Versatility. Comfort. Meets. Choosing a Refractive Platform to Meet Practical Needs and Premium Outcomes

Transcription

1 Supplement to November/December 2017 Sponsored by ZEISS Versatility Meets Comfort Choosing a Refractive Platform to Meet Practical Needs and Premium Outcomes

2 ReLEx SMILE Broadening the vision of success Table of Contents Three Reasons Why the VisuMax Femtosecond Laser is Worth the Investment... 3 The versatility of the VisuMax to perform various laser vision correction procedures makes it an attractive femtosecond laser platform. BY LANCE KUGLER, MD Don t Forget About the Flap... 5 The VisuMax femtosecond laser is much more than a tool for SMILE. BY STEVEN D. VOLD, MD SMILE: Another Opportunity to Make LVC Great... 7 First experiences in the United States. BY GREGORY D. PARKHURST, MD, FACS

3 Three Reasons Why the VisuMax Femtosecond Laser is Worth the Investment Versatility Meets Comfort The versatility of the VisuMax to perform various laser vision correction procedures makes it an attractive femtosecond laser platform. BY LANCE KUGLER, MD It was a little more than 1 year ago that Kugler Vision purchased the VisuMax femtosecond laser system (ZEISS). At the time, in September 2016, we owned the WaveLight FS200 (Alcon), which is a great laser, and we were getting excellent results. Our interest in purchasing a second platform was so that we had redundancy and also so that we could take advantage of the unique features of different platforms. Looking back, purchasing the VisuMax was a wise investment in our quest to maximize patient satisfaction and to grow our overall refractive surgery volume. Herein I review the three main reasons why I believe that the VisuMax femtosecond laser system is worth the investment. THREE REASONS Reason No. 1: The VisuMax provides a unique patient experience. I have used most of the femtosecond lasers that are available today, whether in my own practice or during my fellowship training, and I feel that the VisuMax provides the most comfortable patient experience. This is mainly because the docking interface to the eye (Figure 1) is so soft meaning the cornea is not applanated nearly as much as with some other platforms that patients barely feel it. It has been described to me that the pressure felt by the patient during docking the interface of the VisuMax laser feels roughly the same as the amount of pressure that is applied with Goldmann applanation tonometry. From the patient s perspective, this translates to a rather comfortable docking process. I had heard from colleagues and patients who have been treated with the VisuMax that it is a comfortable laser, but I did not realize just how much more comfortable it is for patients than other laser platforms. This aspect alone has enhanced the LASIK experience for patients, and it has been a big benefit of owning the VisuMax. The downside to the soft dock is that suction break can be more common if the patient is not still during treatment. However, with what we call verbal anesthesia coaching patients through it and asking them to focus on the fixation light and not move their eye suction breaks have been a rare occurrence. The other good news is, if a suction break does occur, the software is very user friendly and guides the surgeon through completing the treatment. It is better at that than any of the other lasers I have used. Figure 1. A patient is docked under the VisuMax femtosecond laser. Reason No. 2: The VisuMax makes beautiful LASIK flaps. Something that goes hand-in-hand with the unique patient experience is the fact that the laser makes beautiful LASIK flaps. When we purchased the VisuMax, we exclusively used it as a flap maker for 6 months; once SMILE was approved by the FDA, we then started performing that procedure as well. What I quickly found out in those first 6 months is that the VisuMax offers an adequate range of flap diameters and that patients are likely to have a positive surgical experience. This can translate into more word-of-mouth referrals because of the excellent patient experience. The bottom line is that having a gentler laser matters to our patients. Something else relevant is that I have found the VisuMax is the laser most likely to achieve a good docking in patients who have narrow lid fissures. If a patient has trouble opening his or her eye, or if he or she has a tight lid fissure or a prominent brow, I immediately prefer the VisuMax. Reason No. 3: SMILE is an exciting new refractive surgery procedure. One of the main reasons that we chose the VisuMax is that we knew small incision lenticule extraction (SMILE) would NOVEMBER/DECEMBER 2017 SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY 3

