A protocol for topographic-guided corneal repair utilizing the US Food and Drug Administration-approved Wavelight Contoura

Authors Motwani M
Received 16 November 2016
Accepted for publication 28 February 2017
Published 23 March 2017 Volume 2017:11 Pages 573—581
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Amy Norman
Peer reviewer comments 6
Editor who approved publication: Dr Scott Fraser

Purpose: To demonstrate how Wavelight Contoura can be used to repair corneas damaged by trauma and prior poor surgical outcomes.

Methods: Four representative eyes are presented that show different scenarios in which highly irregular corneas can be corrected with Wavelight Contoura using a protocol (named the San Diego Protocol) designed to use the information in Contoura processing. Both laser-assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) were used.

Results: Highly aberrant corneas with large amounts of warpage can be corrected safely with the Wavelight Contoura system. The San Diego Protocol requires individual analysis of each case with decisions based on the level of warpage and the level of epithelial hyperplastic compensation. The need for a second refractive power equalization procedure should be planned for.

Conclusion: Contoura measured refraction can be integrally used as part of the San Diego Protocol to safely repair highly warped corneas. The refractive outcomes show dramatic improvement in vision, best-corrected visual acuity (BCVA), refraction, and topographic uniformity.

The use of Wavelight® Contoura to create a uniform cornea: the LYRA Protocol. Part 1: the effect of higher-order corneal aberrations on refractive astigmatism

Authors Motwani M
Received 3 February 2017
Accepted for publication 18 April 2017
Published 16 May 2017 Volume 2017:11 Pages 897—905
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Amy Norman
Peer reviewer comments 4
Editor who approved publication: Dr Scott Fraser

Purpose: To demonstrate how higher-order corneal aberrations can cancel out, modify, or induce lower-order corneal astigmatism.

Patients and methods: Six representative eyes are presented that show different scenarios in which higher-order aberrations interacting with corneal astigmatism can affect the manifest refraction. WaveLight® Contoura ablation maps showing the higher-order aberrations are shown, as are results of correction with full measured correction using the LYRA (Layer Yolked Reduction of Astigmatism) Protocol.

Results: Higher-order corneal aberrations such as trefoil, quadrafoil, and coma can create ovalization of the central cornea, which can interact with the ovalization caused by lower-order astigmatism to either induce, cancel out, or modify the manifest refraction. Contoura processing successfully determines the linkage of these interactions resulting in full astigmatism removal. Purely lenticular astigmatism appears to be rare, but a case is also demonstrated. The author theorizes that all aberrations require cerebral compensatory processing and can be removed, supported by the facts that full removal of aberrations and its linkage with lower-order astigmatism with the LYRA Protocol has not resulted in worse or unacceptable vision for any patients.

Conclusion: Higher-order aberrations interacting with lower-order astigmatism is the main reason for the differences between manifest refraction and Contoura measured astigmatism, and the linkage between these interactions can be successfully treated using Contoura and the LYRA Protocol. Lenticular astigmatism is relatively rare.

The use of WaveLight® Contoura to create a uniform cornea: the LYRA Protocol. Part 2: the consequences of treating astigmatism on an incorrect axis via excimer laser

Authors Motwani M
Received 3 February 2017
Accepted for publication 18 April 2017
Published 16 May 2017 Volume 2017:11 Pages 907—913
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Amy Norman
Peer reviewer comments 4
Editor who approved publication: Dr Scott Fraser

LYRA PROTOCOLPurpose: To show how an incorrect manifest astigmatism axis can cause an abnormal induced astigmatism on a new axis.

Patients and methods: Four eyes of three patients were treated primarily with WaveLight® EX500 wavefront optimized (WFO) treatments for astigmatism. All four eyes needed enhancements and were analyzed retrospectively via WaveLight® Contoura to determine the reason for the incorrect astigmatism treatment. Two of the eyes were retreated with topographic-guided ablation, and two were treated with WFO correction.

