Multifocal Implant Cataract or Refractive Lens Exchange with the Mplus Implant

October 17th, 2014

After over 250,000 procedures with the Mplus implant in Europe, we introduced this technology in Canada 3 years ago.
•    The implant is a segmented bifocal with minimal loss of light.
•    Unlike other multifocal implants patients typically have satisfactory reading, intermediate, and distance vision.
•    The Mplus is not pupillary dependent and as such reading can be very good even in dim light.
•    Patients can have some glare and/or halos at night but typically this is mild and improves with time.
•    The best candidates are those in which their line-of sight is less than 0.4 mm of the centre of the pupil. We are currently measuring this factor with the Acutarget machine.

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Difficulty Reading? Raindrop Corneal Inlay

October 17th, 2014

The Raindrop Corneal Inlay is the newest inlay and was performed first in Canada at the Bochner Eye Institute 5 months ago. The inlay is currently available only through special access through Health Canada.
•    The inlay is transparent, only 2 mm in size, and placed beneath a corneal flap.
•    The Raindrop increases central steepening to enhance reading.
•    Unlike other inlays it can provide satisfactory reading vision even in dim light.
•    Follow-up on our initial patients have been very encouraging with a high patient satisfaction and quick return of both distance and near vision.

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Laser Cataract Surgery- The First Centre in Canada to use the Catalys Precision Laser

October 17th, 2014

After performing over 800 laser cataract procedures with the Catalys system here are our results and/or impressions:
•    Perfectly round capsulotomy in 100% of eyes
•    Elimination of phacoemulsification in 85% of cases
•    Reduction of phacoemulsification in all hard lenses
•    No cases of ruptured posterior capsules
•    Less corneal edema, especially in those with corneal guttata
•    Less intraocular tilting because of a perfectly round capsulotomy
•    High patient satisfaction

Read our Article on Femtosecond Cataract Surgery

Topography-PRK & CXL Enhancing BCSVA

October 17th, 2014

Topography-PRK (TG-PRK) combined with CXL continues to evolve in the treatment of keratoconus, pellucid marginal degeneration, and ectasia. Here are a few important points to understand:
•    The excimer laser guided by topography can flatten steep areas and steepen flat areas of the cornea to decrease irregular astigmatism. By reducing irregularity of the corneal surface, BCSVA can be improved.
•    Results are better if TG-PRK is combined with CXL rather than performing CXL initially and TG-PRK at a later date.
•    The best candidates are those with clear corneas, a thickness of over 450 microns, and a dioptric difference across the cornea of less than 10 diopters.
•    The main goal is to improve BCSVA and not necessarily UCVA. Glasses and or contact lenses are still typically required postoperatively.
•    98% of cases have shown success in stabilizing the corneal curvature and preventing the need for a corneal transplant.

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Top Choice Awards is honoured to announce that Bochner Eye Institute has been voted Top Laser Vision Correction Services of 2014 in City of Toronto

October 17th, 2014

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Lessons Learned in Treatment of Keratoconus by Raymond Stein MD

April 8th, 2014

Experience with CXL, Topography-linked PRK, Intacs, & Phakic IOLs

Over the past years 6 years, we have performed over 4,000 CXL procedures and/or CXL combined with a topographically-linked PRK. In addition, in selected keratoconus patients, we have inserted either intracorneal rings or toric phakic IOLs. Here are our top 10 lessons learned in the surgical management of keratoconus.
1.    CXL is successful in halting keratoconus progression in 98% of eyes. Success rate is higher for corneas that are clear and are less than 60
2.    CXL should be performed on patients as young as possible to halt disease progression and loss of best-corrected spectacle acuity. We have treated patients as young as 10 years of age with corneal stability over a followup period of up to 6 years.

3.    Bilateral CXL should be performed in patients under 25 years of age with unilateral disease. Theoretically the “normal” eye can be followed for signs of disease progression, but unfortunately in some cases the disease can progress rapidly with a loss of best-corrected spectacle acuity. Since keratoconus occurs bilaterally in over 90% of patients we feel it is clinically prudent to perform bilateral CXL in younger patients.

4.    Specialized Riboflavin solutions can induce corneal swelling by at least 100 microns. Preoperatively this means that a 350 micron cornea prior to epithelial removal can usually be treated by CXL. The only corneas that cannot be swollen to any significant extent are those with corneal scars.

