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Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753

454. Refractive Surgery Organizing Section: CO

4335 - B693

Alcon LADARVision Wavefront-Guided Photorefractive Keratectomy and Laser in

situ Keratomileusis: 6 Month Results
R.VanRoekel1, S.C. Schallhorn2, K.Lombardo2, J.M. Burka1, K.S. Bower1, R.D. Stutzman1,
C.P. Kuzmowych1. 1Center for Refractive Surgery, Walter Reed Army Medical Center,
Washington, DC; 2Department of Ophthalmology, Naval Medical Center, San Diego, CA.

Purpose: To report the 6-month visual outcomes after wavefront-guided (WFG) photorefractive keratectomy (PRK) and laser in-situ
keratomileusis (LASIK) using the Alcon LADARVision excimer laser system. Methods: 62 subjects (42 PRK and 20 LASIK) were
included in this prospective, multi-center study. All subjects underwent WFG treatment in their dominant eye and conventional treatment
in their non-dominant eye. Outcome measures included uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), and
low contrast acuity (CA) at 6 months postop. High contrast (HC) BCVA, photopic 5% CA (80-140 cd/m 2), and mesopic 25% CA (0.8-1.2
cd/m 2) were performed with best correction and compared to preoperative measurements. Surgically induced changes were compared
for the four procedures: WFG PRK, conventional PRK, WFG LASIK, and conventional LASIK. Results: There was no difference in
UCVA or HC BCVA between treatment groups. The 5% CA improved by a mean of 0.02 logMAR following both WFG PRK and WFG
LASIK, compared to a mean decrease of 0.03 logMAR for both conventional procedures. The net difference in postop 5% CA between
WFG and conventional procedures was 0.05 logMAR (equivalent to half a line). The 25% CA decreased the most following conventional
LASIK (mean 0.04 logMAR) and conventional PRK (mean 0.03 logMAR). 25% CA following WFG LASIK decreased on average by only
0.01 logMAR, and improved by 0.02 logMAR following WFG PRK. Conclusions: Although HC visual acuity was equal following all 4
procedures, low contrast acuity was generally better following PRK than LASIK, and better with WFG treated compared to conventional
treatments. There was an overall improvement in 5% CA for eyes treated with WFG procedures compared to a slight decrease in
performance for those eyes treated with conventional procedures. Of the four procedures, only the WFG PRK improved mesopic
25% CA postoperatively. WFG PRK appears to provide excellent quality vision, particular in low contrast low light environment.

4336 - B694

Corneal Edema and Associated Visual Quality Following Lasek: A Preliminary

J.Qu, Q.Wang, F.Lu, C.Xu, Y.Yu. School of Opto & Ophthal, Wenzhou Medical College,
Wenzhou, China.
P u r p o s e :To e v a l u a t e t h e e f f e c t of c o r n e a l e d e m a o n v i s u a l
Methods: Fifteen human subjects (30 eyes) with myopia ranging from -3.50D to
-7.00D were treated by routine LASEK. Eyes were evaluated for 9 months postsurgically, including evaluation of the epithelial ap, corneal responses and visual
acuity (LogMAR) twice during the rst week and once a week thereafter. Contrast
sensitivity and wavefront aberrations were measured at 2 and 12 weeks and 9 months.
Results: LASEK was successfully performed in all eyes with no obvious post-surgical
discomfort. Moderate edema at the subepithelial cornea occurred in all eyes immediately after
surgery and this substantially subsided in 70% of eyes (n = 21) at 3 weeks and 30% of eyes (n =
9) at 5 weeks. Visual quality was compromised depending on the severity of edema in all eyes
after surgery. This included a signicant reduction in best-corrected visual acuity (BCVA)
and contrast sensitivity function (CSF) with an increase in wavefront aberrations (p < 0.01 or
0.05, compared to pre-surgical levels). The reduction in CSF was mainly at high frequencies
and the increase in wavefront aberrations was most obvious at coma aberrations. All visual
quality components recovered towards pre-surgical levels as edema subsided. Complete
recovery required approximately 3 months for BCVA, CSF and non-coma aberrations
in most of the eyes following LASEK, with recovery of coma aberrations taking longer.
Conclusions: Subepithelial edema is the major corneal response which compromised visual
quality after LASEK. Recovery of the visual quality depends at least in part to the length
of time needed for corneal edema to subside, indicating the importance of active treatment
for the edema after LASEK.
CR: J. Qu, None; Q. Wang, None; F. Lu, None; C. Xu, None; Y. Yu, None.
Support: Zhejiang Provincial Natural Science Foundation of China, ZB0202

CR: R. VanRoekel, None; S.C. Schallhorn, None; K. Lombardo, None; J.M. Burka, None; K.S. Bower, None; R.D. Stutzman,
None; C.P. Kuzmowych, None. Support: None.

4337 - B695

4338 - B696

Evaluation of the Prophylactic Use of Mitomycin C to Inhibit Haze Formation After

Photorefractive Keratectomy for Residual Myopia Following Radial Keratotomy
B.A. Nassaralla1, J.J. Nassaralla2. 1Ophth & Refractive Surgery, Instituto de Olhos de
Goiania, Goiania, Brazil; 2Retina and Vitreous, Instituto de Olhos de Goiania and UnB,
Goiania, Brazil.
Purpose: Evaluation of the prophylactic use of mitomycin C to inhibit haze formation
after photorefractive keratectomy for residual myopia following radial keratotomy.
Methods: Twenty two eyes of fourteen patients, 5 men and 9 women, with residual myopia
after RK were included is this study. The RK procedures were performed from 1988 to
1993 in different eye care centers. Mean age at the time of PRK plus mitomycin C was
39.14 years. All eyes were treated with PRK and a single intraoperative topical application
of mitomycin C (0.02%) solution for 2 minutes using a soaked merocel sponge placed over
the ablated area. Before PRK, the mean spherical equivalent was -2.73 D (range, -1.50 to
-4.00D). The inclusion criteria were low myopia, no central corneal opacity and high risk
factors to allow a safe Laser in situ keratomileusis procedure. Refraction, uncorrected visual
acuity, best spectacle corrected visual acuity (BSCVA), slit lamp evidence of corneal opacity
(haze) and other visible complications, were evaluated over a 12-month follow-up period.
Results: Epithelial healing occurred between 4 and 8 days in all eyes. After 12 months,
no eye showed haze grade over 1; 3 eyes showed haze grade 1 and 2 eyes, haze grade
0.5. Best spectacle corrected visual acuity was 20/25 or better in twelve eyes. No eye
lost any line of the BSCVA as compared to the pre-PRK values. Mean nal spherical
equivalent achieved was -0.28 D (range, -0.75 to +0.50 D). No adverse effects related to
the use of mitomycin C were observed during re-epithelialization or during follow up.
Conclusions: PRK with a single intraoperative application of mitomycin C 0.02% was safe
and effective in treating residual myopia in patients with undercorrection or regression
following RK.
CR: B.A. Nassaralla, None; J.J. Nassaralla, None.
Support: None.

Axial Length and IOP Changes With Application of the IntraLase and Moria M2
Suction Rings
W.W. Culbertson1, F.Marangon1, S.H. Yoo1, C.A. Acosta1,2, I.Nose1, P.Superne1, J.Parel1,3.
Ophthalmology, Bascom Palmer Eye Institute, Miami, FL; 2Hospital Oftalmolgico Dr.
P.Lagleyze, Buenos Aires, Argentina; 3CHU Sart-Tilman, Univ. of Liege, Liege, Belgium.
Purpose: To determine how the axial length and the intraocular pressure changes when the
IntraLase suction ring interface and the Moria M2 suction ring are placed on the human eye.
Methods: Ten fresh human cadaver eyes (ve pairs) and six eyes (three pairs) of living
volunteers were studied. Intraocular pressures and axial lengths were obtained both
prior to and during application of an IntraLase suction ring to one of a pair of the eyes.
Similar measurements were obtained with application of a Moria M2 suction ring.
Results: Intraocular pressures increased with both suction rings to between 71 to 84 mmHg
during application of suction in both living and cadaver eyes. Axial lengths either remained
unchanged or shortened during suction application in both IntraLase and Moria M2 cadaver or
living human eyes. The average decrease in axial lengths was 0.47mm for IntraLase cadaver
eyes and 82mm for Moria cadaver eyes. In three pairs of living volunteer eyes the axial length
shortened on the average of 0.19mm for IntraLase eyes and 0.12mm for Moria M2 eyes.
Conclusions: The intraocular pressure is raised signicantly when either the IntraLase or the
Moria M2 suction ring is applied to the human eye. Contrary to recent reports of elongation
of axial length with the Moria M2 suction ring (Flaxel et al, Ophth 111:24-27;2004), we
found that the axial length decreases (instead of increases) when either type of suction ring
is applied to living or cadaver human eyes.
CR: W.W. Culbertson, Intralase R; F. Marangon, None; S.H. Yoo, Intralase R; C.A.
Acosta, None; I. Nose, None; P. Superne, None; J. Parel, None.
Support: NIH center grant P30-EY014801; Research to Prevent Blindness; Henri and Flore
Lesieur Foundation

4339 - B697

4340 - B698

Photorefractive Keratectomy for High Myopia in 124 Eyes

G.Legendre1A, D.Cailliau1B, F.Margaron1B, J.-F.F. Rouland1B. AOphthalmology,
Ophtalmology, 1University of Lille, Lille, France.
Pur pose: To assess the predict abilit y, the safet y and the st abilit y
of photoref ract ive keratectomy for t he cor rect ion of h ig h myopia.
Methods:124 eyes of 71 patients were included. Mean preoperative spherical
equivalent refraction of - 8,35 +/- 1,63 D (range, -6 D to -14,125 D) These eyes
were treated by photorefractive keratectomy using the laser Excimer Keracor 217.
Eyes were divided into three groups : spherical equivalents ranging betwenn 6 and -8 D, -8 and -10 D an more than -10 D. The visual acuity, the subjective
refraction, the evaluation of the central corneal haze and corneal topography were
carried out in preoperative, in one month and more than six months after surgery.
Results: After six months, the mean spherical equivalent was - 0,31 +/- 0,76 D (range
- 3,75 D to + 2,375 D) ; 88 % of eyes were within +/- 1,00 D of attempted correctoin ; the
uncorrected visual acuity was 20/40 or better in 92 % of eyes. One eye lost two Snellen lines,
no eye lost more than two Snellen lines. These results were analyzed according to various
parameters (ablation depth, size of the optical zone, pupil size in photopic environment).
Corneal haze was correlated with ablation depth and with size of optical zone.
Conclusions: Photorefractive keratectomy for high myopia appears to be safety and efcient.
The optical zone diameter of treatment seems to be the most important factor for predicatbility
and wound healing.
CR: G. Legendre, None; D. Cailliau, None; F. Margaron, None; J.F. Rouland, None.
Support: None.

Safety and Efcacy of the Moria Epi-K for Epi-LASIK in Four Centers Worldwide
B.Soloway1, M.Swanson2, R.Rashid3, J.Bai4, C.Starr1, D.Jardim1. 1Vision Correction, New
York Eye and Ear Inrmary, New York, NY; 2Ophthalmology, Swann Ophthalmology and
Laser Institute, Aqua Prieta, Mexico; 3Vision Correction, Eye Physicians and Surgeons,
Charleston, WV; 4Ophthalmology, Chongqing Daping Hospital Eye Center, Chongqing,

Purpose:To assess the safety and eff icacy of the Moria Epi-K for Epi-LASIK
in the hands of 4 refractive surgeons in the United States, Mexico and China.
Methods: Four surgeons performed Epi-LASIK with the Epi-K on 93 eyes. One Single
Use head and one Single Use Plus ring were used per patient. Preoperatively, the spherical
equivalent range was -9.75 D to +3.75. Keratometry ranged from 40.1 to 49.75 D. Pachymetry
ranged from 468 to 634 microns. Flap thickness was measured with ultrasound by subtraction
pachymetry. Flap dimensions were measured with manual or laser calipers. Epithelial ap
quality was evaluated subjectively. Additionally, ap complications, postoperative BSCVA,
patient reported pain level, ability to return to work and time of contact lens removal were
reported. All centers were subject to IRB monitoring and adherence to the Helsinki agreement
Results: An epithelial ap was successfully created in all eyes. We (BS) achieved an average
thickness of 52 +/- 9.6 (38-79) microns in 16 eyes. MS, JB, and RR respectively obtained an average
ap thickness of 46 +/- 8.3 (26-65) microns in 32 eyes, 54 +/- 10 (33-73) microns in 27 eyes and
50 +/- 11 (33-71) microns in 18 eyes. The average ap diameter was 9.2 +/- 0.2 (9-9.5) mm. MS,
JB, and RR respectively obtained an average ap diameter of 9.2, 9.5 and 9.0 mm. Intra-operative
complications were limited to an isolated area of retained epithelium on ap generation in 1 eye and
3 epithelial defects created during ap repositioning with a metal cannula. Postoperatively, 2 eyes
had spontaneous loss of their bandage contact lens (BCL). The BCL was removed between day 3
and day 5 postoperatively. A minimum of 51% of patients were able to return to work on post-op day
three and 87% by post-op day 4 at any center. No patient reported signicant pain by the third post-op
day. No eyes lost BSCVA in any center and up to 42% gained one or more lines at the six-month visit.
Conclusions: The Epi-LASIK with the Moria Epi-K is a safe procedure. The Epi-K creates predictable
and uniform epithelial aps. Flap management techniques and bandage contact lens selection should
be adapted to Epi-LASIK.
CR: B. Soloway, Moria R; M. Swanson, Moria R; R. Rashid, Moria R; J. Bai, None; C. Starr,
None; D. Jardim, None.
Support: None.

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.

Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753
454. Refractive Surgery Organizing Section: CO
4341 - B699

4342 - B700

Central Flap Necrosis: Stage 4 Diffuse Lamellar Keratitis or a Separate Entity?

Y.Myung, M.O. Price, PhD, F.W. Price, Jr., MD. Ophthalmology, Corneal Consultants of
Indiana, Indianapolis, IN.
Purpose: To describe a series of central f lap necrosis after LASIK in
cases where the f lap was created using a variety of microkeratomes.
Methods: Retrospective analysis of 8 eyes in 7 patients who underwent
uncomplicated LASIK surgery and developed severe central f lap necrosis.
Results: The progression of lamellar inammation was strikingly similar in all cases.
Inammation occurred within 48 hours of surgery, culminating in the Mercedes sign between
post op days 5 to 10. The inammation then diminished over two months. This ap necrosis
occurred in only the rst eye to have had LASIK in ve patients. One patient had bilateral
involvement. One patient had LASIK in one eye only. Signicant ndings were central clouding
of anterior stroma, ap striae, loss of UCVA and BCVA. Inammation did not respond to intense
topical steroids or antibiotic-steroid combination. 4 eyes had their aps lifted and irrigated
and 2 appeared to respond to this treatment. The anterior portion of the ap had a jelly-like
consistency. The end result was a hyperopic shift from stromal tissue loss with loss of BCVA.
Conclusions: This severe central f lap necrosis appears to be different from
inammation that begins in the interface. The etiology remains to be elucidated but
could be caused by substances that diffuse into the ap anteriorly during LASIK.
CR: Y. Myung, None; M.O. Price, PhD, None; F.W. Price, Jr., MD, None.
Support: None.

Lasek in Patients Unt for Lasik

A.A. Kotb, K.F. Tabbara. The Eye Ctr/The Eye Foundation for Research in Oph, Riyadh,
Saudi Arabia.
Purpose: To evaluate the outcome and complications of LASEK in patients unt for LASIK
Methods: TwoHundred and nine eyes among 117 consecutive patients were included in this study.
All patients underwent LASEK using Keracor 217z excimer laser (Bausch & Lomb).
Mean age was 29.7 years (Range 19 - 48 yrs).The mean pre-operative epherical
equivalent (SE) was -4.41 D (Range -1.0D to -12.50D).The mean pre-operative
corneal thickness was 529.4 um (Range 482 - 637 um) and mean ablation depth
was 82.25 um.The mean pre-operative posterior surface elevation was 28.8 um.
Patients were not t for LASIK for the following reasons :thin cornea in 61(29.2%) eyes
out of the 209 eyes,low residual corneal thickness in 49(23.4%)eyes ,high keratoconus
index in 34(16.2%) eyes or presence of posterior surface hot spot in 29(13.9%) eyes.
Follow up was for a mean period of 18 months (Range 6-36 months)
Results: Following LASEK the SE was within +/- 1 D in 200(95.7%) eyes and was
within +/-0.50 D in 148(70.8%) eyes.One hundred seventy (81.5%) eyes achieved
the pre-operative BCVA and 29(13.8%) eyes were within one line .After six months
167(80.2%) eyes showed no haze while 26(12.2%)eyes showed minimal haze
and 16(7.6%) eyes showed mild haze.Fourteen (12.1%) patients reported no pain
in the first post-operative 24 hours while 79(67.5%) patients reported mild pain.
Three (2.7%) patients reported severe pain in the first post-operative 24 hours.
The mean post-operative cor neal thick ness was 417 um (Range 320 615um) and mean post-operative posterior surface elevation was 46.24 um.
After a minimum follow up period of two years ,there was no case of posterior corneal ectasia .
Conclusions: LASEK is a safe ,effective and predictable procedure in the treatment of myopia
in patients where LASIK is contraindicated.
CR: A.A. Kotb, None; K.F. Tabbara, None.
Support: None.

