— Bojan Pajic
My parents for everything.
To Vini my Best friend.
— Cyres K Mehta
5CONTRIBUTORS
- A John Kanellopoulos MD
- Director, Laser Vision Gr. Institute
- Athens, Greece.
- Ahmad Salamat Rad MD
- CustomVis Ground Floor, 110 Erindale Road,
- Balcatta - Western Australia-6021
- Australia.
- Annick Ludwig PhD
- Laboratory of Pharmaceutical
- Technology and Biopharmacy,
- University of Antwerp,
- Antwerp, Belgium.
- Antonio Calossi MD
- Via 2 Giugno 52, 50053, Certaldo (FI),
- Italy.
- António Marinho MD, PhD
- Professor of Ophthalmology
- University of Porto, R Crasto 708,
- 4150-243, Porto, Portugal.
- Arthur Cheng MD
- Department of Ophthalmology and Visual Sciences,
- The Chinese University of Hongkong
- C/o Prince of Wales Hospital,
- 7B, Staff Quarters, Shatin, NT, Hong Kong SAR, PRC, China.
- Arturo Pérez-Artega MD
- Medical Director,
- Centro Oftalmologico Tlalnepantla,
- Dr Perez-Arteaga Vallarta no. 42,
- Tlalnepantla, Centro, Estado de Mexico
- 54000, Mexico.
- Arun C Gulani MD
- Director Gulani Vision Institute,
- 8075 Gate Parkway (W),
- Suite 102 and 103, Jacksonville,
- Florida—32216, USA.
- Ashok Garg MS, PhD, FRSM,
- Chairman and Medical Director,
- Garg Eye Institute and Research Centre,
- 235-Model Town, Dabra Chowk,
- Hisar–125005, India.
- Auguste Chiou MD
- Consultant Ophthalmic Surgeon, FMH
- Clinique de I'oeil, 15, Avenue du Bois-de-la-Chapelle, CH-1213 Onex, Switzerland.
- Bahri Aydin
- Fath University,
- Opthalmology Department,
- Aplarslan Turkep Cad. No.57,
- 06510 Emek, ANKARA
- Belquiz A Nassaralla MD, PhD
- Goiania Eye Institute,
- Department of Cornea and Refractive
- Surgery, Goiania, GO,
- Brazil.
- Bojan Pajic MD
- Chief of the Cornea and Refractive
- Surgery Department,
- Klinik Pallas, Louis Giroud-Str. 20
- 4600 Olten, Switzerland.
- C Banu Cosar MD
- Associate Professor of Ophthalmology
- Sinpas Aqua City 1. Etap
- H Block D:13A. Dudullu 80260
- Istanbul, Turkey.
- Caitriona Kirwan MD
- Department of Refractive Surgery
- Mater Private Hospital,
- Eccles St, Dublin 7, Ireland.
- Carlo Francesco Lovisolo MD
- Medical Director, QuattroElle Eye Center,
- via Cusani, 7-9, 20121, Milano,
- Charles WM Stewart MD
- QuattroElle Eye Center,
- via Cusani, 7-9, 20121, Milano, Italy.
- Chitra Ramamurthy MD
- The Eye Foundation, 582-A, DB Road,
- RS Puram, Coimbatore–641002
- Tamil Nadu, India.
- Chris P Lohmann MD, PhD
- Universitats-Augenklinik
- Franz-Josef-Strau B-Allee
- D-93042, Regensburg, Germany
- Christopher J Rapuano MD
- Co-Director, Cornea Service, Wills Eye Institute
- Co-Director, Refractive Surgery Department, Wills Eye Institute, Professor of Ophthalmology
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
- Cornea Service, Wills Eye Institute
- 840 Walnut Street, Suite 920, Philadelphia, PA 19107
- USA
- Chu Renyuan MD
- Eye and ENT Hospital
- Fudan University,
- Shanghai, China.