5.    The combination of a topographically-linked PRK (TG-PRK) with CXL offers the best chance of improving best-corrected spectacle visual acuity. TG-PRK utilizes preoperative topography maps to guide the excimer laser to flatten steep areas and steepen flat areas. This can result in a decrease in irregular astigmatism and improvement in best-corrected spectacle acuity. Thicker corneas allow for treatment using larger optical zones which have a greater effect. In addition, corneas with less than 10 diopters of difference in the central pupillary area tend to have a greater reduction in irregular astigmatism.

Postop—————————- Preop—————————- Difference Map

In the case above, note the preop inferior to superior difference of around 10 D. This allowed for successful treatment of the irregular astigmatism by flattening the inferior cornea by 4.8 D and steepening the superior cornea by 4.7 D. 

6.    Diagnosis of keratoconus should be made using elevation topography (eg Pentacam), and a careful slitlamp exam. Elevation topography evaluates both anterior and posterior corneal elevation and produces a pachymetry map. Pseudokeratoconus can occasionally be seen using only computerized topography. It is not uncommon for the following conditions to create a pseuokeratoconus pattern: epithelial basement membrane dystrophy (see images below), superficial punctate keratopathy, amiodarone keratopathy, focal corneal scars, and Salzman’s nodular degeneration.

7.    TG-PRK is a more customized approach than intracorneal rings. Usually one or two rings are inserted in the midperiphery. We reserve corneal rings for thin central corneas in which TG-PRK cannot be performed. Rings are typically inserted in advanced cases to allow enhanced contact lens wear.

8.    Best-corrected spectacle acuity can take 6 months to be achieved after CXL or CXL with TG-PRK. It takes time for epithelial maturation to occur. The epithelium can undergo hyperplasia and/or hypoplasia to smooth the corneal surface.

9.    Patients at any age with stable keratoconus may benefit from CXL and TG-PRK to improve best-corrected spectacle acuity. By reducing irregular astigmatism, patients may achieve satisfactory vision with glasses or soft contact lenses.

10.    Stable keratoconus patients with minimal irregular astigmatism, that desire an improvement in uncorrected visual acuity may benefit from a toric implantable contact lens. However, if the refractive error is low then PRK can be performed with limited CXL. This CXL procedure is associated with minimal corneal flattening which results in a more predictable refractive outcome.
Summary

I hope you find these clinical observations of interest in the management of keratoconus. If you have any questions or comments please feel free to contact me at info@Bochner.com.

Sincerely,

Raymond Stein, MD, FRCSC
Medical Director, Bochner Eye Institute
Associate Professor of Ophthalmology, University of Toronto

Topography-Linked PRK – Lessons Learned

December 16th, 2013

Value in Keratoconus, LASIK or PRK Complications, Irregular Astigmatism, and Post-RK

We have had a positive experience in performing topography-linked PRK (TG-PRK) for keratoconus, post-LASIK or PRK complications, irregular astigmatism from corneal scars, and post-RK. This technology has demonstrated significant value in improving best-corrected visual acuity and quality of vision.

Technique

The preoperative technique involves the capture of 8 consistent Scheimpflug images utilizing the Oculyzer, a device which is similar to the Pentacam. These images are then digitally transferred to the Allegretto 400 KHz to plan our customized laser ablation. The procedure involves flattening steep areas and steepening flat areas to improve the regularity of the corneal surface.

The surgical technique involves a 50-micron PTK ablation to remove the corneal epithelium. In cases of keratoconus, the corneal epithelium tends to be thinner over the cone compared to the base, and thus the 50-micron laser ablation tends to remove a thin amount of the protruding cone. This treatment is followed by a TG-PRK. In keratoconus, we try to limit the stromal laser ablation to 50 microns. Large optical zones of 6.0 or 6.5 mm, are typically associated with a greater effect and stability compared to smaller zones. The optical zone chosen depends on the preoperative corneal thickness and the degree of corneal irregularity. Corneas with a minimum thickness of 450 microns or greater typically allow for the use of larger optical zones. However, if there is a very high dioptric difference across the cornea then smaller zones may be required to minimize tissue removal.

Case Example #1

76 year old male with a corneal scar that induced significant central flattening and irregular astigmatism. A TG-PRK was performed that resulted in BCSVA improving from 20/80 to 20/30. Note the difference map below which resulted in 7.9 D of steepening centrally and 6.4 D of flattening supronasally.