4343 - B701

4344 - B702

A New Therapeutic Application of Omalcon a After Laser-Assisted Subepithelial

Keratomileusis (LASEK)
R.M. Davis. Ophthalmology, University of South Carolina School of Medicine, Columbia,
Purpose: Therapeutic contact lens wear following LASEK may affect patient outcomes in
the early postoperative period. Little attention has been given to the role of postoperative
contact lens wear with respect to wound healing. A contact lens constituted with a
lipid hydrogel polymer was evaluated as a continuous therapeutic lens after LASEK.
Methods: We performed a retrospective analysis of 78 consecutive eyes (40 patients) that
underwent LASEK in a one-year period. Eligibility included patients with insufcient
residual depth and or a pre-existing diagnosis of dry eye syndrome. The epithelium was
scored with a 9.0 mm serrated trephine followed by a 50 second application of 20% alcohol
in a 9.5 mm trephine well. The epithelium was lifted followed by laser ablation with the
Bausch and Lomb Technolas 317 excimer laser. Following laser treatment, the epithelium
was repositioned, a topical steroid and a broad-spectrum antibiotic were applied four times
per day for one week. All patients were tted with omalcon A (Proclear, Coopervision)
immediately following surgery. Patient records were reviewed for lens movement,
wound healing characteristics, and complications related to the therapeutic contact lens.
Results: The mean preoperative sphere was -8.32 + 1.86 D. The mean cylinder was +1.72
+ 1.20 D. At one week, 76% (49/78) and 18% (14/78) were better than 20/40 and 20/20.
All patients tolerated omalcon A without complications resulting in discontinuation
of the lens. Lens movement was acceptable in all cases by physician report. Wound
healing assessment the rst day after surgery revealed microcystic edema apparent at
the LASEK wound interface and normal appearing central epithelium in the majority
of cases. Continuous contact lens wear for 1-7 days was observed in most cases. The
most common patient complaint attributed to the lens was a foreign body sensation.
Conclusions: Therapeutic contact lens wear with omalcon A after LASEK was well tolerated
facilitating normal wound healing without complications. This may be due to greater tear lm
and lens stability, which may in part be related to the specic lipid hydrogel characteristics
of the contact lens. Extended wear of omalcon A is an off-label application.
CR: R.M. Davis, None.
Support: None.

Purpose: To prospectively compare four excimer laser systems for the treatment of
high myopia with LASIK using a night driving simulator to track visual performance.
Methods: Detection and identication distances of 2 different road signs and a pedestrian
hazard during nighttime driving (rural road at 55 mph, Vision Research Sciences Corp.) with
and without glare was measured in 75 subjects before and 6 months after conventional LASIK
(4 different lasers; preop MSE -5.712D). Each eye was tested independently. 21subjects/42 eyes
were treated with the Alcon Ladarvision 4000, 18/36 with a Bausch & Lomb Technolas 217, 18/36
with a Nidek EC-5000, and, 18/36 with a VISX laser system. Laser group treatments (sphere,
cylinder, MSE) were similar (ANOVA, p0.7). A fth group (28 /56 eyes) of higher myopia
patients treated with the VISX laser (mean MSE=-7.92D) were prospectively measured, as well.
Results: Signicant differences between the four lasers in night driving performance was observed
(MANOVA, p<<0.001); postop to preop performance was not changed for the VISX, slightly reduced
for Alcon, reduced for B&L, and even more reduced in the Nidek group (ANOVA, =0.05). In the
Nidek cohort, average reduction in performance ranged from -29.5ft (0.37sec; 95%CI=-19.3 to
-39.7ft) to -40.7ft (0.50sec; 95%CI= -25.0 to -56.6ft) for detection without glare to identication
with glare, respectively. Change in performance was not signicantly determined by type of road
hazard (trafc or business sign, or pedestrian) or which eye (right/left or dominant/non-dominant)
was used (MANOVA, p0.13). Contrast sensitivity (photopic 5% contrast acuity), intensity of
treatment (extent of myopia), and subjective night glare/halo complaint (index of multiple
questions) all correlated with the change in visual performance during simulated night driving.
Conclusions: Night driving visual performance can be degraded after conventional myopic LASIK
and more frequently with certain laser systems. Changes in the quality of vision, measured clinically
and assessed subjectively, correlated with night driving visual performance.
CR: S.E. Kaupp, None; S.C. Schallhorn, None; D.J. Tanzer, None; C. van de Pol, None; S.E.
Malady, None; K.M. Lombardo, None; M. Brown, None; L. Bourque, None.
Support: None.

4345 - B703

4346 - B704

Histology After EpiLASIK With the Visijet EpiLift Microkeratome

C.W. R. Winkler von Mohrenfels1,2, R.Angunawela2, A.Patmore2, J.Marshall2,
C.Lohmann1,2. 1Technical university munich, Klinikum Rechts der Isar, Munich, Germany;
Rayne Institue, St Thomas Hospital, London, United Kingdom.
Purpose: With LASEK surface ablation is getting more and more popular. Instead
of the ethanol in LASEK a new technique the EpiLASIK has been introduced as a
new technology for refractive surgery. With this technique the epithelial separation
is performed mechanically with a microkeratome.There are different modications
of the microkeratomes. Aim of this study was to look at the plane of the cut and the
viability of the epithelial cells after EpiLASIK with the Visijet EpiLift mikrokeratome.
Methods: Human corneas, which were not suitable for transplantation, were obtained
from Bristol eye bank. An EpiLASIK cut was performed on 5 human corneas with the
EpiLift microkeratome and the epithelium and the stromal bed were embedded for light
and electron microscopy in paraformaldehyde. In 5 corneas the cuts were made and
the cell viability of the epithelial ap cells wrer investigated with trypan blue method.
Results: The cut appears very smooth. In light microscopy the epithelium was separated
above the bowmans layer from the Stroma. Scanning laser microscopy showed a
smooth cut and sharp edges at the cut edge. There was no disruption of the bowmans
membrane. In transmission electron microscopy the plane of the cut was between the
bowmans layer and the basal cells. Over 95 % of all cells were viable direct after the cut.
Conclusions: Mechanical separation did not affect the normal cell morphology. As the
wound is covered with an intact epithelial sheet, this could lead to less pain and a faster
visual recovery.
CR: C.W.R. Winkler von Mohrenfels, None; R. Angunawela, None; A. Patmore, None; J.
Marshall, None; C. Lohmann, None.
Support: None.

Prospective Comparison of Simulated Night Driving Performance After LASIK

Treatment for High Myopia Using Four Different Excimer Laser Systems
S.E. Kaupp1, S.C. Schallhorn1, D.J. Tanzer1, C.van de Pol1, S.E. Malady1, K.M. Lombardo1,
M.Brown1, L.Bourque2. 1Ophthalmology, Naval Medical Center, San Diego, CA; 2UCLA
School of Public Health, Southern California Injury Prevention Research Center, Los
Angleles, CA.

Higher Order Aberrations and Flight Performance in Army Helicopter Flight

Students After PRK or LASIK
C.Van de Pol1,2, G.M. Bissette1. 1Visual Sciences Branch, US Army Aeromedical Research
Laboratory, Fort Rucker, AL; 2Navy Refractive Surgery Center, San Diego, CA.
Purpose: To compare the distribution and magnitude of higher order aberrations (HOAs) in
Army helicopter ight applicants treated with LASIK or PRK (LASEK) to controls (standard
applicants). To determine correlations of quality of optics with performance in ight training.
Methods: HOAs were measured in 100 LASIK, 35 PRK and 40 controls
using the COAS (Wavefront Sciences, Inc) and analyzed for a 5 mm pupil.
Flight performance was graded by Instructor Pilots during 3 main phases
(Primary, Instrument and Night) of Initial Entry Rotary Wing Training (IERW).
Results: HO RMS for both refractive surgery groups were significantly greater
than controls. Specic HOAs (SA, coma and trefoil) were not signicantly different
between LASIK and PRK subjects, but were significantly greater than controls,
with sign shifts in horizontal coma and trefoil. HOAs correlated to differences
in low contrast acuity (R 2 = 0.12), but only weakly to f light performance (R 2 = 0.05) .
Conclusions: Although vision is a key sense in ight, ight performance is multifactorial
involving vision, cognition and coordination. HOAs after refractive surgery help to explain
only a small percentage of performance. A higher correlation is anticipated for more visuallydemanding ight scenerios (e.g. combat, urban or unaided night operations).
CR: C. Van de Pol, None; G.M. Bissette, None.
Support: US Army Medical Command

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.

Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753
454. Refractive Surgery Organizing Section: CO
4347 - B705

4348 - B706

Histologic Effects of Conductive Keratoplasty (CK) on Human Corneas

T.Naoumidi, I.Pallikaris, I.Naoumidi. Vardinoyiannion Eye Institute, University of Crete
School of Medicine, Voutes, Heraklion, Greece.
P u r p o s e : To d e t e r m i n e t h e m o r p h o l o g i c c h a n g e s i n h u m a n
c or ne a s ove r t i me fol low i ng r a d iof r e q u e ncy- b a s e d C K t r e at me nt .
Methods: Lasting changes in corneal curvature following CK treatment depend
on shrinkage of corneal collagen to an effective but safe depth. Six human
corneas with localized peripheral keratoconus (KC) underwent CK treatment in
areas free of KC changes followed by penetrating keratoplasty. Corneal buttons
were examined with light and electron microscopy up to six months post-CK.
Results: In samples assessed on days one and three post-CK, small areas of detachment
between the basal layer of epithelial cells and Bowmans layer were observed. At one week
after the CK procedure the epithelium appeared normal. Endothelium and Descemets
membrane showed no alterations. In all samples thermally induced misconguration of
collagen bers, described as crumpled changes of collagen, was observed reaching 75-80%
of the stromal depth. The alteration had a cylindrical shape with a diameter of 120 microns.
Conclusions: The conductive keratoplasty procedure produced collagen shrinking changes
in human corneas which were observed during the follow-up of 6 months. Areas adjacent to
treatment site were minimally damaged.
CR: T. Naoumidi, Refractec, Inc. R; I. Pallikaris, None; I. Naoumidi, None.
Support: None.

Comparison of Custom LASIK Outcomes Using Femtosecond Laser and Conventional

M.R. Chalita1, M.V. Netto2, W.Dupps3, P.Gupta3, R.R. Krueger3. 1Ophthalmology, Federal
Univ of Sao Paulo, Sao Paulo, Brazil; 2Ophthalmology, Cleveland Clinic Foudation,
Cleveland, OH; 3Ophthalmology, Cleveland Clinic Foundation, Cleveland, OH.
Purpose: To compare the outcomes of Custom LASIK treatment using the
femtosecond laser and the conventional microkeratome to create the corneal ap.
Methods: One hundred and twenty nine eyes submitted to a laser f lap creation
(Intralase, Intralase Corp., CA) followed by the wavefront guided LASIK ablation
(group I) had their clinical and wavefront results compared to 282 eyes submitted
to conventional f lap creation (Moria M2, France) followed by the wavefront
guided LASIK ablation (group II) with the Alcon LADAR Vision4000 platform.
Results: There was no statistically signicant difference in the postoperative mean BSCVA
and spherical equivalent between both groups. There was a slight postoperative increase
in vertical (0.02m) and horizontal coma (0.03m) in group I and group II (0.02 and 0.03).
However, there was a signicant increase in the spherical aberration in group I (0.15m) and II
(0.18m), but there was no statistically signicant difference between both groups (p < 0.05).
Conclusions: Custom LASIK ablation with the femtosecond laser and the conventional
microkeratome, both provided good clinical outcomes, with a slight postoperative increase
in coma and little more signicant increase in spherical aberration. There was no statistically
signicant difference between both procedures in terms of clinical outcomes and induction
of higher-order aberrations.
CR: M.R. Chalita, None; M.V. Netto, None; W. Dupps, None; P. Gupta, None; R.R.
Krueger, None.
Support: None.

4349 - B707

4350 - B708

Visual Outcomes After Photorefractive Keratectomy

C.S. Banning, E.Loft, J.Randleman, R.Stulting. Ophthalmology, Emory University,
Atlanta, GA.
Purpose: To evaluate the early postoperative visual outcomes after photorefractive
keratectomy (PR K) compared to laser in sit u keratomileusis (LASIK).
Methods: Retrospective analysis of 22 eyes from 11 consecutive patients that
underwent PRK and 22 preoperative refraction-matched eyes from 20 patients
undergoing LASIK, all with the Wavelight Allegretto Wave excimer laser. Postoperative
outcomes compared included uncorrected visual acuity (UCVA), best spectaclecorrected visual acuity (BSCVA), and spherical equivalent refractions (SE).
Results: Average preoperative SE was -4.96 D for PRK cases and -4.90 D for LASIK
cases (range -2.25 to -7.88). Average age was 33.1 years (24-49 y) for PRK cases and
35.5 years (22-55y) for LASIK cases. Average 2 week UCVA was 20/26.5 (range 20/15
to 20/70) for PRK cases, and 20/24.8 (range 20/15 to 20/70) for LASIK cases (p = 0.63).
At two weeks, 40.9% achieved 20/20 or better UCVA after PRK and 72.7% achieved
20/20 or better UCVA after LASIK (p = 0.06), while 90.9% achieved 20/40 or better
UCVA after PRK and 90.1% achieved 20/40 or better UCVA after LASIK (p = 1.0).
Average 2 week BSCVA was 20/21.8 (range 20/15 to 20/40) for PRK cases, and 20/19.8
(range 20/15 to 20/30) for LASIK cases (p = 0.11). At two weeks, 68.2% achieved 20/20
or better BSCVA and 95.5% achieved 20/40 or better BSCVA after PRK, while 95.4%
achieved 20/20 or better UCVA and 100% achieved 20/40 or better UCVA after LASIK.
Average 2 week SE was 0.125 D (range -1.25 to 1.5) after PRK and -0.13 D (range 0.88 to 1.75) after LASIK (p = 0.23). Three-month data will be analyzed and presented.
Conclusions: PRK yielded comparable early visual acuity and postoperative refractive
outcomes to LASIK after treatment with the Wavelight Allegretto Wave excimer laser.
CR: C.S. Banning, None; E. Loft, None; J. Randleman, None; R. Stulting, None.
Support: None.

Diffuse Lamellar Keratitis: Risk Factors and the Effect on Visual Acuity Following
E.-S.Han1,2, W.-R.Wee2,3, J.-H.Lee1,2, M.-K.Kim1,2. 1Ophthalmology, Seoul Natl Univ Hosp,
Seoul, Republic of Korea; 2Articial Eye Center, Seoul National University Hospital
Clinical Research Institute, Seoul, Republic of Korea; 3Ophthalmology, Seoul Natl Univ
Bundang Hosp, Seongnam city, Gyoung-gi, Republic of Korea.
Purpose: To investigate the risk factors of diff use lamellar keratitis
(DLK) and to evaluate the effect of DLK on visual acuity after LASIK.
Methods: 144 eyes of 75 patients who underwent LASIK with Visx S4(VISX Inc., Santa Clara,
CA) and M2(Moria, Antony, France) and who were followed at least six month were included.
The effect of various factors -age, sex, previous dry eye, the history of contact lens wearing,
intraoperative ap-lifted time, intraoperative bleeding, postoperative immediate steroid
instillation- was evaluated in DLK and non-DLK group. Postoperative log MAR visual acuities
and log contrast sensitivity(CS) using the VCTS6500(Vistech Consultants, Inc., Dayton, OH)
were compared with those of pre-operation in DLK and non-DLK group at 3, 6 months after LASIK.
Results: Only intraoperative bleeding was signicantly related to the development of
DLK(p=0.001). There was no difference of log MAR visual acuities between in DLK and non-DLK
group till 6 months. However, the CS signicantly decreased in 3, 6, 12 cycle/degree compared with
that of pre-operation((p=0.025, p=0.011, p=0.027) in DLK group, whereas the CS signicantly
increased in 6 and 12 cycle/degree in non-DLK group (p=0.032, p=0.016) at six months.
Conclusions: DLK seemed to be strongly associated with intraoperative bleeding and
postoperative decrease of contrast sensitivity.
CR: E. Han, None; W. Wee, None; J. Lee, None; M. Kim, None.
Support: None.

