Why bladeless Lasik technology is better. Part II

I mentioned previously that not only have I performed Lasik surgery for many years with both bladed and Laser only systems, but I have had Lasik surgery myself. I think this gives me a unique perspective on the process because I can view Lasik from the point of view of a patient as well as an experienced surgeon. It’s interesting for me as a patient because the information I possessed in making my decisions was so much greater than the average patient. And it’s not just a matter of academic or statistical knowledge, it’s the knowledge of actually having held and used the equipment in a real life setting. Most patients don’t have that luxury.

My primary consideration when I was a Lasik surgery patient was to make sure that I had the best, safest, and most reliable equipment for myself. I am an eye surgeon so my vision is critical and you should be as particular about your eyes as I am. I like to be sure that any equipment I use for my patients is what I would choose for myself. Most people probably don’t realize the wide array of equipment choices that Lasik surgeons must make. All Lasik is NOT the same in terms of equipment used.

At the time that I was a Lasik patient over a decade ago, there were only 2 lasers that were FDA approved for doing refractive eye surgery. From my experience and knowledge at the time, I felt that one was superior in terms of operation and ease of use for the surgeon. I also felt that the one company was doing a better job of customer and equipment service which made that laser more reliable. However, the laser I felt was superior was not available in Wisconsin. I had a friend/colleague who had the better laser available to him in Arizona so I traveled to Scottsdale to have my Lasik surgery.

At that time, there were no blade-free flap cutters but we were able to have what I considered the best, most reliable, blade-based microkeratome. To this day, I believe that system remains the most reliable of the blade-based systems.

Now this is the point where I believe that I can tell you without a doubt that you should only have Lasik with the blade-free system that we currently have available. That is because even using the best of the bladed flap cutters in the hands of an experienced Lasik surgeon, we had a significant flap complication in cutting my Lasik flap!! The complication was bad enough that we had to abort the rest of the procedure, let the eye heal-up, and try again in 3 months. Fortunately, the complication (a button-hole or donut shaped hole in the center of the flap) did not cause any permanent visual defect or other problem. However, this type of problem is among the most serious problems encountered during Lasik surgery. Bladed systems can inadvertently cut button-holes, ragged flaps, or amputated flaps. It’s important to realize that the patient in this case was also an experienced surgeon and from the patient perspective I was able to detect a problem before it occurred. I actually did this during surgery which allowed my colleague to reset the equipment and proceed with what he thought should now be a flawless flap. Nonetheless, the button-hole still occurred.

So even using the top of the line bladed microkeratome and having 2 surgeons involved, it was still possible to have one of the more serious flap complications occur. I feel strongly that there are a certain number of inherent mechanical flaws which can and must exist in any bladed system. They are simple mechanical machines with rapidly moving parts and they WILL fail a certain percentage of the time regardless of what the surgical team does. Because the Laser based flap cutters have no moving parts in direct contact with the eye tissue, it is far less likely for them to create these kinds of serious problems. Although there may be great variation from instrument to instrument, the rate of flap complication using a bladed microkeratome is in the range of 1 out of every 2 or 3 hundred. That’s hundred not thousand or 10-thousand. Although that let’s the surgeon say it is less than 1 percent, it is still a relatively high number from a patient perspective. I had one colleague tell me that he had published a series in which he had no flap complications in over 10,000 cases. He finally ran out of luck and had a button-hole and the VERY next day, he went out and purchased the Laser only flap cutting system.

Ultimately, the most compelling evidence that I can give to other surgeons to switch to a blade-free system comes from my own experience as a patient as much as my experience as a surgeon. And since this laser only technology has been around now for several years, it is the only kind of Lasik that we offer in my practice. This type of Lasik is what is now known as the iLasik system which incorporates the Intralase FS laser and the Visx Star S4 laser with Customvue technology.

If you are a serious Lasik patient that is interested in knowing what the differences in technology mean for you in terms of precision and safety, you should come into our practice and learn more.

Why bladeless Lasik technology is better. Part I

I’ve had a lot of experience over the last decade performing Lasik eye surgery with a number of different technologies. I’ve used different lasers and experienced different microkeratomes (the “flap cutters” that are so critical in Lasik eye surgery). In addition, over a decade ago, I had Lasik surgery myself, so I have a unique perspective on how these technologies affect the patient as well as the surgeon.

In my experience, those surgeons that continue to use the older razor blade-based “flap cutters” are those that have little or no experience with the laser-based “flap cutters” like the Intralase FS technology that we use in my Lasik surgery practice. In my opinion, it can be misleading for those who do not have extensive experience using both technologies to give an opinion as to which is better. Although statistics may exist comparing the two, ultimately these are surgical tools and a surgeon should extensively experience them first hand to fully understand the technologies. Any surgeon that dismisses the Laser only technology without having enough experience is denying himself and his patients of the knowledge required to deliver all possible leading edge technology.

In general, people that are considering Lasik eye surgery do not expect or want razor blades cutting their eyes if it is not necessary. Usually, people are surprised to hear that a surgeon will be using a high speed vibrating razor blade to cut a flap on their eye. “I thought I was going to get Laser surgery!” is the usual first thought. Usually it is only with somebody taking time to reassure you that you accept the use of the razor blade. Surgeons may have a variety of reasons for refusing to accept new technology. In my opinion, it is often a fear of change and having to learn new techniques and procedures, rather than being cheap, that keeps many surgeons using the old blade technology. But keeping up with state-of-the-art technology is what surgeons do, and we must not allow ourselves to be complacent when significant advances are made.

