Subtitled ‘ From glasses to corneal grafts – and everything in between’, you can purchase a copy of it by clicking here. All proceeds go directly to research on keratoconus at the University of Sydney.

All proceeds from purchase of the book will go directly to the Sydney Eye Hospital Foundation; Keratoconus Research Fund). To purchase of copy of the book, click here.

 Recently, a number of the US Olympic team competitors have joined the elite laser eye surgery club too, including a speed skater, bob sledder, cyclist, hockey player and a luge specialist.

 No doubt all of them would experience a real difference after the surgery, but the words of Danny Watts, a regular driver in the Le Mans 24 hour race and many other endurance events provides a real insight into his own experience. “When I was racing ( before surgery), I squinted a lot which gave me headaches over a period of time…now, the squinting is no longer, I can concentrate for longer and, above all, my lap times are a lot faster and I’m a lot safer”, he claimed.

 ”When I was back in the car (after treatment), I drove out onto the circuit and suddenly I could see all the sponsors boards, the marshals all waving their flags…it’s made a phenomenal difference to my eye sight,” said Danny.  

 While quality of vision is obviously absolutely critical for top sports stars, for many of them, the ability to avoid wearing glasses or contacts, is equally important. Whether you’re serious about sport, an amateur, or just enjoy an active lifestyle, the many advanced laser options now available are becoming an attractive alternative for people who are demanding high performance vision to enhance their abilities.

 If this sounds like a good option for you, it’s important to recognise that not everyone is suitable for laser vision correction. And, if you are a suitable candidate, it’s very important to allow the recommended time to fully recover after treatment before you start playing sport again. While your eyesight might be transformed almost immediately, it naturally takes time before you can enjoy the rough and tumble of really aggressive sports like martial arts, soccer, or rugby. So, make sure you ask your surgeon the allowable time before you can push 100% again. 

Until intraocular lenses, 'coke bottle glasses' were needed to see.

It wasn’t up until the 1960s, when scientists developed a synthetic lens made of Perspex called the IOL (intraocular lens). The discovery was stumbled upon merely by chance, and is quite a fascinating story. Sir Harold Ridley, a British doctor, was on a mission to find a suitable material for a replacement lens, after being asked by one of his students as to why surgeons never replaced the extracted lens during cataract surgery. After trialling different materials, he found that all of them were being heavily rejected by the human body’s natural defence mechanisms.

He then began to pay attention to soldiers with eye injuries from shattered vehicle windshields. What he found was that  the soldier’s eyes were not rejecting the shattered perspex, hence making the material the perfect candidate for the manufacture of the very first IOL.

This became a medical milestone in the treatment of cataracts and is still one of the most common ways to have cataract surgery performed. With the help of the IOL, doctors were not only able to extract the cataract, but they now had the ability to completely replace the clouded-up layer with the plastic lens. This rendered those awful, thick-rimmed glasses obsolete, and the need for stitches was a thing of the past. In fact, since the advent of the IOL, cataract surgery has been reduced to a simple procedure that takes a professional ophthalmologist under 30 minutes to complete.

Ultrasound and Lasers

More recent technological advancements brought about the development of laser technology (femtosecond lasers, LASIK), and this has provided doctors with even more precision and accuracy in the extraction of cataracts.

Charles Kelman was directly responsible for pioneering a small-incision, cataract operation called phacoemulsification.  It works on the same premise as IOL, however the cataract is broken into tiny pieces using ultrasonic waves. This allows for a much smaller incision – reducing healing times and also patient discomfort. In the past, standard cataract surgery patients have had to spend around 10 days in the hospital, with a recovery period of up to several months.

Kelman’s discovery was an interesting one, as it was inspired by a trip to the dentist. As he was in his dentist chair having his teeth cleaned, he was intrigued by an instrument that his dentist was using. Kelman noticed a layer of mist emanating from what looked like a drill, except the tip of the instrument did not move. When applied to his teeth, it vibrated and made a high-pitched noise. Fascinated by it, he asked the doctor about the instrument – to which the doctor explained that it was an ultrasonic probe. Kelman knew immediately that this technology had the potential to revolutionize cataract surgery.

After years of extensive research, conducting phacoemulsification on cat eyes, the first patient was treated with it in 1967. Conventional doctors were astounded by the fact that Kelman was discharging his patients on the same day as the surgery and that they were fit to go to work the next day. Today, phacoemulsification is the most common and one of the safest options in ophthalmic surgery.