4351 - B709

4352 - B710

Intrastromal Corneal Rings for Myopia: A Ten-Year Follow-Up on Visual Outcomes

A.P. Schwartz, F.Esmail, H.N. Naikoo, A.Babayan, B.Tinio, P.A. Asbell. Ophthalmology,
Mount Sinai School of Medicine, New York, NY.

s a f e t y,
eff icacy
i n t r a s t r o m a l c o r n e a l r i n g s ( IC R s) 10 ye a r s a f t e r pl a c e m e n t fo r myo p i a .
Methods:Ten eyes with myopia treated with the placement of ICRs (360 degree PMMA ring placed in the
peripheral cornea) were evaluated at 10-year follow-up for the following: 1) uncorrected visual acuity (UCVA),
2) best spectacle-corrected visual acuity (BSCVA), 3) manifest refraction spherical equivalent (MRSE), 4)
induced manifest refraction cylinder (IMRC), and 5) self-reported symptoms. In addition, all patients had
wavefront analysis, topography, pachymetry, slit lamp examination, keratometry and Schirmer testing. Ten year
data were compared to 1-year postoperative results to assess visual stability and safety of implants over time.
Results: Data showed that UCVA was 20/30 or better in 80% of eyes and 20/60 or better in 90% of eyes at
1-year follow-up, which is similar to the 60% and 90%, respectively, 10 years after ring placement. One-year
follow-up MRSE ranged from -3.37 diopters to -.12 diopters with a mean of -1.33 diopters. Ten-year MRSE
ranged from -2.87 diopters to +1.50 diopters with a mean of -0.85 diopters. This indicated no statistically
signicant difference in MRSE (F(1,8)=1.57, p=ns) indicating stability from 1-year to 10-year follow-up.
Induced manifest cylinder at 10 years ranged from reduction of as much as .75 diopters of astigmatism to
induction of 1.00 diopter of astigmatism in one case with 70% of patients experiencing induction of 0.25 diopters
of cylinder or less. Mean central pachymetry at 1-year was 540 microns and at 10-year was 565 microns. This
was not a statistically signicant difference (F(1,7)=2.70, p=ns). While patients remained largely satised at
10 years, 50% reported mild blurring of vision and 60% reported mild difculty with night vision. Slit lamp
examinations showed stable ring position and clear corneas in all eyes without signicant structural change.
Conclusions: Intrastromal corneal rings are a safe, effective and stable method of correcting mild to moderate
myopia and most patients continue to be satised with the results after ten years. Refraction and corneal
examinations show stability of effect 10 years after ICR placement and there was no evidence of any safety
issues or corneal instability 10 years post operatively. ICR and Intacts offer a non-laser and reversible
alternative for correcting mild to moderate myopia without removal of tissue and without manipulation of
the central cornea.
CR: A.P. Schwartz, None; F. Esmail, None; H.N. Naikoo, None; A. Babayan, None; B. Tinio, None; P.
A. Asbell, None.
Support: NEI core grant to the Dept. of Ophthalmology at Mount Sinai Hospital, RPB2 (Dr. Penny A.

Factor Analysis of Postoperative Outcome Variables for a CustomCornea LASIK

Clinical Trial
N.J. Keir, T.Simpson, L.Jones, D.Fonn. Optometry, CCLR, Waterloo, ON, Canada.
Purpose: To investigate whether a large set of variables (40) collected for a group
of myopic patients with and without astigmatism following CustomCornea
LASIK can be explained largely or entirely in terms of a smaller number of factors.
Methods: LASIK was performed on 163 myopic eyes with or without astigmatism (82
patients) using the LADARVision laser coupled with the LADARWave Measurement
Device. Mean preoperative sphere was -2.701.34D (range -0.25 to -6.50D) with mean cylinder
-0.880.74D (range 0 to -3.25D). High contrast (HC) and low contrast (LC) uncorrected and
best-corrected visual acuity (UCVA and BCVA, respectively) were measured using ETDRS
charts and contrast sensitivity using the VectorVision CSV1000 at 4 spatial frequencies (3,
6, 12 and 18 cycles/degree). Subjective responses were collected using a descriptive rating
questionnaire. Data for this analysis was from the 3 month postoperative visit and only the right
eyes were included (n=82). Exploratory factor analysis was completed using Statistica 7 for 40
variables. A Scree test and a varimax rotation were used to determine and interpret the factors.
Results: 62% of the variability of the data could be explained using 5 factors. Factors 1,
2, 3, 4, and 5 could each explain 25%, 17%, 9%, 6% and 4% of the variability of the data,
respectively. Based on weighting scores, the primary factor was high luminance vision
(HC and LC UCVA and BCVA). The second factor was sensory ratings (light sensitivity,
glare and haloes). Other separate factors consisted primarily of spherical ametropia
(sphere and spherical equivalent), contrast sensitivity (high and moderate luminance and
different spatial frequencies) and nally ocular discomfort (burning, tearing and dryness).
Conclusions: It can be concluded that there are a variety of factors that contribute to the
outcome variables for this data set and multiple variables for each factor are clinically
important. The key factors (in rank order) are high luminance vision, sensory ratings,
ametropia, contrast sensitivity and ocular discomfort.
CR: N.J. Keir, None; T. Simpson, None; L. Jones, None; D. Fonn, None.
Support: Alcon, Canadian Optometric Education Trust Fund (COETF)

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.

Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753
454. Refractive Surgery Organizing Section: CO
4353 - B711

CustomView Wavefront LASIK Using IntraLase and Visx S4

J.I. Ou, E.E. Manche. Ophthalmology, Stanford University, Palo Alto, CA.
Purpose: To evaluate the efcacy, stability, predictability, and safety of CustomVue
LASIK using IntraLase and Visx S4 for patients with myopia or myopic astigmatism.
Methods: Retrospective analysis of 144 eyes of 77 patients with myopia or myopic
astigmatism who underwent CustomVue LASIK using IntraLase and Visx S4
was conducted. Refraction, mean spherical equivalent (SE), uncorrected visual
acuity (UCVA), best spectacle corrected visual acuity (BSCVA), and mean higher
wavefront analysis were determined pre-operatively and at 3 months post-operatively.
Results: Mean preoperative SE was -4.15 +/-1.78 D (range -8.38 to +0.13 D). Three
month postoperative mean SE was -0.07 +/- 0.30 D (range -1.13 to + 1.13 D). At 3 months
postoperative, 45%, 86%, and 98% of eyes had 20/15, 20/20, and 20/40 or better vision
respectively. 97% of eyes were within 1.0 D of emmetropia at 3 months postoperatively.
At 3 months postoperatively compared to preoperatively, all eyes either gained/loss
1 or had no change in Snellen Line (BSCVA). Stable mean RMS values were obtained
at postoperative month 1 and 3 compared to preoperatively (0.31, 0.31 vs 0.28).
Conclusions: IntraLase and Visx S4 is comparable in efcacy, stability, predictability, and
safety to the Hansatome microkeratome and Visx S4 used in CustomVue LASIK for patients
with myopia and myopic astigmatism.
CR: J.I. Ou, None; E.E. Manche, None.
Support: None.

4355 - B713

4354 - B712

Visual Rehabilitation in Three Patients With Post-Laser in situ Kerstomileusis

F.Eggink1, H.V. Cleynenbreugel2, A.Geerards2. 1Refractive surgery, Rotterdam Eye
Hospital, Rotterdam, The Netherlands; 2Refractive surgery, Rotterdam Eye Hospital,
Rotterdam, The Netherlands.
Purpose: To review ve cases of three patients with corneal ectasia after laser in situ
keratomileusis, and evaluate methods and success rates of visual rehabilitation for these patients.
Methods: Retrospective review of preoperative and postoperative data for each case.
Results: Mean time to the development of ectasia averaged 41.6 +/- 18.0 months (range
24 to 60). Pachometry of the center of the corneal ectasia averaged 409 +/- 36.5 micron
(range 366 to 472). The mean theoretical residual stromal bed thickness after laser ablation
was 220 +/- 16.5 micron (range 200 to 238). Length of follow-up after the detection of
the ectasia averaged 37.6 +/- 21.3 months (range 10 to 65). One eye was corrected
with a RGP contact lens, one with a soft toric lens, and four with glasses. One eye
required deep lamelar keratoplasty. None of the eyes lost more than one line of BCVA.
Conclusions: We did not identify any patient who developed corneal ectasia without
recognizable thinning of the remaining stromal bed under 250 microns. Conservative
visual acuity rehabilitation, with contact lenses, gave the same BCVA as in patients with
corneal transplant. When contact lens tting is compicated, a corneal transplantation may
be considered.
CR: F. Eggink, None; H.V. Cleynenbreugel, None; A. Geerards, None.
Support: None.

4356 - B714

Long-Term Keratocyte Decits in the Corneal Stroma After LASIK and PRK
J.C. Erie, C.B. Nau, J.W. McLaren, D.O. Hodge, W.M. Bourne. Ophthalmology, Mayo
Clinic, Rochester, MN.
Purpose: To determine changes in keratocyte density up to 5 years after LASIK and PRK.
Methods: 17 eyes of 11 patients received LASIK with a planned 180-m ap to correct
refractive errors between -2D and -11D. 18 eyes of 12 patients received PRK to correct
refractive errors between -1.5D and -5.75D. Corneas were examined by using confocal
microscopy before and at 1, 2, 3, and 5 years after the procedures. In PRK patients, cell densities
were determined in 5 stromal layers; 0% to 10% (anterior), 11% to 33%, 34% to 66%, 67% to
90%, and 91% to 100 % (posterior). In LASIK patients, cell densities were determined in the
stromal ap, the anterior and posterior halves of the 100-m-thick retroablation layer, and
the posterior third of the stroma (the region of the stroma that was ablated was omitted from
analysis). Differences between pre- and post-operative cell densities were determined by
using generalized estimating equation models with Bonferroni correction for 4 comparisons.
Results: Before PRK, mean keratocyte density in the anterior 10% of the stroma was
32,084 5,870 cells/mm 3 ( SD). Cell density in this region decreased after PRK by 39%,
42%, 45%, and 47% at 1, 2, 3, and 5 years respectively (P<0.001). At 5 years after PRK,
cell density was decreased by 20-24% in the posterior two thirds of the stroma (P<0.03).
Before LASIK, mean keratocyte density in the stromal ap was 30,104 4,576 cells/
mm 3. Cell density in the stromal ap decreased after LASIK by 23% (P<0.002) at 1 year
and 37% (P<0.001) at 5 years. Cell density in the anterior retroablation layer decreased
after LASIK by 18% (P<0.001) at 1 year and 43% (P<0.001) at 5 years. At 5 years after
LASIK, cell density was decreased by 19-22% (P<0.02) in the posterior third of the stroma.
Conclusions: Keratocyte densities are decreased for up to 5 years in the anterior stroma
after PRK and in the stromal ap and in the anterior retroablation layer after LASIK. A
decrease in posterior stromal keratocyte density is rst noted at 5 years after LASIK and
PRK. We also consider several artifacts of confocal microscopy that might explain some of
these differences.
CR: J.C. Erie, None; C.B. Nau, None; J.W. McLaren, None; D.O. Hodge, None; W.M.
Bourne, None.
Support: NIH Grant EY02037 and Research to Prevent Blindness, Inc., Mayo Foundation,
Rochester, MN

Binocular Visual Performance After LASIK

J.R. Jimenez1, R.G. Anera1, L.Jimenez del Barco1, C.Villa2, R.Gutierrez3. 1Optics,
Universidad de Granada, Granada, Spain; 2Optics, Clinica Novovision, Madrid, Spain;
Ophthalmology, Universidad de Murcia, Murcia, Spain.
P ur pose : To evalu at e bi nocu la r v isu al p e r for ma nce af t e r LASI K .
Methods: We measured contrast-sensivity function (CSF, photopic and mesopic conditions)
and disturbance index (for quantifying halos) under binocular and monocular conditions before
and after surgery. Total aberrations were also measured. Data for 25 observers were analyzed.
Results: Under mesopic conditions monocular and binocular CSF deteriorate
signicantly (p<0.01) after LASIK, this deterioration being higher for the binocular
case. Disturbance index is also higher under binocular conditions. The deterioration
increases significantly (r= 0.92) with interocular-differences in eye aberrations.
Conclusions: Post-surgical deterioration of contrast sensitivity and the increasing of nightvision disturbances is more accentuated under binocular conditions. New approaches in
refractive surgery should include binocular analysis for optimizing visual function after
CR: J.R. Jimenez, None; R.G. Anera, None; L. Jimenez del Barco, None; C. Villa,
None; R. Gutierrez, None.
Support: Ministerio de Ciencia y Tecnologa BFM2003-1492 Spain

4357 - B715

4358 - B716

Effects of Dilation and Dilation Reversal Agents on Pupil Center Decentration in

Refractive Surgery Candidates
M.M. Merchea1A, M.Lagana1B, I.Cox1A. AScientic & Clinical Affairs, 1Bausch & Lomb,
Rochester, NY.

myd r iat ic
phar maceutical
Methods: Thirty preoperative eyes (15 subjects) were enrolled in this prospective non-randomized
study. All measurements were made using the Zywave II WaveFront Aberrometer (v.4.45sp3).
Phase I (Dilation): Pupil center location and wavefront measurements were captured at baseline and in 5
minute intervals up to 30 minutes after instillation of 1 drop each of 2.5% phenylephrine and 1% tropicamide.
Phase II (Dilation Reversal): Two drops of 0.5% dapiprazole hydrochloride (REV-EYES; Bausch &
Lomb, NY) were instilled 30 minutes after completion of Phase I. An additional 2 drops were added 5
minutes later according to package insert dosage recommendations. Pupil center location and wavefront
measurements were captured in 30 minute intervals from 90 to 180 minutes after instillation of REV-EYES.
Results: Phase I: Mean pupil center decentration was statistically and clinically signicant within the
rst 15 minutes after instillation of the mydriatic combination (ANOVA, p<0.001) in the vertical
meridian. After the 15 minute time point, pupil center decentration in the vertical meridian stabilized
at a magnitude of -150um. There was no statistically signicant mean pupil center decentration in the
horizontal meridian (ANOVA, p=0.169) in the dilation phase. A mean spherical refractive error
shift of +0.45D (p=0.024) and mean Defocus (Z200) shift of -0.35um (p<0.027) were observed by 20
minutes after dilation. There were no statistically signicant changes in mean higher order aberrations
normalized to baseline (p>0.05), although signicant variation in individual eyes were observed.
Phase II: Mean pupil center decentration in the vertical meridian stabilized at a magnitude of about +125um
(p<0.001), 3 hours after instillation of REV-EYES. There were no statistically signicant changes in mean higher
order aberrations normalized to baseline (p>0.05), although signicant variation in individual eyes were observed.
Conclusions: Signicant variability of pupil center decentration was observed early in the dilation time
course, as a result of asymmetric pupil mydriasis. The results suggest that wavefront measurements should
be made at least 20 minutes after instillation of mydriatic agents, when the pupil center location is stabilized.
Mydriatic reversal drops should not be used with the intent of performing same-day refractive surgery, as
centration of the treatment will not coincide with the manifest pupil center location.
CR: M.M. Merchea, Bausch & Lomb E; M. Lagana, Bausch & Lomb E; I. Cox, Bausch & Lomb E.
Support: None.

Scattered Laser Radiation and Broadband Actinic Ultraviolet Plasma Emissions

During Alcon LADARVision Excimer Refractive Surgery
K.S. Bower1, J.M. Burka1, R.J. Hope1, J.K. Franks2, T.L. Lyon2, B.A. Nelson1, D.H.
Sliney2. 1Ophthalmology Service, Walter Reed Army Med Center, Washington, DC; 2U.S.
Army Center for Health Promotion and Preventative Medicine, Laser/Optical Radiation
Program, Aberdeen Proving Ground, MD.
Purpose: To evaluate the potential occupational health hazards associated with scattered
actinic ultraviolet laser radiation and broadband actinic ultraviolet plasma emissions during
refractive surgery. Methods: A prospective experimental study. Intraoperative radiometric
measurements were made with the Ophir Power/Energy Meter (LaserStar Model with silicon
detector, Model PD-10) and the International Light Radiometer/Photometer (Model IL 1400
with actinic ultraviolet detector, Model SEL240) with and without ultraviolet blocking
lters (BLK 270 and Schott types WG-280 and WG-230). Measurements made during
laser calibration as well as LASIK and PRK procedures were evaluated using a worst-case
scenario and then compared to the ACGIH TLVs to perform a risk/hazard analysis. Results:
Most optical emissions were between 193nm and 280nm and approximately 25% of the
measurement result was due to broadband emissions greater than 270 nm for calibration
targets. About 25% of optical emissions during LASIK were beyond 230 nm. No emissions
beyond 230 nm were observed during PRK. Ultraviolet scattered radiation level was similar
between PRK and LASIK. Maximum measured values of 80 nJ/pulse at 14 cm for PRK and
45 nJ/pulse at 38 cm for LASIK were used as the absolute worst-case analysis for exposure.
Assuming the worst-case exposure conditions equal to the maximum measured value during
these studies at a patient workload of 20 patients per day, the cumulative occupational
exposure at close range of actinic ultraviolet radiation did not exceed the 8-hour occupational
exposure limit of 3 mJ/cm2 for any 24-hour period. Conclusions: Scattered ultraviolet laser
radiation did not exceed occupational exposure limits at distances greater than 30cm from
either laser calibration targets or patient treatments over a workday. Laser eye protection is
not necessary to protect operating room personnel since exposure levels are very low even
under a worst-case scenario.
CR: K.S. Bower, None; J.M. Burka, None; R.J. Hope, None; J.K. Franks, None; T.L.
Lyon, None; B.A. Nelson, None; D.H. Sliney, None.
Support: None.

