Surgeons conceptualize the ideal excimer laser

SEATTLE — It may be a little early to start thinking of holiday gift ideas, but a few surgeons at the ASCRS Summer Refractive Congress were sharing their wish lists.

Ronald R. Krueger, MD, Roger F. Steinert, MD, and Karl G. Stonecipher, MD, were each asked to speak about their “ideal excimer laser” in their presentations here.

Dr. Krueger said he would optimize the excimer laser spot, eye tracking system, excimer ablation pattern and delivery, and the ergonomics and external efficiency.

“The pulse frequency with some of the lasers are increasing, and I think it would be nice to see most of the lasers coming out to about 400 pulses per second, if possible, in order to decrease the time,” Dr. Krueger said.

Dr. Krueger cited a study that showed the relationship between spot size and ablation efficiency.

“As we start going with smaller spots, in order to get a very ideal shape being ablated, you are going to have to have a very fast tracker with low latency, and that is still somewhat of a challenge,” he said.

To optimize the eye tracking system, Dr. Krueger said he would prefer a tracker frequency of greater than 1,000 Hz and a latency of less than 1 millisecond.

A reproducible and accurate wavefront pattern, corneal wavefront overlap and Q-factor adjustment would also be ideal.

Dr. Krueger said he would incorporate a smart software algorithm or nomogram with the laser to compensate for biomechanics, wound healing and environmental factors. He would top it off with a moveable laser bed, patient auto-alignment and identification, infrared illumination and foot switch controls in a sequential menu of steps.

Dr. Steinert began his presentation by asking meeting attendees to mentally perform a rank order evaluation, which is used by marketers to prioritize needs.

“There really is a thing called Disney University in Orlando, and they teach this well-known marketing technique, and in Disney they teach people the magic of how they market,” he said.

Dr. Steinert asked the attendees to think about what order Disney would rank the elements — waiting times, safety in the park, environment and the shows — and revealed that safety comes first, followed by a clean environment, the shows and waiting times.

He continued by applying a rank order evaluation to lasers.

“Basic attributes include accuracy, reliability, ease of use, versatility and cost,” he said. “I think that is the order, actually.”

Dr. Steinert said he would like to see a machine that can perform a wavefront analysis as well as perform the laser treatment.

“Wouldn’t you really like get your wavefront done with all of your patients laying under the same laser instead of measuring in one place and doing it in another?” he asked.

He said he would also like to see an increase in user-friendly items that minimize the potential for error as well as an integrated femtosecond laser.

“Cheap was listed at the bottom of the list, but you can’t do everything I said and make it cheap,” he said. However, patient throughput can be increased, enhancements are decreased, and patients are happier.

“The ideal system is never going to be achieved, but it is certainly a worthy goal to pursue,” he said. “The properties that increase accuracy are going to be the most critical. Everything else evolves from that – reliability, ease of use and versatility. Cheap will take care of itself.”

Dr. Stonecipher said he would like to see real-time outcome analysis and more speed.

“It’s easy to have a wireless integration or link on our analyzers or topographers,” he said. “It would be wonderful if you could do that in real time under the laser.”

“Innovation is the key to success,” he said in a presentation handout. “However, technology can be our best ally in some instances or, on the other hand, our worst enemy, creating albatrosses around our neck from which we wish to be detached.”