Dr. Chynn graduated from Harvard's ophthalmology program, which is probably the most famous in the world. As the only member of his graduating class to specialize in Refractive Surgery, and now an recognized authority, Dr. Chynn is frequently invited back to Harvard to give updates on the State of the Art in Refractive Surgery. This slide show presentation was given to 100 eye surgeons who flew in from across the country to learn the latest advances in glaucoma, retina, cataract surgery--and laser vision correction (from Dr. Chynn). The title of his talk reflects the movement in the US and worldwide from leading surgeons that is called "Back to the Surface." This means that surgeons are moving away from LASIK and IntraLase, to avoid flap complications and the # 1 problem causing lawsuits (iatrogenic keratoconus, or KC), and back to the surface. For some doctors, this means going back to the original procedure, PRK, which has a lot of pain, delayed healing, and scarring. For Dr. Chynn, this means performing an Advanced Surface Ablation, which is either a LASEK or epiLASEK. These are more advanced than PRK because they do not hurt, healing and recovery is quick, and there is no haze or scarring. For example, Dr. Chynn performs over 1,000 LASEKs and epiLASEKs per year--he performed his last PRK in 1999. Obviously, he moved away from PRK to LASIK, then to IntraLase, and now back to the safer LASEK and epiLASEK procedures. View the following slide show to find out more, and call us with your questions--better yet, come in and meet with our MDs!

1. Emil
William
Chynn,
MD,
FACS,
MBA
Park
Avenue
LASEK
333
Park
Avenue
South,
New
York,
NY
dr@ParkAvenueLASEK.com

2. Evolu&on
of
Refrac&ve
Surgery
 RK,
AK
(Fyodorov
–
Russia/Ukraine)
 PRK
(Trokel
&
L Esperance,
Columbia
U)
 LASIK
(Pallikaris,
Greece)
 LASEK
(Talamo,
Abad
&
Azar,
Mass
Eye
&
Ear
 Intra-­‐LASE,
i-­‐LASIK
(Kurtz,
USA)
 Epi-­‐LASIK,
epi-­‐LASEK
(Pallikaris,
Greece)

3. Original
Procedures:
Incisional
 Chance
favors
the
prepared
mind
–
Louis
Pasteur
 Boy
falls
off
bike/glasses
shatter/corneal
lacs-­‐>no
specs!
 Discovery/invention
of
RK
–
Svyatoslav
Fyodorov
 Hex
K
–
Antonio
Medez
(Mexico)
 Metal
blade-­‐>Diamond
blade-­‐>Guarded
diamond
blade
 Risks:
perforation,
infection
 Side-­‐effects:
starbursts,
irregular
astigmatism
 Unpredictability,
overcorrection
(PERK,
Waring)

4. First
move
to
the
surface:
PRK
 Excimer
( excited
dimer )
laser,
193
nm
 IBM
Labs,
Armonk,
NY
(chip
etching)
 Trokel
(VISX)
&
L Esperance
(Summit),
Columbia
 US
Patent
#5,108,388
(1983/87/92),
Claim
4:
The
method
of
changing
optical
properties
of
an
eye
by
operating
solely
upon
the
anterior
surface
of
the
cornea
of
the
eye
(using)
selective
UV
irradiation
and
attendant
ablative
photodecomposition
of
the
anterior
surface
of
the
cornea
in
a
volumetric
removal
of
corneal
tissue
and
with
depth
penetration
into
the
stroma
and
to
a
predetermined
curvature
profile

5. PRK
advantages/disadvantages
 Accuracy
 Myopia,
hyperopia,
astigmatism
 Stability
 Pain
 Delayed
recovery
 Scarring

6. Move
away
from
surface:
LASIK
 Rapid
recovery
 Nearly
instantaneous
results
/
wow
effect
 Nearly
painless
 Decreased
risk
of
scarring
 Flap
striae,
partial
flap,
button-­‐hole
flap
 Debris,
epithelial
ingrowth,
DLK
 Late
trauma
 Ectasia
(Speaker/$7mil,
Niksarli/$5.6,
DelloRusso/$15.3)

7. Safer
Flaps:
IntraLase/i-­‐LASIK
 Fewer
incomplete
or
button-­‐hole
flaps
 Thinner
flaps
 Safer
for
thin
corneas,
high
Rx,
irregular
astig/FF
KC
 Persistent
inflammation
+
photophobia
 DES
 Late
flap
trauma
 Iatrogenic
KC

