ARTICLE

LASIK in high hyperopia with WaveLight Allegretto Eye-Q

excimer laser – One year results
Mirko R. Jankov II, MD PhD; Vesna Jovanovic, MD MS

PURPOSE: To present one-year results after LASIK in high hyperopia with spherical
equivalent (SEQ) of more than 3D using WaveLight Allegretto Wave 400Hz excimer laser
and WaveLight Rondo microkeratome.
METHODS: Fifty-one eyes of 30 patients underwent LASIK to correct hyperopia.
WaveLight Allegretto Wave 400 Hz excimer laser was used and flaps were created with
WaveLight Rondo microkeratome. Mean preoperative SEQ was +4.16 ± 1.44 D (range: +3.25
to +8.00), and mean cylinder was -1.44 ± 1.52 D (range: 0 to -5.00). Mean preoperative UVA
was 0.10 ± 0.12 (range: 0.01 to 0.40), while mean BSCVA was 0.69 ± 0.18 (range: 0.40 to
1.00). Uncorrected and best spectacle corrected visual acuities (UVA and BSCVA), as well as
manifest refraction, were recorded at 1, 6 and 12 months after the treatment.
RESULTS: One month postoperatively UVA and BSCVA increased to 0.52 ± 0.23 (range:
0.3 to 0.8) and 0.66 +/- 0.19 (range 0.4 to 1.0) respectively and did not change statistical-
ly over 1-year interval (p=0.154 and p=0.196 respectively). One eye lost one line, 35 main-
tained, and 5 eyes gained one line of BSCVA. Manifest SEQ decreased to -0.35 ± 0.88 D
(range: -2.00 to +1.00) at 1 month and stabilized at -0.16 +/- 0.65 D (range: -0.75 to
+1.00) at 1-year follow-up (p<0.05). Manifest cylinder decreased to -0.41 ± 0.50 D (range:
-2.00 to 0) at 1 month and did not change statistically over 1-year (p=0.500).
CONCLUSIONS: LASIK in high hyperopia using WaveLight Allegretto Wave provided
predictable and stable results over the period of 1 year follow-up, comparable to the out-
comes of low to moderate hyperopia. An initial overcorrection was planned to counteract
a possible regression.
J Emmetropia 2010; 1: 64-67

INTRODUCTION assisted lenticule lathing2. Other techniques, such as

Over the past years, we could witness the rapid
development of surgical methods for the correction of
hyperopia. Keratophakia, together with epiker-
atophakia and keratomileusis, was introduced by
Barraquer and was used during the 80’s, but due to the
complexity of the procedure and equipment, the inac-
curacy of refractive results, postoperative complica-
tions, and delayed visual rehabilitation1, it is rarely per-
formed today, even after recent studies of the laser
Submitted: 6/1/2010
Revised: 6/16/2010
Accepted: 6/22/2010
1 LaserFocus – Centre for Eye Microsurgery, Belgrade, Serbia.
Correspondence: Dr Mirko R. Jankov II. LaserFocus – Centre for
Eye Microsurgery. 25, Cara Nikolaja II str, 11000 Belgrade, Serbia.
E-mail: mirko.jankov@laserfocus.eu. tel/fax: +381 11 344 6626
automated lamellar keratoplasty, thermal keratoplasty,
non-contact holmium:YAG laser thermal keratoplasty
(LTK), phakic and aphakic IOL implantation, cover
quite a specific and small proportion of the patients
where the results are not better than reasonable3-9.
Laser assisted procedures as PRK10 and LASIK11 have
also been reported in the last few years for the correc-
tion of hyperopia, with pleasing results in low and
moderate hyperopia, whereas the outcomes for the
higher and secondary hyperopia were not satisfactory12.
The aim of this paper is to evaluate the refractive
results after LASIK for hyperopia with the WaveLight
ALLEGRETTO WAVE Eye-Q Excimer Laser System
and WaveLight Rondo microkeratome.
MATERIALS AND METHODS
Forty-one consecutive eyes of 23 patients under-
went LASIK for hyperopia or hyperopic astigmatism.