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.

Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753
454. Refractive Surgery Organizing Section: CO
4359 - B717

4360 - B718

4361 - B719

4362 - B720

Ultrastructural and Histologic Studies of Femtosecond Laser Incisions in Human

D.Donate1,2, O.Albert3,4, K.Plamann3,4, J.-P.Colliac5,4, P.Sabatier5, G.Mourou3, P.Denis6,
C.Burillon6, Y.Pouliquen2, J.-M.Legeais2. 1service ophtalmologie, pavillon C, Lyon,
France; 2Laboratoire Biotechnologie et Oeil, hpital Htel Dieu, Paris, France; 3Lab
dOptique Applique, Ecole Polytechnique, ENSTA, CNRS UMR7639, Palaiseau, France,
France; 4Laboratoire Biotechnologie et Oeil, Hpital Htel Dieu, Paris, France; 5Banque
Franaise des Yeux, Paris, France; 6Service Ophtalmologie, Pavillon C, Lyon, France.
ult rast r uct u ral
st udies
Methods: We use a CPA femtosecond laser designed to match current instrumentation
for femtosecond surgery, i.e. a Nd:Glass femtosecond laser at a 1065 nm wavelength.
The repetition rate is adjustable from 1 to 10 KHz, with maximum pulse energy of
60 J. The human cornea samples are xed to an anterior chamber system that can be
moved in 3D by micrometric precision motors in front of a xed objective delivering
the fs laser pulses. Human corneas are provided by the French Eye Bank. Laser energy
range for cornea treatment goes from laser induced optical breakdown threshold
up to ten time this threshold. Ultrastructural and histologic are then obtained using
transmission electronic microscopy TEM and scanning electron microscopy (SEM).
Results: Observations of the cornea structures (i.e. epithelium, Bowman membrane, stroma,
Descemet membrane and endothelium) presents no noticeable side damages like burned collagen
or cells damage. Results does not vary with pulse energy (in the experimental energy range : 2 J/cm 2
to 50 J/cm 2) except for excessive delamination due to the shock wave propagation at high energy.
Conclusions: The use of femtosecond laser pulses for keratoplasty implies use of energy
higher than the one used for refractive surgery in transparent cornea. Our results demonstrate
that cornea ultrastructure is not altered by this higher energy pulses opening the way to
surgery in oedematous cornea.
CR: D. Donate, None; O. Albert, None; K. Plamann, None; J. Colliac, None; P. Sabatier,
None; G. Mourou, None; P. Denis, None; C. Burillon, None; Y. Pouliquen, None; J. Legeais,
Support: None.

Preservation of Contrast Sensitivity After LASIK and Clear Lens Extraction With
PCIOL Placement in the Treatment of Mild to Moderate Hyperopia
E.K. Chiu, M.P. Rubin, S.Rao. Ophthalmology, University of Chicago, Chicago, IL.
Purpose: To compare the efcacy of LASIK and clear lens extraction with PCIOL
placement (CLE) for the treatment of mild to moderate hyperopia (+1 to +6 D) in
patients over 40 years of age. In particular, we evaluated the impact of these procedures
on the preservation of contrast sensitivity as well as post-operative visual acuity.
Methods: A retrospective review was performed on consecutive patients who underwent
refractive correction for low to moderate hyperopia. Hyperopic LASIK was performed on 50 eyes
of 26 patients. Phacoemulsication and IOL implantation was performed on 50 eyes of 25 patients.
Results: In the LASIK group, postoperative UCVA was 20/40 or better in all eyes, with a
median UCVA of 20/25 (range 20/20 to 20/40.) Postoperative spherical equivalent was 0.12D
(-0.75 to + 0.75) reduced from preoperative level of 2.75D. In the CLE group, postoperative
uncorrected visual acuity (UCVA) was 20/40 or better in all eyes, with a median UCVA
of 20/25 (range 20/20 to 20/40.) Postoperative spherical equivalent was 0.155D (-0.75 to
+0.75) reduced from preoperative level of 3.59D. Contrast sensitivity curves decreased by
two or more lines in two hyperopic CLE eyes (4%) and 7 hyperopic LASIK eyes (14%.)
Conclusions: In low to moderate hyperopia, clear lens extraction with IOL implantation
preserved contrast sensitivity at a higher rate than LASIK. Additionally, CLE is a safe
procedure and yields comparable postoperative UCVA to LASIK.
CR: E.K. Chiu, None; M.P. Rubin, None; S. Rao, None.
Support: None.

4363 - B721

Thick versus Thin Laser in situ Keratomileusis Flaps in the Correction of Myopic
E.A. Steele, F.W. Fraunfelder. Ophthalmology, Casey Eye Institute, Portland, OR.
P u r p o s e : To e v a l u a t e r e t r o s p e c t i ve l y t h e e f f e c t s of L A S I K
f lap
thick ness
cor rection
astig matism.
Methods: Patients with low to moderate myopia with astigmatism up to -3.75
diopters were included in the study. The eyes were divided into two groups based
on ap thickness, with 171 eyes having ap thickness less than 126 microns and
171 eyes having ap thickness greater than or equal to 126 microns. Six-month data
were analyzed with regard to spherical power, spherical equivalent, astigmatism
power, astigmatism axis, uncorrected visual acuity, and vector astigmatism change.
Results: Mean change in total spherical correction 6 months after surgery for eyes with
LASIK ap thickness less than 126 microns was -3.79 1.90. For ap thickness greater
than or equal to 126 microns, the difference was -2.94 1.99 ( p=0.0001). Mean change
in spherical equivalent 6 months after surgery for eyes with LASIK aps less than 126
microns was 4.11 1.90 diopters compared to 3.19 2.01 for aps greater than or equal to
126 microns (p=0.00003). Mean change in astigmatism magnitude 6 months after surgery
for eyes with LASIK aps less than 126 microns was 0.65 0.80 diopters compared to 0.50
0.71 for aps greater than or equal to 126 microns (p=0.08). Mean change in astigmatism
axis 6 months after surgery for eyes with LASIK aps less than 126 microns was 33.02
82.4 degrees compared to 17.51 81.5 degrees for aps greater than or equal to 126 microns
(p=0.07). Mean change in uncorrected visual acuity (LogMAR) for LASIK aps less than 126
microns was 1.36 0.42 compared to 1.10 0.55 for aps greater than or equal to 126 microns
(p=0.000002). Mean vector-corrected astigmatism change was 1.04 0.75 diopters for LASIK
aps less than 126 microns compared to 0.94 0.67 diopters for aps greater than or equal
to 126 microns (p=0.2). The mean change in axis for vector-corrected surgically-induced
astigmatism at 6 months after surgery was 1.17 52.6 degrees for aps less than 126 microns
compared to 1.94 51.4 degrees for aps greater than or equal to 126 microns ( p=0.89).
Conclusions: There was no signicant difference in myopic astigmatism correction based
on the thickness of the LASIK ap at 6 months after surgery.
CR: E.A. Steele, None; F.W. Fraunfelder, None.
Support: None.

LASEK Induces Less Corneal Wound Healing and Better Transmittance Than PRK in
the Iber Braun Hens Corneal Model
J.M. Merayo-Lloves1A, H.A. Martinez-Osorio1A, T.Blanco-Mezquita1A, C.MartinezGarcia1B, S.Mar-Sardaa1C, R.M. Torres1A. AOphthalmology IOBA, BCell Biology, CPhysics
Applied, 1Universidad de Valladolid, Valladolid, Spain.
P u r p o s e : To c omp a r e c or ne a l wou nd he a l i ng a nd t r a n s m it t a nc e
af ter laser subepithelial keratomileusis (LASEK) and photoref ract ive
k e r a t e c t o m y ( PR K ) i n t h e I b e r B r a u n h e n s c o r n e a l m o d e l .
Methods: LASEK surgery (-6 D, optical zone 6.0 mm, 67 m) was performed on Iber
Braun hens (2,5 kg) corneal model. Iber Braun hens corneal epithelium was exposed to 20%
ethanol in BBS for 40 seconds using as the reservoir a 7.5 mm trephine. The epithelium was
detached by the technique in the bag and then treated with an excimer laser (Summit apex
plus). The epithelial ap was repositioned. Morphologic changes were evaluated by optic
(H-E) and electronic microscopy examination. Proliferation and apoptosis were studied at
24 and 72 hours. The transmittance and scattering measurements were done with a scatter
meter constructed in the Optics Department (University of Valladolid) at 15 and 30 days.
Results: LASEK corneas showed TUNEL positive cells in the basal layer of the
epithelial ap. In the stroma, there are less keratocyte apoptosis in LASEK than PRK
corneas at 24 hours, and both of them decreased at 72 hours but remained higher after
PRK than LASEK. Keratocyte proliferation rate at 72 hours were higher in the two
superior thirds of the corneas in the PRK than the LASEK model. LASEK corneas
had less scattering and better transmittance than PRK corneas at 15 and 30 days.
Conclusions: LASEK induces less stromal scarring compared to PRK in the Iber Braun hens
corneal model. LASEK corneas have better transmittance than PRK corneas. Iber Braun hens
offer a very good model of LASEK corneal refractive surgery.
CR: J.M. Merayo-Lloves, None; H.A. Martinez-Osorio, None; T. Blanco-Mezquita,
None; C. Martinez-Garcia, None; S. Mar-Sardaa, None; R.M. Torres, None.
Support: H. Martinez-Osorio, Carolina Foundation, Ministry of foreign affairs, Spain

Role of Spherical Aberration on Refractive Outcome After Custom LASIK

M.V. Subbaram1A, S.M. MacRae1B,1A, G.Yoon1B,1A, I.G. Cox2. ACenter for Visual Science,
Ophthalmology,, 1University of Rochester, Rochester, NY; 2Bausch and Lomb, Rochester,

Purpose: To analyze the role of spherical aberrations (HOA) on customized LASIK refractive outcome.
Methods: Data from 330 myopic eyes, treated with customized ablation, with Technolas
217z, was followed through six months post-LASIK. Data was classied according to the
amount of preoperative myopia, spherical aberration (SA), and change in astigmatism. The
manifest and wavefront predicted phoropter refractions (PPR) were represented using power
vectors: MSE (mean spherical equivalent), J0 (astigmatism at 0 or 90), and J45 (oblique
astigmatism). The role of SA on post-LASIK manifest refraction was analyzed using ANOVA.
Results: 1) Increased SA was associated with increased sphere treatment magnitude (r=0.65, p<0.0001).
Greater post-LASIK positive SA was signicantly correlated to post-LASIK hyperopia (r=0.45, p<0.0001).
2) Change in SA (post - pre LASIK), or SA, was lower among eyes with high preoperative
SA and greater among those with lower preoperative SA (r=-0.35, p<0.0001). Eyes
with negative preoperative SA had greater SA than those with positive spherical
aberration (t>3.26, p<0.0001). Among eyes with high preoperative positive SA (>0.35
um), SA was inversely correlated to the postoperative hyperopia (r= 0.32, p= 0.028).
3) SA was significantly correlated to MSE (r>0.62, p<0.0001) and J0 (r>0.51,
p<0.001) among eyes with post-LASIK hyperopia and low astigmatism (r= -0.35,
p<0.0001). 3rd RMS and SA were signicantly correlated to MSE (r>0.53, p<0.001)
and J45 (r>0.42, p= 0.003) among eyes with high post-LASIK astigmatism (>0.75 D).
Conclusions: Post-LASIK SA was signicantly correlated to post-LASIK hyperopia. Eyes with
greater preoperative positive SA, have a greater reduction in SA but also tend to be more hyperopic.
Eyes with greater negative SA tend to become more emmetropic or myopic. Increased 3rd RMS was
associated with post-LASIK residual astigmatism. The role of HOA, especially SA, on post-LASIK
refractive outcome is discussed from a biomechanical perspective.
CR: M.V. Subbaram, None; S.M. MacRae, Bausch and Lomb F, C; G. Yoon, Bausch and Lomb
F, C; I.G. Cox, Bausch and Lomb E.
Support: Bausch and Lomb

4364 - B722

Analysis of Factors Affecting the Change of Higher-Order Aberrations (HOA) After

Wavefront-Guided LASIK for Myopia
J.Buehren, T.Kohnen. Dept of Ophthalmology, Goethe University Frankfurt, Frankfurt am
Main, Germany.
Pur pose: To identif y factors that affect the change of higher-order
wavefront aber rations (HOA) after wavefront-guided LASIK for myopia.
Methods: Sixty myopic eyes of 32 patients were treated with wavefront-guided LASIK
(ZyoptixTM version 3.1, Bausch&Lomb) and showed an uncomplicated follow-up of
twelve months. The mean preoperative spherical equivalent (SE) was -5.59 2.20 diopters
(D) (-1.00 to -9.5 D); the mean optical zone (OZ) diameter was 6.70 0.68 mm (5.6 to
8.1 mm). Wavefront measurements were performed preoperatively and 12 months after
LASIK. Wavefront errors were computed for pupil diameters of 3.5 and 6 mm. Multiple
stepwise regression analysis was performed to assess the inuence of patient age, SE,
sphere, cylinder, OZ size and preoperative HOA (individual terms) on HOA difference.
Results: Age, SE, sphere, cylinder and OZ diameter had no signicant impact on individual
Zernike coefcients at 3,5 mm. At 6 mm, SE and OZ diameter had signicant inuence only on
Z 4,0. Preoperative values of single coefcients had the highest effect on their change. For 6 mm
pupils, inuence was lowest for Z 3,1 (R=0,06, b=-0,37) and highest for Z 5,-1 (R=0,59, b=-1,15).
Conclusions: Three groups of factors inuenced the change of HOA: The correlation with the
magnitude of preoperative HOA values varied among the coefcients and reected the effect
of the wavefront-guided algorithm. SE and OZ diameter affected the induction of spherical
aberrations. Third order coma terms were least affected by the factors of the model; their
change seems to be a result of randomly acting effects like decentration or ap creation.
CR: J. Buehren, None; T. Kohnen, Bausch and Lomb C.
Support: None.

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.

Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753
454. Refractive Surgery Organizing Section: CO
4365 - B723

Topography-Guided LASIK Enhancements, Early Experience in 17 Symptomatic

R.Krishnamurthy1, A.J. Kanellopoulos1,2, L.Pe2, M.Jankov2. 1Ophthalmology, NYUManhattan, Eye, Ear & Throat Hospital, New York, NY; Institute, Athens,
Purpose: To evaluate the safety and efcacy of topography-guided LASIK enhancements.
Methods: Peri-operative: refraction, UCVA, BCSVA, cornea asphericity (Q value), and
contrast sensitivity (CS) were evaluated in 17 symptomatic consecutive eyes with 6.5 months
follow-up. Topography guided LASIK enhancement using the Wavelight Allegretto system
was chosen in these patients to correct the small and decentered optical zones, as well as their
vision quality problems (glare, haloes, loss of contrast sensitivity and night vision difculties).
Results: Refractive error: -3.50D (plano to -5.50) improved to -0.65 (plano to 2.00), cylinder: -3.75D (-1.25 to -4.75) improved to -0.50. UCVA improved from
20/200 to 20/35. BSCVA from 20/50 improved to 20/18. Q value improved from
+0.7 to +0.1. CS improved by 70%. There was one loss of BSCVA of 2 lines.
Conclusions: Topography guided LASIK enhancement appears to be a safe and effective
option. It requires little central tissue removal and should be viewed as a possible 2 step
procedure in regard to spherical adjustment.
CR: R. Krishnamurthy, None; A.J. Kanellopoulos, None; L. Pe, None; M. Jankov,
Support: Research to Prevent Blindness

4367 - B725

4366 - B724

Starburst Phenomenon in Wavefront-Guided LASIK Compared With Conventional

M.Shah, B.Larson. Ophthalmology, Loyola University - Chicago, Maywood, IL.

