2006 年 10 月 28 日 中國廈門屈光手術研討會 Early Clinical Outcomes of Epi-LASIK for Myopia in Taiwan 台灣諾貝爾醫療集團 張朝凱醫師. 陳美齡醫師. 王倫奕醫師. 劉淳熙醫師. 張鼎業醫師. 林玉凰醫師. 戴文瑛醫師. 蕭清仁博士

2006 年 10 月 28 日 中國廈門屈光手術研討會 Surface Ablation This year( 2006 ) we went B to B Back to Bowman’s

2006 年 10 月 28 日 中國廈門屈光手術研討會 Back to Bowman ’ s There has been a significant movement back to surface ablation. Major recent improvements in surface ablation include gradual blend zones and Mitomycin C for haze.

2006 年 10 月 28 日 中國廈門屈光手術研討會 Surface Ablation Concerns for Lamellar Ablation –Deeper ablations due to larger ablation zones –Increased concern of ectasia –Improved visual results? No flap related aberrations Bowman ’ s membrane a more regular canvas than stroma

2006 年 10 月 28 日 中國廈門屈光手術研討會 Surface Ablation Indications –Thin corneas –Patients predisposed to ocular trauma –Detachment surgery –Glaucoma –Flat corneas –Steep corneas –Deep-set eyes

2006 年 10 月 28 日 中國廈門屈光手術研討會 Surface Ablation Relative to Lamellar ablation –No flap related complications No striae No striae Less dry eye Less dry eye No irregular flaps No irregular flaps No DLK No DLK

2006 年 10 月 28 日 中國廈門屈光手術研討會 Surface Ablation In epi-LASIK the epithelial layer is mechanically separated from Bowman’s membrane with the use of a mechanized epikeratome without the use of alcohol. After ablation the epithelial flap complex is positioned on the cornea and a bandage contact lens is placed on the eye.

2006 年 10 月 28 日 中國廈門屈光手術研討會 Purpose To evaluate initial clinical outcome with Epi-LASIK for myopia with astigmatism

2006 年 10 月 28 日 中國廈門屈光手術研討會 Methods Three months results from a cohort of 56 eyes ( 30 patients ) that had Epi-LASIK procedures were studied.All operations were done with Amadeus 2 ( AMO, Santa Ana,CA, USA ). Three months results from a cohort of 56 eyes ( 30 patients ) that had Epi-LASIK procedures with and without Flap Removal as well as PRK were studied.All operations were done with Amadeus 2 ( AMO, Santa Ana,CA, USA ).

2006 年 10 月 28 日 中國廈門屈光手術研討會 Methods For Epi-LASIK,epithelial separation was achieved mechanically without the use of alcohol. The epithelial flap was remained (Option1) or removed (Option 2) and a therapeutic contact lens was applied to the cornea immediately for 3 to 5 days. PRK patients were as usual Postoperative epithelial defect size, symptoms, UCVA, BCVA were evaluated at three months postoperatively. Postoperative epithelial defect size, symptoms, UCVA, BCVA were evaluated at three months postoperatively.

2006 年 10 月 28 日 中國廈門屈光手術研討會 Methods Surgical Parameters – Oscillation speed: 11,000 rpm – Translation speed: 1.5 mm/sec – Suction: 22 mm Hg – Epithelial removal 9.0 mm

2006 年 10 月 28 日 中國廈門屈光手術研討會 Epi-LASIK

What is Surface Ablation (Epi Lasik) ? Compare pig eye and human eye

2006 年 10 月 28 日 中國廈門屈光手術研討會 Option 1 (Flap Remain)

2006 年 10 月 28 日 中國廈門屈光手術研討會 Option 2 (Flap Removal)

2006 年 10 月 28 日 中國廈門屈光手術研討會 Methods Epithelial defect size was measured with the slit lamp and recorded with digital photography daily until epithelial defects healed Post-operative symptoms, UCVA, BCVA were studied All patients received postoperative 0.1 FML qid for 3 weeks, Ciloxan qid for 1 week,, and BSS qid for over 6 weeks Bandage contact lenses were removed after 4 days and corneas were stained with fluorescein

2006 年 10 月 28 日 中國廈門屈光手術研討會 Results 1.Epithelial Defect Size 2.Postoperative symptoms 3.UCVA 4.BCVA 1.Epithelial Defect Size 2.Postoperative symptoms 3.UCVA 4.BCVA

2006 年 10 月 28 日 中國廈門屈光手術研討會 1.Epithelial Defect Size (mm) Following Epi-LASIK, with and without Flap Removal, and PRK