8. Move
Back
to
the
Surface
 LASEK
–
remove
epithelium
en
bloc
using
EtOH
 Epi-­‐LASEK(IK)
–
en
bloc
dissection
using
epi-­‐keratome
 Advanced
Surface
Ablation
(ASA)
 Flap-­‐on
vs.
flap-­‐off

9. Epi-­‐LASEK
(epi-­‐LASIK)

10. ASA
indica&ons
(over
LASIK)
 Irregular
astigmatism/
FF
KC
 Thin
corneas
/
high
Rx
 Highest
Rx
treated
in
NYC
(2010)
-­‐22
D
(600
–
250
=
350)
 Preop
BCVA
20/60
OU
-­‐
>
Postop
UCVA
20/40
OU
 Night
vision
concerns
(glare
from
flap,
large
pupils)
 Contact
sports
/
hazardous
duty
(Seals,
etc)
 Anterior
stromal
opacities
(scars,
dystrophies?)
 Prior
RK/AK
 Very
special
cases
(pediatrics?
dogs??)

11. Advantages
of
LASEK/epiLASEK
 Zero
flap-­‐related
complications
(vs.
LASIK)
 90%
of
all
complications
are
flap-­‐related
 Decreased
Dry
Eye
Syndrome
(vs.
LASIK)
 caused
by
neurotrophic
cornea/hypesthesia
 Decreased
inflammation/pain
(vs.
PRK)
 Decreased
risk
of
scarring
(vs.
PRK)
 Quicker
recovery
time
(vs.
PRK)
 Safer
re-­‐treatments
of
complicated
(LASIK)
cases

12. Sta&s&cal
Trends
(MarketScope)

13. Complicated
LASIK
enhancements
 Safer
to
re-­‐treat
surface/flap
 No
increased
depth/decreased
stromal
bed
 No
added
risk
of
ectasia
 No
chance
of
epithelial
ingrowth/corneal
melt
 No
risk
of
DLK
 No
incomplete
flaps
 No
risk
of
recutting
flaps

14. Enhancement
procedure
 LASEK
OU
+
MMC
+
CustomVue
WaveFront
(HD)
 LASEK
–
safer
than
epi-­‐LASEK
on
retreatments
 To
prevent
scarring:
 MMC—mitomycin
C
(1
sec
/
sec.
of
ablation
time)
 Vitamin
C
 oral
steroids
(methylprednisolone)
x
1
week
 PredForte
(prednisolone
acetate)
QID,
taper
over
mos
 UV
protection
 CustomVue
WaveFront—Prevue
Lens

15. PreVue
Lens:
useful
in
complex
cases1
 LASIK
retreatments
 UCVA
close
to
20/20
 BCVA
not
20/20
 No
objective
improvement
on
manifest
refraction
 Subjective
complaints
disproportionate
 Glare,
halos,
diplopia,
ghosting
 Lawyers,
legal
considerations
1Bansal,
Chynn,
Rubinfield,
Refractive
Surgery
Complex
Case
Management,
Cataract
&
Refractive
Surgery
Today,
July
2008

16. Epithelial
PreVue
New
Universal
Way
to
PreVue
 Can
be
used
with
any
laser
platform
(not
just
VISX)
 More
accurate
than
PreVue
 Larger
optical
zone
 More
realistic
real-­‐life
trial
 Zero
downside
risk?
 turning
lemons
into
lemonade
 Useful
to:
 encourage/discourage
enhancement
 pre-­‐sell /justify
WaveFront
upgrade

17. A.F.
–
62
yo
M
s/p
RK
+
AK
 CC:
I
can t
see
well
far
or
near
without
glasses!
 Had
multiple
RK
+
AK
incisions
OU
28
years
ago
 VA
(distance):
20/80
OD,
20/100
OS,
20/60
OU
 VA
(near):
20/100
OD,
20/80
OS,
20/80
OU
 Rx:
+3.25
–
2.25
x
80
OD
+
4.50
–
4.75
x
95
OS
 Saw
numerous
LASIK
surgeons
who
said:
 I
wouldn t
touch
you
with
a
10-­‐foot
pole!
 If
you
get
LASIK
you
will
wind
up
with
pizza
slices!

18. Surgical
plan
 Enhance
non-­‐dominant
eye
first
 Wait
3
months
before
enhancing
second
eye
 Maximum
scarring
prophylaxis
 Stress
patient
compliance
 Frequent
post-­‐op
visits/SLE
to
check
for
scarring
 Slow
taper
of
topical
steroids

19. SLE
–
1
year
postop

20. 1
year
postop
 UCVA:
20/20
at
distance
(OU)
20/25
at
near
(OU)
 Rx:
OD:
+0.50
–
0.75
x
13
OS:
-­‐0.75
–
1.25
x
123
 SLE:
clear
 CC:
I
can
see
near
and
far
like
when
I
was
30,
which
is
good
as
I
just
married
a
30-­‐year-­‐old
and
am
having
my
tubes
reconnected
to
try
to
have
kids!