Purpose: Night vision difficulties consisting of starbursts, glare, and halos are common
complaints following refractive surgery. Previously, we have shown starbursts to be detectable
in over 90% of post-LASIK patients with the Larson Glarometer (Snyder, presented at annual
meeting ARVO 2002). Wavefront guided LASIK is thought to reduce night vision symptoms
of starbursts, glare, and halos. In this study, we objectively measure and compare starbursts
experienced in patients after conventional LASIK with those after wavefront-guided LASIK.
Methods: Three groups of patients were independently studied. The rst group consisted of postconventional LASIK patients. The second group consisted of post-wavefront-guided LASIK patients.
The third was a non-surgical control group that consisted of myopic spectacle wearers with corrected
visual acuity of better than 20/25. All eyes included in this study required no more than 6 diopters
of myopic correction. All post-surgical eyes had uncorrected visual acuities of 20/25 or better. Both
LASIK procedures were performed with standard techniques and nomograms on the VISX S4 using a
6.5 mm optical zone and an 8 mm blend zone. Starburst radius (SR) was recorded in uncorrected eyes
a minimum of 3 months following refractive surgery. A Larson Glarometer was used to quantify the
SR. This device, consisting of two low intensity red light sources separated by 4 inches, was placed
8 feet from the subject in a totally dark room. After 15 seconds of dark adaptation, the subjects were
asked to compare their perceived starburst pattern to a key card depicting starbursts of different
radii. The minimum measurement on the starburst key was 4.0 mm., and the maximum was 50 mm.
Results: A total of 72 eyes were measured. In the conventional LASIK group (n=23) the average starburst
radius (SR) was 20.4 mm. In the wavefront guided LASIK group (n=26), the average SR was 11.75 mm. In
the spectacle control group (n=23) the average SR was (5.5 mm). Both surgical groups showed a statistically
signicant increase in SR when compared with the control group (p<0.01). The wavefront-guided LASIK
group showed a statistically signicant decrease in SR compared with conventional LASIK (p<0.05).
Conclusions: Using an innovative new device for measuring starburst patterns, our data was able to
conrm a statistically signicant increase in the amount of starburst pattern glare experienced after
both conventional and wavefront-guided LASIK compared with spectacle wearers. In addition, this
study demonstrates a new nding: a statistically signicant decrease in starburst pattern glare with
wavefront-guided LASIK compared with conventional LASIK.
CR: M. Shah, None; B. Larson, None.
Support: None.

4368 - B726

Visual Quality Metrics for Refractive Surgery

K.K. Liedel, J.A. Campin, G.H. Pettit. Research, Alcon, Orlando, FL.
wavef ront-derived
met r ics t o prov ide a b et t e r me a n s of a s se s si ng v is u a l qu a l it y.
Methods: Human data was obtained from 366 eyes enrolled in LASIK clinical trials. This
population included both myopic and hyperopic eyes treated either with conventional or
wavefront-guided surgery. Exam data including wavefront measurements and mesopic
visual acuity measures were obtained at the 3-month post-op visit. A computer program
processed the wavefront data and calculated retinal plane parameters (PSF, MTF, and
PTF), as well as numerous single value metrics. The software analysis was performed
over different pupil diameters and with congurable neural threshold and simulated
Stiles-Crawford effects. The measured vision performance parameters were compared to
simple RMS error as well as the calculated metrics under various simulation conditions.
Results: Tested metrics included both novel and previously published parameters (e.g., Strehl
ratio, PSF peak, MTF volume, etc.). Low contrast cycloplegic uncorrected visual acuity
(lccUCVA) was typically better correlated to wavefront metrics than were other tested acuities.
Looking at the optimal wavefront diameter, best correlation between lccUCVA and most of the
metrics was observed for pupil diameters between 4.5 and 5.0 mm. For RMS error the peak
correlation coefcient was 0.74. Better correlation was seen with several of the calculated
metrics. In some instances including a simulated neural threshold effect improved correlation
still further. Correlation between lccUCVA and post-neural PSF entropy was 0.79. Including
a simulated Stiles-Crawford effect (as opposed to simply constraining the wavefront analysis
diameter) did not signicantly improve metric correlations to lccUCVA unless the radial
apodization factor was assumed to be signicantly larger than values reported in the literature.
Conclusions: Several of the metrics evaluated exceed the correlations established with
wavefront RMS and other known metrics published to date. With renement these parameters
should yield useful information regarding vision quality and calculation of the effective
clinical refraction.
CR: K.K. Liedel, Alcon F, E; J.A. Campin, Alcon F, E; G.H. Pettit, Alcon F, E.
Support: Alcon

Evaluation of Post-Myopic LASIK Regression for Cornea Ectasia and Increase of

Globe Length With Optical Interference Biometry in 500 Consecutive Eyes
A.J. Brucker1,2, L.Pe3, L.T. D. Sperber1,2, A.Kanellopoulos1,3. 1Ophthalmology, New York
University School of Medicine, New York, NY; 2Ophthalmology, Manhattan Eye, Ear
and Throat Hospital, New York, NY; 3Ophthalmology, Institute, Athens,
Purpose: To evaluate the occurrence of post-LASIK cornea ectasia with optical interference
biometry in 500 routine, consecutive eyes treated for myopia and myopic astigmatism.
Methods: We evaluated 500 consecutive LASIK cases for axial length change using optical
interference laser immediately before LASIK and 6 months after surgery. Other parameters
studied were peri-operative: refractive error, topography, Orbscan, ultrasonic cornea
pachymetry, ap thickness, UCVA, and BSCVA as well as aberrometry and contrast sensitivity.
Results: Preoperative myopia ranged from -0.75 to -12.0 spherical equivalent (-4.55).
Astigmatism ranged from 0 to -4.50 (-1.25). Axial length changed from 25.92 mm pre-op to
25.79 mm, a mean difference of 0.1375 mm which was statistically signicant (Chi square)
(p<0.05). The change correlated with the amount of myopic spherical equivalent corrected.
There was a well documented increase in the axial length of 150 (15 to 350) microns in 32 cases.
This sub-group had a mean pre-op spherical equivalent of -7.50 and pre-op pachymetry 535
microns. 29 of these eyes received enhancement with stable refraction for 4-9 months (5.2).
Conclusions: In this group of consecutive myopic LASIK cases we were able to correlate
post-operative myopic regression to forward cornea movement and not ectasia, with an
objective measurement of total axial length. As expected, this sequelae appears to correlate
with amount of myopia corrected, pre-op corneal pachymetry and patient age. Within our
treatment protocol it did not appear to be an uncontrolled complication.
CR: A.J. Brucker, None; L. Pe, None; L.T.D. Sperber, None; A. Kanellopoulos, None.
Support: None.

4369 - B727

4370 - B728

Initial Clinical Experience in Epi-LASIK With the Moria Epi-K Epithelial Dissector
and the Allegretto Wave Eye-Q Excimer in 25 Myopic Eyes
A.Kanellopoulos. Ophthalmology, Institute, Athens, Greece.
Purpose: To evaluate the safety and efcacy of the Epi-K epithelial dissector by Moria used
with the ALLEGRETTO Eye-Q excimer laser system in epi-LASIK for myopia and myopic
astigmatism.Methods: Twenty ve consecutive LASIK cases for Myopia with or without
astigmatism treated with epi-LASIK were prospectively evaluated up to 12 months post
operatively. The mean pre-operative sphere was -3.08 (SD+/- 1.56) D with a range of -0.25
to -6.00 D. The mean preoperative cylinder was -0.80 (SD+/- 1.01 D) (range 0 to -4.00). ).
Epithelial Flaps were created with the Moria epi-K (Moria SE, Antony, France) microkeratome.
Parameters evaluated were pre and post-operative refractive error, UCVA, BSCVA, time to
epithelial healing, post-operative discomfort, higher order aberration change and contrast
sensitivity. Results: All twenty ve eyes were available for follow up at 12 months. Mean
uncorrected visual acuity improved from preoperative of 20/200 (SD+/-0.23) to 20/23 (SD+/0.173) 89% of eyes were within +/- 0.50 D of refractive goal respectively. None of the eyes
lost more than 2 lines of BSCVA. Epithelium stabilized in average at day 5 (+/- 1). Discomfort
was graded +2.5 on a 1-5 scale There was an average increase in higher order aberrations
(RMSH) by 36%. Conclusions: Epi-LASIK with the epi-K microkeratome apperas to be a
safe and effective refractive surgery alternative for moderate myopes.
CR: A. Kanellopoulos, None.
Support: None.

Development of Chorioretinal Folds Following Laser in situ Keratomileusis (LASIK)

for Hyperopia
M.G. Parker, Q.Farjo. Ophthalmology, Kellogg University, Ann Arbor, MI.

Purpose: To describe the rst reported case of chorioretinal folds after laser in situ Keratomileusus (LASIK)
M e t h o d s : A 47 y e a r o l d m a l e d e v e l o p e d b i l a t e r a l c h o r i o r e t i n a l
Results: After a complete examination by the retina service, he was diagnosed with bilateral
idiopathic/hyperopic chorioretinal folds. He has been followed for ten months and has persistent
choroidal folds but his best corrected visual acuity remains stable; OD 20/25 and OS 20/20
Conclusions: Chorioretinal folds have been associated with numerous conditions including: orbital
tumors, posterior scleritis, and hyperopia, etc. They have also been reported following surgical
procedures such as trabeculectomy and pars plana vitrectomy. To our knowledge this is the rst
reported case of chorioretinal folds diagnosed in the post-operative period following LASIK.
A 47 year-old male underwent bilateral simultaneious hyperopic LASIK using a Hansatome and
Technolas 217 laser. A complete preoperative dilated ophthalmic exam demonstrated normal retinas
and stable hyperopic refraction. The patient did have poor BCVA due to anterior basement membrane
dystrophy which improved following bilateral diamond burr supercial keratectomy prior to LASIK.
Following LASIK, UCVA was 20/20 OU on day #1. However, six months post-LASIK his UCVA
OD gradually dropped to 20/100 and OS to 20/40 due to hyperopic regression. Dilated fundus
examination did not demonstrate any abnormalities. An uncomplicated enhancement was performed
on the right eye 30 weeks after the initial procedure by ap lift. After one month, dilated fundus
exam, uorescenin angiography.and optical coherence tomography demonstrated choroidal folds
OU. Axial lengths were found to be OD 21.58mm and OS 22.04mm. Consultation with a retinal
specialist was sought who felt the choroidal folds were most consistent with idiopathic/hyperopic folds.
Given the possibility that the LASIK procedure may have produced or exacerbated the choroidal
folds and the greater likelihood for folds to occur in short eyes, the authors recommend obtaining
pre-operative axial length measurements and preforming a careful dilated fundus exam in patients
undergoing hyperopic refractive procedures. A discussion should be had with the patient about the
possibility of choroidal folds occurring post-operatively in eyes with short axial lengths. Choroidal
folds should also be considered in the differential diagnosis of hyperopic regression following
refractive surgery. Dilated retinal examination should be performed prior to any enhancement in a
patient with hyperopic regression.
CR: M.G. Parker, None; Q. Farjo, None. Support: None.

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.

Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753
454. Refractive Surgery Organizing Section: CO
4371 - B729

4372 - B730

Recovery of Corneal Subbasal Nerve Density Is Slower After LASIK Than After
E.J. Winter1A, J.C. Erie1A, C.B. Nau1A, J.W. McLaren1A, D.O. Hodge1B, W.M. Bourne1A.
Ophthalmology, BBiostatistics, 1Mayo Clinic College of Medicine, Rochester, MN.
Purpose: To measure corneal reinnervation during 5 years after LASIK and PRK.
Methods: 16 eyes of 11 patients received LASIK with a planned 180-m ap to correct
refractive errors between -2D and -11D. 18 eyes of 12 patients received PRK to correct refractive
errors between -1.5D and -5.75D. Corneas were examined by using confocal microscopy before
and at 1, 2, 3, and 5 years after the procedures. Subbasal nerves and their branches were
traced and their lengths measured by using a custom program. Nerve density was expressed
as length of nerve per unit area (m/mm 2). Differences between pre-and post-operative nerve
densities were determined by using generalized estimating equation models (to account for
possible correlation between paired eyes) with Bonferroni correction for 4 comparisons.
Results: Mean subbasal nerve density before PRK was 6786 1948 m/mm 2 (SD).
Mean density decreased to 2764 1321 m/mm 2 (-59%, P<0.001) at 1 year. At 2 and 5
years, mean nerve density returned to 6242 1763 m/mm 2 (-8%) and 5903 3086
m/mm 2 (-13%) respectively, densities not signicantly different from densities before
PRK (P=1.0). Mean subbasal nerve density before LASIK was 5589 2436 m/mm 2.
Mean density was 2745 2913 m/mm 2 (-51%, P=0.001) at 1 year, 3661 2773 m/
mm 2 (-35%, P=0.03) at 2 years, and 3683 2517 m/mm 2 (-34%, P=0.006) at 3 years.
By 5 years after LASIK, density recovered to 4441 2819 m/mm 2 (-21%, P=0.58).
Conclusions: After LASIK, nerve ber bundles return to the subbasal layer more slowly
than they do after PRK.
CR: E.J. Winter, None; J.C. Erie, None; C.B. Nau, None; J.W. McLaren, None; D.O.
Hodge, None; W.M. Bourne, None.
Support: NIH Grant EY02037, Research to Prevent Blindness

Corneal Inlays: Results of a 6 Month Phase 1 Clinical Trial

D.F. Sweeney1, M.S. Sridhar2, A.Vannas3, V.K. Pravin2, R.Kala2, T.C. Hughes4, M.D.
M. Evans4, K.M. McLean4, R.Z. Xie1. 1Vision CRC, Sydney, Australia; 2LV Prasad Eye
Insitute, Hyderabad, India; 3Dept of Ophthalmology, Central Military Hospital, Helsinki,
Finland; 4CSIRO, Melbourne, Australia.
Purpose: To assess the safety of synthetic corneal inlays over a 6 month period.
Methods: Porous Peruropolyether corneal inlays (LD: 4.3mm ct: 80 microns) were placed
under a microkeratome ap (180 microns thickness) without sutures in the unsighted eye
of 5 patients. Three patients, aged from 58 to 68 years, were unsighted in one eye as a
result of optic atrophy whilst a further 2 patients, aged 24 and 38 years, were unsighted
in one eye as a result of traumatic optic neuropathy and central retinal artery occlusion.
The contralteral eye had good vision (20/20-20/40). A microkeratome ap without
implantation was performed on another 1 unsighted eye of patients aged 50 years. This
patient served as a control. The patients undergoing surgery were assessed at baseline,
immediately post-operative, at 7 days, 1 month and every month thereafter for 6 months.
Results: Surgery for all cases was uneventful. All implants have been well tolerated with no
episodes of inammation, signicant vascular in-growth or other adverse reactions reported.
The position of the inlays has remained stable over the 6 month period. The clarity of the inlays
has remained unchanged after an initial very slight decrease in the days immediately following
surgery for 2 patients. There have been reports of slight haze overlying and around the inlays.
Conclusions: Corneal inlays made from peruoropolyether offer a safe and biologically
acceptable alternative to other forms of refractive surgery.
CR: D.F. Sweeney, None; M.S. Sridhar, None; A. Vannas, None; V.K. Pravin, None; R.
Kala, None; T.C. Hughes, None; M.D.M. Evans, None; K.M. McLean, None; R.Z. Xie,
Support: Australian Government Cooperative Research Centres Grant

4373 - B731

4374 - B732

Immunohistochemical Evaluation of Two Corneal Buttons With Post LASIK

B.Maguen1, E.Maguen1, A.V. Ljubimov1,2. 1Ophthalmology, Cedars Sinai Medical Center,
Los Angeles, CA; 2UCLA School of Medicine, Los Angeles, CA.
Purpose: To perform an immunohistochemical evaluation of two corneal buttons
diagnosed with post LASIK keratectasia, obtained following corneal transplantation.
Methods: Two ectatic corneas after penetrating keratoplasty were embedded in OCT
within 3 hours after surgery and cryostat sections analyzed by immunouorescence
with antibodies to 29 extracellular matrix (ECM) components and proteinases.
Results: The ratio of distance between the LASIK ap interface and the upper epithelial layer
to the total corneal thickness was 0.2 in the rst case and 0.32 in the second. The interface was
highlighted only with an antibody to bronectin. Other stromal ECM components (types VI
and XIV collagen, brillin-1, tenascin-C, and vitronectin) were unchanged with no evidence
of brosis. In the epithelial basement membrane (EBM) type IV collagen 5 chain, nidogen-2,
chains of laminin-8 and laminin-10 showed weak and discontinuous staining. Type IV collagen
1/2 chains were found in the EBM but were absent there in control healthy corneas. These
changes were similar to those observed in bullous keratopathy and keratoconus corneas. Other
EBM components did not show visible changes. Of ve matrix metalloproteinases (MMP)
studied, MMP-10 showed increase in the epithelium and MMP-3, in some stromal keratocytes
compared to control healthy corneas. MMP-3-positive keratocytes were usually found in the
vicinity of ap interface. Patterns of urokinase and cathepsins F, H, and L were similar to
normal. A limbal basal epithelial marker, -enolase, was absent in the rst case and only showed
scattered positive cells in the second, attesting to essentially normal epithelial differentiation.
Conclusions: Abnormal EBM structure similar to that found in keratoconus and bullous
keratopathy along with an increase in certain MMPs were found suggesting an ongoing
lysis and remodeling of basement membrane. Further studies are needed to nally conrm
these ndings.
CR: B. Maguen, None; E. Maguen, None; A.V. Ljubimov, None.
Support: Skirball Program in Molecular Ophthalmology

Low-Contrast Visual Acuity and Small Letter Contrast Sensitivity in Adult Patients
With Refractive Error
A.M. Betts1,2, K.S. Bower1,2, D.K. Bigelow1,2, J.C. Rabin3, J.M. Burka1, R.C. VanRoekel1.
Center for Refractive Surgery, Walter Reed Army Medical Center, Washington, DC;
Uniformed Services University of the Health Sciences, Bethesda, MD; 3College of
Optometry, Pacic University, Forest Grove, OR.
Purpose: To establish normative values for a low-contrast visual acuity (CA) test and a small
letter contrast sensitivity test (SLCT) in a sample of patients with refractive error. Methods:
Pre-op records of 438 patients who underwent refractive surgery at an Army laser center were
reviewed. 5% CA, SLCT score, manifest and cycloplegic refraction, and age were recorded
from each patients record. The distribution of scores for contrast testing was analyzed and
examined for correlations with age and refractive error. Results: The mean logarithmic 5%
CA was 0.34 for both right and left eyes (20/44 Snellen equivalent). The mean logarithmic
SLCT score was 0.38 (contrast threshold of 42%) for the right eyes and 0.40 (threshold 40%)
for the left eyes. The mean SLCT score was lower than previously reported. Higher levels of
myopia were associated with poorer performance on both tests. Neither test showed signicant
correlation with age in this sample. Conclusions: This retrospective review provides normative
values for two methods of contrast testing in a military refractive surgery clinic. The inverse
correlation between myopic refractive error and performance on contrast testing may be
attributed to optical effects of spectacle correction and/or retinal factors in myopic eyes. The
reduction in SLCT compared to previously established values is likely attributed to the nonstandard luminance conditions under which the SLCT was administered in this clinical setting.

