I have several questions. Any answers to these questions would be very much appreciated.

1. Isn't it true that the FDA is rather slow in approving new technologies, and if wavefront or custom lasik is a significant advancement, as some suggest, would it be worth going to Canada for this rather than waiting until it is available in the USA? I understand that this is available in Canada right now in fact.

2. Assuming wavefront lasik is a significant improvement, and that it will be available within a couple of years in the USA, and that treatment in the USA is desired, would it be best to wait or to have standard lasik performed now, with the hope of getting a wavefront enhancement when it is available? I understand that healing will still be a significant variable, but doesn't it make sense to use the most advanced technology for the first attempt at vision correction with lasik surgery? It seems that using such advanced technology the first time would also decrease the chances of needing an enhancement. Also, would there be any problems or difficulties getting an enhancement using wavefront technology a year or two after having the standard procedure performed?

3. When will it be known as to how significant of an advancement wavefront lasik will be? I understand that the first wavefront lasik procedure performed in the world was in July of 1999. Since then it has been performed in Europe, Canada, and even some early trials in the USA. If this is truly a big step forward it would be extremely helpful to find this out right away so those considering treatment could make an intelligent decision as to whether or not to wait for it or whether or not to travel for this procedure now. I do not know where to go to find any published data on wavefront lasik that would help me answer this question. From a theoretical point of view, it seems that there are only advantages to this new technology, no disadvantages at all, other than cost. Are there any potential problems with wavefront lasik that one should be wary of? Will wavefront lasik reduce the chances of loosing best corrected vision on the first surgery attempt as well as for enhancements? I have heard that it yields better night vision results also, is this correct?

4. This is a general question about laser equipment that is currently available. Is there any data available that suggests that any one type of laser is better than any other? I understand that larger treatment zones are needed for patients with large pupils, and that this may require the use of a certain laser. However I am interested in the differences in laser results with the treatment diameter variable removed from the equation. For example, do the eye tracking lasers such as the Autonomous Ladar Vision, give better results than Visx Star2, given the same treatment diameter? Does the Visx Star2 with Smooth Scan produce a smoother ablation and therefore better healing, than spot scanning lasers? Does the Visx Star2 remove significantly less corneal thickness for the same treatment diameter and treatment result, compared to spot scanning lasers? How does the Bausch and Lomb Technolas 217 laser compare? I understand that refractive eye surgery is an industry with many competing technologies and also many competing organizations and doctors. However with eyesight being so incredibly precious to all of us, is there some way to cut through all the noise, so to speak, to find out what is really best, without having to wait years for the answers to finally become apparent? If I were the world's richest man, I would encourage doctors all over the world to submit data on all this, I would then publish the results, and reward everyone for participating. It seems that this would shorten the development time considerably, and benefit people all over the world. The current process must do this in some less efficient way, through publications in medical journals, through medical conferences, and through clinical trials monitored by regulatory agencies, and so forth. Can you comment on how the current process works, and how the best technologies are discovered?

5. Do you have any suggestions for how to find general statistical data on lasik that would help one in understanding the risks that are involved?

I realize that these are extremely detailed questions, and that they will probably be difficult to answer. Please understand that it is extremely important to me that I make the right choices for my surgical vision correction. I think the answers to these questions would also help many others who are interested in obtaining the best possible results. My prescription is about -6.00 with just slight astigmatism. I would be extremely happy with 20/20 or better vision in each eye with good night vision as well, and no significant loss of best corrected vision. I am currently correctable with eyeglasses to better than 20/20 in each eye. Thank you in advance for any replies to these questions.

John One of the best sources of information on Wavefront is www.asclepion.com . Asclepion-Meditec manufactures the Mel 70 laser in Germany and appears to be the leader in the wavefront race. A number of people have had wavefront guided lasik surgery with spectacular results. The company manufacturing the Wavelight laser in Germany were the first to report results for about ten people,about 6 of the 10 accheived vision ranging from 20/15 to 20/8. Dr. D. Dausch presented the results of Asclepion-Meditecs first 20 people treated with their wavefront system which they call WASCA in Boston at the last wavefront conference. According to the information I have gathered about 20% of the general population can benefit greatly from wavefront guided custom ablation. It appears for the first trial done by Asclepion they used their new wavefront diagnostic system called WACS to test people and determine who could benefit from wavefront guided custom ablation. The WACS system can generate your wavefront supported optical correction which can then be cut into a lense with the Mel 70 laser and placed in the WACS spectacles so that you can actualy see what your wavefront corrected vision is like. Asclepion appears to have selected 20 people with WACS and treated them with WASCA (wavefront). The results where spectacular 19 of the twenty people acheived better than 20/20 vision most around the 20/10 mark with 2 acheiving 20/8 and one acheiving 20/6. Dr. Mitchell at is the first Dr. in north America I know of to receive Asclepions system and I look forward to learning how this works out in the real world. Dr. Mitchell is taking general questions at www.surgicaleyes.com under lasik new technology's if you would care to quiz him.

