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Photo Feature From Premier Surgeon in Elkins Park

November 11, 2011 By d p

James S. Lewis, MD, and The Eye Institute of Salus University

Creating the premium practice means staying “ahead of the pack” in a number of areas, not the least of which being the technology aspect of ophthalmology. At The Eye Institute of Salus University, James S. Lewis, MD, has done just that, creating a high-tech yet inviting environment for his patients.

“I’ve been interested in imaging, particularly video imaging, even before I started my practice,” Dr. Lewis told Premier Surgeon. “It’s the perfect match because ophthalmology lends itself to the creative use of optics, ultrasound, laser interferometry and laser techniques.”

Dr. Lewis’ love of technology can be seen in every aspect of the well-appointed office. Within the waiting areas, patients watch educational videos on large-screen, high-definition LCD and plasma monitors, and each surgical procedure is recorded to DVD using top-of-the-line cameras so patients can view their surgery at home. Images by Peter Olson Photography.

Click cover art and open the article on Premier Surgeon’s Site

Filed Under: Introduction, State of the Art Tagged With: Corneal Subspecialist, DVD, Elkins Park, high-definition, LCD, Peter Olson Photography, Premier Surgeon, premium practice, state of the art, surgeon, technology

OCT imaging

July 7, 2011 By d p

Potential clinical implications of femtosecond laser flap furrows unknown

by Cheryl Guttman Krader in Paris

EUROTIMES | Volume 16 | Issue 5

eurotimes masthead

Anterior segment OCT imaging (RTVue, OptoVue) post-LASIK revealed the presence of a stromal tissue gap between the distal flap edge and peripheral untouched cornea in eyes whose flap was fashioned with a 60 kHz femtosecond laser (IntraLase, AMO), reported James Lewis MD, at the XXVIII Congress of the ESCRS in Paris, France.

This newly described phenomenon was seen immediately after surgery and the first day post-op. This femtosecond furrow was more subtle one week after surgery. No such findings were observed in eyes whose flap was created with a mechanical microkeratome (One Use Plus SBK, Moria), said Dr Lewis, director of cornea and refractive surgery, Salus University, Elkins Park, PA, US. “The discovery of an early post-op stromal furrow nullifies any benefit of the 150 degree inverted-bevel side cut. The concept of tongue-in-groove tissue alignment can have no merit if there is no stromal apposition. The espoused theory of improved flap adhesion, enhanced biomechanics stability, and reduced risk of epithelial ingrowth are now highly suspect,” he said.

The OCT images were captured in a two surgeon, two-centre study involving two groups of 30 eyes each. Flaps were created using the femtosecond laser (90-degree side cut) or a mechanical microkeratome. Images were interpreted by a third, masked observer. Immediately after surgery, a furrow was observed in all femtosecond laser eyes. Its width was irregular from the surface to the bottom of the furrow, measuring at least 10 microns in all eyes, averaging 42 microns, and extending up to 62 microns in some cases, Dr Lewis reported.

With a mechanically constructed flap, a 5 to 10 micron gap separated the flap epithelium from the epithelium of the peripheral untouched cornea. In all of these cases the stromal edges were in perfect apposition for 360 degrees.

At one week, the OCT images suggested that the femtosecond furrow was filled with an epithelial plug, Dr Lewis said.

He theorised that the femtosecond laser may ablate and thereby remove stromal tissue. Another possibility, he said, is heat damage and resultant collagen foreshortening. Dr Lewis also suspected that the epithelial plug may erode as can happen in old RK incisions. He is currently using thermal imaging to detect excess heat generated during the femtosecond side cut. He is also studying flap apposition in eyes with a 150-degree inverted bevel. Further study is needed to explore whether the femtosecond furrow represents a peculiarity of an individual surgeon’s technique, Dr Lewis said.

Although it appears that the gap becomes filled with epithelium, Dr Lewis said there is no evidence of an increased incidence of epithelial ingrowth after primary LASIK procedures performed with the 60k Hz femtosecond laser. Currently, epithelial ingrowth is a complication of late flap lifts regardless of the flap creation modality. As many surgeons are now choosing advanced surface ablation for LASIK enhancements, the issue becomes moot.

