From Maclean’s, Canada’s Newsmagazine, June 11, 07, pages 49 and 50.
“Eye surgery without a blade

Ophthalmologist David Rootman watches
through a microscope as tiny laser beams
pulse over each of Rico Ho’s eyes, forming a
microscopic layer of bubbles within the cor-
nea. A monitor in the surgery suite shows
the same magnified image Rootman sees: a
circle filling with bubbles from top to bottom
creating a “flap” (a sliver of the cornea about
100 microns thick) that is then folded back
to apply a custom-designed corrective laser
treatment. “It’s going beautifully,” says Root-
man, still looking through the microscope
as he passes a cellulose sponge over Ho’s eye-
ball, smoothing the flap back into place where
it immediately begins reattaching to the cor-
nea. As he steps through the waiting area to
the recovery room, Ho is clearly excited. “It’s
already better,” he says.
A year after his condition (a mix of myopia,
or nearsightedness, and astigmatism, a cur-
neal irregularity that distorts images) worsened
to the point that he had to ditch his contact
lenses for uncomfortably thick glasses, Ho,
27, decided to try laser eye surgery. in research-
ing his options, he quickly decided he wanted
it done with IntraLase. Commercially avail-
able for about four years, the computer-oper-
ated lntraLase is often described as the “blade-
less” option in LASIK (the form of laser eye
surgery that involves creating a corneal flap).
IntraLase carves the flap with bubbles instead
of a hand-held oscillating metal blade, known
as the microkeratome, that has been used
since LASIK first became available in Canada
in the mid ‘90s,
Rootman introduced the IntraLase tech-
nology to the Yonge Eglinton Laser Eye Centre,
in July 2005. After using it only one day, he
never wanted to go back to the microkera-
tome. IntraLase is superior, says Rootman,
for two reasons: precision and safety. He
believes it allows better control over the thick-
ness, shape and smoothness of the corneal
flap, and is much less likely to result in any
kind of surgical complication, such as a
“buttonhole” (in which a piece of tissue from
the flap remains on the cornea). “With the
microkeratome, the staff hold their breath
for the 10 seconds it takes for the blade to go
across the cornea and come back,” he says.
“So does the surgeon.”
While many eye centres across Canada are
adopting the technology, there is some debate
in the ophthalmology community about its
benefits. LASIKMD, which has 17 Canadian
locations and performs about 40 per cent of
laser eye surgeries in the country annually,
does not offer IntraLase, “To date there is no
scientific evidence that proves it is a better
way to create a flap,” says spokesman Michel
Lanctot. “Yet people are paying between $300
and $500 more an eye just for that special
technology.” Naysayers also point out that
the procedure takes slightly longer with
IntraLase, which has to do with the Suction
pressure required to harden the cornea prior
to making an incision.
It isn’t that Rootman thinks the microkera-
tome is unsafe; he used it for almost seven
years and had good results “99.99 per cent
of the time.” But Rootman thinks IntraLase
can do much more than get people out of
glasses; he sees it as the future of ophthalmol-
ogy: “I think in five years, all corneal surgery
will be done with the laser, we won’t be using
knives at all.” Already, he has performed 10
corneal transplants using IntraLase, operat-
ing on patients from his practice at the Toronto
Western Hospital in his private clinic, as part
of a study. “Those patients are only a couple
of months out now,” says Rootman, “but I’m
convinced that it’s going to be way better for
patients compared to the standard.”
And that’s not the only way in which laser
eye surgery traditionally thought of as “cos-
metic” because it eliminates the need for
glasses, is increasingly becoming an adjunct
to medically necessary procedures. For ex-
ample, in order to work properly, the new
Lasers are taking over corneal procedures
multi-focal lens many cataract patients are
now having implanted requires the removal
of any residual refractive error. “The com-
bination of intraocular and laser refractive
surgery has become the state-of-the-art care
for many cataract patients,”

I thought our patients might be interested in this story, since the Lasers used in the Air Force are the same as the  ones used at our Yonge Eglinton Centre-  DSR.
5/24/2007 - WASHINGTON (AFPN) – Air Force officials have changed the policy to allow people applying for aviation and aviation-related jobs to have had LASIK surgery. The change became effective May 21. The change also removes the altitude and high-performance aircraft restrictions for people who have had LASIK.

