Introduction To Refractive Eye Surgery

General Medical Clinics, 3rd September 2008
INTRODUCTION TO REFRACTIVE
SURGERY
Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth
London Vision Clinic, London, UK

dzr@londonvisionclinic.com
Why can’t I see well without
my glasses?
Emmetropia: Normal Eyesight
• Light is focused onto the retina
©DZ Reinstein 2008

Myopia: Short-Sighted
• Objects in the distance are
blurred
• Objects up close are clear
• Light is focused in front of

the retina
©DZ Reinstein 2008

blurred
• Objects up close are clear
• The cornea is too steep

• The eye is too long
©DZ Reinstein 2008

• The point of focus needs to be brought back to the retina

• This is achieved by flattening the centre of the cornea
©DZ Reinstein 2008

Hyperopia: Long-Sighted
clear
• Objects up close are blurred
• The light is focused behind

the retina
©DZ Reinstein 2008

Hyperopia: Long-Sighted
clear
• Objects up close are blurred
• The cornea is too flat

• The eye is too short
©DZ Reinstein 2008

Astigmatism
• Causes image ghosting
• Blurring at all distances
• There are two curvatures so

two points of focus
©DZ Reinstein 2008

Presbyopia
Near vision is blurry
Long/Short Sighted
Presbyopia with Presbyopia
©DZ Reinstein 2008

How can I correct my vision?
How Can I Correct my Vision?
Contact Refractive
Glasses
Lenses Surgery
©DZ Reinstein 2008

Vision with Glasses
• Distorted peripheral vision
• Magnification effect
– Objects appear to be in a different position and have a
different size through spectacles lenses
©DZ Reinstein 2008

Vision with Glasses
• Limited peripheral vision
– Reduced peripheral vision with glasses
– Exact prescription only in the centre of the lens

– As the eye is looking through a different part of the lens,
the prescription is no longer optimum (in particular for
progressive lenses)
©DZ Reinstein 2008

Risks with Contact Lenses
• Ocular changes
– Oedema
– Neovascularisation
• Risk of infection
– Microbial Keratitis
– Acanthamoeba
• Incidence of Microbial keratitis per patient/year:

– 0.04% DW SCL (or 0.8% over 20 years of wear)
• Risk of permanent visual loss
– 0.1% for DW SCL over 20 years of wear
©DZ Reinstein 2008

Safety of Contact Lenses
• Adverse reactions to contact lens wear
– Dryness
– CLPC (contact lens papillary conjunctivitis)
• Autoimmune reaction to SCL
– CLARE (contact lens acute red eye)
– Sterile peripheral ulcers
• Secondary to exotoxins from bacteria = corneal infiltrates
– Hypoxia (corneal oedema = halos and night glare)
• Not present with silicone hydrogel for High Dk RGPs lenses but
these only account for 10-15% of C/L wearers in the UK
– Corneal warpage
– Endothelial cell loss or dysfunction due to chronic
oedema
©DZ Reinstein 2008

Risk of Infection and vision loss – Soft Contact Lenses
• Primary cause of vision loss with soft CLs is MICROBIAL KERATITIS

– Organisms most commonly associated with microbial keratitis
• Pseudomonas
• Staphylococcus
• Acanthamoeba
• Fungal (eg aspergillus)
• Schein et al 2005 Ophthal

– Continuous wear soft contact lenses for up to 30 days and nights
n=6245, 80% completed 12 mths f/u = 5561 person years WT
• 18.0 per 10000 (0.18%)
• With vision loss 3.6 per 10,000 (0.036%) – 1 in 5 !!
< 3 weeks continuous wear > 3 weeks continuous wear

MK with vision loss 7.9 per 10,000 MK with vision loss 2.3 per 10,000 (0.023%)
(0.079%) MK without vision loss: 0.12%
MK without vision loss: 0.4%
• Risk of MK with Daily Wear soft contact lenses is 1/5 of that with
Continuous Wear soft contact lenses
©DZ Reinstein 2008

Myths in refractive surgery
Myths in Refractive Surgery
• It’s still very new
• It hurts
• If you blink or move during the procedure it can go wrong
• It doesn’t work very well
• It cannot correct long-sightedness
• It cannot correct astigmatism
• It cannot correct the need for reading glasses as you get
older – Presbyopia
• You could end up blind
• If something goes wrong there is nothing that can be done
• It doesn’t last very long
• We don’t know about the long-term safety
©DZ Reinstein 2008

