ENTER RELEX-GOODBYE EXCIMER

Dr. Rupal Shah Clinical Director, New Vision Laser Centers, India www.drrupalshahlasik.com

EXCIMER LASER
Technology has been around since at least 20 years Stable Technology Excellent results (>95% of all eyes are within +/0.5D) Ability to customize treatments High Patient Awareness and Acceptance

CONVENTIONAL LASIK

Mechanical Microkeratome to create a hinged flap Flap is lifted to one side and excimer laser ablation is carried out In excimer Laser ablation a lens is ablated from the cornea, equivalent to the correction achieved

Lens material is removed in the shape of a gas plume from the corneal surface

FEMTOSECOND LASER
Well

established Safety Profile for making LASIK Flaps Several Advantages

Locked In Flap Fully Sterile Tight control of Flap thickness Thin Flaps possible More Predictability and better complication profile relative to mechanical microkeratome flaps

Preferred choice for making LASIK flaps

RELEX
Uses only the femtosecond laser for completing the entire LASIK procedure No need for an excimer laser Possible only with the VisuMax Laser from Carl Zeiss Two Procedures

FLEx=Femtosecond Lenticule Extraction SMILE-Small Incision Lenticule Extraction

Surgical steps of the ReLeX Procedure

1

WHY RELEX?

STABILITY OF THE LASER

Excimer Laser is a gas based laser. Even after many improvements, it is not as stable as a fiber based femtosecond laser In a study we did, our MEL 80 excimer laser required about six interventions in the year ended February 2011 (including gas bottle changes) Our VisuMax Femtosecond Laser required only two interventions (of which one was for software upgradation)

CORNEAL RESHAPING WITHOUT ABLATION

An excimer laser performs photoablation The photoablation rate increases linearly with fluence beyond a certain threshold Excimer Laser fluence and photoablation rate gets influenced by various factors corneal hydration levels, humidity levels, the presence of organic vapors, the depth of ablation This results in a scatter, especially for the treatment of high myopia

RELEX
Uses cutting instead of ablation A binary process instead of linear Much less influence of any external factors Reflected in the tremendous accuracy achieved, even in the first 1500-2000 eyes treated worldwide Results are especially interesting for high myopia, a group in which excimer lasers dont fare as well

RESULTS OF REFRACTIVE CORRECTION USING RELEX WITH A 500 KHZ VISUMAX

100% 90% 80% 70% 60% 50% 40% 30%
CZM-Application Pujara

month (eyes) 1 m (410) 6 m (261)

3 m (377) 1 y (64)

97% 98% 94% 95%

20% 10%

1% 1% 1% 2%
0%

2% 2% 3%

1% 1% 1%

1% 0%

0%

-2

-1

+0

to

to

+1

01

51

to

-1 ,

-0 ,

51

Refractive outcome - Percentage within Attempted

+0 ,

+1 ,

01

to

+2

,5

SCATTER PLOT OF RELEX WITH A 500 KHZ LASER (AT 3 MONTHS)

Achieved [D]
15 14 13 12 11 10 9 8 7 6 5 4 3 2
CZM-Application Pujara

Scatter: Attempted vs. Achieved SEQ 'PREDICTABILITY'

377 eyes

overcorrected

y = 0.99x + 0.02 R2 = 0.98

undercorrected

1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Attempted delta SR equiv. [D]

RESULTS OF RELEX FOR HIGH MYOPIA (>-5D UPTO -10D)

RELEX AND INFLAMMATION

Total amount of energy input into the eye with ReLEx is less than with Femto LASIK Results in less inflammation and higher stability of the treatment

RELEX-STABILITY AFTER TREATMENT WITH A 500 KHZ LASER

1.00 0.00 pre op -1.00 -2.00 -3.00
-4.43 -0.02 -0.02 -0.03 -0.03

1m

3m

6m

1y

-4.00 -5.00 -6.00

422 410 377 261
CZM-Application Pujara

-7.00

64

Achieved Correction SEQ over Time 'STABILITY'

STABILITY AFTER RELEX FOR THE TREATMENT OF HIGH MYOPIA (>-5D)

1.00 0.14 0.00 pre op -1.00 -2.00 -3.00 -4.00 -5.00 -6.00 -6.41 -7.00 123 -8.00 118 113 Time 83 43 1w 1m 3m 6m 0.07 0.08 0.06

POTENTIAL FOR MINIMALLY INVASIVE TREATMENT

One can easily remove the lenticule from a 3 mm incision. We are working on techniques to reduce this to less than 1.5 mm

VIDEO

SMALL INCISIONS
No risk of flap displacements (There is a cap. There is no flap!!!) Small Incision results in minimal cutting of corneal nerves less dry eyes, smaller reduction in corneal sensitivity Less discomfort for the patient for a smaller period Possible better biomechanical stability relative to Femto-LASIK

INDUCTION OF ABERRATIONS

Excimer lasers suffer from peripheral fluence loss

Fresnel reflection losses at a high angle of incidence Increase in spot size in the periphery Minimized by newer ablation profiles

Leads to an increase in spherical aberrations

However, with ReLEx, this problem is essentially not there

Should lead to less induction of spherical aberration In our study, there was an induction of less than 0.12 microns of spherical aberration (5 mm pupil)

WORKFLOW IMPROVEMENTS
No need to change stations No need to keep placing and removing the speculum In a study we conducted,

SMILE (2 Eyes) took an average of 12.9 minutes Femto LASIK (2 Eyes) took an average of 21 minutes

At our volume, doing ReLEx on all patients would result in a net saving of 120 hours a year, or half an hour every working day

PATIENT ACCEPTANCE
Patients really like the idea of a flap less procedure without the pain and slow visual recovery of surface procedures In my experience, ReLEx is an easier sell to patients than Femto-LASIK

COSTS
Only one laser needed instead of 2 Capital cost is reduced by nearly 50% Consumables of only one laser Maintenance contract of only one laser

SO WHEN IS AN EXCIMER NEEDED

Wavefront Guided Procedures (< 5% of a normal refractive practice) Retreatments (< 1% in ReLEx procedures- In over 1000 eyes treated, I have actually retreated only 3 eyes) Hyperopia (Latest results of ReLEx for Hyperopia are quite encouraging)

GOODBYE EXCIMER
Enter ReLEx drrupalshahlasik.com