64 © 2010 SECOIR ISSN: 2171-4703

Sociedad Española de Cirugía Ocular Implanto-Refractiva
 LASIK IN HIGH HYPEROPIA 65

Paul, Minnesota). The WaveLight Rondo microker-

Figure 1. Visual acuity before and after the treatment.
Figure 2. Manifest refraction before and after the treatment.
atome was used to cut the corneal flaps with a nasal
hinge in all cases. The flaps were cut to expose a stro-
mal bed of at least 9.0 mm in diameter to accommo-
date hyperopic (large diameter) ablations.
The ALLEGRETTO WAVE excimer laser (Alcon-
WaveLight, Erlangen, Germany) was used to perform the
ablations in all cases. These were all wavefront optimized
(non-wavefront guided) ablations. We targeted to correct
the cylcoplegic refraction for emmetropia in all cases in
this study. The ALLEGRETTO WAVE excimer laser is a
flying spot laser system; it works with a 0.95 mm Gaussian
spot and fires at a rate of 400 Hz. Eye tracking latency is
6 ms. Optical zone diameter 6.5 mm and together with
the transition, the total ablation zone was 9.0 mm.
The spherical corrections were achieved by ablating
an annular zone of tissue in the mid-peripheral cornea
making the central cornea steeper. The cylindrical
refractive error was corrected on a similar manner by
ablating the mid-peripheral zone of the flat meridian.
Patients were examined half an hour after the sur-
geries to check for any flap irregularities or complica-
tions. Patients were seen at regular postoperative inter-
vals at 1 day, 4 days, 1 month, 3 months, 6 months and
at 12 months when the manifest refraction were repeated.
Paired student t-test was performed for statistical
analysis, and the p values of <0.05 were regarded as sta-
tistically significant.