- Claes Feinbaum MD
- Professor Emeritus Optometry,
- OkoMedica, Warsaw, Poland
- D Ramamurthy MD
- Medical Director, The Eye Foundation
- 582-A, DB Road, RS Puram,
- Coimbatore–641002
- Tamil Nadu, India.
- Dai Jinhui MD
- Eye and ENT Hospital
- Fudan University, Shanghai,
- China.
- Daniel S Durrie MD
- Medical Director
- Durrie Vision, 5520 College Boulevard
- Overland Park, Kansas 66211
- USA.
- Danny Mathysen MSc
- Department of Ophthalmology,
- University Hospital of Antwerp,
- Antwerp, Belgium.
- David Donate PhD
- Laboratorie Biotechnologie et Oeil
- Universite Paris V, 1, Place du Parvis Notre-Dame
- 75181 Paris cedex 4, France.
- David PS O'Brart MD, FRCS, FRCOphth
- Department of Ophthalmology,
- St. Thomas' Hospital, London,
- UK.
- Dennis SC Lam MD, FRCO
- Professor of Ophthalmology
- Dept. of Ophthalmology and Visual Sciences,
- The Chinese University of Hong Kong
- 3/F, Hong Kong Eye Hospital, 147K Argyle Street, Kowloon, HKSAR PRC, China.
- Dimitrii Dementiev MD
- Chief and Medical Director,
- Blue Eye Centro di, Michro Chirurgia Oculare Eye Clinic, Arese 20020 (MI), Via Campo
- allo 21/10, Italy.
- Doga A MD
- S. Fyodorov Eye Microsurgery
- Complex State Institution,
- 127486 Moscow, Beskudnikovsky blvd 59A
- Russia.
- E Milani MD
- QuattroElle Eye Center, via Cusani, 7-9, 20121
- Milano, Italy.
- Edward E Manche MD
- Director of Cornea and Refractive
- Surgery, Associate Professor
- Stanford University School of
- Medicine, 900 Blake Wilbur Drive,
- W 3002, Stanford, CA 94304,
- USA.
- Emanuel Rosen MD
- Rosen Eye Associates, Harbour City,
- FJ Zhang MD
- Department of Ophthalmology,
- The First Affiliated Hospital,
- Dalian Medical University,
- Dalian, China–116011.
- Frank Goes MD
- Director, Goes Eye Centre,
- W Klooslaan 6 B2050, Antwerp, Belgium.
- Frederic Hehn MD
- Centre de La Vision, Nations - Vision,
- 23, Boulevard de l'europe 54500, Vandoeuvre, France.
- George A Kounis BSc, PhD
- Department of Ophthalmology, Institute of Vision and Optics, University of Crete, Greece.
- George D Kymionis MD, PhD
- Department of Ophthalmology,
- Institute of Vision and Optics,
- University of Crete, Greece.
- Grace Lie MD
- Department of Ophthalmology,
- University Hospital Antwerp, Wilrijkstraat 10,
- B-2650, Edegem (Antwerp) Belgium.
- Hermann Anhalm PhD
- Senior Optometrist, Deptt. of Ophthalmology,
- Klinik Pallas, Louis Giroud-Str. 20
- 4600 Olten, Switzerland.
- I-Jong Wang MD PhD
- Department of Ophthalmology
- National Taiwan University Hospital,
- Taipei, Taiwan.
- Ioannis G Pallikaris MD PhD
- Director, Department of Ophthalmology,
- Institute of Vision and Optics,
- University of Crete, Greece.
- Iwona Liberek MD PhD
- Head of the Ophthalmology Clinic
- Post Graduate Centre of Medical
- Education, SPSK im. Prof. W. Or3owswkiego
- 00-416, Warszawa, tul. Czerniakowska 231
- Poland.
- Jean-Marc Legeais MD PhD
- Hopital HOTEL DIEU, Service d'Ophthalmologie
- 1, Place du Parvis Notre Dame
- 75181, Paris Cedex 04, France.
