Diametral ablation--a technique to manage decentered photorefractive keratectomy for myopia.

PURPOSE: Decentered ablation after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) is an intraoperative complication that may significantly influence the visual outcome. Currently, there is no accepted technique available to manage this problem. METHODS: A technique of reoperation for eccentric ablation after PRK called diametral ablation is presented that uses a transepithelial phototherapeutic keratectomy (PTK) that leaves epithelium over the area of primary PRK. This residual epithelium acts as a shield for the previously treated stroma during a second PRK located opposite to the primary PRK with reference to the pupil center. The results of six such retreatments (6 eyes of 6 patients) are presented. RESULTS: In all eyes, a significant improvement regarding centration and subjective complaints was achieved. The eccentricity was reduced from 1.43+/-0.66 mm to 0.36+/-0.15 mm (P = .003). CONCLUSION: Diametral ablation is a promising alternative treatment of eccentric ablation.

[A prospective clinical study of correction of myopic astigmatism by combined treatment with PRK and T-incision and photoastigmatic refractive keratectomy. The results after one year]. / Astigmatismuskorrektur mittels PRK kombiniert mit T-Inzision und photoastigmatischer Keratektomie. Einjahresergebnisse einer prospektiven klinischen Studie.

BACKGROUND: In contrast to the correction of simple myopia there is no widely accepted technique for the correction of myopic astigmatism. Currently two techniques are available: the photoastigmatic refractive keratectomy (PARK) and the combination of arcuate keratotomies with standard PRK (PRK-T). METHODS: In two groups, 67 patients underwent a correction of myopic astigmatism in a total of 87 eyes (19 by PRK-T and 68 by PARK), and were followed for 1 year. The spherical equivalent was -6.7 D in both groups and the refractive astigmatism ranged from -1.0 to -6.5 D. The PARK procedure was performed by means of an elliptic ablation (Kertom I, Schwind) with a 5.8 x 8.1 mm zone. The PRK-T technique consisted of two arcuate keratotomies with a free optical zone of 7 mm and a standard myopic PRK at least 6 weeks later. RESULTS: The 1 year follow-up was completed in 57 out of 87 eyes included in the study. At 1 year post-operation, 83% of the PRK-T group and 80% of the PARK group had an uncorrected visual acuity of 20/40 or better. The refractive astigmatism was reduced by 76% in the PRK-T group and by 67% in the PARK group. The spherical equivalent was -0.59 +/- 1.1 D at 1 year after PRK-T and -0.28 +/- 1.04 D after PARK. In three eyes of the PARK group (6.7%) a visual loss of more than one Snellen line occurred. Two of these eyes had a preoperative myopia of more than -6 diopters. CONCLUSION: Both techniques have the potential to reduce myopic astigmatism, however, the success rate is not as high compared to spherical PRK. Also, the complication rate of 2.5% in corrections to -6 D is significantly higher than that with spherical myopic PRK.

[Laser-induced pressure waves in the eye. Propagation characteristics]. / Laserinduzierte Druckwellen am Auge. Ausbreitungscharakteristik.

BACKGROUND: The characteristics of shock waves during photoablation were investigated for an IR and a UV laser. These stress waves may be harmful to ocular structures. MATERIAL AND METHODS: The amplitude of shock waves was measured by a needle-shaped hydrophone in enucleated porcine eyes during excimer laser (193 nm, 23 ns, diameter of ablation 1.5-7.5 mm) and Er:YAG laser photoablation (2.94 microns, 200 microseconds, 1.2 mJ/cm2, diameter of ablation 4 mm). RESULTS: With the excimer laser at ablation zones larger than 4.5 mm, a pressure focus occurs at a distance of 4-6 mm behind the cornea. The pressure amplitudes are smaller than 80 bar for a fluence of 180 mJ/cm2 and decrease steadily to values below 10 bar towards the retinal level. Higher fluences produce higher pressure values; in the range of 60 to 220 mJ/cm2 the relation is linear. For the Er:YAG laser, pressure amplitudes are smaller than 0.5 bar. CONCLUSIONS: Mechanical damage of the retina is unlikely during excimer-or Er:YAG-laser ablation. The existence of a pressure focus may result in mechanical damages of the posterior lens or anterior vitreous at large ablation diameters. During Er:YAG laser ablation, shock waves could not be detected with our measurements. Theoretical estimations yield values of less than 700 mbar at a fluence of 1.2 J/cm2. The pressure load of the endothelium is independent of diameter but dependent on fluence.

Thermomechanical behavior of the cornea.

Shrinkage of corneal collagen is used during thermokeratoplasty, a method to remodel the corneal curvature. The goal of our investigations was to determine the optimal temperature range for maximal shrinkage of the collagen fibers with minimal damage. By means of a commercially available stress-strain-measuring device including a paraffin oil bath at temperatures varying from 35 degrees to 120 degrees C, strips of pig cornea measuring 5 mm in width and 9 mm in length were investigated in the stress range of sigma = (0.5-12.5) x10(4) N/m2 by stress-strain, stress-relaxation, and creep measurements. The biomechanical properties of the cornea remained unchanged in the temperature range of 30-50 degrees C. Starting at 60 degrees C, shrinkage occurred that increased up to a temperature of 90 degrees C. The maximal rate of shrinkage of 57 +/- 12% was determined at temperatures of 75 degrees and 80 degrees C. At above 100 degrees C the shrinkage effect decreased because of the destruction of intermolecular bonds between the collagen fibers. The stress-strain curves generated for shrunken corneas were flatter than those generated for native corneas, which means that Young's modulus is significantly reduced. For the achievement of optimal shrinkage during thermokeratoplasty, temperatures of 70-85 degrees C should be reached in the tissue to be coagulated. Higher temperatures are capable of causing a shrinkage effect but also induce the destruction of tissue.