2006 年 10 月 28 日 中國廈門屈光手術研討會 Patient 1(Epi - LASIK) 手術後第 1 天 手術後第 2 天 手術後第 3 天 手術後第 5 天

2006 年 10 月 28 日 中國廈門屈光手術研討會 Patient 2 (PRK) 手術後第 1 天 手術後第 3 天 手術後第 5 天 手術後第 7 天

2006 年 10 月 28 日 中國廈門屈光手術研討會 Fluorescing Stain Flap removal 24 hours Flap removal 48 hours Flap removal 72 hours PRK 24 hours PRK 48 hours PRK 72 hours

2006 年 10 月 28 日 中國廈門屈光手術研討會 2.Pain Following Epi-LASIK, with and without Flap Removal, and PRK Pain significantly greater with PRK on day 1 and 3

2006 年 10 月 28 日 中國廈門屈光手術研討會 3.UCVA Following Epi-LASIK, with and without Flap Removal, and PRK UCVA significantly better with flap removal on day 3 and 7

2006 年 10 月 28 日 中國廈門屈光手術研討會 4.BCVA Following Epi-LASIK, with and without Flap Removal, and PRK BCVA significantly better with flap removal on day 3 and 7

2006 年 10 月 28 日 中國廈門屈光手術研討會 What are the advantages of Surface Ablation compared with Lasik? What are the advantages of Surface Ablation compared with Lasik? He can do higher correction on thin cornea. No stroma is leaving on the flap. No cut through the stroma Less risk by doing the flap Discussion 1 Discussion 1

2006 年 10 月 28 日 中國廈門屈光手術研討會 Why is Surface Ablation not always used? Why is Surface Ablation not always used? In average patients have more pain during the first 5 days post OP. It is a little more difficult to handle a Surface Ablation flap than a Lasik Flap. Surface Ablation does not substitute the Lasik : Surface Ablation is a complementary method to Lasik. Because of the wider range of possible patients, Doctor can operate about 12-17% more patients if he can use both systems. Discussion 2 Discussion 2

2006 年 10 月 28 日 中國廈門屈光手術研討會 Discussion 3 The most important initial event following surface ablation is for the corneal epithelium to heal as rapidly as possible as the outcome of surface ablation is closely related to the epithelial wound healing response. 1 1 Fagerholm P. Wound healing after photorefractive keratectomy. J Cataract Refract Surg 2000.

2006 年 10 月 28 日 中國廈門屈光手術研討會 Discussion 4 Delayed re-epithelialization increases –Time for visual rehabilitation –Incidence of postoperative haze –Pain and photophobia –Risk of infectious keratitis 1 Fagerholm P. Wound healing after photorefractive keratectomy. J Cataract Refract Surg 2000.

2006 年 10 月 28 日 中國廈門屈光手術研討會 Discussion 1  Epi –LASIK -Mechanical separation without alcohol preserves the integrity of the epithelium and stroma.  Partners well with wavefront-guided custom ablation.  This may allow for improved: Comfort Comfort Predictability Predictability Visual recovery. Visual recovery.

2006 年 10 月 28 日 中國廈門屈光手術研討會 Conclusion 1 Epi-LASIK with the Amadeus II microkeratome removes the entire corneal epithelial layer with no discernible damage to the removed tissue or damage to Bowman’s membrane.

2006 年 10 月 28 日 中國廈門屈光手術研討會 Conclusion 2 Epi-LASIK (with flap remain) with the Amadeus II microkeratome provides greater patient comfort than PRK or Epi- LASIK (with flap removal) during the immediate post-operative period

2006 年 10 月 28 日 中國廈門屈光手術研討會 Conclusion 3 Epi-LASIK (with flap removal) with the Amadeus II microkeratome provides more rapid visual rehabilitation than PRK or Epi-LASIK (with flap remain) during the immediate post-operative period

2006 年 10 月 28 日 中國廈門屈光手術研討會 Conclusion 4 We need long term studies to evaluate the efficacy of Epi-LASIK looking at –BCVA/UCVA –Corneal Haze –Corneal Sensitivity and Tear Function (AJO Volime 142, issue 4, Oct 2006) –Quality of vision and high order aberrations

2006 年 10 月 28 日 中國廈門屈光手術研討會 CONCLUSION Epilasik for moderate to high myopia with the Amadeus II Epikeratome –Safe –Reproducible –Good patient satisfaction Thank you