History of refractive surgery
It is still very new…

Barraquer pioneered surgery in 1960
Jose Barraquer: Keratomileusis
• Jose Barraquer invented a new innovative method of
vision correction: Keratomileusis
©DZ Reinstein 2008

• Cut and freeze a ~300 µm corneal disc
• Reshape the corneal disc to reduce
myopia: shape change calculated using
trigonometry
©DZ Reinstein 2008

• Reshaping achieved using a lathe
©DZ Reinstein 2008

• The corneal disc is sutured back onto the eye
©DZ Reinstein 2008

• Procedure required a
very skilled surgeon
• Took a long time
©DZ Reinstein 2008

Advances: Excimer Laser – 1991
• Excimer laser originally funded by IBM for etching
computer integrated circuits (1970s)
• It has moved on considerably into a number of
applications since then!
©DZ Reinstein 2008

Advances: Excimer Laser
• Each pulse penetrates only 1/4 µm from the surface ~
equivalent to 1/200 of a human hair
• Underlying tissue remains cool
©DZ Reinstein 2008

Photo-Refractive Keratomileusis (PRK)
• Epithelium is removed using alcohol
and a “hockey stick”
• Excimer laser is used to reshape

stromal surface
©DZ Reinstein 2008

Laser In Situ Keratomileusis (LASIK)
• Corneal flap ~130 µm created using
microkeratome or femtosecond laser
• Flap is lifted, stromal surface is

reshaped using excimer laser
©DZ Reinstein 2008

Femtosecond Laser Flap Creation
• VisuMax (Carl Zeiss Meditec)
• Bubble layer created, then separated manually
• Advantages over mechanical microkeratomes
– More precise
– Less trauma; patient able to see throughout procedure
©DZ Reinstein 2008

Millions of Procedures Performed
• 1996-2007: 28,492,590 laser refractive surgery
procedures performed worldwide
4,000,000
3,500,000 US
# Procedures / Year
3,000,000 Global
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
1997
2001
2002
2006
1996
1998
1999
2000
2003
2004
2005
2007
Data courtesy Dave Harmon, Market Scope, Manchester, MO, USA
©DZ Reinstein 2008
It hurts…
When I sat up my first
words were, “That’s
amazing!”
I don’t remember much
about the procedure,
mainly because it was so
quick – less than 10
minutes.
It was a similar sensation Sitting on the edge of
to when you close your the chair, my eyes
eyes and then press doused in saline, I
firmly on them could read the vision
chart on the wall
opposite.
©DZ Reinstein 2008

Quick Procedure
The
Your time in the procedure is
clinic is brief and brief and
the procedure painless
itself is over in a
matter of minutes
©DZ Reinstein 2008

The procedure is
indeed painless
The best thing

about it is that it
is over in about
10 minutes
©DZ Reinstein 2008

The Procedure
• It does not hurt
• It is very quick: 10 to 15 minutes in surgery
• Visual recovery
– Vision recovers 3 hours after LASIK
– Back to work the day after surgery
– One day results: 97% driving standard
• Staff at London Vision Clinic back to work after 35
minutes!
©DZ Reinstein 2008

If you move …
Procedure
• Sophisticated eye trackers follow the eye movements
©DZ Reinstein 2008

It cannot correct long-sightedness

It cannot correct astigmatism
Who Is Suitable?
LASIK / PRK
-14.00 D 0.00 D +8.00 D
Bioptics: Clear Lens Exchange & LASIK

-30.00 D 0.00 D +15.00 D
©DZ Reinstein 2008

Who is Suitable?
Who Is Not Suitable?
• Some eye conditions
– Keratoconus
– Terriens Marginal Degeneration
– Corneal Herpes Zoster Keratitis
– Autoimmune corneal melts
• Some general conditions

– Severe diabetes with active retinopathy (higher
risk of infection and slower healing responses)
– Uncontrolled active auto-immune disease: Lupus,
Rheumatoid Arthritis, etc
©DZ Reinstein 2008

