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Moderator
Vance M. Thompson, MD
Panelists
Karl G. Stonecipher, MD, ABO; Helen K. Wu, MD, ABO
Viewing Papers
Expand a paper title to the right to view the paper abstract and authors. Use the video link to jump to that poster in the session.
Presenting Author
Michael Mimouni, MD
Co-Authors
Adir Sommer (MD), Margarita Safir (MD), Waseem Nasser (MD, PhD), Dror Ben Ephraim Noyman (MD, BSc), Tzahi Sela (BScOptom), Gur Munzer (BA), Igor Kaiserman (MD), Eyal Cohen (MD)
Purpose
To compare the visual and refractive outcomes of myopic patients undergoing high astigmatic laser-assisted in situ keratomileusis (LASIK) surgery with and without pupillary decentration of treatment.
Methods
A retrospective study was conducted at Care-Vision Laser Centers in Tel-Aviv, Israel. We reviewed medical records of myopic patients with high astigmatism (>3 diopters) who underwent LASIK surgery between January 2013 and December 2023. Patients were divided into two groups based on whether the surgeon applied pupillary decentration during surgery. Preoperative, intraoperative, and postoperative parameters were compared, adjusting for baseline and intraoperative differences.
Results
The study included 332 eyes from 250 patients, with 89 eyes treated with pupil decentration. The pupil-decentered group had higher preoperative astigmatism (-3.99±0.77 D vs. -3.73±0.60 D, P=0.002), a more negative treated sphere (-1.69±1.48 D vs. 0.75±1.64 D, P<0.001), and a greater maximum ablation depth (79.98±19.05 ?m vs. 64.42±16.55 ?m, P<0.001). Postoperatively, there was no significant difference in uncorrected visual acuity (UCVA) (logMR 0.12±0.70 vs. 0.12±0.70, P=0.916), subjective spherical equivalent (SEQ) (-0.32±0.57 D vs. -0.41±0.59 D, P=0.238), or efficacy index (0.98±0.31 vs. 1.01±0.29, P=0.464).
Conclusion
Our findings suggest that in myopic patients undergoing high-astigmatic LASIK surgery, pupil decentration does not improve postoperative visual or refractive outcomes. Surgeons can safely omit pupil decentration without compromising the efficacy or safety of the procedure.
Presenting Author
Manoj V. Motwani, MD
Purpose
The visual results of topography guided ablation with a new proprietary system designed to integrate imaging data from topography, wavefront, and OCT devices using a proprietary algorithm, on eyes with and without posterior ocular astigmatism for correction of refractive astigmatism while reducing corneal total higher-order aberrations.
Methods
yes were treated with NuClarityVision using Femto-LASIK with a WaveLight Contoura system. NuClarityVision includes proprietary algorithms that are designed to utilize and integrate data from 3 different imaging technologies to determine the surgical parameters of a topography guided (WaveLight Contoura) excimer laser ablation procedure. Outcomes were measured for accuracy of astigmatism treatment, detection and treatment of posterior ocular astigmatism (POA), 20/15 and 20/20 vision, as well as total higher-order aberrations (HOA) change and compared to 19 other excimer laser system from 12 studies.
Results
One 180 eyes of 101 patients were included. 98% eyes were 20/20 after primary LASIK, and 76.7% of eyes were 20/15 after primary LASIK. Sixteen (16) of 180 (8.9%) eyes of the cohort had POA detected pre-op. Fifteen (15) of the 16 (93.75%) were corrected accurately with plano outcomes after primary LASIK. Overall, 174 of the 180 (96.7%) eyes were corrected to a plano outcome after primary LASIK and 6 out of the 180 (3.3%) eyes had residual refractive error leading to a non-plano outcome. Corneal total Root Mean Squared (RMS) HOA across the cohort were reduced by an average of 48.6%, with reduction in HOA in 169 of 180 eyes (93.8%). Eleven (11) of 180 eyes (6.1%) had an increase in HOA. N
Conclusion
Topography guided ablation using the mapping parameters provided by NuClarityVision provided high levels of accuracy and plano outcomes post-primary LASIK with or without POA, with low incidence of non-plano outcomes while reducing corneal RMS HOA values by half. It was the only system out of 19 in published literature that lowered total RMS HOA.