Overview

Cataract surgery has come a long way since its inception in India. In place of needles, butter and breast milk – today’s doctors are now equipped with intraocular lenses and advanced laser technology. Most would also be happy to know that the days of administering cocaine and blows to patients heads are long-gone. Due to the marvelous technology out there, we have seen the realm of ophthalmic surgery revolutionized – and is now as safe, quick and painless as it ever was. Providing the eye is healthy, an impressive 99% of cataract surgery patients will have a positive result with today’s professional doctors.

One particular treatment that this now well established  is Laser-Assisted-Epithelial Keratomileusis, also referred to as LASIK. It works extremely well to correct astigmatism, long-sightedness and short sightedness. Once the procedure is carried out, it can potentially remove the person’s need for contacts or reading glasses. Those over forty five  years of age may still be required to wear them in some circumstances (such as in darkly lit rooms), as the eye’s natural lens won’t be able to focus quickly enough between near and distant objects.

First performed by Ianni Pallikaris in Greece in 1998, LASIK surgery is now a commonplace procedure all over the world. ( Picture of me and Ianni Pallikaris can be inserted here.  The treatment has been refined over the last 15 years  and usually does not take more than half an hour to complete.

The first step of the procedure is to administer anaesthetic drops to the eye, to sedate the eye and minimize discomfort. There are two stages to the procedure in the first a femtosecond laser is used to create a potential flap. In the second aprt of the procedure the flap is carefullty retracted a And a second laser, an excimer laser delivers mputer-controlled pulses of blue light onto the surface of the cornea, reshaping its outer layer.

As soon as the laser has been switched off, the surface area of the cornea’s outer layer is restored to its original position. Once the anaesthetic wears off this may result in a little discomfort,  This usually lasts for 2-4 hours onlyWhile it remains a popular treatment, LASIK is not suitable for everyone and people should seek professional advice from one of our ophthalmologists. Book an appointment with one of our specialists today to find out if LASIK is right for you.

 This year the guest lecturer was Professor Mark Terry from Portland Oregan USA who is a pioneer in endokeratoplasty, the preferred surgical technique for endothelial diseases such as Fuch’s dystrophy and pseudophakic bullous keratopathy. He was an engaging and generous speaker who provided an update on current surgical techniques and clinical outcomes. His key point was that the surgical techniques and outcomes were improving rapidly. The use of an automated machine to prepare the corneal button (DSAEK) was superior to manual preparation of tissue (DSEK) but the newest, and still investigational, technique (DMEK) which involves to thinnest transplantation of tissue was superior still. Unfortunately, the complication rate associated with this latest development has presented wide-spread uptake amongst surgeons around the world, many of whom believe that the failure rate and the loss of corneal tissue is too high at present. I believe that this technique is the future, however, as the rejection rates in these early series is much lower than with traditional transplanting techniques.

 The Department of Ophthalmology, Auckland University hosted the meeting and the basic research from the Department was really quite amazing. Professor Trevor Sherwin and colleagues presented novel results in the culture of corneal stromal cells with a view to inserting them into patients with keratoconus to “strengthen” the cornea. Professor Nick Di Girolamo from the University of New South Wales summarized his pioneering work in limbal epithelial stem cells and Associate Professor Mark Daniel summarized the CERA, Melbourne University’s work on endothelial stem cell culture.

 Professor Kerryn Williams provided her annual report on the Australian Corneal Graft Registry based at Flinder’s University. Despite a move amongst Australian Corneal surgeons towards lamellar corneal procedures, visual outcomes have yet to surpass those of traditional penetrating keratoplasty (full thickness transplantation).

 One session of the conference was devoted to Ethics. I was asked to host a round table discussion looking at ethical situations in eyebanking. Our guests included Associate Professor Martin Wilkinson and Professor Ron Patterson, both experts in ethics and health. It was a vibrant and lively debate on a number of topics including directed organ transplantation and a family’s right to veto the wishes of the deceased. It was Hannah Arendt who said, “Truth comes from arguments amongst friends.”

 Overall it was an absorbing two days and I would strongly encourage anyone with an interest in any aspect of corneal disease or research to attend next March when the meeting will be held in Adelaide.

Lasik eye surgery will be a 2 step process which involves the generation of a slim flap in the cornea (front surface of the eye) and elimination of a tiny level of tissue from inside the cornea. Lasik eye surgery results in the corneal form necessary to offer crystal clear vision without glasses or contacts. The corneal flap is usually created with a blade known as the micro-keratome. This flap is normally made using the most up to date laser named IntraLase®. The IntraLase® laser, having its micron level accuracy and reliability, generates the flap with the laser beam with virtually no cutting. There are a lot of alternatives available with our doctors, so there can be some variation in approaches and products employed. Your actual laser eye treatment is going to be explained to you at length included in your consultation process. The process outlined below is provided as a general guide only.