Case Example #2

28 year old female with keratoconus that underwent TG-PRK and CXL on Dec 3, 2012. Examination 11 months postop showed an improvement in BCSVA from 20/40 to 20/25. Pentacam maps showed the inferior steepening to be resolved and replaced with a symmetric bow-tie pattern of astigmatism.

I hope this information is of help to you in understanding the clinical significance of a topographically-linked laser ablation. If you have any questions or comments please feel free to contact me at info@Bochner.com.

Learn more here
Sincerely,

Raymond Stein, MD, FRCSC
Medical Director, Bochner Eye Institute
Associate Professor of Ophthalmology, University of Toronto

Laser Cataract Surgery: Impressions on the first 250 Eyes treated at Bochner Eye Institute

October 18th, 2013

Improving Precision, Improving Results

Laser cataract surgery has surpassed my expectations of enhanced precision, accuracy, and safety. I was cautiously optimistic based on reported clinical results in other countries. Over the past six months, I have been impressed by the sophistication of the machine, the ease of use, reproducibility, and patient outcomes. The Catalys Laser System has been an exciting and easy procedure for patients to undergo with a quick visual recovery. Patient satisfaction has been extremely high. Here are my initial clinical impressions:

Perfect Capsulotomy

The capsulotomy is computer programmed to be centred over the visual axis with the creation of a perfect circular opening of 5 mm. Although I am comfortable with traditional surgery using forceps to create a capsulotomy, no surgeon can consistently make a perfect 5 mm opening. By creating a precise capsulotomy the residual anterior capsule overlaps the edge of the implant and holds the lens in position. With a less than perfect capsulotomy the implant can be tilted, or vault forward or backward. Laser cataract surgery with a precise capsulotomy results in a more predictable final resting position of the implant, which improves the refractive outcome and results in fewer induced higher-order aberrations.

Elimination or Reduction of Phacoemulsification

The Catalys system using 3-D OCT imaging and a femtosecond laser can fragment the nucleus into tiny cubes, which can then be primarily aspirated. In traditional cataract surgery, phacoemulsification is utilized to break the nucleus into tiny pieces prior to aspiration. This phaco energy from a tip that vibrates very quickly (20,000 times per minute) can cause adverse ocular effects. The ultrasound energy can result in corneal endothelial cell loss as well as a higher incidence of cystoid macular edema. By eliminating or reducing ultrasound energy we can preserve the corneal endothelium and hence corneal clarity, both short-term and long-term, as well as reducing the incidence of cystoid macular edema. My experience in the initial cases treated is that the corneas were clearer one day postop, and there was a quicker recovery in terms of uncorrected visual acuity and best-corrected visual acuity. Eighty percent of the initial cases were performed without phaco energy. Of the twenty percent of cases that required some phaco energy the level was significantly reduced compared to traditional surgery.

Correction of Astigmatism

Femtosecond technology can perform precise arcuate corneal incisions to reduce astigmatism. Using real-time OCT imaging the thickness of the cornea is determined. We can plan arcuate incisions at a 9 mm optical zone and at a depth of 85%. We have the option of opening these incisions at the time of surgery or to do this postoperatively to titrate the effect. We are creating these small incisions in anyone with 0.50 D or more of astigmatism. The outcomes have been significantly more predictable than performing limbal relaxing incisions with a blade. These laser arcuate incisions can be combined with a toric implant for higher degrees of astigmatism. Postoperatively, if necessary, the incisions can be opened to enhance the astigmatism correction.

I hope you find these initial impressions on Laser Cataract Surgery of interest. Please let me know if you would like to see a procedure or desire any further information.

Raymond Stein, MD, FRCSC
Medical Director, Bochner Eye Institute
Associate Professor of Ophthalmology, University of Toronto

About Bochner Eye Institute
Established 1929

The Bochner Eye Institute is a tertiary eye-care facility that was founded by Dr Maxwell Bochner in 1929 and devoted to providing leading-edge technology and excellence in patient care. Our building is a historical house that encompasses 4 floors of clinical activity.The surgeons were among the first in North America to offer laser vision correction, corneal crosslinking, topography-linked PRK for irregular corneas, phakic implants, and laser cataract surgery. The surgeons have written over 35 textbooks and hundreds of scientific articles.