Presenting Author
Manoj V. Motwani, MD
Purpose
To present the outcomes of a retrospective study in keratoconus/corneal ectasia patients of treating the higher order aberrations compensated for the corneal epithelium in addition to topographic guided ablation followed by corneal cross linking.
Methods
Twenty-seven eyes of 14 patients were treated for keratoconus/corneal ectasia utilizing trans-epithelial topographic guided ablation photorefractive keratectomy (PRK) for treatment of corneal higher order aberrations and lower order astigmatism followed immediately by 15-minute cross linking were examined retrospectively. Six-month results were analyzed via measurement of vision, refraction, residual higher-order aberrations (HOAs), residual lower-order and higher-order aberrations, as well as for loss or gains of lines of best corrected visual acuity.
Results
All eyes save one had reduction in K1, K2, K Max, and K Mean. All eyes had reduction in manifest astigmatism, Contoura measured astigmatism, 57% reduction of higher-order aberrations (HOA), and 53% reduction of higher-order aberrations grouped with lower-order aberrations (Grouped). Nearly all (96.3%) eyes achieved 20/40 vision or better, 20 eyes had 1– 7 lines gained of vision, and no eyes had any loss of lines of vision. HOA reduction increased from 32% to 57% when compared to a prior study that did not treat epithelial compensation of HOA.
Conclusion
Use of the CREATE+CXL protocol combined with 15-minute corneal cross linking results in a significant increase in HOA reduction, as well as a significant improvement in corrected distance visual acuity over past procedures.
Presenting Author
Manoj V. Motwani, MD
Purpose
To present the outcomes of a retrospective study of treatment of radial keratotomy-induced corneal irregularity with topographic guided ablation and a trans-epithelial approach based on epithelial compensation.
Methods
Sixty eyes of 31 patients were treated for radial keratotomy-induced corneal irregularity utilizing a customized trans-epithelial topographic guided ablation photorefractive keratectomy (PRK) for treatment of corneal higher-order aberrations and lower-order astigmatism. Three-month results were analyzed via measurement of vision, refraction, residual higher-order aberrations (HOAs), residual lower-order and higher-order aberrations, as well as for loss or gains of lines of best corrected visual acuity.
Results
Higher-order aberrations (HOA) were reduced by 69%, with an 80% reduction of higher-order aberrations grouped with lower-order aberrations (Grouped). Most (95%) of eyes achieved 20/40 vision or better, 50% of eyes gained 1– 9 lines of best corrected vision, and no eyes had loss of best corrected vision.The HOA reduction improved from 52% to 69% as compared toa prior study that did not treat the epithelial compensation of HOA.
Conclusion
Use of the CREATE protocol to treat RK-induced corneal irregularity resulted in a significant decrease in HOA, as well as a significant improvement in corrected distance visual acuity.
Presenting Author
Blake Oberfeld, MD
Co-Authors
Betul Bayraktutar (MD), Walter Steigleman (MD), Nathaniel Rieveschl (MD)
Purpose
Post-PRK haze is a visually significant complication and is more likely with high myopic treatment. Our scanning electron microscopy study is the first to quantitively associate the strength of myopic treatment with post-PRK surface roughness as rougher corneal surfaces require more remodeling and are more predisposed to a loss of transparency.
Methods
Human corneoscleral tissues were deepithelialized and ablated with an excimer laser for myopic treatments of -2, -4, -6, -8, and -12 diopters. Samples were fixed, dried to the critical point, mounted, sputter-coated, and examined with scanning electron microscopy (SEM). In qualitative analysis, three cornea-trained ophthalmologists performed a masked review of SEM images using two published scales for corneal surface smoothness. Quantitative analysis of surface roughness assessed textural features with gray level co-occurrence matrices (GLCM). Statistical analysis used Spearman's rank correlation.
Results
Three masked cornea-trained ophthalmologists did not show a trend of different roughness across samples with two previously published scales (p = 0.25, p = 0.95). In quantitative analysis, GLCM contrast, which represents surface texture, had a significant increase with stronger myopic ablations (p < 0.001; Spearman's rho = -0.81). GLCM entropy and variance independently showed significant trends toward more disorganization and more variability respectively as myopic ablation power increased (both p < 0.001).