The inclusion criteria were hyperopic sphere of at least

RESULTS
+4.0 D, astigmatism of up to 5.0 D; with a minimal
spherical equivalent of + 3.0 D. Patients under 18 years Forty-one eyes of 23 patients (80%) of the initial 51
old, those with history of previous corneal surgery, his- eyes were available for follow up on the 12th month;
tory to herpetic eye disease, corneal dystrophy, corneal seven patients (10 eyes) were lost to follow up.
scarring, keratoconus, severe dry eye, and collagen vas- There were no significant intra-operative complica-
cular diseases were excluded from this study. tions noted in this limited group.
Preoperative evaluation included uncorrected visual Pre and postoperative results can be found on Table
acuity (UCVA), refraction (manifest and cycloplegic), 1. One month postoperatively UVA and BSCVA
best spectacle corrected visual acuity (BSCVA), slit
lamp examination, fundus evaluation, corneal tomog-
Table 1: Pre and post operative clinical data
raphy with the ALLEGRETTO WAVE Oculyzer™
(Oculus, Wetzlar, Germany), corneal topography with Pre 1m 6m 1y
the ALLEGRETTO WAVE Topolyzer™ (Oculus,
Wetzlar, Germany), and ultrasound corneal pachyme- UVA 0.10±0.12 0.52±0.23 0.55±0.23 0.47±0.14
try with the Nidek US-1800 (Echoscan, Achi, Japan). (0.01 to 0.40) (0.20 to 0.80) (0.20 to 0.80) (0.20 to 0.80)
All surgeries were performed by a single surgeon BCVA 0.69±0.18 0.66±0.19 0.70±0.21 0.66±0.22
(0.30 to 1.00) (0.30 to 1.00) (0.30 to 1.00) (0.30 to 1.00)
(MJ) in an outpatient refractive surgery clinic in
Within 0% 76% 73% 71%
Belgrade, Serbia. Measurements and data gathering ±0.50 D
were obtained by the surgeon and his staff. Within 0% 90% 91% 93%
The procedures were carried out under topical ±1.0 D
anaesthesia with a drop of proparacaine 1 % (Alcaine, Sphere 4.88±1.18 -0.15±0.68 0.04±0.74 0.21±0.55
Alcon, Fort Worth, Texas) instilled into patient’s eye [D] (4.00 to 8.00) (-3.00 to 1.25) (-2.00 to 1.25) (-0.75 to 1.00)
just before the procedure. Eyelids were cleaned with Cylinder -1.44±1.52 -0.41±0.50 -0.50±0.52 -0.75±0.41
povidone iodine antiseptic 10% (Betadine, Purdue [D] (-5.25 to 0.00) (-2.00 to 0.00) (-1.75 to 0.00) (-1.25 to 0.00)
SEQ [D] 4.16±1.42 -0.35±0.88 -0.21±0.94 -0.16±0.65
Pharma L.P. CT) and the eye lashes were isolated with (3.25 to 6.50) (-2.00 to 1.00) (-1.00 to 0.50) (-0.75 to 1.00)
sterile plastic drapes (Tegaderm, 3M Health Care, St.
JOURNAL OF EMMETROPIA - VOL 1, APRIL-JUNE
66 LASIK IN HIGH HYPEROPIA
increased to 0.52 ± 0.23 (range: 0.3 to 0.8) and
0.66 ± 0.19 (range 0.4 to 1.0) respectively and did not
change statistically over 1-year interval (p=0.154 and
p=0.196 respectively).
One eye lost one line, 35 maintained, and 5 eyes
gained one line of BSCVA.
Manifest SEQ decreased to -0.35 ± 0.88 D (range:
-2.00 to +1.00) at 1 month and stabilized at
–0.16 ± 0.65 D (range: -0.75 to +1.00) at 1-year fol-
low-up (p<0.05). Manifest cylinder decreased to
–0.41 ± 0.50 D (range: -2.00 to 0) at 1 month and did
not change statistically over 1-year (p=0.500).
Seventy-six percent of the eyes after 1 month and
71% after 1 year were within ±0.5 D, while 90% of the
eyes after 1 month and 93% after 1 year were within
±1.0 D.
DISCUSSION
Broad beam scanning excimer lasers for correction
of hyperopic refractive errors had been moderately sat-
isfactory10. Unlike in myopia where corneal flattening
corrects the refractive error, in hyperopia and mixed
astigmatism, central corneal steepening is needed to
compensate for the refractive error. This can only be
achieved by ablating corneal tissue mid-peripherally
and leaving tissue centrally, which was a challenging
task with broad beam excimer systems that were con-
trolled by aperture mechanisms. With the advent of
flying spot lasers it may have become possible to over-
come this limitation. These lasers can accurately ablate
the cornea into more complex shapes compared to the
older scanning systems. Thus hyperopic and mixed
astigmatism ablation patterns are theoretically more
efficient with these lasers.
We have shown in this case series that indeed the
ALLEGRETTO WAVE system can safely and effec-
tively perform hyperopic and hyperopic astigmatic cor-
rections, which is comparable to the results we obtain
when doing myopic corrections.
At twelve months follow up our mean refraction
manifest spherical equivalent was -0.16 D (SD±0.65)
and 71% of eyes were within 0.50 D of the intended
post-operative refraction, which was slightly more
overcorrection than in the USFDA trials at 6 months:
mean SEQ +0.24 D (SD ±0.54) with 70% of eyes
within 0.50 D of refractive target13. The reason for this
difference may be the inclusion criteria of extreme