The decision to make these changes was based on studies that showed there was little to no effect on LASIK-treated eyes when subjected to the wind blast experienced during aircraft ejection or exposure to high altitude.

Due to stresses placed on the eyes during flight combined with the active lifestyle of military members, the recommended refractive surgeries are Wave Front Guided Photorefractive Keratectomy, or WFG-PRK, and Wave Front Guided Laser In-Situ Keratomileusis, know as WFG-LASIK, using the femtosecond laser. The eyes are more trauma resistant after surgery using one of these methods compared to other forms of refractive surgeries.

With all refractive surgeries, there is no guarantee of “perfect” sight after undergoing the procedures. Individuals must still meet the standards prescribed in AFI 48-123, Medical Examination and Standards, for entrance into the Air Force and aviation and special-duty positions.

Additional information and guidance can be found at the AF Knowledge Exchange  by accessing the restricted “Dot Mil” site: https://kx.afms.mil/USAF-RS%20or%20public%20access or public access: 
http://airforcemedicine.afms.mil/USAF-RS

Watch out for the MacLean’s magazine issue at the end of May, I think May 31st, 2007 issue.  They were in to speak to us about our centre and about IntraLase and Customvue.  The US Navy has done a very big study on the same technology we use here at YELC and have found it to be superior to other modes of Laser vision correction with the microkeratome (the blade) and other excimer lasers.  That is one reason why we have the Visx Star S4 and IntraLase, as we want to use only the best and proven technology to acheive the greatest results for our patients.

At our centre, we have decided to concentrate on IntraLase for preparing the flap, and VisX CustomVue for the corneal shaping.  Why?  because there are now several good studies that show that this is the winning combination to give people the best results, closest to target, in the safest way possible.  So we don’t want to offer anything else, even though decent results can be obtained with other methods.  To us, decent is not good enough.  IntraLase/CustomVue is giving us outstanding results, which is what it is all about.  So we think we are offering tremendous value to our patients.  High likelihood of no glasses, with the lowest chance of having a flap problem.  In comparison, I once had to take my dog to the vet for an operation, and the bill was $2000.  When I looked it over, it was totally reasonable. The doctor has a business to run, and has expenses we don’t even imagine.  So too in the Laser vision correction area, there are expensive devices, insurance, staffing etc, that actually makes $2500 per eye  sound like a very good value for a life changing experience.

We offer CustomVue, wavefront guided treatment to almost all our patients.  The standard treatments, while good, represent older, less precise ways of reshaping the cornea.  Without CustomVue, we cannot utilize the iris registration program, which allows us to precisely align the laser treatment and uniquely identify our patients by the laser.  This alignment ensures a great result and takes into acount the shifting of the pupil when the pupil gets smaller.  I can tell you, the smoothness of the surface after the laser is applied, is truly remarkable.  While our older laser was good, the VisX Star S4 with iris registration is a quantum leap forward, so much so that we recommend it in most instances.

No, not at all.  After the first day of using the IntraLase, I decided not to offer the treatment to patients.  I felt the microkeratome, while  a good device, has had its time in the sun, and it was appropriate to move on to better methods of creating the flap.  And now there is lots of information and data out there to support the better outcomes that are available combining IntraLase with CustomVue (VisX) laser treatment.  When I had my PRK and my wife had her LASIK (9 years ago),  the IntraLase and CustomVue were not available, but if they were, we would have had it done that method.

Yes, sometimes they do.  Most often on the day of surgery, less than 2% of the time.  When this happens we will float the flap back into place and that takes care of the problem.  In terms of late dislocations, this happens rarely.  We have had 3 patients in the past 10 years that have had direct blows to the eye that have moved the flap.  They were repaired promptly and all recovered excellent vision.  Interestingly, we have not had a single flap dislocated since we switched to IntraLase, I think due to the stronger healing that occurs with the IntraLase. 