CR: A.M. Betts, None; K.S. Bower, None; D.K. Bigelow, None; J.C. Rabin, None; J.M.
Burka, None; R.C. VanRoekel, None. Support: None.

4375 - B733

Comparison of Visual Outcomes of Wavefront Guided and Conventional LASIK

D.E. Setlik1, K.L. Fry1,2, P.S. Hersh1,2. 1The Cornea and Laser Eye Institute, Teaneck, NJ;
Ophthalmology, UMDNJ - New Jersey Medical School, Newark, NJ.
Purpose: To compare visual outcomes between eyes treated using conventional and custom LASIK.
Methods: A retrospective chart review of 271 eyes (166 patients) treated for myopia and/or
astigmatism was performed using the LADARVision excimer laser. One hundred and eighty
eyes (108 patients) were treated with conventional LASIK and 91 eyes (58 patients) with
the LADARWave CustomCornea System. Outcome variables included UCVA, BCVA,
predictability, and wavefront aberrations (6.0mm pupil). Preoperative and 3-month follow-up
data (mean 110 days) were analyzed. Patients in both groups were matched for age, preoperative
manifest refraction spherical equivalent (MRSE) (up to 6.25D) and astigmatism (up to 1.0D).
Mean MRSE of conventional eyes was -3.69 1.48 D and -3.42 1.46D for custom treated eyes.
Results: There was not a statistically signicant difference in mean postoperative UCVA between
groups. Mean UCVA was 20/24 in custom and 20/26 in conventionally-treated eyes, respectively.
However, custom eyes were more likely to reach 20/20 UCVA; 60 custom eyes (66%) achieved
20/20 compared to 96 conventional eyes (53%) (p=0.047). Difference in BCVA between groups
did not meet statistical signicance; mean pre- and postoperative BCVA was 20/20 for both groups.
Mean predictability for custom ablations was -0.33 0.47 D and for conventional ablations
was -0.32 0.47 D. Sixty eyes (66%) treated with custom LASIK were within 0.50 D of
attempted correction compared with 122 eyes (71%) treated with conventional ablation
( p>0.05). However, no statistical signicance differences in predictability were found.
Comparison of pre- and postoperative wavefront error showed that both procedures
induced signicant amounts of coma, spherical aberration, other and total aberrations.
However, only 16% of custom ablations compared with 38% of conventional
treatments induced 0.50 microns of RMS of total higher order aberrations ( p=0.02).
Conclusions: Both conventional and custom LASIK produce similar visual outcomes.
However, eyes treated with custom LASIK were more likely to achieve 20/20 uncorrected
vision and less likely to have induced wavefront aberrations after surgery.
CR: D.E. Setlik, None; K.L. Fry, None; P.S. Hersh, Alcon Inc. C.
Support: None.

4376 - B734

Comparison of the Change in Corneal Higher Order Aberrations with WavefrontGuided Epi-LASIK versus Wavefront-Guided Conventional LASIK Using the
LadarWave CustomCornea Platform
J.J. Wong1, K.Masselam1, D.Jardim2, B.Soloway2, C.Starr1. 1New York University/
Manhattan Eye, Ear & Throat Hospital, New York, NY; 2New York Eye and Ear Inrmary,
New York, NY.

Purpose: To compare the efcacy of wavefront-guided epipolis laser in situ keratomileusis (Epi-LASIK)
versus wavefront-guided conventional LASIK in reducing high order aberrations (HOA) of the cornea.
Methods: Using the wavefront-guided CustomCor nea LadarWave system (Alcon
Laboratories Inc, Fort Worth, TX), eighteen eyes underwent Epi-LASIK using the
Moria Epi-K microkeratome (Moria Inc., Antony, France) and twelve eyes underwent
conventional LASIK. Wavefront analysis preoperatively, at 3 months, 4 months, and 6 months
postoperatively was performed with the iTrace Aberrometer (Tracey Inc., Houston, TX).
Results: Wavefront analysis showed the preoperative root mean squared (RMS) HOA for patients
undergoing LASIK to be 0.171 in the 3 month group, 1.137 in the 4 month group, and 0.192 in the
6 month group. In the Epi-LASIK group, the preoperative RMS HOA was 0.272 in the 3 month
group, 0.359 in the 4 month group, and 0.184 in the 6 month group. Overall, the preoperative RMS
HOA was 0.499 in the LASIK group and 0.322 in the Epi-LASIK group. Postoperatively, the RMS
change in high order aberrations (HOA) for the LASIK group was 0.079 at 3 months, -0.596
at 4 months, and 0.026 at 6 months. Postoperatively for the Epi-LASIK group, the RMS HOA
was 0.139 at 3 months, 0.128 at 4 months, and 0.087 at 6 months. Overall, the postoperative RMS
HOA was -0.188 for the LASIK group and 0.124 for the Epi-LASIK group. Thus, LASIK had a
signicantly higher decrease in HOA than Epi-LASIK(P<.05, independent t-test). However, there
was less follow up at 6 months with the Epi-LASIK group in contrast to the LASIK group. Plotting
HOA versus time, it was found that the LASIK group had a trendline with a positive slope (y =
0.029x - 0.2052) in contrast to a negative slope (y = -0.0284x + 0.2335) of the Epi-LASIK group.
Conclusions: In this preliminary study with limited follow-up, CustomCornea LASIK on average
induced fewer higher order aberrations than Epi-LASIK. However, a consistent trend towards
decreasing HOA over the 6 month follow-up was seen with Epi-LASIK and not LASIK. Longer
follow-up is needed to determine if this advantage of Epi-LASIK will continue.
CR: J.J. Wong, None; K. Masselam, None; D. Jardim, None; B. Soloway, AlconLabs C, R; C.
Starr, None.
Support: None.

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.

Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753
454. Refractive Surgery Organizing Section: CO
4377 - B735

4378 - B736

Nomogram for the Pre-Operative Prediction of Ablation Depth With Custom Cornea
Refractive Surgery
K.L. Masselam1, J.Wong1, D.Jardim2, D.Pettinelli1, B.Soloway2, C.Starr1,2. 1Ophthalmology,
New York University/Manhattan Eye, Ear and Throat Hospital, New York, NY;
Ophthalmology, New York Eye and Ear Inrmary, New York, NY.

Thin Corneas Undergoing Lasik 4 Years Follow Up Clinical and OCT 3 Analysis
B.A. Ameline1, M.G. Puech2, A.El Maftouhi1, E.A. Brasnu1, L.Laroche1. 1Hopital 15/20,
Paris, France; 2Centre Imagerie et Laser, Paris, France.
Purpose: The aim of this study was to evaluate the stability of thin corneas after Lasik procedures.
Methods: We retrospectively examined 12 eyes of 7 patients, who underwent a Lasik
procedure, from March 1998 to December 1999, even though their ultrasonic corneal
pachymetry ranged from 465 to 505 (Mean pachymetry 495.5 + 10.8). Their mean ametropia
was -6.55 + 3.14D. The maximum correction was -9 D. Corneal anterior topographies showed
no sign of keratoconus (Rabinowitz criteria) The ap was created with an ALKe (7 eyes)
or a Hansatome (5 eyes), Excimer ablation was performed with a Technolas 217c. Four
years later we studied their refraction and its stability, their keratometry by TMS2 and
Orbscan and we performed for each eye an OCT3 examination including the optical
measurement of their corneal pachymetry, ap thickness and residual posterior wall.
Results: At the nal examination 45% of the eyes were within 0.5 D of emetropia and
82% within 1.5 D. The myopic shift between the 6 month and four years end points was
0.62+0.63D. No eye lost more than one line of best corrected visual acuity. No corneal
ectasia was detectable with the Orbscan. Optical corneal pachymetry was comparable to
ultrasonic measurement (+6), whereas Orbscan underestimated the total pachymetry
by 49 in average. Optical measurement of the ap thickness ranged from 135 to 218
(M=169+25). Posterior wall was 264+44 in average, but ranged from 203 to 334.
Conclusions: OCT3 examination has allowed a retrospective in vivo analysis of the ap
thickness and residual stroma. None of our patients showed any sign of corneal ectasia during
a four years follow up even though the posterior wall could be as thin as 203.
CR: B.A. Ameline, None; M.G. Puech, None; A. El Maftouhi, None; E.A. Brasnu, None; L.
Laroche, None.
Support: None.

4379 - B737

4380 - B738

Purpose: To develop a novel nomogram for predicting the ablation depth of corneal-based
refractive surgery (LASIK and Epi-LASIK) using Alcons LadarWave CustomCornea platform.
Methods: In this retrospective study, a ratio of ablation depth in microns (u) perDiopter (D) of either spherical
equivalent (SE), sphere only (SO), or sphere plus cylinder (SC) was established in 45 eyes which underwent either
CustomCornea LASIK or Epi-LASIK. Average SE, SO, and SC were calculated and then divided into the average
ablation depth for all 45 eyes to determine three ratios (u/D). A sub-analysis compared the ratios of ablation depth
per diopter (SE, SO, SC) in 19 eyes with pre-op higher order aberrations (HOA) > 0.4u versus 26 eyes with pre-op
HOA < 0.4u. Higher order aberrations were assessed using the iTrace Aberrometer (Tracey Inc., Houston, TX).
Results: The average predicted ablation depth for all (45) eyes was 77. 1 u. Average SE, SO, and SC in all 45
eyes was -4.35 D, - 3.97 D, and -4.57 D, respectively. The ratio of ablation depth per diopter of SE, SO, and SC
was 17.7 u/D, 19.4 u/D and 16.9 u/D, respectively. The eyes were then sub-analyzed based on HOA, 19 eyes with
HOA > 0.4u (average 0.59u) and 26 eyes with HOA < 0.4u (average 0.25u). For 19 eyes with HOA > 0.4u, average
ablation depth was 89.8 u and for 26 eyes with HOA< 0.4u was 67.9 u. Average SE, SO, and SC for the increased
HOA group were -5.08D, -4.61 D, and -5.58 D, respectively. Average SE, SO, and SC for the lower HOA group
were -3.94 D, -3.64 D, and -4.25 D, respectively. Therefore, for the increased HOA group, the ratio of ablation
depth per diopter of SE, SO, and SC was 17.7 u/D, 19.5 u/D and 16.1 u/D, respectively, and for the lower HOA
group the ratio of ablation depth per diopter of SE, SO, and SC was 17.2 u/D, 18.6 u/D and 16.0 u/D, respectively.
Conclusions: A novel nomogram can be used in the ofce setting to predict ablation depth prior to customized
refractive surgery using Alcons LadarWave platform. The ratio of ablation depth per diopter ranged from
16.9 -19.4 u/D (average of 18.1 u/D) for all eyes. We found no signicant difference between the ratio of
ablation depth per diopter between the increased HOA group (16.1 - 19.5 u/D) and the lower HOA group (16.0
- 18.6 u/D). Using a nomogram of 18 microns of ablation per diopter of spherical equivalent, the refractive
surgeon can accurately predict the amount of corneal tissue to be removed at the time of surgery and avoid
post-operative complications including corneal ectasia.
CR: K.L. Masselam, None; J. Wong, None; D. Jardim, None; D. Pettinelli, None; B. Soloway, Alcon
Labs C, R; C. Starr, None.
Support: None.

A Prospective Evaluation of Asphericity-adjusted LASIK With the Allegretto-wave

and the M2 in 105 Eyes
J.Shein1,2, A.Kanellopoulos1,2, L.Pe3, M.Jankov3. 1Ophthalmology, Manhattan Eye, Ear &
Throat, NYU, New York, NY; 2Ophthalmology, New York University, New York, NY;
Ophthalmology, Institute, Athens, Greece.
Purpose: To evaluate the safety and efficacy of asphericity-adjusted LASIK
surgery, utilizing the Allegretto-wave 400 Hz system and the M2 microkeratome.
Methods: 105 consecutive LASIK cases for myopic astigmatism underwent treatment
with asphericity adjustment to the pre-operative attest keratometry (Q-value 0.15
to -0.46), based on 20 degrees topographic measurement. We evaluated pre- and postoperative refraction, asphericity (Q value), total higher order aberrations (RMSH),
contrast sensitivity and possible complications. Follow-up was 3-7 months (4.5).
Results: 96 eyes were included. The mean values were: refractive error sphere: -3.80D
(-0.50 to -6.75D) and cylinder: -0.85D (plano to -3.75D). UCVA improved from 20/200
to 20/18. At 3 months, 92% of the eyes were 20/20, 57% 20/15, and 34% 20/10. 100%
of the eyes were within +/-0.50 D of the refractive goal at 3 months. There was no
loss of BSCVA in any cases. Q value changed from a mean of -0.3 to -0.11. There was
a positive shift of Q value proportionate to the amount of refractive error corrected.
The mean RMSH decreased from 0.25 to 0.10. CS showed no statistical change.
Conclusions: Asphericity-adjusted LASIK with the Allegretto-wave system (a 0.9mm ying
spot and 400Hz) and the M2 appears to eb safe and very effective for correction of myopic
astigmatism. It has demonstrated in this limited study clinical ability to reduce higher order
aberrations following LASIK possibly through limiting the change in Q value.
CR: J. Shein, None; A. Kanellopoulos, None; L. Pe, None; M. Jankov, None.
Support: Research to Prevent Blindness

4381 - B739

The Role of Restasis in Faster Visual Acuity Recovery After Refractive Surgery
R.Ursea, M.Lovaton, M.Ehrenhaus, B.Tan, C.Heichel, D.J. Schanzlin. University of
California San Diego, Shiley Eye Center, La Jolla, CA.
Purpose: Restasis (cyclosporine 0.05%, Allergan), is thought to improve tear
production and combat post-LASIK inammation. Our aim in this study was to compare
refractive outcome and complications following LASIK in a group of 54 patients
treated with Restasis (Cyclosporine 0.03%) in addition to the usual topical steroids
and antibiotic drops versus a control group of 46 subjects not receiving Restasis.
Methods: Retrospective analysis of one hundred patients underwent Lasik correction
for different refractive errors. Patients underwent a complete ophthalmic examination
prior to the procedure for evidence of dry eyes. All patients in this series were initially
evaluated with best corrected visual acuity, complete slit lamp biomicroscopy and
dilated fundus examination, Schirmer test, tear break-up time, uorescein and rose
Bengal staining. They answered a questionnaire regarding dry eyes complains before
and 6 weeks after the refractive surgery. Restasis was added to the postoperatory drops
regimen in 54 patients. Results were compared with patients that did not receive Restasis.
Results: Our 100 patients consisted of 54 females and 46 males, with an age ranging from 22
to 69 years. Fifty-four patients were treated with Restasis. At the onset of Restasis therapy
63% patients had complains of dry eyes. Almost half (25 patients, 46.3%) achieved 20/15
vision at one week after surgery, 21 patients (38.9%) had 20/20 vision and 8 patients (14.8%)
had worse than 20/25. In the group of 46 patients not receiving Restasis, the majority (26
patients, 56.5%) did not improve to better than 20/25 at 1 week postop. During the course
of therapy none of the patients reported adverse effects to the use of Restasis. Patients
using Restasis were signicantly more likely than patients who did not use Restasis to have
20/15 vision (P=.017). Patients who did not use Restasis were signicantly more likely
than patients who did use Restasis to have a visual outcome worse than 20/20 (P<.001).
Conclusions: Restasis might be effective in fast visual recovery after refractive surgery,
besides improving the dry eyes syndrome. Future studies are required to determine longterm efcacy of Restasis in maintaining a good visual acuity and in treating dry eyes and if
higher Restasis doses are required and well-tolerated.
CR: R. Ursea, None; M. Lovaton, None; M. Ehrenhaus, None; B. Tan, None; C. Heichel,
None; D.J. Schanzlin, None.
Support: None.

