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Higher refractive volumes demand highest clinical outcomes
When more patients are treated, it is more imperative to maintain excellent outcomes.
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Safe and accurate technology has always been important in my practice, as I’m sure it is for all refractive surgeons. When we were performing radial keratotomy, my enhancement rates approached 50%. It became obvious rather early on that patient satisfaction, workload and profit margin were intimately intertwined with the accuracy of the equipment and the preoperative refractive errors of our patients.
To date, we have performed more than 115,000 LASIK procedures at the Boothe Eye Care and Laser Center. The safety parameters of the equipment we use in refractive surgery are especially important in high-volume practices, because any patient complication can deplete the amount of time we can spend with new patients. Plus, in an elective surgery such as LASIK, patients need additional handholding; the slightest perceived problem can rapidly escalate.
For my practice, once the safety of the femtosecond laser technology was verified, we began using it routinely for our LASIK patients. In my opinion, the femtosecond technology has been the greatest single leap in safety for refractive surgery. Using the IntraLase femtosecond laser (Abbott Medical Optics) has also helped with increased accuracy, to some degree.
Improvement in re-treatment rate
When wavefront technology was first introduced, again we saw improved accuracy in the patients who underwent customized surgery with the Visx laser (AMO) compared to those who opted for conventional (non-customized) LASIK surgery with the Visx laser. Furthermore, once we began using wavefront technology and the IntraLase, we found a higher rate of accuracy than what was achieved using blade keratomes. Before implementing the wavefront technology, re-treatment rates were around 10% to 15%. Once wavefront was integrated into the practice, our re-treatment rates fell to 5% to 8%. With IntraLase, our re-treatment rate fell even further, to 5%.
About a year ago, we were introduced to the WaveLight laser platform (Alcon). We realized in a short time that WaveLight was more accurate in our hands than the earlier platforms, as our re-treatment rates were reduced once again. This was especially true on patients with moderate to high astigmatism, high myopia or hyperopia.
Two key reasons I believe that the WaveLight performs better are the treatment profile and the speed of the ablation. With the WaveLight, the treatment zone is almost 100% of the optical zone, with a very small transition zone. The speed of the ablation — up to 400 Hz — reduces the variable of tissue dehydration that can adversely influence accuracy. I also firmly believe that a good manual refraction is more accurate than a custom wavefront autorefraction. With the WaveLight, the ablation appears smoother on the corneal bed; this is similarly noticeable when evaluating calibration plastic under a microscope.
However, what has impressed me the most with this latest technological advance is the accuracy of the WaveLight platform when treating large amounts of astigmatism — even in patients with more than 3 D of cylinder. Combined with the IntraLase, the WaveLight laser platform offers the best safety profile and most accurate outcomes. Our current re-treatment rate across all patients is about 3% at 3 months postop; 97% of my patients who undergo vision correction on the WaveLight platform are within 0.5 D of emmetropia. Our patients with higher astigmatism also have a similar re-treatment rate of around 3%.
Less surgical time
At the Boothe Eye Care and Laser Center, a typical busy day can mean performing 150 LASIK procedures. When we were first introduced to the IntraLase and custom wavefront technology, there was a lengthy learning curve, which slowed the number of operations we could perform in a day. The number of our man-hours increased dramatically as well. With the IntraLase, it initially took about 90 seconds to produce a single flap. When we added in the wavefront capabilities, our back-office time increased with additional patient preparation, and our intraoperative time increased with increased ablation times.
As newer generations of the IntraLase came to market, the time to create a flap was greatly reduced to about 10 to 12 seconds. With the WaveLight platform, preoperative preparation time is also reduced because we have eliminated the need to perform wavefront testing. Add to that the increased speeds of ablation — almost three to four times faster than before — and we have been able to cut hours off our surgical time. I average 12 to 14 eyes per hour with the WaveLight and IntraLase combination.
Although the Visx laser is still useful for patients with higher root-mean-square values, I use the WaveLight in more than 95% of my cases. I have found it to be just the right blend of effectiveness for surgical outcomes and efficiency for operational flow on busy surgery days.
- William Boothe, MD, is medical director of The Boothe Eye Care and Laser Center, 3900 W. 15th St., Suite 104, Plano, TX 75075; 214-328-0444; e-mail: texeyecare@aol.com.