Conclusion
Quantitative analysis of corneal SEM images with GLCM offered a fast, automated method which may outperform the subjectivity of visual inspection. GLCM analysis demonstrated a strong association between increased myopic ablation power and corneal roughness, which may in turn affect corneal transparency, wound healing, and refractive outcome.
Presenting Author
Robert Edward T. Ang, MD
Purpose
This prospective, randomized, single-surgeon study evaluated the safety and efficacy outcomes of transepithelial photoreactive keratectomy (tPRK) compared with conventional photoreactive keratectomy (PRK) at 3 years of follow-up.
Methods
Thirty-five patients who underwent refractive surgery for correction of ametropia were evaluated. Patients were bilaterally treated with PRK in one eye and tPRK in the other. Clinical endpoints include absolute refractive predictability, adverse events (AEs), manifest refraction spherical equivalent (MRSE), monocular uncorrected and corrected distance visual acuity (UDVA/CDVA) and patient-reported visual outcomes at 36 months.
Results
Both treatment approaches achieved excellent efficacy and safety with no statistically significant differences between study groups. Median photopic UDVA was 0.0 logMAR (range −0.20 to +0.50) and median photopic CDVA −0.10 logMAR (range −0.20 to 0.00); median mesopic UDVA was 0.0 logMAR (range −0.10 to –0.50) and mesopic CDVA −0.10 logMAR (range −0.10 to –0.40). Median MRSE was close to plano in both arms (range −0.50 D to +0.50 D). Contrast sensitivity remained comparable under both photopic and mesopic conditions. Intraocular pressure was comparable and unremarkable, and no haze or adverse events were reported.
Conclusion
The tPRK procedure offers the surgeon improved speed and efficiency over conventional PRK. In this analysis, tPRK provided outcomes equivalent to conventional PRK in terms of refractive predictability, visual acuity, and contrast sensitivity. Both procedures were well tolerated, effective, and stable through 36 months.
Presenting Author
Adrianna Bevis, None
Co-Authors
Karl Stonecipher (MD)
Purpose
To analyze the outcomes in a large (N-33669), single surgeon, prospective data set monitoring complications and outcomes with the FS 200 and Intralase femtosecond laser and the WL Excimer laser platforms.
Methods
The prospective, single-center, open-label, reported outcomes series from a single surgeon analyzed 25-year data from 33669 eyes with a myopia of up to -12 D of sphere and up to -6D of cylinder. Data was collected prospectively specifically looking at enhancements rates, loose epithelium without epithelial defect (Grades 1-3), anterior chamber bubbles, slipped flaps, pressure induced stromal keratitis (PISK), diffuse lamellar keratitis (DLK Grade 1-3), central toxic keratopathy (CTK or Grade 4 DLK), vertical gas break through (VGB), rainbow glare, keratoectasia, and infection.
Results
At 25 years, we will discuss the reduction in enhancement rates from 4.5% to 0.27%; the low risk of epithelial issues with the femtosecond laser of 0.27% (no epithelial defects or grade 4 were reported in this series); the unique femtosecond complication of anterior chamber bubbles and the treatment (0.25%); slipped flaps and there causes (0.16%); diffuse lamellar keratitis (0.044%) (Grade 1-3) and central toxic keratopathy (0.003%) (Grade 4) incidence and treatment; vertical gas break through (0.027%); persistent rainbow glare (0.006%); keratoectasia (0.006%); and the lack of primary LASIK infections (0.0%) in 33669 cases.
Conclusion
Prospective, single-center, single surgeon, open-label data series can provide surgeons real world data to discuss with prospective patient's real term risks and postoperative patient's real-world outcomes. They can also provide discussion points when patients and media present negative and embellished complications with laser vision correction.
Presenting Author
Despoina Karadimou, MD
Co-Authors
A. John Kanellopoulos (MD), Alexandros Kanellopoulos (MD), Filippos Vingopoulos (MD)
Purpose
To evaluate the safety and efficacy of myopia correction treatments with SMILE-pro.
Methods
An observational Consecutive Case Series; 100 consecutive myopic and myopic astigmatic SMILE-pro treatments. All cases were treated with SMILE-pro with Zeiss VISUMAX-800. Visual Acuity, Refractive Error, Scheimpflug and OCT Tomography, were evaluated over a three-month follow-up.