It does not work very well…

How To Get Good Outcomes
©DZ Reinstein 2008

Myopia Outcomes: up to -12.50 D
Binocular Vision (588 patients)
100% 98% 98% 100% 100%
Cumulative Percentage Patients
90%
80% 74%
70%
Post LASIK
60%
50%
50% Normal Population
40% 34% with Correction
30%
20%
9%
10%
0%
20/12.5 or better 20/16 or better 20/20 or better 20/25 or better
(supervision) (fighter pilot) (normal)
Uncorrected Visual Acuity
©DZ Reinstein 2008

Myopia: Improved Contrast Sensitivity
*
*
*
*
©DZ Reinstein 2008

Better Vision Than Glasses
With Glasses
Before LASIK
Without Glasses
After LASIK
©DZ Reinstein 2008

Better Vision Than Glasses
32% of myopic eyes have better vision without glasses after
surgery than with glasses before surgery
95.7% of myopic eyes have vision as good or better without
glasses after surgery than with glasses before surgery
60%
48.8%
50%
Percentage Eyes
40%
30.1%
30%
20% 15.1%
10% 4.3%
1.7%
0%
2 or more off 1 better than 2 better than
1 off glasses Pre BSCVA
glasses glasses glasses
Myopia [350] 4.3% 15.1% 48.8% 30.1% 1.7%
Lines Difference Between Glasses Before and Vision

After LASIK
©DZ Reinstein 2008

Hyperopia Outcomes: up to +7.25 D
Binocular Vision (336 Patients)
98% 100%
100%
93%
90%
Cumulative Percentage Patients
80%
70%
60%
50% 47%
40%
30%
20%
8%
10%
0%
20/12.5 or 20/16 or 20/20 or 20/25 or 20/32 or
better better better better better
(supervision) (fighter pilot) (normal)
Uncorrected Visual Acuity
©DZ Reinstein 2008

Hyperopia: Improved Contrast Sensitivity
*
*
©DZ Reinstein 2008

Advances: Correcting Wavefront Error
• Original images from the Hubble telescope were no better
than ground-based telescopes
• Mirror was found to have irregular non-spherical optics
(aberrations) causing blurring
• NASA developed wavefront mirror to correct the aberrations
©DZ Reinstein 2008

Advances: Wavefront-Guided Treatment
• Aberrometers can measure the wavefront of an eye
• Modern lasers can use this data to calculate the shape
change needed to correct the aberrations
• These treatments might be able to improve people with
“normal” vision to give them Super Vision
©DZ Reinstein 2008

Advances: Super Vision
Glasses or Contact
lenses:
Correction of lower
order aberrations
Wavefront-guided
refractive surgery:
Correction of higher
order aberrations
©DZ Reinstein 2008

Wavefront-Guided Treatment
Refraction: -1.50 -0.75 x 163
With Glasses Without Glasses

No Glasses Before LASIK After LASIK
Vision
©DZ Reinstein 2008

It cannot correct presbyopia

Current Presbyopic Refractive Surgery
• Intra-Ocular Lenses
– Multi-focal
– Accommodative
• Laser Refractive Surgery
– Multi-focal
– Monovision
– NEW: Laser Blended Vision
©DZ Reinstein 2008

Problem With Multi-focality
Multi-focal IOLs
PROBLEM:
ReSTOR ReZoom
Two Images
Diffraction design Concentric distance

near zones
Multi-focal Ablation Profiles
Near
Far Far
Near
Anschütz,Dausch,Klein,Joly Avalos, Rozakis, Agarwal (PARM-technique, 1998)

(Meditec group, 1991) G.Tamayo (2000)
©DZ Reinstein 2008
Visualization of Light Path for Multi-focal IOLs
2. Tecnis ZM900 (5 mm pupil)
4. ReZoom NXG1 (5 mm pupil) 5. ReSTOR SA60D3 (5 mm pupil)
©DZ Reinstein 2008

Retinal Image with Multi-focal IOLs
2. Tecnis ZM900 3. Tecnis ZMA00
4. ReZoom NXG1 5. ReSTOR SA60D3
©DZ Reinstein 2008

Optical Performance Multi-focal IOL
3 mm pupil 6 mm pupil
ReSTOR ReZoom Tecnis ZM900
©DZ Reinstein 2008

Accommodative Intra-Ocular Lenses
• Theory: lens movement forward and back replicates
accommodation
• Published studies have shown little lens movement
• Even with Pilocarpine: max 455 µm would be only 0.50 D of
accommodation
©DZ Reinstein 2008