Description of the process

The Laser eye treatment method takes about 15 minutes for each eye. Your cornea is anaesthetised using eye drops. Your surgeon administers anaesthetic eye drops, and then uses an instrument known as a lid speculum to keep you from blinking. A corneal flap is established. The flap is comprised of a thin layer of surface corneal tissue. The flap is carefully hinged again over the cornea so as to expose the corneal ‘bed’. The corneal bed is re-shaped.

Your laser eye surgeon uses an Excimer laser in order to re-contour the corneal bed specifically to your particular prescription needs. The laser uses an ultraviolet light beam to specifically vaporise a pre- determined quantity of tissue throughout the cornea. The corneal flap is re-positioned. No stitches are needed because the eye offers natural suction capability that holds the flap in place. Anti-biotic and anti- inflammatory eye drops are usually used. An eye shield is applied to guard the eye while it is healing. Both eyes can usually be treated on the same day.

Post-op visual recuperation

People can resume many routines on the day after laser vision correction, the reason being the smoothness of the corneal surface is only minimally disrupted through the eye laser treatment.

Post-op comfort and ease

The eyes should feel fairly comfortable the day after LASIK. This is because the topmost layer of the cornea is only minimally disturbed in the surgery.

Dr Chauhan (second from left) and the Vision Eye Institute team

Vision Eye Institute is pleased to announce a partnership with the Australian chapters of Rotary International. Our combined mission – to fight the progress of macular degeneration by ensuring that as many people as possible over the age of 50 self-test using an Amsler Grid. (The sooner macular degeneration is detected, the better chance there is to slow the progress of the disease).

Our partnership was officially launched at the District 9790 Conference on 23rd March. Our stand at the Rotary District 9790 Conference (pictured left) was particularly successful. Amsler Grids were handed out, along with information about macular degeneration, while the fruit and vegetable box served as a reminder to all attendees that a diet high in leafy greens and other brightly colours fruit and vegetables play an important part in eye health (as does quitting smoking). The highlight of the Conference was a lecture to over 700 Rotarians Dr Devinder Chauhan, retinal specialist at Vision Eye Institute in Melbourne.

 Distribution of the Amsler Grids is being undertaken at Craft and Sewing Shows around the country, with the first ones held from 8th-11th March in Brisbane, and on 22nd-25th March in Sydney. Promotion at Craft and Sewing Shows continues throughout 2012 in Melbourne, Townsville, and Newcastle. on Thursday 8th March at the annual Sydney Craft and Sewing Show, where Vision Eye Institute and Rotary staff joined forces to educate Australians on macular degeneration.

To date nearly 45,000 co-branded Amsler Grids have been distributed at these Expos, Shows and Conferences, and a number of the Rotary Clubs in District 9790 have expressed an interest in providing education sessions at the local level.

Gerard Sutton chose a career in ophthamology over cardiology because operations on eye patients have a high success rate. “I originally wanted to become a neurologist of cardiologist but in those fields people don’t always get better,” he said.

The Mosman doctor has practised surgical ophthamology for 16 years, specialising in procedures such as laser surgery and corneal transplants.

He said there had been a number of breakthroughs in treatments for eye conditions, including keyhole surgery, since he trained at Sydney Eye Hospital almost 20 years ago. “There was no laser eye surgery back then and patients needed to lie in hospital for days allowing cataract surgery – now they’re in and out with keyhole techniques.”

Dr Sutton was recently appointed the first Sydney Medical School Foundation professor of corneal and refractive surgery at the University of Sydney. The position will allow him to teach medicine students theory and also instruct them in surgical practices two days a week.

He will spend the rest of his time working at the Vision Eye Institute in Chatswood and at his Cremorne practice. “It’s exciting, it combines all the elements of opthamology that I love: clinical research, teaching and performing eye surgery,” he said.

The surgical professorshop will also allow Dr Sutton to run the keratoconus research program to find a cure for the “cone-shaped cornea” which causes nearsightedness and astigmatism over time.

“The causes of keratoconus are still unknown – hopefully we’ll get closer to finding that out through the program,” he said.

Dr Sutton was the first Australian to complete a refractive fellowship overseas, where he studied at Moorfields Eye Hospital and St Thomas Hospital in the UK, and Erlangen University Hospital in Germany.