Results: The eyes that had an incorrect manifest axis resulted in a new abnormal induced astigmatism on a wholly new axis. Treatment with topographic-guided ablation completely eliminated the newly induced astigmatism. Treatment with WFO of an abnormal induced astigmatism corrected the refraction but still left topographic evidence of the abnormal astigmatism behind. One eye was incorrectly treated for astigmatism due to coma affecting refraction when the patient was dilated. This eye had a normal induced astigmatism on a perpendicular axis and was corrected using WFO. The use of manifest refraction with WaveLight® Contoura topographic-guided ablation will lead to incorrect astigmatism correction when the manifest astigmatism and axis differ from the WaveLight® Contoura measured.

Conclusion: Correction of an incorrect manifest refraction astigmatic axis does not simply create undercorrection of the astigmatism but induces an entirely new abnormal astigmatism on a different axis. Manifest refraction is less accurate and can lead to abnormal astigmatism when laser ablation is performed.

The use of Wavelight® Contoura to create a uniform cornea: the LYRA protocol. Part 3: the results of 50 treated eyes

Authors Motwani M
Received 3 February 2017
Accepted for publication 18 April 2017
Published 16 May 2017 Volume 2017:11 Pages 915—921
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Amy Norman
Peer reviewer comments 4
Editor who approved publication: Dr Scott Fraser

LYRA PROTOCOL PART 3Purpose: To demonstrate how using the Wavelight Contoura measured astigmatism and axis eliminates corneal astigmatism and creates uniformly shaped corneas.

Patients and methods: A retrospective analysis was conducted of the first 50 eyes to have bilateral full WaveLight® Contoura LASIK correction of measured astigmatism and axis (vs conventional manifest refraction), using the Layer Yolked Reduction of Astigmatism Protocol in all cases. All patients had astigmatism corrected, and had at least 1 week of follow-up. Accuracy to desired refractive goal was assessed by postoperative refraction, aberration reduction via calculation of polynomials, and postoperative visions were analyzed as a secondary goal.

Results: The average difference of astigmatic power from manifest to measured was 0.5462D (with a range of 0–1.69D), and the average difference of axis was 14.94° (with a range of 0°–89°). Forty-seven of 50 eyes had a goal of plano, 3 had a monovision goal. Astigmatism was fully eliminated from all but 2 eyes, and 1 eye had regression with astigmatism. Of the eyes with plano as the goal, 80.85% were 20/15 or better, and 100% were 20/20 or better. Polynomial analysis postoperatively showed that at 6.5 mm, the average C3 was reduced by 86.5% and the average C5 by 85.14%.

Conclusions: Using WaveLight® Contoura measured astigmatism and axis removes higher order aberrations and allows for the creation of a more uniform cornea with accurate removal of astigmatism, and reduction of aberration polynomials. WaveLight® Contoura successfully links the refractive correction layer and aberration repair layer using the Layer Yolked Reduction of Astigmatism Protocol to demonstrate how aberration removal can affect refractive correction.

Treatment of moderate-to-high hyperopia with the WaveLight Allegretto 400 and EX500 excimer laser systems

Authors Motwani M, Pei R
Received 3 March 2017
Accepted for publication 1 May 2017
Published 24 May 2017 Volume 2017:11 Pages 999—1007
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Amy Norman
Peer reviewer comments 2
Editor who approved publication: Dr Scott Fraser

Purpose: To evaluate the efficacy of treating patients with +3.00 diopters (D) to +6.00 D of hyperopia via laser-assisted in situ keratomileusis (LASIK) with the WaveLight Allegretto 400 and EX500 excimer laser systems.

Setting: Private clinical ophthalmology practice.

Patients and methods: This was a retrospective study of patients undergoing LASIK treatments of +3.00 to +6.00 D on two different WaveLight laser systems: 163 eyes on the 400 (Hertz) Hz system and 54 eyes on the 500 Hz system. The duration of follow-up was 6 months postoperation. Data were evaluated for uncorrected distance visual acuity, corrected distance visual acuity (CDVA), spherical equivalents (SEQs), and changes in these parameters (eg, loss of vision, regression over time).