- Jenna M Burka
- 3000 Washington Blvd,
- #526, Arlington,
- VA. 22201,
- USA
- Jeroen JG Beerthuizen MD FEBOphth.
- Department of Ophthalmology,
- VU University Medical Center,
- De Boelelaan 1117, 1081 HV, Amsterdam, Netherland.
- Jerome Bovet MD
- Consultant Ophthalmic Surgeon, FMH
- Clinique de I'oeil,
- 15, Avenue du Bois-de-la-Chapelle,
- CH-1213 Onex, Switzerland.
- Jes Mortensen MD
- The Eye Department, Orebro University Hospital
- SE-70185 Orebro, Sweden.
- Jichang He PhD
- Tianjin Medical University,
- Tianjin Eye Hospial and Eye Institute
- No.4, Gansu Rd, Tianjin 20020, China
- João J Nassaralla Jr MD PhD
- Faculty of Health Sciences
- University of Brasilia, DF
- Goiania Eye Institute,
- Department of Retina and Vitreosu
- Goiania, GO, Brazil.
- Jörg Müller MS
- Department of Ophthalmology, Klinik Pallas,
- Louis Giroud-Str. 20 4600 Olten
- Switzerland.
- Jorge L Alió MD, PhD
- Professor and Chairman,
- Instituto Oftalmologico De Alicante,
- Avda. Denia 111, 03016, Edificio Vissum, Alicante,
- JT Lin PhD
- Technical Director, New Vision, Inc.
- Room # 826, Section 3, No. 144,
- Min-Chuan East Road, Taipei, Taiwan 105.
- Juha M Holopainen MD
- Department of Ophthalmology,
- University of Helsinki, Finland.
- Justyna Izdebska MD PhD
- Department of Ophthalmology,
- Warsaw Medical University,
- Warsaw, Poland.
- Kachalina G MD
- Department of Ophthalmology
- S Fyodorov Eye Microsurgery
- Complex State Institution,
- 127486 Moscow, Beskudnikovsky blvd 59A
- Russia.
- Kanxing Zhao MD PhD
- Tianjin Medical University,
- Tianjin Eye Hospital and Eye Institute
- No.4, Gansu Rd, Tianjin 20020
- China.
- Laura de Benito-Llopis MD
- Consultant Ophthalmologist,
- Vissum Madrid, Spain.
- Lee T Nordan MD
- Gulani Vision Institute, 8075 Gate Parkway (W),
- Suite 102 and 103, Jacksonville, Florida-32216, USA.
- Lu Yang MD
- Department of Ophthalmology,
- The First Affiliated Hospital,
- Dalian Medical University,
- Dalian, China–116011.
- Lung-Kun Yeh MD
- Department of Ophthalmology
- Chang-Gung Memorial Hospital
- (Linko), Chang-Gung University,
- College of Medicine, Taipei,
- Taiwan.
- Maria I Kalyvianaki MD
- Department of Ophthalmology,
- University of Crete, Heraklion, Crete, Greece.
- Marie-José Tassignon MD PhD
- Department of Ophthalmology,
- University Hospital Antwerp,
- Wilrijkstraat 10, B-2650,
- Edegem (Antwerp) Belgium.
- Massimo Camellin MD
- Consultant Ophthalmologist
- Rovigo, Italy.
- Maychuk N MD
- S Fyodorov Eye Microsurgery
- Complex State Institution, 127486 Moscow,
- Beskudnikovsky blvd 59A,
- Russia.
- Michael O' Keefe FRCS
- Professor, Department of Refractive Surgery
- Mater Private Hospital,
- Eccles St, Dublin 7, Ireland.
- Miguel A Teus MD
- Consultant Ophthalmologist,
- Universidad de Alcla Madrid, Spain.
- Mikhail Pojaritsky MD
- Blue Eye Centro di,
- Michro Chirurgia Oculare Eye Clinic,
- Arese 20020 (MI) Via Campo Gallo 21/10, Italy.