Patients and Methods

A retrospective chart analysis of the fi rst 1000 consecutive LASIK procedures utilizing the IntraLase femtosecond laser by a single surgeon was reviewed. Outcome measures included intraoperative complications such as partial or incomplete fl aps, epithelial defects, and irregular or decentered caps. Epithelial defects were deemed as signifi cant when a bandage contact lens was required. Postoperative cap slippage requiring repositioning and later adverse events such as diffuse lamellar keratitis (DLK), epithelial ingrowth, and infection were recorded.

A single surgeon (G.S.) using the IntraLase femtosecond laser performed all surgical procedures. Eight hundred thirtyeight eyes were operated with the 15-KHz laser, and 162 eyes were operated using the 30-KHz version. The initial IntraLase procedure was performed in October 2004 and the fi nal procedure was performed in January 2006. The corneal ablations were performed with the LADARVision 6000 platform (Alcon Laboratories, Ft Worth, Tex

Prior to IntraLase

Prior to the IntraLase procedure, a single drop of Minims oxybuprocaine hydrochloride 0.4% (Chauvin Pharmaceuticals, London, United Kingdom) was applied to the operated eye. No speculum was used. A separate suction ring and applanation cone were used for each eye. The surgical technique was a modified version of the soft docking technique, whereby the clip on the suction cup was locked at the time of applanation. Applanation was centered on the cornea and the applanation pressure was increased until the meniscus fell outside the virtual flap profile. In all cases, the attempted fl ap diameter was 9.2 mm. Subsequent adjustments to the centration of the fl ap resulted in some caps being smaller, but all caps were between 8.9 and 9.2 mm. The average flap diameter for the 15-KHz cohort was 9.040.13 mm compared to 9.140.09 mm for the 30-KHz group. The difference in fl ap size was statistically significant (P=.000) although it may be due to increasing surgical experience and comfort with centration procedures than a function of the upgraded unit. In no case was there any loss of suction, and no cases were aborted or deferred. Both caps were created 15 minutes prior to lifting the fl ap to allow settling of any opaque bubble layer. No change to technique was made between the 15- and 30-KHz units.

 A subgroup of 260 eyes was prospectively analyzed to assess the predictability of flap thickness. The subgroup was composed of 119 and 141 eyes treated with the 15-KHz and the 30-KHz laser, respectively. The intended fl ap thickness for all patients undergoing the procedure using the 15-KHz and 30-KHz laser was 105 and 115 μm, respectively. The intended flap thickness used for both units was according to the manufacturer recommendations and was not changed throughout the review period. Energy settings for both units were different; however, they also remained consistent throughout the study period. The energy settings for each unit are shown in Table 1. Flap thickness was derived by subtraction pachymetry. Intraoperative corneal thickness was performed utilizing ultrasound pachymetry (Corneo-Gage Plus; Sonogage, Cleveland,Ohio), and the lowest of three readings was taken ensuring there was no indentation. Immediately after flap elevation, central stromal bed thickness was again calculated using a mean of three central readings to ensure minimal tissue compression. These data were analyzed for correlation with preoperative corneal thickness, keratometry, and order of surgery. The pachymetry readings and refractive results were analyzed using Pearson correlation statistics. T tests were used to compare differences in fl ap thickness between the first and second eyes. A P value .05 was considered to be statistically signifi cant. The statistical program used was SPSS V13.0 (SPSS Inc, Chicago, Ill).

No sight-threatening intra- or postoperative complications were seen. Three (0.3%) patients had epithelial defects requiring a bandage contact lens. Four (0.4%) patients had slipped caps on day 1 that required repositioning. Two (0.2%) patients developed grade I DLK. No patient developed DLK grade II, epithelial ingrowth 1 mm from the flap edge, or transient light sensitivity. No infections were noted. Table 2 shows the IntraLase flap complications noted in this study. With an attempted fl ap thickness of 105 μm using the 15-KHz laser, the mean fl ap thickness was116.7910.75 μm (range: 95 to 148 μm). In the 30-KHz group, the attempted corneal flap thickness was 115 μm, and mean fl ap thickness was 114.029.82 μm (range: 93 to 163 μm). Table 3 presents the mean SD and range of patient keratometry, preoperative Orbscan, and ultrasound pachymetry and fl ap thickness for the 15-KHz and 30-KHz units, respectively. In flaps created with the 15-KHz laser, 79.2% were within 20μm of the intended depth whereas 98.6% of caps created with the 30-KHz laser were within this range. The Figure shows the difference in fl ap thickness from the intended target. No signifi cant correlation in either group between keratometry and fl ap thickness, and preoperative pachymetry and flap thickness (r=0.002 and 0.073, respectively; P=.973 and .241, respectively) was noted. T test analyses revealed no statistically signifi cant difference between fl ap thickness and the order on which the eyes were operated for either unit. Table 4 indicates the mean SD fl ap thickness for the first and second eyes for the 15-KHz and 30-KHz units. The final safety measure analyzed was loss of BSCVA. Although 8.52% of patients lost one line of BSCVA at 3 months, no eye lost 2 lines, which is the standard measure of procedure safety.