Results: Treatment with both lasers was safe and effective, with loss of one line of CDVA in four of 162 eyes using the 400 Hz laser system, and none of the 54 eyes with the 500 Hz laser system. Overall, regression ≥0.75 D from goal at 6 months was observed in 11.7% (19/163) of eyes in the 400 Hz laser group and 9.26% (5/54) of eyes in the 500 Hz laser group (regression ≥0.50 D =77.9% [127/163] and 77.8% [42/54], respectively). The mean SEQ regressions for all eyes with moderate hyperopia were 0.10 and 0.18 D for those with high hyperopia.

Conclusions: Both the 400 and 500 Hz excimer laser systems were safe and effective for the LASIK treatment of moderate-to-high hyperopia. The overall rate of regression was low and the amount of regression was relatively small with both systems.

Treatment of high myopia/myopic astigmatism with a combination of WaveLight Contoura with LYRA protocol and wavefront-optimized treatment

Authors Motwani M
Received 19 November 2017
Accepted for publication 23 February 2018
Published 10 May 2018 Volume 2018:12 Pages 875—883
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Colin Mak
Peer reviewer comments 2
Editor who approved publication: Dr Scott Fraser

Purpose: The aim of this article was to demonstrate how WaveLight Contoura and wavefront optimization (WFO) can be used together to treat high myopia/myopic astigmatism corrections.

Materials and methods: A retrospective analysis was conducted on 24 consecutive myopic/myopic astigmatism eyes that exceeded the Contoura labeling of -8.00 with -3.00 D of astigmatism. Residual correction after Contoura with Layer Yolked Reduction of Astigmatism protocol was treated with WFO Contoura LASIK correction. All patients had 3 months of follow-up. Accuracy to the desired refractive goal was assessed by postoperative refraction, regression, postoperative vision, and anecdotal subjective night vision quality.

Results: No eyes lost best-corrected visual acuity (BCVA), and 54% of eyes gained BCVA. Out of 22 distance eyes, five achieved 20/15 or better, 18 achieved 20/20 vision, two achieved 20/25, and three achieved 20/30 vision. Preoperatively, only 14 eyes could achieve 20/20 vision. No night vision issues were observed in anecdotal reporting by patients except for those who needed enhancements that had not yet been performed.

Conclusion: Treatment of high myopia/astigmatism with this combination of Contoura with LYRA protocol and WFO results in excellent visual outcomes, large ablation zones on topography, and few subjective reported night vision issues.

Topographic-guided treatment of hyperopic corrections with a combination of higher order aberration removal with WaveLight® Contoura and wavefront-optimized hyperopic treatment

Authors Motwani M
Received 14 January 2018
Accepted for publication 20 March 2018
Published 1 June 2018 Volume 2018:12 Pages 1021—1029
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Andrew Yee
Peer reviewer comments 3
Editor who approved publication: Dr Scott Fraser

Purpose: This pilot study was conducted to test the hypothesis that WaveLight® Contoura and wavefront-optimized (WFO) hyperopic treatment can be used together for hyperopia/hyperopic astigmatism to create more uniform corneas.

Materials and methods: A retrospective analysis was conducted in 35 consecutive hyperopic/hyperopic astigmatism eyes of 22 patients treated via LASIK on the Wavelight® EX500. Higher order aberrations and astigmatism were removed using Contoura with the Layer Yolked Reduction of Astigmatism (LYRA) Protocol, and hyperopia was treated with WFO correction. All patients had 3 months of follow-up. Outcome measures were assessed by post-operative refraction, regression, and post-operative vision. Topographic analysis showed the degree of uniformity of the cornea achieved.