- Mohamed H Shabayek MD
- Instituto Oftalmologico De Alicante,
- Avda. Denia 111, 03016, Edificio Vissum, Alicante,
- Spain.
- Neil Vice MD
- CustomVis Ground Floor, 110 Erindale Road,
- Balcatta-Western Australia–6021,
- Australia.
- Nikolaos S Tsiklis MD
- Department of Ophthalmology,
- Institute of Vision and Optics,
- Nurullah Cagil
- Ataturk Research and Training Hospital
- Ophthalmology Department
- 06800 Bilkent,
- Aankara
- Okihiro Nishi MD
- Higashinari-Ku, Nakamichi 4-14-26,
- 537-0025, Osaka,
- Japan.
- Patrick Schraepen MD
- Department of Ophthalmology,
- University Hospital Antwerp,
- Wilrijkstraat 10, B-2650, Edegem (Antwerp)
- Belgium.
- Ramiro Salgado MD
- University of Porto, R Crasto 708
- 4150-243, Porto, Portugal.
- René Trau MD
- Department of Ophthalmology,
- University Hospital Antwerp,
- Wilrijkstraat 10, B-2650,
- Edegem (Antwerp), Belgium.
- Roberto Pinelli MD
- Director, Istituto Laser Microchirurgia Oculare
- Crystal Palace, Via Cefalonia, 70
- 25124 Brescia, Italy.
- Ronald Singal MD
- Blue Eye Centro di,
- Michro Chirurgia Oculare Eye Clinic,
- Arese 20020 (MI), Via Campo Gallo 21/10,
- Italy.
- Sanjay Chaudhary MS
- Chaudhary Eye Centre and Laser Vision,
- 4802, Bharat Ram Road,
- Ansari Road, 24, Darya Ganj,
- New Delhi–110002.
- Srinivas K Rao MD
- Director, Darshan Eye Clinic,
- T 80, Fifth Main Road,
- Anna Nagar, Chennai–600017.
- India.
- Stephen D McLeod MD
- Department of Ophthalmology
- University of California,
- San Francisco, CA, USA
- Takhchidi K MD
- Director General, S Fyodorov Eye Microsurgery
- Complex State Institution, 127486 Moscow,
- Beskudnikovsky blvd 59A, Russia.
- Tarak Pujara MS
- CustomVis Ground Floor, 110 Erindale Road,
- Balcatta - Western Australia–6021
- Australia.
- Timo MT Tervo MD
- Department of Ophthalmology
- University of Helsinki,
- PO Box 220, 00029 HUS, Finland.
- Vikentia J Katsanevaki MD
- Department of Ophthalmology
- University of Crete, Heraklion Crete
- Greece.
- Waldir Neira Zalentein MD
- Department of Ophthalmology
- University of Helsinki,
- PO Box 220, 00029 HUS,
- Finland.
- Wei Wang MD
- Tianjin Medical University,
- Tianjin Eye Hospital and Eye Institute
- No. 4, Gansu Rd, Tianjin 20020
- China.
- Weldon W Haw MD
- Associate Clinical Professor
- Corneal, Cataract and Refractive Surgery
- UCSD School of Medicine
- 9415 Campus Point Drive
- La Jollam, CA 92093-0946, USA.
- Wim Weyenberg PhD
- Laboratory of Pharmaceutical,
- Technology and Biopharmacy,
- University of Antwerp, Wilrijkstraat 10, B-2650,
- Wu Ying MD
- Eye and ENT Hospital
- Fudan University,
- Shanghai, China.
- Yan Wang MD
- Professor, Tianjin Medical University,
- Director, Refractive Surgery Center
- Tianjin Eye Hospital and Eye Institute
- No. 4, Gansu Rd,
- Tianjin 20020, China
- Yao Peijun MD
- Eye and ENT Hospital, Fudan University,
- Shanghai, China.
- Yongji Liu PhD
- Tianjin Medical University,
- Tianjin Eye Hospital and Eye Institute
- No. 4, Gansu Rd,
- Tianjin 20020, China.