Results
The femto-lenticule preparation was under 8 seconds in all cases compared to the minimum 25 seconds with the older version of the Visumax 500, that we had published extensively. At the three-month follow-up, all eyes reached UDVA of 20/20 or more, change from pre- to post- operative mean values were: refractive error from -4.34D (range -7.25 to -2.00D) to -0.35 D; refractive astigmatism from -0.75 D (range 0 to -3.25D) to -0.44 D, mean topographic astigmatism from -1.28D (range -4.1 to -0.7D) to -0.88D. Defocus equivalent of 0.55 D
Conclusion
We report safe and efficient initial outcomes in Greece using SMILE-pro for myopic treatments. This technique carries the comparable outcomes and advantages with standard myopic femto LASIK without the potential short and long term disadvantages of a stromal flap.
Presenting Author
A. John Kanellopoulos, MD
Co-Authors
Athanasios Zisimopoulos (MD, MSc)
Purpose
Raytracing customization (wavelight plus) used off-label in pseudophakic eyes, may offer the unique customization option of incorporating potential coinciding corneal, intraocular lens aberrations deriving from the angle between IOL optical center and the line of sight and/or IOL tilt optical data.
Methods
55 cases of pseudophakia with to include: monofocal toric, EDOF and trifocal diffractive IOLs underwent raytracing LASIK enhancement using the Alcon/Wavelight Sitemap diagnostic device, the FS200 femto and the EX500 excimer lasers (Refractive Suite), to treat residual refractive error and aberrations. At 3 month followup improvement in refractive error, UDVA, UNVA, contrast sensitivity and high order aberration change will be evaluated
Results
Mean UDVA 20/23, CDVA 20/16, Mean residual refrac;ve error SE: -0.45D (+0.5 to -0.75), mean redidual refrac;on cylinder -0.85D (-0.50 to -1.75), mean HOA: 1.55um RMSh post raytracing PRK at 3 months respec;vely: Mean UDVA 20/16, mean CDVA 20/12, SE: +0.15, Mean cyl: -0.25D, HOA: 0.45um from 1.55um pre enhancement, CS: improved minimum one step to max 7 steps in all cycles/degree special frequencies in mesopic condi;ons tested.special frequencies in mesopic conditions tested.
Conclusion
RayTracing excimer laser refractve enhancements in pseudophakia in a range of IOL types-even those posing measurement challenges- can significantly improve residual refractve error and visual functon, underlining the efficacy of raytracing in calculatng accurately total eye aberraton and refractve error, even in pseudophakia, off-label.
Presenting Author
A. John Kanellopoulos, MD
Co-Authors
Filippos Vingopoulos (MD), Athanasios Zisimopoulos (MD, MSc)
Purpose
wavelight plus LASIK utilizes a 6.5mm optical zone (OZ) with the EX500 excimer laser in myopic LASIK using the FS200 femto for flap creation. The 7mm OZ option has not been studied. We theorize 7mm OZ will offer superior asphericity, and other high order aberration postoperative data especially in myopias with SE over 3 diopters
Methods
Prospective randomized contralateral eye study of 7mm vs. 6.5mm optical zone raytracing (wavelight plus) LASIK evaluation at 3 months of 25 patients for UDVA, CDVA, lines of vision gained (comparing preop CDVA to postop UDVA) High order aberrations measured by the sitemap, Spherical aberration, Corneal asphericity, contrast sensitivity
Results
7mm vs. 6.5mm at 3 months: UDVA 20/12 vs 20/14, CDVA: 20/12 vs 20/12, HOA: 0.25um vs. 0.45, C12: -0.20 vs -0.10, CS: 7mm was statistically better in all special frequencies studied.
Conclusion
Ray Tracing LASIK appears to be very accurate in myopic refractive error correction with lines of vision gained in all cases with both OZs. Enlarging the targeted optical zone to 7mm appears to offer statistically better outcomes in HOA, asphericity, contrast sensitivity and lined of vision gained, as measured 3 months postoperatively
Presenting Author
Margarita Safir, MD
Co-Authors
Michael Mimouni (MD), Dror Ben Ephraim Noyman (MD, BSc), Igor Kaiserman (MD), Adir Sommer (MD), Waseem Nasser (MD, PhD), Gur Munzer (BA), Tzahi Sela (BScOptom)
Purpose
Cyclorotation during PRK may misalign ablations and affect outcomes. Although modern lasers provide automatic angle correction, the clinical effect of small rotations remains unclear. This study evaluated whether automatically corrected cyclorotation angles ?10° influence results after myopic PRK.