Merlin,

Thank you very much for the reply. I could not get into the message board for a while, and that is the reason for the late reply. The results that you mention imply that there is indeed a significant improvement with the wavefront approach. One question that comes to mind is whether or not wavefront custom ablation is better for everyone, or whether it is advised just for people with irregular astigmatism and so forth. It seems that it would be better for everyone, but would tend to greatly benefit those who have vision that is correctable to 20/20 at this time. It would be great to be able to see the hard data results for all the wavefront procedures that have been done so far. Another difficult question it seems is how much the unpredictable healing of the human eye is a factor in all this. Maybe this effect dimishes the results on the first attempt to some extent, but one would think that it would work very well for an enhancement procedure since any irregular healing could be dealt with. I looked at the website for Asclepion and found it to be very interesting. Thanks for all the info on this. I will look into it some more. It seems that treatment with the Mel 70 laser for custom ablation is not yet available, unless one could participate in a clinical study. Another question I am wondering about now is Lasik vs PRK. I am wondering if the flap heals with sufficient strength or if it is a permanent weakness in the eye. I spoke with one gentleman who had PRK and he thinks that although the healing takes longer with PRK, it is worth it because the cornea is much stronger. He also argues that it is a safer procedure with less that can go wrong. Interesting thoughts on this. I noticed that Dr. Trattler also responded to my message, so I will present these questions to him as well.

Regards,

John

I think the issue with wavefront is that it is a very exciting technology - but it will be a while
(probably 1-3 years - or more) before wavefront will be optimized.
Wavefront is a technology that allows the surgeon and the laser to precisely measure the optical aberrations of the eye. There are 4-5 different wavefront measuring devices that have now been developed, each using slightly different technologies. It seems that each of the laser companies have teamed up with one of these wavefront companies - so we will have to wait to see which wavefront device is best.
The next steps required are to be able to take the eavefront measurements and feed them into the excimer laser computer. Then the computer has to be able to precisely treat the cornea using the wavefront measurements. This step has now been set up on a number of systems.
Now the dificulties are figuring out the healing process and figuring out the exact way to precisely deliver the laser treatment to the eye so that the treatment stays. For example - the laser may be able to precisely shape the cornea - but the surgeon must also take into consideration the healing process, which varies based on the level of myopia treated. Plus, the healing process can vary based on a person's age, ethnicity, corneal thcikness (potentially), and the type of post-operative medications used. This is why it is important for surgeons to carefully analyze everything before jumping into "wavefront".
For example - Dr. Margarette McDonald in New Orleans has performed wavefront LASIK. In her first set of LASIK eyes, I believe that she did not find much of a difference between the eyes that had wavefront versus the eyes that had regular LASIK. She has adjusted her nomogram, but even her more recent series of cases has shown that although wavefront LASIK can perform a very nice treatment - that some patients preferred their "regular" LASIK eye. I believe that with time, the "kinks" will be worked out, and wavefront will help optimnize our LASIK results.
Now - lets get to some of your questions. The first key is that the results with lasers clearly show that the surgeon is more important than the type of laser used. The current generation of lasers provide very nice treatments. The key is finding a fantastic surgeon - who will not only provide a beautiful surgery, but will also be available during the critical post-op period. In my experience, it is the post-op period that is a major determining factor as to the success of LASIK.
I will be happy to elaborate on this if you have specific questions.
Obviously, you have a number of options - you can have LASIK now, or wait. LASIK in the year 2000 with an experienced surgeon can provide excellent results. However, as with most things in life, one can not guarantee a perfect result, because there are risks with LASIK (infection, inflammation, flap problems, etc).
I have tried to answer your questions - and I will be happy to further clarify or answer any more questions that you might have.

Best of luck

Bill Trattler, MD
Miami, FL

Dr. Trattler,

Thank you very much for the reply. I could not get into the message boards for a while and this is the reason for the late reply to your message.

As to the quality of the results that have been obtained with wavefront lasik, for me at least, any sort of hard data such as published trial results would help a great deal. I am guessing that the laser manufacturers are not interested in publishing any data on this yet. However, please let me know if you know of any data that is available that I could look at. There must be a lot of data at this point since they have been doing trials for over a year now with wavefront lasik. I understand what you are saying about the process of developing the nomogram, however, I wonder what could be so different as compared with standard lasik (performed on an average patient, using flying spot laser) as far as healing is concerned, given the same procedure with the flap and basically the same laser being used. If wavefront lasik will be yielding much better results, then I guess the law of supply and demand will take over at some point and there will be higher fee charged for it, which I think would be appropriate. There is also the question of whether or not wavefront lasik tends to improve night vision, I am curious if you have any thoughts on this.