The increased biomechanics stability some attribute to femtosecond flaps is based on a false premise since no “tongue in groove” stromal contact is actually achieved. If, in the future, a femtosecond flap could be created without the furrow, the rabbit studies suggesting increased strength are still not applicable. These studies are based on full thickness bevelled penetrating keratoplasty incisions with an over-sized donor-recipient tissue diameter and over 10 times the amount of stroma to stroma contact as is in LASIK.

Dr Lewis calculated that a 150 degree bevelled incision offers only a 20 per cent increase in tissue apposition surface area as compared to a typical femtosecond vertical incision. Furthermore, mechanical microkeratomes often achieve an even greater stroma to stroma contact although the edge is not inverted.

Other proposed evidence of enhanced adhesion is based on a peculiar hooking of the flap with a measure of the force needed to gradually peel the flap from the underlying cornea. Flaps are not exposed to such an unusual force vector in non-experimental conditions making these comparisons irrelevant. Real proof would require data showing higher rates of trauma-induced flap loss or dislocation in mechanical flaps. Dr Lewis has shown repeatable 99 micron flap thicknesses with a mechanical microkeratome in a controlled study of over 500 eyes.
James Lewis

Filed Under: State of the Art Tagged With: Dr Lewis, LASIK, LASIK flap, microkeratome, OCT, OCT images, surgeon

LASIK Up Sell

November 1, 2009 By d p

The practice of many laser vision care providers and almost all corporate LASIK eye surgery centers is to up sell LASIK surgery.  Basically, you go for LASIK surgery expecting to pay x and you leave getting custom bladeless wavefront guided wavefront optimized femtosecond laser assisted all laser LASIK for x + $1750.  You are basically told the surgery that prompted your visit isn’t the best you can do for yourself.  For a few thousand extra dollars you can get top of the line surgery.  “After all…..these are your eyes!”, they say.

If you elect not to pay extra you get standard LASIK.  If a surgeon really feels this is not the optimal surgery why is he/she performing a second best procedure electively on eyes that are entirely healthy except for some nearsightedness and astigmatism?  Granted, different surgeons have different preferences and some like one laser platform and technique over another.  I just don’t want an eye surgeon or a laservision corporation giving second best care if you don’t pay the extra money.

I’ve been asked to buy a warranty on a piece of electronics for y extra dollars.  I don’t mind this practice because I am getting exactly the product I want.  The extra money is for insurance that it won’t break before it become obsolete.   I’ve been asked whether I wanted leather seats, a sun-roof, and undercoating for z extra dollars.  I don’t mind that practice either because I am getting the car I want and I am choosing to pass on some luxuries that I don’t find important.  When a surgeon tells me I have to pay more for the safer, more effective, and visually superior procedure I’m good with that.  The fact that that same surgeon will perform the less safe, less effective and visually inferior procedure if I don’t have the money is just plain wrong.  I feel those laser vision providers and LASIK Centers should instead send those patients home without surgery. If you can’t trust your doctor to provide the best care who can you trust?

Some people describe this as bait and switch.  I would prefer bait and switch because it means the LASIK patient gets the best possible care.  They just mislead you into visiting the center and then change the price.  That is much better than pay me or get second level care.

In fact,  the official name for this model is Tiered Pricing.  At national meetings world famous surgeons have no compunction providing as many as four levels of care.  While this does not technically violate the Hippocratic Oath, “Do no harm”, I suspect if Hippocrates was living today he would prefer, “Do what is best”.

This is just one reason I charge $2500 total for both eyes regardless of the procedure:   LASIK, epi-LASIK, SBK, or Advanced Surface Ablation.  You should not have to pay extra for the best procedure for your eyes.

Filed Under: LASIK Cost Tagged With: $2500, Advanced Surface Ablation, Extra Dollars, Hippocratic Oath, LASIK, LASIK Cost, surgeon, Tiered Pricing

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