Methods
Care Vision Laser Center, Tel Aviv, Israel (2013-2023). Retrospective consecutive cohort; eyes stratified by preop cyclorotation: Small (?3.3°), Medium (3.4-6.6°), and Large (6.7-10°). Visual and refractive outcomes, efficacy & safety indexes, and Alpins vector metrics were assessed in a 1 year follow-up inerval. Multiple linear regression was performed to identify the effect of potential confounders.
Results
17,214 eyes (10,859 pts; mean age 25.9±7.5; 44.3% female). Large-angle group showed slightly lower UCVA/BCVA vs Small/Medium (mean differences ?0.01-0.02) but no clinically meaningful differences in refractive outcomes or efficacy/safety indexes. Alpins metrics: no between-group differences. Regression: preop BCVA strongly predicted final BCVA (??0.63, p<0.01); cyclorotation angle showed statistically detectable but clinically negligible associations (e.g., BCVA R?-0.016; CI R?-0.017).
Conclusion
Within the platform's compensation range (0-10°), cyclorotational angle magnitudes have limited impact on myopic PRK outcomes . Preoperative BCVA—not cyclorotation—drives postoperative acuity. These findings lend confidence to clinicians in iris registration and autocorrection to achieve favorable results without manual�maneuvers.
Presenting Author
Margarita Safir, MD
Co-Authors
Dror Ben Ephraim Noyman (MD, BSc), Adir Sommer (MD), Waseem Nasser (MD, PhD), Gur Munzer (BA), Tzahi Sela (BScOptom), Igor Kaiserman (MD), Michael Mimouni (MD)
Purpose
Cyclorotation on reclining may misalign LASIK ablations. Modern platforms detect and autocorrect angle, but whether the magnitude (?10°) still affects outcomes is uncertain. We assessed if autocorrected angle size (?10°) influences vision, refraction, and vector metrics after myopic LASIK.
Methods
are Vision Laser Center, Tel Aviv, Israel (2012-2023). Retrospective consecutive cohort; eyes stratified by preop cyclorotation: Small (?3.3°), Medium (3.4-6.6°), Large (6.7-10°). Visual and refractive outcomes, efficacy & safety indexes, and Alpins vector metrics were assessed in a 1 year follow-up inerval. Multiple linear regression was performed to identify the effect of potential confounders.
Results
6,920 eyes (4,454 pts; 30.7±8.7 years; 47.7% female). No between-group differences in refractive outcomes or efficacy/safety indexes. CDVA differed by ANOVA but not on pairwise testing. Alpins vectors/indicators showed no group differences. Regression: age, ablation depth, and axis correlated mainly with vector angles, not with vision or refraction endpoints.
Conclusion
Within the 0-10° compensation window, cyclorotation magnitude has limited clinical impact on myopic LASIK outcomes. Iris registration and autocorrection are sufficient; manual angle-reduction maneuvers are�unnecessary.
Presenting Author
Aaishwariya A. Gulani, MD
Co-Authors
Arun Gulani (MD), Yash Gulani (BA)
Purpose
To describe a staged approach in managing a complex case of aggressive pterygium overlying a LASIK flap with central corneal scarring.
Methods
A 40-year-old female presented with a nasal pterygium extending to the pupillary axis, central corneal scar on a prior LASIK flap, visual acuity of 20/400, marked redness, and discomfort. Baseline astigmatism measured 5.7D. A two-stage surgical plan was designed. First, meticulous, suture less, pterygium excision was performed without disturbing the LASIK flap, with the goal of restoring surface anatomy and reducing induced astigmatism. After confirming refractive stabilization, a refractive Laser surface-ablative technique was employed to address the central corneal scar and emmetropia.
Results
Following pterygium removal, astigmatism reduced from 5.7D to 1.7D with improvement in ocular surface health. The second stage successfully regularized the corneal surface, restoring optical clarity and achieving emmetropia. The patient reported complete relief from redness and discomfort along with a dramatic improvement in vision.