Case Example: Post RLE
• Pre-op Rx +3.00 D OD, +3.50 D OS
• No sign of cataract
• Monovision RLE in 2003 – monofocal lenses
• Complained of misting vision and felt off balance
• 3 months post-op, LASIK to correct “off balance
feeling”
– Visual symptoms made worse
• Diagnosed with PCO in 2006
– Bilateral YAG capsulotomies performed
– No improvement in symptoms
©DZ Reinstein 2008

Case Example: Post RLE
• Visual Symptoms
– Constant mist over vision day and night
– Halos; can’t drive at night
©DZ Reinstein 2008

Case Example: Post CLE
• 46 yo divorced mother of 2.
• CLE performed Nov 2006; ReStor IOLs implanted
• Extremely fatigued eyes and couldn’t drive at night
• Extreme glare and scattering of head lights
• ReStor IOLs removed in Jan 2007, replaced with
monofocal IOLs – 2.5 hour procedure (bilateral!)
• Yag capsulotomy in November 2007
– Night vision improved
– Fatigue better but not resolved
– Foreign body sensation “like a piece of glass in the eye”
– Distance vision clear, near blurred (absolute presbyopia)
©DZ Reinstein 2008

©DZ Reinstein 2008

• Pre-op Rx +5.50 -1.00 x 85 OD, +4.75 -1.50 x 95 OS

• Bilateral CLE in 2003; accomodating IOLs implanted
• Severe night vision symptoms
• Bilateral Yag treatment in 2005 to relieve night vision
symptoms
• Night vision as below after Yag treatment
©DZ Reinstein 2008

• Night vision in 2008

• Floaters
©DZ Reinstein 2008

Case Example: Post RLE – OD
• Elshnig pearls
• Posterior capsule opacification
©DZ Reinstein 2008

Case Example: Post RLE – OS
• Elshnig pearls
• Posterior capsule opacification
©DZ Reinstein 2008

Laser Blended Vision
Presbyopia
Right Eye Left Eye
Far Distance
Distance
Intermediate
Near
©DZ Reinstein 2008

Presbyopia: Ideal Solution
Right Eye Left Eye
Far Distance
Distance
Intermediate
Near
©DZ Reinstein 2008

Current Possible Depth of Field Increase
Right Eye Left Eye
Far Distance
Distance
Intermediate
Near
©DZ Reinstein 2008

Laser Blended Vision – Micro-Monovision
Dominant Eye Non-Dominant Eye
Far Distance
Distance
“Blend Zone”
Intermediate
Near
©DZ Reinstein 2008

Contact Lens Monovision
Dominant Eye Non-Dominant Eye
Far Distance
Distance
“Blur Zone”
“Blend Zone”
Intermediate
Near
©DZ Reinstein 2008

Correcting Presbyopia: Contact Lens Monovision
Dominant eye: ~60%

mainly corrected Patients Tolerate
for distance
Non-dominant eye:
mainly corrected Brain merges two
for near images to see near and
far without glasses
©DZ Reinstein 2008

Correcting Presbyopia: Laser Blended Vision
Dominant eye: ~97%

mainly corrected Patients Tolerate
for distance
Non-dominant eye:
mainly corrected Brain merges two
for near images to see near and
far without glasses
©DZ Reinstein 2008

Myopia BV: Efficacy – Binocular Vision
Combined Binocular Distance & Near UCVA
©DZ Reinstein 2008

Hyperopia BV: Efficacy – Binocular Vision
Combined Binocular Distance & Near UCVA
©DZ Reinstein 2008

Safety and refractive surgery
You could end up blind..

If something goes wrong there is nothing that can be done…
Risks: Surgical Information Pack
©DZ Reinstein 2008

Risks
©DZ Reinstein 2008

Risks: Expert Surgeon
©DZ Reinstein 2008

Safety: All Risks Combined
-8.00 D
Preop -8.00 D Postop Situation 1
UCVA Hand movements UCVA 20/25 (little blurry)
BSCVA 20/16 BSCVA 20/16
Enh to 20/16
Postop Situation 2
UCVA 20/25 (little blurry)
BSCVA 20/25 (lose 2 lines)
0.1% chance
©DZ Reinstein 2008

Complication Rate
• According to CRSQA (Council for Refractive Surgery
Quality Assurance), a complication rate of "less than
three percent is the norm" among ophthalmic
surgeons performing LASIK, or 3 complications over
100 procedures (every eye treated counts as a
procedure).
©DZ Reinstein 2008