Discussion

A number of clinical case series of LASIK results utilizing the IntraLase femtosecond laser have been reported. With the exception of Binder et al,8 the literature reports relatively small case series, and those that made a comparison with mechanical microkeratomes differed as to whether IntraLase provides a clear benefit in terms of safety and predictability. This study of a significant number of consecutive cases performed by a single surgeon without proprietary interest in any of the devices used supports the evidence that the IntraLase femtosecond laser is a safe and effective method for cap creation in LASIK. Flap thickness has been an important measure of LASIK safety because of the importance of stromal preservation. Mechanical microkeratomes characteristically demonstrate a standard deviation of between 18 and 24 μm.13-17 In 2005, Duffy et al18 published a LASIK case series using the Moria SK1 in which the mean flap thickness was 107 μm, and they had a stringent standard deviation of 14 μm. In a comparative study by Kezirian and Stonecipher,12 the flap thickness was 11414 μm with the IntraLase, and 15326 μm utilizing the Carriazo-Barraquer microkeratome (Moria, Antony, France) and 15629 μm with the Hansatome microkeratome (Bausch & Lomb Inc, Rochester,NY). In Binder’s series of 1000 consecutive caps,8 the standard deviation varied from 10.2 to 21.7 μm. Previous studies have demonstrated a signifi cant difference in flap thickness between the fi rst and second eyes among various microkeratomes, which was attributed to repeated blade use. Our results, however, show no difference in fl ap thickness between eyes. It adds further support to the reproducible nature of the IntraLase system.

 The predictability of flap thickness in our series is similar to others using the IntraLase femtosecond laser, and compares favorably with all studies utilizing a mechanical microkeratome. In this study, 79.2% of patients treated with the 15-KHz had a corneal flap within 20 μm of intended, which was increased to 98.6% with the 30-KHz laser. It is not possible to conclude this difference is purely due to the increased translational speed of the 30-KHz unit. Although both groups were analyzed prospectively, this was not a randomized study, and the 30-KHz group was treated when the upgrade became available from the IntraLase Corporation. It is possible that the increased predictability of fl ap thickness relates to an improvement in the surgical skill of the surgeon. It should also be noted that individual lasers behave differently, and monitoring of the fl ap thickness allows optimization of the laser functions. An attempt was always made to have the meniscus outside the virtual cap, but to see the meniscus so that it was not totally excluded. The theory behind this technique was to ensure repeatability of the applied corneal thickness, which may have an impact on actual corneal flap thickness.

 Conclusions

The intraoperative complication rate in this series is low. There were no buttonholes, partial flaps, loss of suction mandating cessation of treatment, nor was any patient unable to have the flap elevated. In the early stages, adjustments were made to the bed and sidecut energy to facilitate flap elevation, and subsequent changes were made when the upgrade to the 30-KHz translational speed occurred. The only intraoperative complication was three epithelial defects that required contact lenses. None of these patients lost BSCVA, nor was there any significant inflammation or epithelial ingrowth. On postoperative day 1, four patients had evidence of flap slippage that required repositioning. Three of the four cases occurred in the first 200 operated. Throughout the first 200 cases, phenylephrine 10% was used to assist tracking the patient with the excimer laser. Binder8 suggested a link between neosynephrine and reduced endothelial pump function leading to possible flap slippage and as a result, the phenylephrine was stopped. However, increased surgical experience and a longer period of fl ap drying following repositioning may also have led to the subsequent reduction in the rate of flap slippage. Two cases of grade I DLK occurred early in the 30-KHz series, but no case of grade II or greater was noted. No evidence of epithelial ingrowth or infection was seen. In contrast to previous reports, there were no cases of transient light sensitivity. Stonecipher reported an incidence of transient
light sensitivity of 1.1%. They also noted that when the raster and side-cut energy settings were lowered there was a significant reduction in the incidence of transient light sensitivity. The lack of transient light sensitivity in our series may represent appropriate energy settings but the limitations of a retrospective review preclude an absolute exclusion of this adverse event. Stonecipher noted a reduction in the incidence of transient light sensitivity with reduced pulse
energizer. The IntraLase femtosecond laser is an effective method to create flaps in LASIK surgery that are of predictable thickness. It is also associated with a low rate of intra- and postoperative complications. Surgical technique is important in minimizing these adverse effects.