21. LASEK
of
Granular
Dystrophy
 22
yo
F
–
Hx
Granular
Dystrophy
OU
 UCVA
OD:
20/100
OS:
20/80
OU:
20/70
 BSCVA:
OD:
-­‐1.75
–
1.50
x
170
(20/80)
OS:
-­‐1.00
–
0.50
x
5
(20/70)
OU:
20/60

22. Preop:
Granular
Dystrophy

23. 1
–year
post
LASEK
for
Granular

24. 1-­‐year
post-­‐LASEK
for
Granular
 UCVA
OD:
20/50
(20/100
preop)
OS:
20/40
(20/80
preop)
OU:
20/30
(20/70
preop)
 BSCVA:
OD:
-­‐.75
–
0.50
x
160
(20/30)
(20/80
pre)
OS:
-­‐.50
–
0.50
x
15
(20/30)
(20/70
pre)
OU:
20/25
(20/60
pre)

25. Sze
H.
Wong,
BS
Lynnette
P.
Williams,
MD
Emil
W.
Chynn,
MD,
FACS,
MBA
The
authors
have
no
financial
interest
in
the
Presented
at
ASCRS,
2011
subject
ma4er
of
this
poster.

26.
Study
Popula&on:
Characteris&cs
n
=
93
Patients
(153
Eyes)
Female
47
%
Male
53
%
Age
(mean
±
SD;
range)
31.4
±
8.3
(19
-­‐
66)
Eyes
With
Extreme
Myopia
(SE
≥
-­‐9)
72
%
Eyes
With
Extreme
Hyperopia
(SE
≥
+6)
4
%
Eyes
With
Extreme
Astigmatism
(cyl
≥
-­‐3)
31
%
LASEK
Eyes
83
%
Epi-­‐LASIK
Eyes
17
%
WaveFront
Eyes
61
%
Rx
Range
-­‐22.00
to
+7.50
Preop
Corneal
Thickness
554
±
39
µm
Ablation
Thickness
125
±
36
µm
Postop
Corneal
Thickness
429
±
50
µm

27. Gain
in
VA
at
3
months
Postop
UCVA
vs.
Preop
Best
Corrected
Visual
Acuity
(BCVA)
100
%
of
eyes
had
postop
UCVA
>
preop
UCVA!
Extreme
Myopic
Eyes
Extreme
Extreme
Hyperopic
Eyes
Astigmatic
Eyes
Number
of
Lines
Gained
8.42
3.58
6.68
LogMAR
Gained
1.51
0.77
1.08

28.
Postop
UCVA
vs.
Preop
BCVA
(%)
1-­‐Mo.
2-­‐Mo.
3-­‐Mo.
Postop
UCVA
≥
40
57
72
Preop
BCVA
Postop
UCVA
>
Preop
BCVA
18
25
34
Postop
UCVA
=
Preop
BCVA
22
32
38

29. Complica&ons
" 11/153
(7
%)
of
eyes
had
postop
haze
(tr
to
2+)
" 3/153
(2%)
of
eyes
lost
≥
1
line
of
BCVA
due
to
postop
haze
" 1/153
(0.7%)
of
eyes
lost
≥
2
lines
of
BCVA
due
to
postop
haze

30. CONCLUSION
 Extreme
prescriptions
may
be
safely
and
effectively
treated
with
Advanced
Surface
Ablation,
combined
with
adjunctive
treatments
to
prevent
scarring
 72%
eyes:
3-­‐mo.
postop
UCVA
≥
preop
BCVA
 Further
studies
are
needed
to
determine
whether
extremely
hyperopic
eyes
are
more
likely
to
lose
BCVA
and
how
to
avoid
this
loss

31. Summary:
ASA
=
LASEK
+
EpiLASEK
 10x
safer
than
primary
LASIK
or
i-­‐LASIK/
IntraLase?
 Definitely
safer
in
complicated
enh
(RK,
AK,
PK)
 Need
steroids
+
MMC
to
prevent
scarring
 Slower
healing
/
patient
compliance
 Combine
safety
of
PRK
with
comfort
of
LASIK
 Can
Return
to
the
Surface
revitalize
Refractive
Surgery?
(still
0%
penetration
of
candidate
population)