Complication Rate – Prof Reinstein
FLAP COMPLICATIONS Eyes out of 12,977 % Lose 2 Lines
Free Cap 1 (0.01%) 0.0000000%

Thin Flap 2 (0.02%) 0.0000000%
Incomplete Flap (no ablation) 6 (0.05%) 0.0000000%
Corneal Perforation 0 (0.00%) 0.0000000%
Blindness (total loss of vision) 0 (0.00%) 0.0000000%
Corneal scarring reducing vision 0 (0.00%) 0.0000000%
Inflammation with decrease of vision 1 (0.01%) 0.0000000%
Infection 0 (0.00%) 0.0000000%
Epithelial Ingrowth (requiring further surgery) 21 (0.19%) 0.0000000%
Need for corneal transplantation 0 (0.00%) 0.0000000%
Keratectasia 0 (0.00%) 0.0000000%
LASER COMPLICATIONS Eyes out of 12,977 % Lose 2 Lines

Visually sig. decentrations 0 (0.00%) 0.0000000%
Laser parameter data entry error 3 (0.03%) 0.0000000%
©DZ Reinstein 2008

Routine Post-Operative Management
• If managed properly, complications do not have to
result in loss of BSCVA
• Routine follow up visits
– 1 Day
– 1-3 Weeks
– 3 Months
– 6 Months
– 1 Year
– Annually
• More frequent follow ups if required
©DZ Reinstein 2008

Safety: Myopia up to -12.00 D
Safety:
Safety: Lines Change
Lines Change BSCVA
BSCVA
60%
45%
Percentage Eyes
41%
40%
20%
10%
4%
0.0% 0.0%
0%
Loss 3 or Gain 2 or
Loss 2 Loss 1 No Change Gain 1
More More
Safety 0.0% 0.0% 4% 45% 41% 10%
Lines Change BSCVA
©DZ Reinstein 2008

Safety: Hyperopia up to +7.25 D
Safety:
Safety: Lines Change
Lines Change BSCVA
BSCVA
80%
62%
Percentage Eyes
60%
40%
21%
20% 16%
0.0% 0.0% 2%
0%
Loss 3 or Gain 2 or
Loss 2 Loss 1 No Change Gain 1
More More
Safety 0.0% 0.0% 16% 62% 21% 2%
Lines Change BSCVA
©DZ Reinstein 2008

Long term safety and refractive
surgery
Advances in diagnostic tools

LASIK: The Future
• LASIK approved for all US Military personnel
©DZ Reinstein 2008

Topography Screening for Keratoconus
©DZ Reinstein 2008

Pentacam Screening for Keratoconus
©DZ Reinstein 2008

Ocular Response Analyzer
• Measurement of the stiffness of the cornea
• Could help diagnose keratoconus
Normal
Keratoconus
©DZ Reinstein 2008

Advances: Artemis
Ron
Cornell University
Bio-Acoustic Lab
1991-1998
Dan
©DZ Reinstein 2008

Advances:“Artemis 2” by Ultralink LLC
• 50 MHz Arc-Scan
• Meridional sweep (0.4sec):
– Whole anterior segment
– Whole Cornea
• Scan positional control
– IR video-image of eye
– Corneal light-reflex
– Internal fixation targets
• Exam time: 3-min per eye
FDA 2000
www.ArcScan.com
©DZ Reinstein 2008

Artemis - LASIK
©DZ Reinstein 2008

Epithelial Thickness Profile: Normal v Keratoconus
• Average Epithelium All Eyes – Left Eyes Mirrored
Normal (n=110) Keratoconus (n=40)
T N T N
Thinnest 52 µm 44 µm
Thickest 58 µm 62 µm
Difference 6 µm 12 µm
©DZ Reinstein 2008
Probability Model of the Inaccuracy of
Residual Stromal Thickness Prediction to
Reduce the Risk of Ectasia after LASIK
Long Term Safety: Risk of Ectasia
• Probability RST <200 µm for an eye with predicted RST of 250 µm
Risk
Microkeratome Head Mean SD
RST<200µm
Allergan Surgical
160 µm 181 µm 30.5 µm 18.62%
Amadeus
Moria M2 130 µm 124 µm 21.9 µm 1.15%
B&L Hansatome 160 µm 128 µm 21.1 µm 0.03%
B&L Hansatome zero