[Thermo-mechanical behavior the the cornea]. / Thermo-mechanisches Verhalten der Hornhaut.

BACKGROUND: Shrinkage of corneal collagen is used during thermokeratoplasty, a method to remodel the corneal curvature. The goals of our investigations were to determine the optimal temperature range for maximal shrinkage of the collagen fibers with minimal damage. MATERIALS AND METHODS: By means of a commercially available stress-strain-measuring device with a paraffin oil bath of temperatures varying from 35 degrees C to 120 degrees C strips of pig cornea 5 mm in width and 9 mm in length were investigated in the physiological stress range from sigma = (0,5-12,5) . 10(4) N/m2 by stress-strain, stress relaxation and creep measurements. RESULTS: Biomechanical properties of the cornea remain unchanged in the temperature range from 30 to 50 degrees C. Starting at 60 degrees C shrinkage occurs that increases up to 90 degrees C. The maximal rate of shrinkage of (57 +/- 12)% was measured at temperatures of 75 to 80 degrees C. Above 100 degrees C this effect is reduced by the destruction of intermolecular bonds between the collagen fibers. The stress-strain curves of the shrunk corneas are flatter than that of native corneas, which means, the Young's modulus is significantly reduced. CONCLUSIONS: In order to realize optimal shrinkage during thermokeratoplasty temperatures of 65-85 degrees C should be achieved in the coagulated tissue. Higher temperatures cause also a shrinkage effect but also a destruction of tissue.

Determination of excimer laser ablation rate of the human cornea using in vivo Scheimpflug videography.

PURPOSE: To determine in vivo the amount of human corneal tissue removed by each excimer laser pulse, the so-called ablation rate, during photorefractive keratectomy (PRK). There is confusion in the literature because the experimentally determined ablation rate of 0.4 to 0.5 microns per pulse differs from the nominal ablation rate of 0.23 to 0.3 microns per pulse, which is the value used in clinical procedures. METHODS: Eleven eyes of 11 patients were treated with PRK for correction of myopia. The corneal curvature was determined by Scheimpflug videography before and immediately after surgery. Starting from this curvature change, the authors calculated the real ablation rate. RESULTS: The real ablation rate is coincident with the nominal ablation rate and differs significantly from the ablation rate derived from deep keratectomy experiments. CONCLUSIONS: The outer layers of the cornea show significantly different ablation behavior than the deeper stroma. This information has clinical relevance for the predictability of intrastromal excimer laser procedures.

Complications of myopic photorefractive keratectomy with the excimer laser.

BACKGROUND: Although many thousands of myopic eyes have been operated on by excimer laser photorefractive keratectomy (PRK), the safety of this procedure is still a concern. METHODS: The results and complications of PRK have been studied for up to 2 years in a prospective trial including 193 eyes in 146 patients. In addition, specific complications of PRK are described that occurred in patients outside the prospective study. RESULTS: Two eyes (1.2%) lost two lines of best-spectacle-corrected visual acuity 1 year after surgery, but at 2 years one of these eyes had regained baseline visual acuity. At 1 year, 12 eyes (7.1%) had lost more than two lines of visual acuity under glare conditions. Significant complications such as manifest scarring, overcorrection, undercorrection, and continued regression are dependent on attempted refraction. Eccentric ablations with resultant induced astigmatism are rare and the incidence is dependent on the experience of the surgeon. Progressive hyperopia did not occur. CONCLUSION: Except in corrections greater than 6 diopters, complications after PRK are rare. Assuming an appropriate patient selection, PRK may be considered a relatively safe procedure compared with other refractive procedures.

Aspheric photorefractive keratectomy with excimer laser.

BACKGROUND: Increased spherical aberration of the cornea is a common finding after excimer laser keratorefractive keratectomy. The shape of the paracentral cornea is probably related to the incidence of side effects like glare and halos at night depending on ablation zone size and pupil diameter. Aspheric curvature changes of the paracentral cornea at the edge of the ablation may decrease those side effects. MATERIALS AND METHODS: Fifteen patients were treated with photorefractive keratectomy for myopia correction with a Summit excimer laser (Summit Technology, Waltham, Mass), one eye using a standard spherical algorithm and the fellow eye using a new aspherical algorithm. Eyes were followed for 6 to 18 months. RESULTS: None of 15 patients reported halos in the aspherically corrected eye stronger than in the fellow eye, whereas five patients claimed stronger halos in the spherically corrected eye. The effective clear zone size was 3.16 +/- 0.35 mm in the spherical cases compared to 3.43 +/- 0.31 in the aspherical cases, although the same ablation zone diameters of 5 mm were used. This difference is highly statistically significant. Effective spherical aberration based on raytracing analysis of the central 5 mm of the corneal topographic maps was significantly smaller in the corneas with aspheric correction than in those with spheric corrections. CONCLUSION: These results indicate better optical homogeneity in eyes after aspheric photorefractive keratectomy for myopia compared to standard spherical corrections.