People ask me:  ”Why did you go this route, using the Intralase for the first step, flap creation in LASIK?  Is it really necessary, I’ve heard that the blade technique has been around a long time”.  At first I also thought that  the microkeratome (blade) is so safe, complications so rare, it is worth the half a million dollars that it cost, plus the continued upkeep in order to switch to IntraLase?  Well, I can honestly say, yes it is worth it.  To my patients, it gives them the assurance they are getting the safest and best possible flap on their cornea.  For me, it makes the surgery more exciting and relaxing at the same time.  It is thrilling to watch the laser form millions of microscopic bubbles in the cornea so close together that a flap is created.  Within 30 seconds, a perfect smooth layer has been made.  We measure the flap thickness each time and it so close to what we predict, it is almost uncanny.  That vertical edge on the flap, makes it like a man-hole cover on the street.  In other words, it flips back into position and seals very securely.  It is more relaxing, because there is not that moment where we hold our breath, as we did with the microkeratome, as the blade passes across the eye.

Lots!  We received the IntraLase laser now 2 years ago, and it has been a fantastic experience for our patients and our staff too.  It makes the whole process of creating the flap for LASIK so much more comfortable.  It is amazing to watch the mini bubbles forming in the cornea.  Each one so close together to the next, that a perfect flap is formed.   We recently upgraded to the FS 60 model, and this means an even faster and smoother flap formation, more than cutting the time in half, so now we can make the flap in less than half a minute.  Super speed and safety.  We use this speed to make the laser spots even closer together, which translates into an even smoother flap surface.We also have a new laser to add to our lineup.  We bought a VisX Star S4 laser with iris recognition.   Why the switch, when we were getting excellent results and happy patients with our previous excimer laser?  The easiest way to explain it is, the difference between flying a 747 and an F-16 fighter plane.  The 747 is a sophisticated plane with all the fancy controls, but an F-16 incorporates all the latest navigation and control electronics.   For instance, on the VisX Star S4, we have a system of Iris Recognition.  What is that?  Iris recognition is a great system.  When your eye is measured with our Wavescan to take a picture of your unique eye, it also photographs your iris with infrared light.  This photo is like the biometric photos that are being used more commonly for security purposes, this picture is used to uniquely identify your eye and the laser is then aligned using the pattern of the colored part of your eye, the iris.   I looked around at all the available lasers and was convinced that the VisX system was the best on the market, and our experiences have verified that we made the right choice!

What other features does this laser have?  It also centers the laser treatment on the centre of your pupil, the dark central part of the eye.  This is important, because the centre of the pupil can shift when the pupil gets small, for instance, when the light shone in the eye is bright.  The laser knows this, and makes a compensating movement.  This ensures that the laser treatment is applied exactly where it should be.

 Customvue is the laser system used on the VisX laser.  All lasers out there treat the major imperfections of the eye, the ones we commonly call nearsightedness, farsightedness and astigmatism.  Yet there are other irregularities that we notice most in the dark, when the pupil is very large.  The best example of this is driving at night.  That is when people notice that headlights of oncoming cars are not distinct, small points of light. This is because at night, our pupils enlarge, and the edge of our lens and cornea contribute more to the images we see.  It is the edges that make lights seem to flare and spread.  The VisX system measures these imperfections; we call them higher order aberrations.   The laser then programs the treatment to correct not only your nearsightedness, but also these higher order aberrations.  Why is this important?  It lessens the chance of having glare and star bursting at night by correcting the aberrations and thus images are more sharply focused on our retina, the seeing part of our eye.

Getting back to the IntraLase, it is used for making the LASIK flap, but it doesn’t stop there.  The company behind this machine has now made it possible to use the laser for therapeutic applications.  This means that my patients with cornea problems that are fixable with a corneal transplant can now be operated on with a laser.  The cornea is a very thin curved tissue on the front of the eye.  It functions like a lens, and that is why we can reshape it with the laser and correct for the need to wear glasses.   But, there are many unfortunate people out there with problems with the cornea that cannot be corrected with the laser.  For these patients, a corneal transplant may correct their problem by putting a new clear window in place.  This is great, but has its down side too.  The healing is prolonged, and often there is much astigmatism after.  This is where the IntraLase comes in and can help.  The laser is so precise, that it can cut a perfect circle, give us alignment marks and even shape the edge, much as a carpenter does to shape a tongue-in-grove joint.   This makes the cornea heal better and quicker.  Truly science fiction.  And we at Yonge Eglinton Laser Eye Centre, are the first in Canada, in fact one of the few places in the world to be able to offer this type of transplant.  It is very exciting to be part of this revolution and can’t wait to see the further developments.