But what are the technical differences between the old blade-based microkeratomes and the laser only Intralase FS technology. There are several and they are very important.

1) Depth of cutting: the laser technology allows us to cut much thinner Lasik flaps at around 100-110 microns rather than the much thicker 160-200 microns created with the blade-based microkeratomes. That means that a lot of tissue is spared and allows for far greater safety, especially for highly nearsighted people. But even with individuals with lower correction, it has been shown that thinner flaps give better optics.
2) Precision of cutting is much greater with the laser so each flap is more reliable and repeatable than is possible with a mechanical, blade driven cutter.
3) The shape and positioning of a flap is far more controllable with the laser flap maker. Since the cut is largely software driven, the shape of the cut is adjustable on a computer screen during the surgery in a way that is just not possible with bladed systems. With the bladed system, once the instrument is put onto the eye, it becomes somewhat a blind procedure and it is now out of the hands of the surgeon. The laser based system allows the surgeon to adjust to what he sees on that specific patient and can customize it to that patient in very precise ways.
4) The bladed systems by nature run the risk of leaving small bits of foreign material (metal or oils off of the blades) beneath the flap. Since there is no physical blade that passes beneath the flap with the laser, the risk of introducing metal fragments, oils, etc is greatly reduced.
5) There appears to be much less risk of flap related complications like button-holes or amputated flaps with the laser system. Every Lasik surgeon has experienced these complications and they are the ones that we worry about the most.
6) There is likely less variability in instrument to instrument function with the laser systems. Each blade has to be carefully inspected for any minute defect, and most likely there are little microscopic differences in the microkeratomes used at different surgery centers. Even small microscopic defects in one blade or instrument can significantly change the function and incidence of complications. There are actually many different manufacturers of microkeratomes and, in my experience, they do NOT all function as reliably. There is likely to be some variability from instrument to instrument even with microkeratomes made by the same manufacturer. That only makes sense considering the extremely sensitive, microscopic nature of the instruments. We see these kinds of variations all the time in other kinds of surgical instruments and it is unrealistic to expect that it wouldn’t affect performance of instruments for Lasik surgery.
7) There is also less likelihood for wear-and-tear to the instrumentation over time with the laser-based systems because of fewer mechanical parts in direct contact with tissue.

Having considered all of these logical reasons for the superiority of the laser only systems and directly experienced both systems in my own hands, I feel strongly that the old bladed microkeratomes are out of date and inferior technology.

In my next blog, I’ll further discuss my experience as a Lasik patient and why that is the strongest reason of all to use blade-free Lasik technology.

I had the chance to attend the largest meeting of Lasik and Cataract surgeons in the country early this April. The American Society of Cataract and Refractive Surgery (ASCRS) met this month in April. This meeting is always a great one for exchanging new ideas, techniques, and technologies from around the world. There were well known surgeons and scientists from as far away as India that presented their thoughts and techniques on various topics.

One of the things that has amazed me in the last decade is the pace and ease with which new ideas can be shared from around the world. Complicated or difficult procedures which were being tried out in difficult third world conditions were on digital video and able to be shared with thousands of us here in the USA. It was fascinating for me to observe techniques being tried with very simplified technology due to extreme poverty conditions and yet the outcomes achievable were relatively decent considering. The digital video technology available to us today allows to see and learn things which, a couple of decades ago, many would have dismissed as impossible or exaggerated. But to be able to see and share those techniques with the world allows us now to quickly learn and disseminate new ideas in a way that was never possible.

This fact is especially true among younger surgeons like myself that came of age in the computer age. Access to high speed internet for information comes as second nature to us, so of course, we have sought to improve and develop our fund of surgical knowledge through the internet. In the last 5-10 years, I’ve been impressed that new ideas in surgery have been posted easily and readily not only on individual websites but even to places like YouTube. It surprised me actually, a few years back when I discovered that I could find high quality digital video of cataract surgery or lasik surgery on YouTube. I have, in fact, incorporated a number of cataract surgery techniques that I discovered by watching others on the internet.

Many surgeons, young and old, become very complacent in their surgical technique. It’s a natural thing to become comfortable with one set of technology or techniques and feel that they are good enough. As things change, the surgeon will often become reluctant to move ahead with those changes. This mental stagnation is one of the greatest things that a doctor and surgeon must avoid. If you are not constantly evaluating what you are doing and what is on the horizon, your physical and mental skills are deteriorating. As they say, "if you don’t use it, you lose it."

Exploring these new techniques at meetings and through the internet has allowed me to add a host of improvements to my cataract surgeries for better, faster, and safer surgeries for my patients. Similarly I am constantly examining and adopting newer technologies for Lasik surgery. Many Lasik surgeons continue to use the bladed microkeratomes for Lasik surgery and I think a lot of that is fear of change more than anything else. Before I used the Intralase technology for Lasik, I was happy and comfortable using the steel razor blade based microkeratomes despite the rare problems that they created. But after I had adopted the all laser Intralase technology, it was clear to me that there was no comparison. I realized afterward that this was just another example of me wanting to stay in my comfort zone and not make a change, despite the fact that the newer technology was better and safer. I think that any surgeon that spends a significant amount of time and becomes comfortable with both the newer and older technology will agree that the Intralase technology is far superior to the bladed microkeratomes.