Management of a Severe Corneal Scar Using Lamellar Keratoplasty With a Standard

Hansatome Microkeratome and a Frozen Globe
E.P. Herlihy1, P.N. Youssef 1, M.V. Netto2, T.T. Shen1. 1Ophthalmology, University
Washington, Seattle, WA; 2Ophthalmic Research, Cole Eye Institute, Cleveland Clinic
Foundation, OH.

Purpose: To report the management of a severe corneal scar at the LASIK ap interface using lamellar keratoplasty
with a Hansatome microkeratome and subsequent LASIK enhancement to correct residual astigmatism.
Methods: Case report of a 56-year-old man who developed a severe Pseudomonas corneal ulcer
two years after uncomplicated LASIK surgery. On presentation, visual acuity in the affected eye
was light perception only; hypopyon and severe DLK were noted. The corneal ulcer resolved after
aggressive treatment with fortied antibiotics as well as topical and oral steroids. However, a dense
corneal scar at the level of the LASIK ap interface resulted and extended into the visual axis.
A lamellar keratoplasty was performed to remove the corneal scar at the LASIK ap interface. Using
standard technique with a Hansatome microkeratome (Bausch & Lomb), a 180 micron ap was created to
remove the old LASIK ap and the corneal scar from the previous infection. A donor ap from a whole globe
was created using an identical Hansatome microkeratome arrangement. A superior hinge was then cut in
the host and in the donor tissue. The donor ap was sutured to the host stromal bed, with the superior hinge
well matched. Postoperatively, the eye was treated with a bandage contact lens, antibiotics and steroids.
Results: At post-operative week one, the transplanted LASIK ap was completely epithelialized.
There was no evidence of epithelial ingrowth. Selective suture removal began at post-op week
three. Residual corneal astigmatism (4.5 D) was later treated with standard LASIK enhancement
technique by lifting the transplanted lamellar ap. Post-op management included standard bandage
lens and antibiotic therapy. At post-enhancement week one the ap was well positioned and
there was no evidence of striae or epithelial ingrowth. Post LASIK enhancement VA was 20/40.
Conclusions: Bacterial corneal ulcer occurring after LASIK surgery may result in severe interface
scar with signicant decrease in vision. Using a standard Hansatome microkeratome set-up, lamellar
keratoplasty can be successfully performed to eliminate the interface scar. This approach offers faster
visual recovery than penetrating keratoplasty and provides the potential for post-transplant LASIK
enhancement. In addition, the requirement for eye bank tissue is less strict, as the tissue may be
obtained from a frozen globe.
CR: E.P. Herlihy, None; P.N. Youssef, None; M.V. Netto, None; T.T. Shen, None.
Support: None.

4382 - B740

Tear Film Function and Corneal Sensation After LASEK for the Correction of
W.A. Herrmann1, C.P. Lohmann2, C.P. Shah3, K.Hufendiek1, C.Winkler von Mohrenfels2,
V.-P.Gabel1. 1Ophthalmology, University Eye Clinic, Regensburg, Germany;
Ophthalmology, University Eye Clinic, Technische Universitt Mnchen, Germany;
School of Medicine and Denstristry, University of Rochester, Rochester, NY.
Purpose: Corneal nerves are damaged during LASEK surgery. This leads to a reduction
of corneal sensation and to alterations of the tear lm function. The aim of this study
was to evaluate tear lm function, corneal sensation and subjective symptoms of
a dry eye in the early postoperative period after LASEK for the correction of myopia.
Methods: LASEK surgery was performed in 20 eyes of 10 consecutive patients for the correction
of myopia(-1.0 D to -8.0 D, mean -4.86 D). Subjective symptoms of a dry eye were evaluated
with a standardized questionnaire. Schirmer Test without local anaesthesia, tear lm breakup
time, uorescein staining of the cornea and corneal esthesiometry (Cochet Bonnet) were
performed before surgery and 3 days, 1 week, 1 month, 2 months and 3 months after LASEK.
Results: Corneal sensation is reduced 3 days and 1 week after LASEK and recovers
during the 1 month after LASEK. The tear lm breakup time is reduced after LASEK
and reaches preoperative values 2 months after surgery. Fluorescein staining was
increased 3 days and 1 week after LASEK. Subjective symptoms of a dry eye were
increased during the rst 2 months after LASEK. Concerning the Schirmer Test no
signicant changes were assessed after surgery as compared to preoperative values.
Conclusions: LASEK surgery alters tear lm function and reduces corneal sensation in the
early postoperative period. Subjective symptoms of a dry eye were described during the
rst 2 months after surgery. 3 months after LASEK no statistically signicant changes were
observed concerning the assessed parameters as compared to preoperative values.
CR: W.A. Herrmann, None; C.P. Lohmann, None; C.P. Shah, None; K. Hufendiek,
None; C. Winkler von Mohrenfels, None; V. Gabel, None.
Support: None.

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.

Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753
454. Refractive Surgery Organizing Section: CO
4383 - B741

Gender and Other Factors That Affect Questionnaire Response: An Analysis of

Wavefront Guided LASIK Outcomes
K.-M.A. Tuan. Research, VISX, Incorporated, Santa Clara, CA.

Purpose: To compare the results of clinical vision tests with patient perception of vision following wavefrontguided LASIK, and to determine how closely and under what circumstances perception correlated with test results.
Methods: Wavefront-guided LASIK was performed on myopic-astigmatic eyes at 6 clinical sites.
Questionnaires were administered and comprehensive vision evaluations were conducted before and 6 months
after surgery. Questionnaire responses were compared with test results using ordinal logistic regression.
Results: Two hundred seventy-four eyes completed 6 months of follow-up. After surgery, the very satised
responses increased in all areas by as much as 70%. Improved visual performance was consistently reected both
perceptually and in test scores. However, patients were more vocal if they experienced decreases in vision. Preop magnitude of myopia had minimal inuence on questionnaire outcome (p>0.05), but post-op refractive error
was a signicant predictor for the majority of the questionnaire items (p<0.01 or 0.05). Day vision experience,
i.e., sharpness, and daily visual uctuation, was inuenced by uncorrected visual acuity and post-op Rx (p<0.01
or 0.05). Night vision experience was inuenced by post-op Rx and mesopic glare contrast sensitivity (CS)
(p<0.01). Additionally, the perception of changes in vision seems to be related to mesopic CS and mesopic CS
under glare (p<0.01 or 0.05). Mesopic pupil diameter was not a major predictor of visual experience (p>0.05).
Male patients were more likely to report frequent visual symptoms and voiced stronger complaints regarding
night vision (p<0.01). However, according to their questionnaire scores, the changes in the male subjects vision
were the same as the changes in their female counterparts. In addition, subjects who used contact lenses prior
to surgery were more satised with their post-operative vision than subjects who had worn spectacles (p<0.05).
Conclusions: Results suggest that in addition to objective visual outcomes, subjective factors affect
questionnaire responses. Patients who experienced visual degradation were more expressive of their displeasure.
In addition, the patients sex and the type of corrective lens used before surgery may be factors in subjective
responses. Night vision complaints were corroborated by mesopic contrast testing and post-operative refractive
error. Undesirable visual experiences could be reduced and patient satisfaction maximized if post-operative
refractive error can be minimized and the overall optical quality of the eyes improved.
CR: K.A. Tuan, VISX, Incorporated E.
Support: VISX, Incorporated

4385 - B743

4384 - B742

Early Visual Recovery After Photorefractive Keratectomy

J.B. Randleman, C.S. Banning, E.S. Loft, R.D. Stulting. Ophthalmology, Emory
University, Atlanta, GA.
Purpose: To examine the early time course of visual recovery after photorefractive
keratectomy (PRK) and to identify risk factors for delayed visual recovery.
Methods: Retrospective review of 22 eyes from 11 patients with PRK performed
with the Wavelight Allegretto Wave excimer laser. Variables analyzed included
uncorrected visual acuity (UCVA) at day 1, day 7, and day 14 postoperatively.
Results: Average day 1 UCVA was 20/37.9 (range 20/20 to 20/70). At day 1, 18.2%
achieved 20/20 or better UCVA, 50% achieved 20/25 UCVA, and 68.2% achieved 20/40
or better UCVA. Average day 7 UCVA was 20/38.2 (range 20/20 to 20/100). At day 7,
27.3% achieved 20/20 or better UCVA, 50% achieved 20/25 or better UCVA, and 68.2%
achieved 20/40 or better UCVA. Average day 14 UCVA was 20/26.6 (range 20/15
to 20/70). At day 14, 40.9% achieved 20/20 or better UCVA, 72.7% achieved 20/25 or
better UCVA, and 90.9% achieved 20/40 or better UCVA. There were no signicant
differences in terms of age, preoperative pachymetry, ablation depths, or refractions
between eyes that achieved 20/40 or better UCVA and those that did not at any time point.
Conclusions: Most eyes achieve 20/40 or better UCVA on the rst postoperative day after
PRK, and most achieve 20/25 or better UCVA by two weeks postoperatively. We did not
identify any denitive predisposing factors for delayed visual recovery.
CR: J.B. Randleman, None; C.S. Banning, None; E.S. Loft, None; R.D. Stulting,
Support: None.

4386 - B744

Clinical Study on a Modied Y-Type Laser Epithelial Keratomileusis (LASEK)

Q.Wang, F.Lu, Y.Yu, W.Li, J.Qu. Eye Hospital, Wenzhou Medical College, Wenzhou,
bet ween
modif ied
cor rection.
Methods: Fifty myopic patients (100 eyes) were equally assigned to 2 groups. In Group 1, a
routine LASEK procedure was performed. This included that an intact epithelial ap was made
and retracted after a prior treatment by 20% ethyl alcohol, followed by laser ablation at the
stromal surface and rolling-back of the ap onto the ablated area. In Group 2, the prior alcohol
treatment and laser ablation were identical to the routine LASEK procedure. However, instead
of making an epithelial ap from one end to the other, a Y-scratch was made through the entire
epithelium at the central cornea, resulting in 3 valves with a meeting point at the center of Y.
The 3 limbs of the Y were extended towards the periphery of the cornea followed by turningover of the 3 valves to expose the stromal bed for laser ablation. The 3 valves were returned
to the stromal bed after the laser treatment. The success, time spent, post-surgical comfort,
corneal appearance and visual recovery were evaluated for the two LASEK procedures.
Results: The overall results were summarized within 1 week after surgery. Between
routine (group 1) and Y-type (group 2), the mean time spent in ap making was
15minutes and 3 minutes, the f lap making success rate was 82% and 95%, the
patientss comfort P.O. was mild to moderate and mild, the corneal and conjunctiva
injection was moderate and mild. The mean time spent until complete epithelial
healing (Day) was 5.5 days for both group and the BCVA is 20/25 for both groups.
Conclusions: The Y-type ap procedure is much easier than the routine one with a higher
successful rate and a milder tissue response. The epithelial healing process is similar between
the two procedures.
CR: Q. Wang, None; F. Lu, None; Y. Yu, None; W. Li, None; J. Qu, None.
Support: Zhejiang Provincial Natural Science Foundation of China, ZB0202

Use of PTK and Intraoperative Mitomycin C for Anterior Corneal Disease

B.D. Ayres, C.J. Rapuano. Corneal Associates, Wills Eye Hospital, Philadelphia, PA.
Purpose: To evaluate the safety and efcacy of using intraoperative mitomycin C
topically at a concentration of 0.02% during PTK for anterior corneal pathology.
Ret rospect ive
char t
u nder went PT K with m itomyci n C f rom July of 20 01 to present.
Results: After 37 months of follow up no complications have been seen in any of our
patients related to the use of one time topical administration of mitomycin C. Average
time to heal of the epithelial defect after PTK is less than three days with an average
improvement in vision of greater than 2 lines of snellen visual acuity. As of this time
we have not seen any recurrence of anterior corneal disease in the region treated with
PTK and MMC, however, two patients have had mild peripheral recurrence of disease.
Conclusions: Topical intraoperative application of mitomycin C during PTK appears to be
safe. Mitomycin C also seems to be additive to PTK for prevention of recurrent anterior corneal
disease. MMC also did not retard epithelial defect healing in our patients.
CR: B.D. Ayres, None; C.J. Rapuano, None.
Support: None.

4387 - B745

4388 - B746

Central Epithelial and Stromal Thickness 5 Years After LASIK and PRK
C.B. Nau1A, J.C. Erie1A, D.O. Hodge1B, J.W. McLaren1A, W.M. Bourne1A. ADepartment
of Ophthalmology, BDepartment of Biostatistics, 1Mayo Clinic College of Medicine,
Rochester, MN.
Purpose: To examine changes in epithelial and stromal thickness for 5 years after
LASIK (laser in situ keratomileusis) and PRK (photorefractive keratectomy).
Methods: Seventeen eyes of 11 patients were treated with LASIK to correct refractive errors
between -2D and -11D. Stromas were cut with a Hansatome microkeratome with a planned
180 m-depth. Eighteen eyes of 12 patients were treated with PRK to correct refractive errors
between -1.5D and -5.75D. Central corneas were examined by confocal microscopy (Tandem
Scanning, Reston, VA) before and at 1 month, 3 months, 6 months, 1 year, 2 years, 3 years,
and 5 years after the procedure. Epithelial thickness was determined from the number of video
frames between the brightest image of epithelial cells and either the subbasal nerve plexus
or the intensity peak just anterior to the rst keratocytes if nerves were not visible. If neither
endpoint was present after LASIK, thickness was not determined. If neither was present after
PRK, the rst frame of anterior keratocytes was used as the endpoint. Epithelial thicknesses
after treatment were compared to thickness before treatment, and stromal thicknesses were
compared to stromal thickness at 1 month. Signicances of differences were determined by
using Generalized Estimating Equation models (to account for potential correlation between
eyes from the same patient) and the Bonferroni method to correct for multiple comparisons.
Results: Mean epithelial thickness before LASIK was 41 4 m ( SD, n=17). It increased to
50 5 m at 1 month (p<0.001, n=12) and 53 5 m (p<0.001, n=16) at 5 years. Mean stromal
thickness was 391 39 m (n=17) one month after LASIK, and 393 31m (p=1.0, n=16) at
5 years. Mean epithelial thickness before PRK was 44 5 m (n=18). At 5 years it was 45 5
m (p=1.0, n=18), although at 3 years it had increased to 49 7 m (p<0.001, n=18). Stromal
thickness was 395 41 m (n=15) 1 month after PRK, and 416 47 m (p=0.12, n=18) by 5 years.
Conclusions: Epithelial thickness increases after LASIK and remains elevated for at least
5 years. The stroma does not thicken or thin during the same time, after the initial surgical
reduction. After PRK the epithelial and stromal thicknesses do not change for at least 5
CR: C.B. Nau, None; J.C. Erie, None; D.O. Hodge, None; J.W. McLaren, None; W.M.
Bourne, None.
Support: NIH Grant EY02037, Research to Prevent Blindness, Inc.

Dry Eye Symptoms and Corneal Sensitivity Following LASIK for High Myopia
T.Tervo. Helsinki Univ Eye Hospital, University of Helsinki, Helsinki, Finland.
Purpose: To assess subjective symptoms and objective clinical signs of dry
eye and corneal sensitivity after > 10 D myopic LASIK., and to correlate
the severity of dry eye symptoms with corneal sensitivity threshold values.
Methods and subjects: Twenty eyes of 20 patients (mean age 34 + 7.5 years), who had
undergone > 10 D myopic LASIK two to ve years earlier, were enrolled in the study.
Clinical objective signs of dry eye in addition to normal ophthalmic examination and a
subjective dry eye questionnaire were used to harvest the data. The central corneal
mechanical sensitivity was assessed with a modied Belmonte Non-Contact Esthesiometer.
Results: The preoperative refraction (spherical equivalent; SE) was -11.4+1.4 D (mean +
SD) and the intended correction SE was -10.4+1.1 D. Postoperatively, the mean manifest
refraction was -1.9 + 1.6. The mean UCVA was 10/20 and BCVA 20/20. The postoperative
Schirmer I test value was 14.4 + 8.9 mm and 6.9 mm + 4.9 mm in controls and BUT 15.9 +
11.2 s and 17.0 + 11.0 s, respectively. The majority of the patients still complained about dry
eye symptoms (60%), glare and halos (80 %) under scotopic conditions. However, almost all
of the patients (95 %) were generally satised and would have chosen the surgery again. The
mean postoperative mechanical corneal sensitivity (treshold) was 73.5 + 29.6 ml/min and 77.5
+ 18.3 ml/min (p=0.97) in the controls. Ocular surface disease index (OSDI) score, indicating
degree of dry eye symptoms, was signicantly higher in LASIK patients (18.6 + 13.4) compared
to control individuals (5.2 + 7.6 ;p < 0.05). Anecdotally, we also observed postoperative
hypersensitivity in a patient, who had undergone an unilateral 9 D PRK of D 8 years earlier.
Conclusions: Corneal mechanical sensitivity threshold values had returned to normal level 2-5
years following LASIK for correction of high myopia . Despite the reported high prevalence of
dry eye symptoms, objective clinical signs of dry eye were rare. Abnormal neural regeneration
and/or irritability may account for some of the dry eye symptoms that persist years after
correction of high myopia with LASIK.
CR: T. Tervo, None.
Support: HUS EVO grant

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.

Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753
454. Refractive Surgery Organizing Section: CO
4389 - B747

4390 - B748

Laser Insitu Keratomileusis Performed by Residents and Fellows

M.M. Lai1,2, P.K. Sangani3, D.G. Hwang3. 1Department of Ophthalmology, University
of Southern California, Los Angeles, CA; 2Department of Ophthalmology, University
of California, San Francisco, San Francisco, CA, CA; 3Department of Ophthalmology,
University of California, San Francisco, San Francisco, CA.

A Comparison of Induced Astigmatism in Conventional and Wavefront-Guided Laser

in situ Keratomileusis
K.Komaromy, S.T. Awwad, D.Oral, R.W. Bowman, H.D. Cavanagh, J.P. McCulley.
Ophthalmology, University of Texas Southwestern, Dallas, TX.
Purpose: To compare the magnitude and axis of surgically induced astigmatism (SIA)
after conventional and wavefront-guided (WG) laser in situ keratomileusis (LASIK).
Methods: In this single-center retrospective study, two laser platforms, VISX S4 and LADAR
4000, were used to deliver conventional and custom treatments for a total of 208 eyes (52
consecutive eyes in each group). The primary outcome measure was manifest refraction,
which was evaluated preoperatively and at 1 week, 1 month, and 3 months postoperatively. The
magnitude and axis of the SIA were calculated using vector analysis. The Student t-test was used
to compare the magnitude of the SIA while the axial shift was compared using the chi-square test.
Results: The mean preoperative manifest cylinder was 0.74 +/- 0.34 D for conventional
VISX, and 0.60 +/- 0.51 D for WG-VISX (P=0.1), and 0.74 +/- 0.56 D for conventional
LADAR and 0.62 +/- 0.37 D for WG-LADAR (P=0.12). The mean values for the SIA
at 3 months were 0.04 +/- 0.26 D for conventional VISX and 0.08 +/- 0.34 D for WGVISX (P=0.56), and 0.04 +/- 0.26 D for conventional LADAR and 0.06 +/- 0.24 D for
WG-LADAR (P=0.63). The mean SIA axis of rotation at 3 months was 4 degrees for
conventional VISX and 17 degrees for WG-VISX, and 7 degrees for conventional LADAR
and 9 degrees for WG-LADAR. The differences were not statistically signicant.
Conclusions: Wavefront-guided ablation tends to increase the magnitude and axis of surgically
induced astigmatism more than conventional post LASIK though not to a statistically
signicant degree. Care should be emphasized in registration, centration, and ap alignment
to minimize SIA in WG-LASIK.
CR: K. Komaromy, None; S.T. Awwad, Alcon Laboratories, Inc R; D. Oral, None; R.W.
Bowman, None; H.D. Cavanagh, None; J.P. McCulley, Alcon Laboratories, Inc F, C, R.
Support: Research to Prevent Blindness

4391 - B749

4392 - B750

Purpose: To compare the outcomes of laser in situ keratomileusis (LASIK) performed by residents and
fellows with those of cornea trained faculty members at an academic ophthalmology training program.
Methods: A retrospective cohort study was conducted of all myopic LASIK cases performed by residents
or fellows (trainees) between 1/1/99 and1/15/04 at the University of California, San Francisco. Cases
performed by trainees were compared with age-matched and preoperative spherical equivalent-matched
faculty-performed cases. The primary endpoint was the percent of eyes achieving uncorrected visual
acuity (UCVA) of 20/25 or better at 1 month. Secondary endpoints were percent of eyes achieving UCVA
of 20/20 or better, percent of eyes attaining UCVA of 20/40 or better, postoperative refractive error,
complication rates, enhancement/reoperation rates, and percent of eyes losing 1 or more lines of BSCVA.
Results: A total of 124 trainee and 108 faculty cases were identied. Trainee and faculty cases were comparable
in age, sex, mean age, mean follow-up, and baseline refractive error. At 1 month follow-up, UCVA of 20/25
or better was achieved in 71% of trainee and 79% of faculty cases (p=0.02), UCVA 20/20 or better attained
in 50% of trainee and 65% of faculty cases (p=0.01), and UCVA 20/40 or better achieved in 91% of trainee
and 94% of faculty cases (p=0.12). Residual refractive error was similar between groups. The incidence of
microkeratome complications and any observable epithelial ingrowth, diffuse lamellar keratitis, or microstriae,
regardless of clinical severity, was 36% in trainee vs. 27% in faculty cases (p = 0.02), but severe complications
(microkeratome-related and those requiring reoat) occurred only in trainee cases (4% vs. 0% in faculty cases).
Enhancement/reoperation was performed in 16% of trainee and 10% of faculty cases (p<0.01). One-line loss of
BSCVA occurred in 7% of trainee and 9% of faculty cases (NS); neither group lost 2 or more lines of BSCVA.
Conclusions: Patients undergoing LASIK by a resident or fellow were less likely to achieve 20/20 or 20/25
UCVA, more likely to experience postoperative complications, and more likely to require enhancement/
reoperation when compared to cases performed by fellowship-trained faculty. Residual refractive error and
frequency of loss of BSCVA was comparable between the groups. Patients should be appropriately counseled
on the outcomes of LASIK performed by trainees.
CR: M.M. Lai, None; P.K. Sangani, None; D.G. Hwang, None.
Support: Unrestricted grant from Research to Prevent Blindness

Epi-LASIK is Not Equal to Alcohol-Free LASEK

J.Dai, R.Chu, C.Chen, X.Zhou, J.Zou. Ophthalmology, Eye/ENT Hosp Aff Fudan Univ,
Shanghai, China.
Purpose: To analyze the difference in the histological ult rast r uct u re
of hu m a n c o r n e a l e pit h el i a l f l a p by E pi - L A SI K a n d L A SE K .
Methods: 6 eyes of 6 patients and 4 eyes in vitro were included in this study. Epithelial ap
was obtained by Epi-LASIK method using rotational epikeratome (Made in China) in 3
eyes of 3 patients and 2 eyes in vitro. And epithelial ap was created by LASEK technique
in the other 5 eyes using 20% alcohol for 20 seconds. All specimens were assessed by light
and electron microscopy, and the histological difference of the two methods was compared.
Results: Epithelial aps were created smoothly in all the 5 eyes of mechanical method
and in 4 eyes of alcohol-assisted method. Epithelial ap was not intact in 1 eye. Light
microscopic examination showed most of the basal border of the Epi-LASIK epithelial ap
was continuous with occasional focal disruptions. There was no evident morphological
abnormalities. The alcohol-assisted epithelial ap had signicant interruption along the basal
border of the epithelium. Bowmans membrane and anterior stroma remained completely
intact in any specimen for both methods. Transmission electron microscopy showed that
most of the basement membrane of the mechanical epithelial ap was integrity. The lamina
densa, lamina lucida and the hemidesmosomes had normal morphology along most of
basement membrane. The basal cell showed normal ultrastructure. Most of the basement
membrane was abnormal in specimens obtained with alcohol-assisted separation. Most
lamina densa was absent and lamina lucida was interruption. The mitochondrion of basal
cell was swelling and crista was disruption. And part of basal cell membrane was damaged.
Conclusions: The cleavage plane of mechanically separated epithelial ap was underneath
the basement membrane. Most of the basement membrane was integrity and cell morphology
was normal. The cleavage plane of alcohol-assisted method was mostly between basal cell
membrane and basement membrane. Basement membrane and the basal cell morphology
were abnormal.
CR: J. Dai, None; R. Chu, None; C. Chen, None; X. Zhou, None; J. Zou, None.
Support: None.

4393 - B751

The Effect of LASIK on Post-Op Physical Pupil Size

J.R. Lewis1A, C.Ford1B, E.Herderick1C, A.M. Mahmoud1C, D.Castellano1A, R.G. Lembach1A,
P.Vinciguerra2, C.Roberts1A,3. AWilliam H. Havener Eye Center, BCollege of Medicine,
Biomedical Engineering, 1Ohio State University, Columbus, OH; 2Ophthalmology,
Istituto Clinico Humanitas, Milan, Italy; 3Biomedical Engineering, The Ohio State
University, Columbus, OH.
Purpose: To determine whether physical pupil size is affected by LASIK.
Methods: From a retrospective randomized study of 120 eyes of 60 patients, physical pupil
size was calculated using the formula physical pupil diameter (PP, in mm) = measured
pupil diameter (in mm)*(1-B) where B = anterior chamber depth (in meters)* central K (in
Diopters)/1.3375. The measured pupil under dark conditions (Zywave, Bausch&Lomb), mean
central K (Keratron Scout Optikon, Rome, Italy) and processed over central 3-mm region using
OSUCTT software (Mahmoud AM, et al. IOVS 2000;41:ARVO Abstract 3599) and anterior
chamber depth (Orbscan, Bausch&Lomb) were collected pre- and six-months post-LASIK.
Subjects were divided into two groups by different surgeon. Group A eyes were treated in pairs
by a Technolas 217A (Bausch&Lomb) and LADARVision 4000 (Autonomous) for each eye and
Group B eyes the Technolas 217A and the Star S3 (VISX). Analysis of variance (SAS) was used
to compare the mean difference in physical pupil size between the two groups post-LASIK.
Results: The mean difference in physical pupil diameter at 6 months post- versus
pre-LASIK for all subjects was 0.190.50mm and ANOVA confirmed that the
difference was signcantly non-zero (P>.01). ANOVA analysis of the mean difference
in postop PP for each group was 0.320.47 for Group A that was signicanly nonzero (P>.01) and 0.0540.50 for Group B that was not signicantly non-zero (P=.41).
Conclusions: The calculated mean physical pupil diameter signicantly increased following
LASIK across all eyes. The measured increased effect was observed in Group A (P>.01)
however not in Group B (P=.41).
CR: J.R. Lewis, None; C. Ford, None; E. Herderick, None; A.M. Mahmoud, None; D.
Castellano, None; R.G. Lembach, None; P. Vinciguerra, None; C. Roberts, Bausch&Lomb
F, C.
Support: Bausch&Lomb

Observations on Early Stage Healing Following a Wavefront-Guided PRK Refractive

K.Holliday, C.E. Campbell. Research & Development, VISX Inc, Santa Clara, CA.

Purpose: This paper reports early changes in the surface shape of two eyes of the same subject
following wavefront-guided PRK treatments for refractive error. The asymmetry of epithelial
recovery and the interaction between the uneven epithelium and the tear lm were closely observed.
Me t ho d s : Me a s u r e me nt s a r e r e p or t e d for c or ne a l t op og r aphy u si ng a
Hu mph rey Atlas device, wavef ront aber romet r y usi ng a V ISX WaveSca n
device, and cor neal and epithelial thick ness using a Haag-Streit Pachymeter.
Corneal topography measurements were begun four days after treatment, a few hours after the bandage
contact lens was removed, and were continued several times per week for seven weeks. The data
gathered by the topographer were analyzed by purpose-written MatLab programs that determined
the corneal shape changes both on a day-by-day basis and relative to the intended post-treatment
shape. During these examinations the mire images were used to observe post-blink changes in the
tear lm as the initially formed tear lm owed to even out underlying epithelial layer irregularities.
Wavefront aberrometry and corneal and epithelial thickness measurements were used as complements
to the corneal topography measurements to construct an overall picture of the shape of the surface
of the eye. Changes on the order of microns could be observed so that day-to-day variation of
the surface shape could be distinguished, especially during the very early stages of recovery.
Results: The tear film can replicate a very irregular underlying surface, but between
blinks the lm changes to smooth its own surface. The epithelial layer initially thickens
preferentially in the nasal and temporal periphery so that astigmatism is induced.
Differential epithelial thickening took place primarily in a brief period between the 6 th and
8th days post-operatively. The differential peripheral thickening was of the order of 3-4 m.
Conclusions: By combining corneal topography, wavefront aberrometry and pachymetry the early
stage recovery of the surface of the eye following PRK surgery can be followed with high resolution
allowing day-to-day changes to be mapped and the dynamics of the tear lm to be studied.
CR: K. Holliday, VISX, Incorporated E; C.E. Campbell, VISX, Incorporated C.
Support: None.

4394 - B752

Refractive Results After LASIK With Esiris Excimer Laser - Investigation of the Flap
Thickness of 140 m compared to 160 m
G.Unger, D.Sandner, D.Langner, T.Baier, M.Kohlhaas, L.E. Pillunat. Ophthalmology,
University Eye Clinic, Dresden, Germany.
Purpose: To avoid an iatrogene Keratectasie after LASIK the remaining thickness of
the stroma has to be 250 m. In cases that need higher corrections and have a primary
smaller corneal thickness a thinner ap is desired to to keep more stroma for ablation.
inf luence
f lap
thick ness
f unctionell
ref ract ive
i nvest igated.
Methods: During the period from 03/04 to 06/04 14 eyes of 7 patients (mean age of 32 years) was
performed in LASIK with the Esiris Excimer Laser. The Amadeus microceratom was used to cut
the ap. 0n the right eyes a ap thickness of 160m were chosen on the partner eyes one of 140m.
The preoperative mean spherical equivalent was -5.35 D (SD 2,22 D; -8,25 D to
-2,0 D) in the 140m ap thickness group vs -4,94 D (SD -2,43 D; -8,75 D to 1.75 D) in the 160m ap thickness group. All treatments were realized to same
standards and were nished succesfully. Postoperative complications didnt occur.
Results: With both aps a slight undercorrection could be observed which stayed stable during
follow-up. There was no signicant difference between both groups (-0,63D vs -0,67D). In
comparison, in 55% (vs 67%) visual acuity remained the same, in 18% (vs 17%) visual acuity
improved by one line and in 27% (vs 17%) there was a reduction of best corrected visual
acuity by one line in eyes treated with a 140m (vs 160m). 69% of the eyes in the 160 m
ap-group showed a uncorrected visual acuity of 0,8 or better vs 85% in the 140m ap-group.
Conclusions: There is no increase in complications while performing LASIK with a ap
thickness of 140m. Occurance of corneal striae was not observed more often with 140m
aps. In tendency, the risk for a reduction in visual acuity is slightly lower with a ap thickness
of 160m, but the chance of an improvement in visual acuity and of reaching a best corrected
visual acuity of 0,8 or better is higher with a ap thickness of 140m.
CR: G. Unger, None; D. Sandner, None; D. Langner, None; T. Baier, None; M. Kohlhaas,
None; L.E. Pillunat, None.
Support: None.

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.

Wednesday, May 4, 8:30 AM - 10:15 AM Hall B/C Poster Session Program Number/Board # Range: 4335-4395 / B693-B753
454. Refractive Surgery Organizing Section: CO
4395 - B753

Comparison of Outcomes With and Without Use of an Automatic Centration Feature

S.T. Awwad, J.P. McCulley. Ophthalmology, UT Southwestern Med Ctr-Dallas, Dallas,
Pur pose: To compare the clinical outcomes of LASIK patients who
underwent wavefront-guided ablation who were treated with the use of autocentration software on the LADARWave aberrometer to those treated without.
Methods: Prospective study in university based keratorefractive center with retrospective
comparison. Results: Prospective clinical outcomes from LASIK patients treated with
CustomCornea incorporating the new auto-centration feature on the LADARWave
aberrometer were compared to a retrospective cohort of LASIK patients treated with
CustomCornea prior to implementation of the new software feature. Standard outcome
measures were compared between groups. In addition, preoperative and postoperative dilated
wavefront measurements were used to compare aberrations for 25 patients in each group.
Conclusions: The use of auto-centration features during CustomCornea treatment has
been shown theoretically to improve the accuracy of wavefront registration, and in this
study suggest that patient outcomes will be superior. Wavefront capture efciency was also
greatly enhanced.
CR: S.T. Awwad, Alcon R; J.P. McCulley, Alcon F, C, R.
Support: Research to Prevent blindness RPB

Copyright 2005 by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. For permission to reproduce any abstract, contact the ARVO Ofce at
Commercial Relationships are noted at the end of each abstract by None or with codes.