Results: Average hyperopia treated was +2 diopters (D) (range +0.50 D to +7.25 D), with the average amount of astigmatism treated +1.05 D (range -0.25 D to -2.25 D). The average difference between the Contoura-measured and manifest magnitude of astigmatism was 0.674 D and the average axis difference was 5.65°. No eyes lost corrected distance visual acuity (CDVA), 22.8% of eyes gained CDVA. At 3 months, 18 (54%) eyes had regressed or not achieved their targeted goal, and the average spherical equivalent (SE) from the targeted goal was 0.973 D. Following primary procedure, 10 of these eyes had myopic SE, six had hyperopic SE, and two had SE of 0. Prior to surgery, 19 of 24 distance eyes were able to achieve 20/20 vision, and if secondary corrections are included 100% achieved 20/20 or better post-operative, and eight (42%) achieved 20/15 or better at 3 months post-operative. No eyes lost CDVA.

Conclusion: This pilot study demonstrated that more uniform corneas can be created while treating hyperopic corrections, but a high level of secondary corrections were needed.

The use of WaveLight Contoura to create a uniform cornea: 6-month results with subjective patient surveys

Authors Motwani M, Pei R
Received 29 May 2018
Accepted for publication 23 July 2018
Published 28 August 2018 Volume 2018:12 Pages 1559—1566
DOI https://doi.org/10.2147/OPTH.S175661
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Colin Mak
Peer reviewer comments 2
Editor who approved publication: Dr Scott Fraser

Purpose: The aim of this study was to report on the 6-month visual results of Contoura with Layer Yolked Reduction of Astigmatism (LYRA) protocol, as well as the subjective patient-reported outcomes (PRO) by standardized survey.

Patients and methods: A retrospective analysis was conducted in 50 consecutive eyes with 6-month results that had bilateral Contoura laser-assisted in situ keratomileusis (LASIK) correction of measured astigmatism and axis using the LYRA protocol. PRO were measured via the Refractive Status and Vision Profile (RSVP) standardized survey. Objective visual results, subjective patient results, and rates of regression were reported.

Results: Most (78%) of the eyes achieved an uncorrected visual acuity (UCVA) of 20/15 and 98% of the eyes achieved an UCVA of 20/20 vision after primary correction. After enhancements, the percentage of uncorrected eyes achieving 20/15 vision was 90 and 20/20 vision was 100. RSVP patient-related outcomes showed that all patients (100%) were either satisfied or very satisfied with their vision. Most patients (21/25, 84%) were very satisfied. On a numerical ordinal scale of 1–10 (where 10 is the best vision), as reported by patients post-operative (post-op), 15 (60%) patients reported a vision score of 10, nine (36%) patients reported a score of 9, and one (4%) patient reported a score of 8. Initial correction was accurate on all patients, but nine eyes had refractive error changes due to epithelial masking of higher order aberrations (HOAs) over the follow-up period, a number that was also likely artificially high due to study bias.

Conclusion: Contoura measured axis and astigmatism-eliminated HOA, resulting in a more uniform cornea with an accurate removal of astigmatism, excellent 20/15 and 20/20 visual outcomes, and favorable patient-reported subjective outcomes.

Response to: WaveLight® Contoura topography-guided planning: contribution of anterior corneal higher-order aberrations and posterior corneal astigmatism to manifest refractive astigmatism

Clin Ophthalmol. 2018; 12: 2001–2004.
Published online 2018 Oct 11.
PMCID: PMC6188177
PMID: 30349183
Manoj Motwani

See the article “WaveLight® Contoura topography-guided planning: contribution of anterior corneal higher-order aberrations and posterior corneal astigmatism to manifest refractive astigmatism” on page 1423.