You mentioned the importance of having a top quality surgeon for lasik. I have heard this argument from many sources and have no question about that. However, I am starting to question whether or not PRK would be better for me than a Lasik procedure. Perhaps you can comment on this. I understand that most doctors and patients currently prefer lasik and probably will continue to do so since the recovery time is much quicker (e.g. the "Wow" effect). However, it concerns me that doctors can lift the flap several months or even a year or more later on for enhancement procedures. Doesn't this mean that the structural integrity of the cornea has been compromised to some extent? And if so, isn't this decreased structural integrity permanent to some extent? It seems that the flap heals around the edges, but does not become bonded, so to speak, to the corneal material underneath the flap. Also, with PRK, it would seem that there would be more corneal thickness available for enhancement procedures, since the flap thickness has to be ignored for the enhancement calculations. And, there would be no risk of flap complications, and less risk with regards to the experience of the surgeon, and follow up care (other than the risk of infection, which is perhaps the same). To put it simply, I am wondering if PRK is the safer way to go for anyone that is willing to put up with temporary (i.e. 1 to 3 months) inconvenience in exchange for a better, healthier result, and lower overall risk to the eye. Is this reasoning correct? My correction is about -6.00 with mild astigmatism. Also, is there any problem doing an enhancement using PRK? Lastly, I heard something to the effect that for people with high levels of myopia, lasik yields better results. Can you comment on what level of myopia this corresponds to and why this is so?

In general, I am a person who is comfortable with taking calculated risks, after I have enough information as to the probabilities involved. When it comes to my eyesight, I am willing to do allmost anything to increase the chances of achieving a successful result, because vision is so important to me. Given my philosphy on this, what approach would you recommend for me? Traveling within the USA or Canada for the procedure is an option I am consdering.

Thanks again for your help with my questions.

Regards,

John

Dear John

If you have a hold on any data, pls do let me know as well... i like u am considering customised lasik (wavefront). if i go ahead, it will be using the Technolas 217.

thanks.

angel

I would gladly have had PRK instead of LASIK if it had been offered to me. The structural integrity of the cornea after LASIK is never what it was prior to LASIK and the flap cut. PRK is generally consider safer and just as effective up to about -4 diopters. Most of my complications are flap problems and after 7 operations, I still can't see.

Cindy,

I am sorry to hear about your experience with Lasik. Since I am about -6.00 diopters I may be into the range where there is more risk with PRK than Lasik, but I am not sure about that. I heard of haze problems with PRK for high levels of myopia, and I am thinking this problem may be permanent, but not sure. Hopefully I will get more information on this later to help decide which is best.

Best wishes,

John

Cindy;
I am researching doctors for LASIK in Phoenix and would be interested to know who did your surgery. If you like, you can send me an email rather than post on the BB. My address is .
Thanks!

Angel,

I have not found any data, it has been sort of a dead end in this regard. One comment on the Technolas 217 laser, if you have a high level of myopia, say about -5 to -6 or more diopters, you might want to look at the frequently asked questions portion of this website for laser information. It seems this laser takes off more corneal thickness than some of the others. I am not a doctor, I am just going by what I read.

Regards,

John

Dr. D Dausch from Germany presented the results from the first 20 people to have wavefront guided custom ablation with Asclepion-Meditecs Mel 70 laser Boston. I requested and received this data from via zip file through the internet. you may have to down load winzip from www.winzip.com to unzip the file.

I am a student of the grauating class of 2005 at the Dow Medical college, Karachi , Pakistan.I am thinking of having the Lasik procedure done. I had the corneal topography as well as the wavefront diagnostic procedure[zywave] done. I am -2.5 myopic and my no. has been more or less stable for 2 years. The results that came on corneal topography were...
RIGHT EYE
P.B.F.S- 52.4 D{<55D}
difference-0.033 mm{0.050mm}
K1-44.2 D{48D}
K2-43.3D {39D}
W.T.W-11.6mm
Pupillary diameter 4.3mm
thinnest point-595 um
pachy ratio 1.14 um {<1.16}
Corneal thickness-596 mic.
LEFT EYE
P.B.F.S- 52.6 D
difference 0.035 mm
K1-43.9 D
K2- 43.3 D
W.T.W-11.8 mm
P.diameter- 4.7 mm
thinnest point-590 um {>480um},
Pachy ratio-1.16 um.
Corneal thickness-591 mic.
and on Zywave.....
WAVEFRONT DATA
RIGHT EYE-
MANIFEST REFRACTION
Sphere- 2.50
UNDILATED ZYWAVE REFRACTION(3.5mm PPR)
Sphere. -1.90, Cylinder. -0.24, Axis- 39 degrees, Pupil Diameter- 6.49 mm
DILATED ZYWAVE REFRACTION(3.5mm PPR)
Sphere. -1.82, Cylinder. -0.16, Axis- 45 degrees, Pupil Diameter- 7.27 mm
LEFT EYE
MANIFEST REFRACTION
sphere. -2.50
UNDILATED ZYWAVE REFRACTION
Sphere. -2.09, Cylinder. -0.23, Axis- 100 degrees, Pupil Diameter- 6.90 mm
DILATED ZYWAVE REFRACTION
Sphere. -1.87, Cylinder. -0.35, Axis- 94 degrees, Pupil Diameter- 7.78 mm

The doctor is now saying that my pupil diameter is a relative contraindication to any kind of Laser refractive surgery. I am 24 years old male and i do not have any associated opthalmic or any systemic disease whatsoever.I have read that Pupil size if large can result in problems with night vision but it is not a contraindication esp for a low myope like me with good corneal thickness.I would like some feedback.

Fahad Khan.