hyperopia and high hyperopic astigmatism in our study
compared to a low to moderate one in the USFDA
trial, as well as our decision to correct the full cyclo-
plegic refraction rather than manifest one. If we con-
sider spherical error only, the values of +0.16
(SD±0.55) are comparable with the USFDA trial data.
Our results are also similar to those published with the
laser system of the same manufacturer (14) or better than
JOURNAL OF EMMETROPIA - VOL 1, APRIL-JUNE
published results achieved with other similar systems for
the correction of hyperopic refractive errors10-12,15-18.
Our results showed a mean regression of +0.37
(SD±0.21) over the first year follow up, most of which
occurred in the first 6 months, while the SEQ main-
tained the stable value over 1 year follow-up period. In
comparison, a mean +0.32 (SD±0.02) D regression in
the manifest refraction between the first month and 3rd
month and a smaller regression thereafter (not-signifi-
cant) has been described by Kanellopoulos et al with
the older model (200 Hz) of the same laser14.
This laser system has been shown to have extreme
stability for hyperopic treatments over the period of
more than four years based on FDA and post FDA
data13. Stability for 151 patients regarding the manifest
refraction spherical equivalent within ±1.00 D or less
was seen in 119/127 (93.7%) eyes. Regression of effect
of >1.00 D was seen in 6/127 (4.7%) eyes and progres-
sion of effect was seen in 2/127 (1.6%) eyes13.
In comparison, evaluation of mean regression
(increasing hyperopia) between 3 and 36 months post-
operatively in low hyperopia with SCHWIND ESIRIS
laser (SCHWIND eye-tech-solutions, Kleinostheim,
Germany) resulted in a Maloney index of 0.016
D/month, or 0.2 D/year15.
There was a virtually no change of lines in the
BSCVA, as expected in hyperopic treatments because
correcting hyperopia in the cornea plane induces some
«minification» effect as compared to the patient’s spec-
tacle correction. This is slightly different than with the
results obtained in the FDA clinical trials, and study by
Kanellopoulos et al where a marginal overall gain of 0.3
to 0.4 lines was reported13,14.
Other systems showed slightly worse results in hyper-
opia over +3.00 D. Llovet et al performed hyperopic
LASIK with MEL 80 excimer laser (Carl Zeiss Meditec,
Jena, Germany), where 4.0% of the patients lost 2 or
more lines and the enhancement rate was 18.4%16.
Waring et al. described that 63.1% (176/279) of
eyes after hyperopic LASIK with NIDEK EC-5000
excimer laser (Nidek Co. Ltd., Gamagari, Japan).
achieved a SEQ within ±0.50 D. Less than 2% (4/279)
of eyes lost 2 lines of distance BCVA. Stability of
refraction was demonstrated by 6 months, with a mean
hyperopic shift of < 0.03 D from 3 to 6 months17.
Desai et al showed results of Visx Star S2 excimer
laser (Abbott Laboratories Inc. Abbott Park, Illinois,
USA) where a residual of +0.59±1.18 D was encoun-
tered after 3 years follow up in the high hyperopia
group. The percentage of eyes within ±1.00 D of
emmetropia was 66.7%, and the hyperopic shift
between 1 year and the last visit was +0.55 D18.
We theorize that good results with WaveLight
ALLEGRETTO WAVE Eye-Q 400 Hz excimer laser
system may be explained at least in part, by the fact
that the system uses the wavefront optimized ablation
 LASIK IN HIGH HYPEROPIA
profile. This profile uses peripheral compensation for
predicted energy loss due to corneal curvature, fluence
decrease and reflection increase by increasing up to
35% more pulses in the periphery19. Thus the excimer
laser effectively treats hyperopia and cylinder close to
the theoretical peripheral ring of 6.5 to 9.5 mm from
the center of the visual axis. This principle along with
the smooth stromal surface created by the microker-
atome may contribute in the rapid visual recovery
noted at day one in this limited case series14.
Hyperopic LASIK utilizing the ALLEGRETTO
WAVE excimer laser and the WaveLight Rondo micro-
keratome appears to be safe and effective in the correc-
tion of high hyperopia. The post-operative results at 1
year are notable for hyperopic and astigmatic refractive
error correction, improvement in both UCVA and
BSCVA, with minimal regression and need for
enhancement. This study course through one year of
follow up is considered short by the authors, as our pre-
vious clinical experience with other laser platforms has
shown late hyperopic regression. Larger and longer fol-
low up studies can elucidate on the safety, efficacy and
stability of this surgical intervention.
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First author:
Mirko R. Jankov II, MD, PhD
LaserFocus - Centre for Eye Microsurgery,
Belgrade, Serbia