160 µm 124 µm 12.5 µm 0.00002%
compression (DZR)
Carl Zeiss VisuMax
135 µm 111 µm 7.8 µm 0.00007%
femtosecond (DZR)
©DZ Reinstein 2008

Conclusions
Conclusions
• 29 million LASIK procedures performed worldwide

• “LASIK” started in the 1960s
• Procedure has been refined ~ for a modern expert
surgeon, the risk of major visual problem is extremely
unlikely
800 years
©DZ Reinstein 2008

Thank You
Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth
London Vision Clinic, London, UK

LASIK in Corneal Graft: Pre-Op
©DZ Reinstein 2008

LASIK in Corneal Graft: Post-Op
©DZ Reinstein 2008

Topography Guided LASIK in Corneal Graft
Post-Graft 1 Year Post-LASIK
Manifest -1.25 -7.00 x 92 -2.75 -1.25 x 120

BSCVA 20/40 20/25+2
UCVA 20/200 20/63-2
Intended -1.50 -1.00 x 92
©DZ Reinstein 2008

Topography Guided LASIK in Corneal Graft
Rx -1.25 -7.00 x Rx -2.75 -1.25 x 120
92
BSCVA 20/40
Post-Graft 1 Year BSCVA 20/25+2
UCVA 20/63-2
UCVA 20/200
Int -1.50 -1.00 x
92
Ablation Difference
©DZ Reinstein 2008

What questions should your patient
ask to select a skilled surgeon?
Safety
Technology
Expertise “Do not pass go” – 8 questions
Experience
Results
Do No Pass Go Checklist: Question 1
• Question: Did the surgeon undergo formal refractive

surgery training and for how long?
• Expected Answer: You want an eye surgeon that

1. Has had at least 3 months formal training specifically in laser eye
surgery.
2. Did 100 procedures under supervision and
3. Has done at least 1000 procedures since training.
©DZ Reinstein 2008

• Question: What preoperative examinations,

preoperative testing and laser technology do you
have?
• Expected Answer: You want a clinic that provides a

dilated pupil exam, dry eye evaluation, contrast
sensitivity testing, infrared pupil size measurement,
front and back surface corneal topography, ultrasound
pachymetry (corneal thickness), and Wavefront
analysis. The laser should be able to perform custom
treatments and have an eye-tracking device.
©DZ Reinstein 2008

• Question: What percentage of patients that present to

your practice are turned down for medical reasons?
• Expected Answer: Should be at least 5% but no more

than 20%
©DZ Reinstein 2008

• Question: Do you monitor your surgical success rates

on an ongoing basis?
• Expected Answer: Must be YES
©DZ Reinstein 2008

• Question: Could you provide me with a table of your

personal most recent outcomes (not those of other
surgeons) including complication rates
• Expected Answer:
– % 20/20 should be at least 75%
– % eyes losing 2 lines BSCVA no higher than
• 0.2% shortsight
• 1.0% longsight
©DZ Reinstein 2008

• Question: What is the enhancement rate for all

shortsighted (myopic) patients treated by you? What is
it for longsighted (hyperopic) patients
– Short-sighted ~ 5%
– Long-sighted ~ 15-20%
©DZ Reinstein 2008

• Question: How many procedures have you performed

in the last 12 months?
– At least 500 per year
©DZ Reinstein 2008

• Question: Have you ever had a claim put against you

for malpractice in refractive surgery? Have any of these
been successful or settled out of court?
– No
– Delicate question but necessary
©DZ Reinstein 2008

Outcomes: Comparison with
Spectacles and Contact Lenses
Safety of Spectacles
• Spectacles generally protect the eyes but if broken can
cause serious injury such as corneal or ocular laceration
• Increased protection from injury with:
– Frames: Large wrap around frames or goggles
(Sources of injury: UV light, Blunt Trauma, High velocity projectiles
(eg metal from grinding wheels) and Chemicals
– Materials:
• Polycarbonate
• CR-39 Decreasing impact
• Toughened Glass resistance
• Untoughened Glass
©DZ Reinstein 2008

Vision Correction with Spectacles
• Many patients aren’t wearing the most accurate
prescription in their spectacles
– Reasons
• Inaccurate refraction or incorrectly dispensed spectacles
• Cost of spectacles and/or eyecare
• Failure to attend annual or biannual routine ophthalmic
examinations
• Reinstein et al 1993 Br J ophthal

