REFRACTIVE DECISIONS: Wavefront-guided Vs Wavefront-optimized Ablation: An Eye-To-Eye Comparison

Edward E. Manche

Wavefront-guided and wave front optimized ablations employ quite different technologies to minimize
aberrations in the optical system. Despite that, FDA clinical trial data for both types of excimer laser technology
is very similar when it comes to the percentage of eyes achieving 20/40, 20/25, and 20/20 visual acuity.

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In order to determine whether there are advantages to either system, we prospectively compared results of wavefront-
guided to wavefront-optimized procedures in eyes receiving LASIK or PRK.

A wavefront-guided excimer laser platform uses an aberrometer to detect individual aberrations (both lower and higher
order) and designs an ablation to correct the unique wavefront of a given eye. In contrast, a wavefrontoptimized system
bases the correction on the refraction and keratometry. The wavefront is “optimized” by placing extra pulses in the
periphery of the ablation in order to maintain the cornea’s natural aspheric shape and to reduce the induction of
spherical aberration—without taking patients’ individual higher order aberrations into account.

Study Design

We conducted a prospective, contralateral eye study of 102 eyes that received LASIK and 92 eyes that received PRK.
Eyes were randomized to either wavefront-guided or wavefront-optimized treatment based on ocular dominance. We
aimed to assess the type and extent of differences between wavefront-guided and wavefront- optimized treatments
across both interventions.

We used the wavefront-guided AMO VISX CustomVue™ STAR S4 IR™ excimer laser system (Abbott Medical Optics
Inc.) and the wavefront- optimized Allegretto Wave® Eye-Q excimer laser system (Alcon) for this study.

Study Results

Overall, both treatments were very safe, and efficacy was excellent in both groups. There were, however, statistically
significant differences between the two treatments. In the LASIK arm, the wavefront-guided group demonstrated a
statistically significant advantage in the number of eyes achieving 20/16 or better and 20/12 or better at all time
intervals (1 day, 1 week, 1 month, 3 months, and 6 months). At the 6 month visit, 70% of eyes in the wavefront-guided
group achieved 20/12.5 or better, compared to 48% of eyes in the wavefront-optimized group.

The eyes in the wavefront-guided LASIK group also had significantly better 5% and 25% contrast acuity compared to
the wavefront-optimized LASIK group. This speaks to the quality of vision achieved within the wavefront- guided
group (especially when measuring low contrast sensitivity, a subtle measure of visual acuity).

Within the PRK arm, wave frontoptimized eyes showed faster visual rehabilitation at 1 day, 1 week, and 1 month; but
after 1 month, results evened out. Uncorrected visual acuity was nearly identical between the wavefront-guided and
wavefront-optimized groups at 3 and 6 months. However, results for 5% contrast acuity demonstrated a statistically
significant difference (with wavefront-guided treatment resulting in superior contrast acuity) even at 6 months. These
contrast acuity results are similar to those found in our LASIK patients. Among eyes receiving PRK, those treated with
wavefront-optimized ablation showed a statistically significantly greater induction of HOAs.
Clinical Significance

Based on the data collected and analyzed thus far, I endorse the use of both wavefront-guided ablations and wavefront-
optimized ablations for many clinical scenarios. If a very short procedure time and rapid visual recovery are needed,
wavefront-optimized ablation could offer some benefits in eyes receiving PRK. Wavefront-guided ablation can be
especially useful in eyes with low levels of astigmatism and/or HOAs greater than 0.35 microns; for re treatments; and
where there is an asymmetric corneal topography.

We are currently engaged in a study that compares results from wavefront-guided and wave front optimized laser
platforms using the Alcon Allegretto excimer laser platform. If the results of this study are similar to the results I
detailed above, it will strengthen the case for the use of wavefront-guided ablations in the majority of situations.