Conclusion
This case illustrates the importance of staged surgical planning in eyes with multiple vision-limiting pathologies. Sequentially addressing the pterygium and corneal scar without disturbing the underlying LASIK flap allowed for a cosmetic and maximized unaided visual outcomes while avoiding invasive surgical interventions.
Presenting Author
Hannuy CHOI, MD, MS
Co-Authors
Tae Keun Yoo (MD), Youngsub Eom (MD, PhD), Ik Hee Ryu (MD, MS), Hyunjean Jung (MD), In Sik Lee (MD, PhD)
Purpose
Posterior phakic intraocular lens (pIOL) implantation is safe and effective method to treat high refractive errors. However, sometimes, pIOL exchange may be required for vault correction, toric stabilization, or refractive adjustment. This study aimed to analyze the impact of pIOL exchange on corneal endothelial cells.
Methods
We retrospectively reviewed 10,779 patients who underwent bilateral posterior pIOL implantation over 11 years. Among them, 110 eyes required pIOL exchange. Patients with unilateral pIOL exchange, at least 1 year of follow-up period, and available specular microscopy study were included. Endothelial cell density (ECD), hexagonality (HEX), and coefficient of variation (CoV) were analyzed in a paired-eye manners, between pIOL exchanged eyes and contralateral eyes with primary implantation to minimize the effect of physiologic endothelial changes and the impact of primary implantation.
Results
56 patients underwent unilateral ICL exchange after bilateral ICL implantation. 31 Patients had 1-year postoperative follow-up. Preoperative ECD was comparable between exchanged eyes and fellow eyes (2856.29±314.75 vs 2906.59±305.51 cells/mm², p=0.432). There was no significant inter-eye difference in ECD at 1 year (2743.94±364.31 vs 2837.87±293.51, p=0.418), nor up to 10 years (all p>0.05). Hex and CoV also showed no significant inter-eye differences at all time points up to 10 years. Both groups showed gradual ECD decline without accelerated loss in exchanged eyes.
Conclusion
Contrary to common belief that ICL exchange compromises corneal endothelial cells, carefully performed ICL exchange by experienced surgeons showed no statistically significant endothelial loss.
Presenting Author
Gabriel Quesada, MD
Co-Authors
Rodrigo Quesada (MD), John Vukich (MD), Kevin Waltz (OD, MD), Jose Rivera (MD)
Purpose
The purpose of this single-site, prospective study was to characterize the performance of a robotic, multifunctional, laser system, ALLY (LENSAR, Orlando, FL) for the creation of laser in situ keratomileusis (LASIK) flaps including flap quality, thickness, accuracy and precision.
Methods
Following Ethics Committee and IRB approval, 80 eyes of 80 subjects were enrolled. Using a novel curved contact PID, subjects underwent flap creation with ALLY (LENSAR, Orlando FL) at diameters of 8mm and 9.5mm with thicknesses of 150, 130, 110, and 100 microns, beginning with 150 microns. At each step flaps were assessed for central flap thickness accuracy (intended vs achieved), precision (standard deviation), flap dissection quality, stromal bed quality and degree of opaque bubble layer (OBL). Subjects were followed for 3 months with flaps assessed at varying intervals with rate of adverse events and was recorded.
Results
Forty-one eyes underwent flap creation. Two flaps were not able to be lifted, one in each surgical session. No additional intraoperative complications, device-related serious adverse events, or vision-threatening sequelae were observed. For 150-µm targets, mean achieved thickness was 149.8 ± 4.5 µm (MAE 2.6 µm); for 130-µm targets, 129.6 ± 3.9 µm (MAE 2.1 µm). OBL was more prominent early and improved after software modification. At 3 months, 35 treated eyes were evaluable.Mean UDVA was 80.4 ± 7.3 letters; 49% achieved ≥20/20 and 71% ≥20/25. Mean MRSE was −0.20 ± 0.32 D; 89% were within ±0.50 D and 97% within ±1.00 D. No eye lost ≥2 lines of CDVA. (682/700)
Conclusion
In this initial clinical series, the ALLY robotic dual-pulsed femtosecond laser demonstrated predictable flap thickness with low variability, favorable intraoperative characteristics, and encouraging 3-month visual and refractive outcomes. Continued evaluation in a larger cohort with longer follow-up is warranted. (314/350)
