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Femtosecond Laser Technology. Femtosecond Lasers. IntraLase (Abbott) VisuMax femtosecond laser ( Zeiss ) Zeimer LDV ( Zeimer ). Microkeratome Most Commonly Used. *. The disposable docking suction ring is positioned on the eye & suction applied. IntraLASIK ™. Tear Film. Epithelium.

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femtosecond lasers
Femtosecond Lasers
  • IntraLase (Abbott)
  • VisuMaxfemtosecond laser (Zeiss)
  • Zeimer LDV (Zeimer)
intralase laser procedure

Tear Film

Epithelium

Bowman’s

Stroma

Descemet’s

Endothelium

IntraLase Laser Procedure
  • Glass Lens applanates cornea to flatten eye & maintain precise distance from laser head to focal point

Glass Applanation Surface

Cornea

benefits of intralase versus microkeratome
Benefits of IntraLase versus Microkeratome
  • Less Risk
    • Flap complications
    • Corneal abrasions
  • More Precise
    • Flap is more precise
      • Thickness
      • Diameter of flap
  • Better Outcomes
    • Better Visual Acuity
    • Less Dryness
flap complications
Flap Complications
  • Relatively unusual complication but can be devastating
    • Buttonhole flap
    • Free cap
    • Incomplete flap
    • Corneal perforation
corneal abrasions
Corneal Abrasions
  • Microkeratome transcends across the cornea, rubbing up against the epithelium
  • Risk factors for developing abrasions
    • EBMD, older patients, fair skin, smokers
  • Kerizian and StonecipherJ Cataract Refract Surg 2004; 30:804-811
  • Loose Epithelium
    • 9.6% for Moria
    • 7.7% for Hansatome
    • 0.0% for IntraLase
corneal abrasions1
Corneal Abrasions
  • The IntraLase laser merely docks upon the cornea rather then rubbing across the cornea
mechanical keratomes
Mechanical Keratomes

Principles of Operation

The keratome flattens the cornea & the oscillating razor blade cuts a circular flap of tissue

= “x” microns

Flap thickness is determined by the gap between the blade & the footplate

flap thickness kerizian and stonecipher j cataract refract surg 2004 30 804 811
Flap ThicknessKerizian and StonecipherJ Cataract Refract Surg 2004; 30:804-811
  • Mean Flap Thickness:
    • 114 m (SD 14m) for Intralase (130m)
    • 153 m (SD 26m) for Moria (130m)
    • 156 m (SD 29m) for Hansatome (180m)
  • IntraLase Flap has a more reliable thickness
  • Thinner Flap
    • Lessens the risk of a thin post-operative cornea
      • Keratectasia
    • Leaves more room for enhancement surgery
      • Flap lift
side cut flap edge
Side Cut Flap Edge
  • Edge of flap
    • Flap fits back in place
    • Manhole cover
    • Less risk of epithelial ingrowth on primary and enhancement procedures
intralase laser gives better vision
IntraLase Laser gives Better Vision?
  • More precise correction of astigmatism
    • Kerizian and StonecipherJ Cataract Refract Surg 2004; 30:804-811
  • Less high order aberrations
    • Tran et.al. J Cataract Refract Surg 2005 31;97 – 105
  • Controversial
visual outcome
Visual Outcome
  • Montes Mico R, Et al. Femtosecond Laser versus Mechanical Keratome for Myopia. Ophthalmology 2006;114(1):62-68.
    • Slightly better visual results
    • Better results in high spacial frequency contrast sensitivity
    • Greater percentage of patients within intended target +/-0.50 D
    • IntraLase laser created fewer higher order aberrations
  • Lim found no difference in visual results
    • Lim . Comparisons of Intralase and mechanical microkeratome for LASIK. Am J Ophthalmol.2006;141:833-9
intralase flap is planar
IntraLase Flap is Planar
  • Planar Flap: IntraLase
    • Uniform thickness
    • Induce less astigmatism
    • Induce less high order aberrations
  • Meniscus Flap: Microkeratome
    • Thinner in center then periphery
interface bed is dryer
Interface Bed is Dryer
  • Lessens risk of irregular ablation because of dryer bed

SEM image of 110 μm flap at 13X courtesy of Dan Tran, MD

less dryness
Less Dryness
  • IntraLase laser separates the corneal lamellae versus cutting nerve fibers with a blade
  • Durrie et. Al.ASCRS - April, 2005
    • Compared microkeratome versus IntraLase Laser
    • Schirmers, staining and corneal sensation were better with IntraLase at 1, 3 and 6 months
  • Lim T .Comparison of the IntraLase femtosecond laser and mechanical microkeratome for LASIK. Am J Ophthalmol.2006:141(5):833-9.
    • Corneal sensation returned faster with IntraLase vs Microkeratome
patients who benefit from intralase
Patients who benefit from IntraLase
  • Patients at risk for microkeratome complications
    • Steep and thin corneas
      • Buttonhole flaps
    • Very flat corneas
      • Free Caps
    • Blepharospastic patients
  • Higher risk for abrasions
    • Older
    • Fair skin
    • Subtle EBMD
patients who benefit from intralase1
Patients who Benefit from IntraLase
  • Higher risk for dryness
    • Low Schirmer’s
    • History of dryness
  • Patients who are risk adverse
  • Patients who have thin corneas
disadvantages of intralase
Disadvantages of IntraLase
  • Increased cost
  • Transient Light Sensitivity Syndrome (TLSS)
  • Longer procedure time
    • Opaque bubble layer may occur
    • Gas bubbles in the anterior chamber
  • Flaps do not look as good
    • Meibomian secretions
    • Flap edge
intralase flap margin
IntraLase Flap Margin
  • Hyperreflective fibrils at flap margin
    • Indicates a stronger wound healing response
  • Sonigo et al. In vivo corneal confocal microscopy comparison of IntraLasefemtosecond laser and mechanical microkeratome for LASIK. Invest Ophthalmol Vis Sci. 2006;47:2803-11.
transient light sensitivity syndrome
Transient Light Sensitivity Syndrome
  • 1 in 1000 cases
  • Eyes become very sensitive to light
  • No ocular findings
  • Presents 3-6 weeks post-operatively
  • Treat with high dose topical steroid
  • Resolves without complications
  • May be related to higher energy absorbed into anterior chamber
  • Related to energy level of femtosecond laser
other uses for intralase
Other Uses for IntraLase
  • Lamellar keratoplasty
  • Corneal Intacs
    • Corneal channels
my experience
My Experience
  • Initially saw increased rate of DLK
    • Increased energy
  • Initially had increased incidence of flap slips
    • Unknown etiology
    • Possible eyedrop usage
  • Visual outcomes same
  • Maybe less dryness
  • Less incidence of complications
    • Flap complications
    • Abrasions
    • Epithelial Ingrowth
my experience1
My Experience
  • Co-managing doctors did not embrace new technology
  • No increase in volume
  • Price per patient went up
  • Surgeon loves it!