40 Prince Arthur Avenue
Toronto, Ontario M5R 1A9

416 921 2131

www.Bochner.com

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Over 20 Years of Laser Vision Correction at Bochner Eye Institute

May 20th, 2013

Laser vision correction has been the most common and successful refractive procedure in North America over the past 2 decades. Clinical outcomes have been excellent when respecting the indications and contraindications of the procedure, utilizing advanced technology, surgical competence, and careful follow-up care. After more than 20 years of performing laser vision correction at the Bochner Eye Institute, this is my top list of factors to ensure outstanding patient outcomes:

1.    Rule out keratoconus and pellucid marginal degeneration (PPMD)
LASIK is a contraindication in eyes with keratoconus and PPMD. Creating a flap in a structurally weak cornea can lead to cornea ectasia. There are many clinical signs of keratoconus and PPMD but the most helpful involve topographical and pachymetry imaging utilizing Pentacam technology. Findings of clinical value include: A. Inferior to superior steepening of greater than 1.6 D; B. Central steepening of 48 D or greater; C. Elevation of posterior cornea of 17 microns or greater; and D. Area of corneal thinning that corresponds to the area of anterior and posterior corneal elevation.

2.    Rule out dry eyes
Dry eye syndrome especially with a superficial punctate keratopathy can delay the visual recovery. Patients with severe dry eyes should not undergo laser vision correction. Patients with mild to moderate dry eyes if treated aggressively preoperatively may be satisfactory candidates for LASIK. Dry eye treatments may include preservative-free artificial tears, oral omega fatty acids, lubricating gels or ointments, Restasis drops, hot compresses to the lids if plugged meibomian glands, or the Lipiflow procedure. Bochner Eye established a Dry Eye Clinic to try to rehabilitate patients and enhance their comfort and visual function.

3.    Femtosecond flap creation
Femtosecond technology has revolutionized the safety of LASIK. The creation of a thin flap that has the same thickness in the centre and periphery reduces the risk of serious complications. Unfortunately discount laser centres continue to utilize a mechanical microkeratome that exposes patients to significantly higher risks. Femtosecond lasers have eliminated the risks associated with mechanical micrkeratomes, which include: button holes, free flaps without a hinge, partial flaps, and irregular flaps.

4.    Surgical competence
Although excimer lasers and the creation of femtosecond flaps have added some automation to the procedure there are many steps that require surgical care. A skilled surgeon will insure proper centration of the corneal flap, a dry corneal bed prior to and during the excimer ablation, satisfactory patient fixation during the excimer ablation, minimal irrigation beneath the flap, and careful repositioning of the corneal flap.

5.    Postoperative care
Although complications are uncommon using advanced technology, the identification of any early complications and proper management can insure an excellent outcome. Most early complications include visually significant striae, diffuse lamellar keratitis, and an epithelial defect. The rare complications are microbial keratitis and corneal ectasia. If the refractive outcome is not satisfactory then an enhancement can be performed. It is typically best to wait at least 4 months for an enhancement to ensure refractive stability.

6.    Maintenance and Calibration of Equipment
A laser centre must insure proper calibration and maintenance of all the equipment. Excimer laser and femtosecond technology require frequent maintenance checks to be sure optimal function. A dedicated technical staff that is experienced with daily calibration of the equipment and ensures regular maintenance is critical to achieving outstanding results.

7.    Communication between the surgeon and comanging doctor
Communication between the surgeon and comanging doctor about any patient concerns or general education concepts is vital for optimal care. At the Bochner Eye Institute, communication can be accomplished with a phone call, email, or fax.

8.    Ability to customize excimer laser ablations using either topographically-linked, wavefront-guided, or wavefront-optimized techniques
The surgeon should be able to choose the right technology for the right patient to achieve the best possible outcome. Technology continues to advance with more sophisticated treatment options. When patients have any corneal irregularity, a topographically-linked ablation is the treatment of choice to smooth the corneal surface. Eight Pentacam images, representing 20,000 data points per image, are transferred to the excimer laser system and a customized laser ablation is performed. In addition, we now have the ability to centre the excimer ablation over the line-of sight and not the centre of the pupil using a topographically-linked ablation. We all recognize that a patient’s refractive error is aligned with the line-of sight, which is not necessarily the centre of the pupil. By performing the laser ablation over the line-of sight we can enhance the refractive accuracy especially in hyperopic patients.