Dear editor

I would like to thank Wallerstein et al1 for his thoughtful research letter, but I do have some issue with the analysis. The paper references only Part 1 of the LYRA Protocol series, and not the other two parts. Part 3 provides the data for treatment with Contoura-measured astigmatism using the LYRA Protocol (termed anterior corneal astigmatism [ACA]). The concept of anterior corneal higher-order aberrations (CHOA) modifying the manifest refractive astigmatism (RA) was illustrated in an ovalization form to demonstrate why the LYRA Protocol works. These interactions are three-dimensional (3D) in nature, and we are demonstrating with 2D CHOA maps from Contoura. These maps are impacted by user/technical error, and also by epithelial compensation of the CHOA, adding a layer of inaccuracy in these comparisons. In fact, the concept of epithelial compensation affecting the ability to measure and treat CHOA is not part of any current refractive system, Contoura, Ray tracing, etc. The static Gullstrand model has mainly been used, ignoring the fact that epithelial compensation causes variability.

Prior studies looking at posterior corneal astigmatism (PCA) did not fully consider that ACA could be modified by CHOA. If their findings were correct, then we simply could not achieve the level of accuracy that we did in Part 3 of the LYRA Protocol, nor in 2.5 years of performing Contoura with LYRA Protocol on primary eyes in our clinic. If 9% of eyes had -0.5 D of astigmatism caused by PCA, then at least 9% of eyes would have residual astigmatism immediately after treatment with LYRA Protocol, and that is not the case. If anterior/posterior lenticular astigmatism, lens decentration, and retinal astigmatism were also clinically significant, an even higher number of patients have incorrect outcomes post-Contoura with LYRA Protocol. These patients would have residual RA, but no ACA on Contoura processing, and have astigmatism present on Wavefront analysis. We have documented two types of cases where residual RA is present after laser correction utilizing Contoura with LYRA Protocol- residual RA immediately post-op (very uncommon), and change in clinical refraction from plano to RA over 3–6 months. In virtually all of these cases measurable ACA has been found. This was confirmed by using Wavefront analysis to look for astigmatism sources other than ACA. For this reason, a study is currently being conducted to examine epithelial thickness compensation of CHOA as the reason for the uncommon eyes that have significant RA after ACA treatment, or for the 6%–7% of eyes that develop RA over 3–6 months postop.

Finally, it is important to note that PCA is usually antagonistic to ACA. PCA is against the rule in most eyes, and ACA is with the rule in most eyes; therefore, it is not additive as is stated by Wallerstein et al.1

The reason the ovalization theory was initially postulated was due to the outcome data not being explained by prior theories on the source of ocular residual astigmatism. The outcome data overwhelmingly shows that ocular astigmatism is anterior corneal in origin. The most important part of any theory is that it explains the observed outcome data.2,3

Photorefractive Keratectomy After Late Traumatic LASIK Flap Loss

Manoj Motwani, MD; Guillermo J. Lizano, BA;
Kenneth Yam, BS; Carter English, BS

ABSTRACT

PURPOSE: To present a case of photorefractive keratectomy (PRK) after late traumatic LASIK flap loss.

METHODS: The initial LASIK procedure was performed in 2003 with a Moria M2 microkeratome and NIDEK EC-5000 excimer laser using a 5.0/9.0-mm aspheric ablation pattern, resulting in 20/20_ uncorrected distance visual acuity (UDVA) and plano refraction. Traumatic fl ap loss of the right eye occurred in 2007. The patient was treated for the trauma, and PRK for _5.00 _1.25 _ 090° was performed 2 months later.

RESULTS: Posttraumatic fl ap loss UDVA was 20/200 in the right eye, with corrected distance visual acuity (CDVA) of 20/25+2. After PRK with mitomycin C (MMC), UDVA was 20/15 2 months postoperatively and was maintained through the last postoperative follow-up in 2010 (approximately 3 years after PRK).

CONCLUSIONS: Treating a patient with traumatic LASIK fl ap loss can be done by careful, conservative treatment of the abrasion followed by correction of the refractive error using PRK with MMC.

[J Refract Surg. 2011;27(7):542-544.]

doi:10.3928/1081597X-20110210-02