– Study of Px presenting to A&E > 65 year old
– Screened for “Correctable undetected visual acuity
deficit” (CUVAD) with pinhole testing
– 34% of Patients had a CUVAD
©DZ Reinstein 2008

Safety of Contact Lenses
• Adverse reactions to contact lens wear
– Dryness
– CLPC (contact lens papillary conjunctivitis)
• Autoimmune reaction to SCL
– CLARE (contact lens acute red eye)
– Sterile peripheral ulcers
• Secondary to exotoxins from bacteria = corneal infiltrates
– Hypoxia (corneal oedema = halos and night glare)
• Not present with silicone hydrogel for High Dk RGPs lenses but
these only account for 10-15% of C/L wearers in the UK
– Corneal warpage
– Endothelial cell loss or dysfunction due to chronic
oedema
©DZ Reinstein 2008

Risk of Infection and vision loss – Soft Contact Lenses
• Primary cause of vision loss with soft CLs is MICROBIAL KERATITIS

– Organisms most commonly associated with microbial keratitis
• Pseudomonas
• Staphylococcus
• Acanthamoeba
• Fungal (eg aspergillus)
• Schein et al 2005 Ophthal

– Continuous wear soft contact lenses for up to 30 days and nights
n=6245, 80% completed 12 mths f/u = 5561 person years WT
• 18.0 per 10000 (0.18%)
• With vision loss 3.6 per 10,000 (0.036%) – 1 in 5 !!
< 3 weeks continuous wear > 3 weeks continuous wear

MK with vision loss 7.9 per 10,000 MK with vision loss 2.3 per 10,000 (0.023%)
(0.079%) MK without vision loss: 0.12%
MK without vision loss: 0.4%
• Risk of MK with Daily Wear soft contact lenses is 1/5 of that with
Continuous Wear soft contact lenses
©DZ Reinstein 2008

What does it mean to see well?
Vision testing
Quality of vision is not only

being able to read black letters
on a white background
©DZ Reinstein 2008

Vision Testing
Quality of vision =
Visual Acuity Contrast Sensitivity Aberrations =

Quality of the
optics of the eye
©DZ Reinstein 2008

Vision Testing
Good Quality of vision =
1. Good Visual Acuity: small letters on the chart
2. High Contrast Sensitivity
3. Low level of aberrations:

Low order aberrations can be corrected with glasses
and contact lenses
High order aberrations cannot be corrected with
glasses and contact lenses
©DZ Reinstein 2008

How can I correct my vision?
How Can I Correct my Vision?
Glasses Contact Lenses Refractive Surgery
©DZ Reinstein 2008

History of Glasses
©DZ Reinstein 2008

Inconvenience with Glasses
• Can’t see when you wake up
– Alarm clock
– Toilet!!
• Glasses require cleaning
• Glasses steam up
• Discomfort
• Ugly imprint on nose
• Can’t wear other types of
glasses
– Sunglasses (need clip-on)
– Swimming goggles
– Telescopic gun sights
©DZ Reinstein 2008
Inconvenience with Glasses
• People just don’t look • Children wearing glasses
good in glasses!!! get bullied!
©DZ Reinstein 2008

Risk with Glasses
• Losing glasses
• Glasses can get
knocked off
• Glasses can break
• Sharp pieces of
glasses or lenses
may cause injury
©DZ Reinstein 2008

Vision with Glasses
• Distorted peripheral vision
• Magnification effect
– Objects appear to be in a different position and have a
different size through spectacles lenses
©DZ Reinstein 2008

Vision with Glasses
• Limited peripheral vision
– Reduced peripheral vision with glasses
– Exact prescription only in the centre of the lens

– As the eye is looking through a different part of the lens,
the prescription is no longer optimum (in particular for
progressive lenses)
©DZ Reinstein 2008

Vision with Glasses
Riding at night was
the most unpleasant
because of the glare
and ghosting from
the glasses
Riding in the rain
totally smeared
the lenses
Glasses don’t have

full peripheral
vision, so you are not
fully aware of people
coming up behind you
©DZ Reinstein 2008

Inconvenience with Contact Lenses
• Daily cleaning
• Risk of losing contact lenses
©DZ Reinstein 2008