9.    Presbyopic Considerations
Understanding the patient’s lifestyle can allow one to customize the treatment. There are many options for the correction of presbyopia including reading glasses, monovision LASIK, KAMRA or other corneal inlays, monovision with an aspheric implant, or multifocal implant with refractive lens exchange. There are advantages and disadvantages to each option. Factors that can influence a presbyopic decision include the value of stereoscopic distance vision and/or stereoscopic near vision, early crystalline lens changes, requirements of night time driving, and personality traits that can play a role in dealing with any visual imperfections. At Bochner we explore all the presbyopic options with our patients before a decision is made for final treatment.

10.    Realistic Patient Expectations
Although over 98% of patients undergoing LASIK at Bochner have excellent  uncorrected visual acuity there are some patients that may require an enhancement. As we all know, laser surgery is performed on human tissue and not on a piece of plastic. As a consequence there can be an individual variation in outcome as a result of the laser interaction with the cornea, as well as a difference in postoperative healing. At the Bochner Eye Institute, laser enhancements are performed at no charge. This life-time warranty has been our policy for over 20 years.

By Dr Raymond Stein

Laser Cataract Surgery using the Catalys Precision Laser System:

May 20th, 2013

Laser Cataract Surgery using the Catalys Precision Laser System:
Impressions on the first 80 patients treated at Bochner Eye Institute

Laser cataract surgery has surpassed my expectations of enhanced precision, accuracy, and safety. I was cautiously optimistic based on reported clinical results in other countries. Over the past four months, I have been impressed by the sophistication of the machine, the ease of use, the reproducibility, and patient outcomes. The Catalys Laser System has been an exciting and easy procedure for  patients to undergo with a quick visual recovery. Patient satisfaction has been extremely high. Here are my initial clinical impressions:

1.    Perfect Capsulotomy
The capsulotomy is computer programmed to be centred over the visual axis with the creation of a perfect circular opening of 5 mm. Although I am comfortable with traditional surgery using forceps to create a capsulotomy, no surgeon can consistently make a perfect 5 mm opening. By creating a precise capsulotomy the residual anterior capsule overlaps the edge of the implant and holds the lens in position. With a less than perfect capsulotomy the implant can be tilted, or vault forward or backward. Laser cataract surgery with a precise capsulotomy results in a more predictable final resting position of the implant, which improves the refractive outcome and results in fewer induced higher-order aberrations.

2.    Elimination or reduction of phacoemulsification
The Catalys system using 3-D OCT imaging and a femtosecond laser can fragment the nucleus into tiny cubes, which can then be primarily aspirated. In traditional cataract surgery, phacoemulsification is utilized to break the nucleus into tiny pieces prior to aspiration. This phaco energy from a tip that vibrates very quickly (20,000 times per minute) can cause adverse ocular effects. The ultrasound energy can result in corneal endothelial cell loss as well as a higher incidence of cystoid macular edema. By eliminating or reducing ultrasound energy we can preserve the corneal endothelium and hence corneal clarity, both short-term and long-term, as well as reducing the incidence of cystoid macular edema. My experience in the initial cases treated is that the corneas were clearer one day postop, and there was a quicker recovery in terms of uncorrected visual acuity and best-corrected visual acuity. Eighty percent of the initial cases were performed without phaco energy. Of the twenty percent of cases that required some phaco energy the level was significantly reduced compared to traditional surgery.

3.    Correction or reduction of astigmatism
Femtosecond technology can perform precise arcuate corneal incisions to reduce astigmatism. Using real-time OCT imaging the thickness of the cornea is determined. We can plan arcuate incisions at a 9 mm optical zone and at a depth of 80%. We have the option of opening these incisions at the time of surgery or to do this postoperatively to titrate the effect. We are creating these small incisions in anyone with more than 0.50 D of astigmatism. The outcomes have been significantly more predictable than performing limbal relaxing incisions with a blade. These laser arcuate incisions can be combined with a toric implant for higher degrees of astigmatism. Postoperatively, if necessary, the incisions can be opened to enhance the astigmatism correction.

I hope you find these initial impressions on Laser Cataract Surgery of interest. I am delighted to be able to offer this advanced technology at the Bochner Eye Institute. Learn more about Dr Raymond Stein