- Yutaro Nishi MD
- Higashinari-Ku,
- Nakamichi 4-14-26,
- 537-0025, Osaka, Japan.
- Zhou Xingtao MD
- Eye and ENT Hospital
- Fudan University
- Shanghai, China
As our knowledge advances in the sphere of corneal biomechanics, surface ablation for laser vision correction once again increases its appeal. A resurgence of photorefractive keratectomy, whatever other name may be applied to the technique, limits the structural alteration of the cornea. Topography guided ablation for irregular corneal surfaces or wavefront guided ablation for correction of eye aberrations are indicators of the increasing sophistication of the ablative process.
The text is supported with reviews of the basic science of corneal ablations including biophysics of thermal as well as non-thermal techniques. Experienced surgeons share their pearls which is an invaluable guide for surgeons to avoid pitfalls during their learning curve. Adjunctive methods include reviews of the role of mitomycin C, anti-inflammatory and antibiotic medications to prevent adverse events after treatment. Corneal laser vision correction in common with so many aspects of modern medicine in general and ophthalmology in particular, is a rapidly developing subject and this volume provides immediate insights into the current status of surface corneal ablations.
Surface and near surface ablative techniques form the subject matter of this volume variously characterized as PRK, Epi-LASIK, LASEK and SBK. The collective experience of the world's leading laser vision correction surgeons, have been drawn together by that master of the genre of clinical ophthalmic textbooks Dr Ashok Garg. He always provides up to the minute information for the enlightenment of his readers for he recognized the rapid evolution of knowledge and the need to bring it to notice as soon as possible. Once again he is to be congratulated on another masterly volume which will contribute greatly to the welfare of countless patients who undergo treatment for low and moderate myopia, astigmatism and low hyperopia by the various techniques described herein. Dr Garg's productivity is a modern marvel that deserves all our congratulations and support.
Professor Dr Emanuel Rosen
BSc, MD, FRCSEd, FRCOphth, FRPS
10 St John Street Manchester M3 4DY UK
Tel 44 161 832 8778, Fax 44 161 832 1486
Email contact; louise_brennan@btinternet.com
12PREFACE
Since the inception of PRK as Refractive Surgery procedure 20 years back the Laser Refractive Surgery has gone full circle. For the last a few years LASIK has been the attractive and popular refractive procedure worldwide. Recently due to LASIK postoperative long- and short-term severe complications there is renewed interest in Laser Surface Ablation procedure among Refractive Surgeons. Indeed there is resurgence of Advanced Surface Ablation procedures with a bang. Laser vision correction without preparation of a LASIK flap include LASEK, Epi-LASIK, Surface LASIK and SBK which are known as Advanced Surface Ablation Techniques (ASA). As an appeal derives from two unique factors (a) For an equivalent correction (b). It leaves a structurally stronger cornea than LASIK thus lower incidence of corneal ectasia. Advanced Surface Ablation is certainly a better procedure than LASIK for High Myopia, atypical corneal topography, inferior steepning, steep central cornea and high oblique astigmatism. The ASA offers a more conservative option than LASIK.
64 chapters in this International Book practically covers all techniques of Advanced Surface Ablation in comprehensive manner. Leading International Refractive Surgeons have shared their experiences in these chapters and are of opinion that ASA is more safe and stable than that of First Generation Surface Ablation performed with excimer laser.
Hats off to our publisher Sh Jitendar P Vij (CEO), M/s Jaypee Brothers Medical Publishers Pvt Ltd (India), Mr Tarun Duneja (General Manager — Publishing) and all staff members who took keen interest and done hard work in timely preparation of this ASA book first of its kind in the world. With renewed interest in Advanced Laser Surface Ablation procedure worldwide, we are hopeful this unique book shall provide complete information on ASA techniques to every Refractive Surgeon. Next decade certainly belongs to Resurgent Advanced Surface Ablations.
Editors