Inconvenience with Contact Lenses
• Discomfort
– Dehydration
– Dryness at the end of the day
– Dry conditions (air conditioning, aeroplane)
– Dusty, windy conditions
©DZ Reinstein 2008

Vision with Contact Lenses
• Fluctuating vision with toric contact lenses
Lens rotation
• Decreased quality of vision with bifocal contact lenses

©DZ Reinstein 2008
Risks with Contact Lenses
• Ocular changes
– Oedema
– Neovascularisation
• Risk of infection
– Acanthamoeba
• Incidence of Microbial keratitis per patient/year:

– 0.04% DW SCL (or 0.8% over 20 years of wear)
• Risk of permanent visual loss
– 0.1% for DW SCL over 20 years of wear
©DZ Reinstein 2008

What are the advantages of
refractive surgery?
Convenience for Outdoor Activities
©DZ Reinstein 2008

Golf: Michael Hoey
I was playing against the

best players in the world
and I couldn’t see where
my ball was finishing
…my vision is probably

better than 20/20 and it has
made an outrageous
difference to me on the golf I feel I can read
course greens a lot
better
©DZ Reinstein 2008

Sports Vision: Golf
Official World Golf Rankings (2005)
1. Tiger Woods
2. Vijay Singh
3. Phil Mickelson
4. Retief Goosen
5. Ernie Els
Tiger Woods says that the hole looks bigger and his ability to read greens
has improved dramatically
Tiger Woods won the first five tour events after having the surgery
Then he won the Tiger Slam of four consecutive majors in 2000-01
©DZ Reinstein 2008

Diving
If you take part in any
water sports and suffer
from poor eyesight, the
benefits of refractive
surgery are enormous
Your time in the clinic

is brief and the
procedure itself is over
in a matter of minutes
The procedure is
brief and
painless
©DZ Reinstein 2008

Diving
I don’t think it
would be
exaggerating to call
it a life changing
moment
©DZ Reinstein 2008

Some workers will
become more
productive following
the operation
They are the crack gun cops who guard

Tony Blair, ready to respond in a split
second with a precision shot to rub out
anyone deemed to threat his life.
Trouble is, some of them don’t exactly
have 20/20 vision…
©DZ Reinstein 2008

©DZ Reinstein 2008
Results for the Met Police
Population
• 7 officers: 6 myopic patients (short-sighted) and 1
hyperopic patient (long-sighted)
• Age: 41-56 years
Average Average
Distance Vision Near Vision
Pre op:
20/82
Pre op:
N12
Post op:
20/14.8
Post op:
N4
©DZ Reinstein 2008
Visual Acuity Improvement
Dark blue columns are the vision levels achieved after LASIK
Red columns are the level of vision without glasses before LASIK
Light blue columns representing the vision of ‘normal’ eyes in the population
©DZ Reinstein 2008


Introduction To Refractive Eye Surgery

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General Medical Clinics, 3rd September 2008

Dan Z Reinstein MD MA(Cantab) FRCSC DABO FRCOphth

London Vision Clinic, London, UK

• Light is focused onto the retina

©DZ Reinstein 2008

• Light is focused in front of

©DZ Reinstein 2008

• The cornea is too steep

©DZ Reinstein 2008

• The point of focus needs to be brought back to the retina

©DZ Reinstein 2008

• The light is focused behind

©DZ Reinstein 2008

• The cornea is too flat

©DZ Reinstein 2008

• There are two curvatures so

©DZ Reinstein 2008

Near vision is blurry

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

– Exact prescription only in the centre of the lens

©DZ Reinstein 2008

• Incidence of Microbial keratitis per patient/year:

©DZ Reinstein 2008

©DZ Reinstein 2008

• Primary cause of vision loss with soft CLs is MICROBIAL KERATITIS

• Schein et al 2005 Ophthal

< 3 weeks continuous wear > 3 weeks continuous wear

©DZ Reinstein 2008

©DZ Reinstein 2008

It is still very new…

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

• Excimer laser is used to reshape

©DZ Reinstein 2008

• Flap is lifted, stromal surface is

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

The best thing

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

It cannot correct long-sightedness

Bioptics: Clear Lens Exchange & LASIK

©DZ Reinstein 2008

• Some general conditions

©DZ Reinstein 2008

It does not work very well…

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

©DZ Reinstein 2008

Lines Difference Between Glasses Before and Vision

©DZ Reinstein 2008

Uncorrected Visual Acuity