4 eventually be approved by the FDA, and we were very interested in getting involved with the procedure. We have now been offering SMILE since Spring 2017, and it has been a nice addition to the armamentarium of procedures we can offer our patients. SMILE has a prominent place in refractive surgery treatments. I particularly like it for people who have dry, irritated eyes and I am concerned that a lot of disruption to their surface might be uncomfortable for them. In terms of the healing process, SMILE tends to be a little more gentle to the ocular surface than other procedures that we can offer patients. I also like SMILE for people who play contact sports or may sustain repeated trauma to their eyes, like boxers or mixed martial arts fighters. In situations like these, in the past I might have chosen PRK; now, I am more likely to choose SMILE. There are also patients who have already decided on their own that they do not want to undergo a flap-based procedure. They have done their research, and, in their opinion, they do not want a flap. SMILE appeals to these patients, because there is no flap and they do not have to go through the PRK healing process. The other thing I like about SMILE is that it is performed with one laser system. I think, over time, that is going to prove to be a nice advantage compared with LASIK. The excimer laser can be difficult to maintain; the gas exchange, the calibrations, and the nomograms that are associated with it can be daunting. Compared with the excimer laser, the femtosecond laser is easier to maintain, it does not need as frequent calibration, and it allows the entire procedure to be performed under the same system. I think that once the astigmatism indication is approved by the FDA, we will see an upsurge in the number of SMILE procedures being performed; it will really open the door to SMILE, as more patients will be eligible for the procedure. With that said, we have a way to go until SMILE achieves the precision and reproducibility that we are accustomed to with modern LASIK. CONCLUSION It is an exciting time in ophthalmology. With a variety of new technologies and procedures at our disposal, we should not be marketing one against another. If the guy across town is doing SMILE but you are not, that is okay. Our message must be cohesive: We have lots of ways to fix your vision so that you can see the best you can possibly see. We need to not get caught up in different technologies being better than others. We need to take advantage of the excitement in refractive surgery and concentrate on the fact that we have many different ways to help people achieve refractive correction. I am excited by the prospects of the VisuMax femtosecond laser in this journey, but I also recognize that other technologies and tools are just as valuable to my practice and, ultimately, to the happiness of my patients. n Lance Kugler, MD n Surgeon and CEO, Kugler Vision, Omaha, Nebraska n Director of Refractive Surgery, University of Nebraska Medical Center n lkugler@kuglervision.com n Financial disclosure: None acknowledged 4 SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY NOVEMBER/DECEMBER 2017

5 Don t Forget About the Flap The VisuMax femtosecond laser is much more than a tool for SMILE. BY STEVEN D. VOLD, MD Right now in refractive surgery, there is much excitement surrounding new surgical procedures, and for good reason. The addition of novel techniques like small incision lenticule extraction (SMILE) to our armamentarium not only create excitement about refractive surgery in general, but give us a better opportunity to treat a wider range of patients more effectively. Truth told, one reason that Vold Vision decided to purchase the VisuMax femtosecond laser (ZEISS) in August 2016 was so that we could perform SMILE. But what I quickly realized is that the VisuMax is much more than a tool for that procedure. It is the most gentle, kind, and precise laser that I have ever used, and herein I explain why it has been so valuable to my practice. WHAT SETS IT APART There are several things that set the VisuMax femtosecond laser apart from other platforms. No. 1: It is a great flap maker. For starters, of all the other femtosecond laser platforms I have used to make LASIK flaps, nothing compares to the VisuMax. On average, I can create a flap in about 18 seconds, and the design of these flaps has been instrumental in achieving superb postoperative outcomes. I cannot think of a single patient in who we did not have a superb LASIK outcome with the VisuMax. Generally speaking, I use a flap diameter between 8.2 to 8.5 mm, but the VisuMax is also capable of creating much larger flaps, such as those required in treatments for hyperopia and astigmatism. In my experience, the accuracy of the VisuMax as a flap creator has been unbelievable. No. 2: It is gentle. The patient interface of the VisuMax applanates on the cornea, not on the sclera like other laser platforms. For the patient, this creates a much gentler experience. For the surgeon, this means that IOP is not elevated nearly as much as it can be with other lasers. No. 3: It has given us the confidence to perform more LASIK procedures. I am grateful to have the VisuMax femtosecond laser, as it has helped us to change our standard of care. Prior to owning this platform, we probably only performed LASIK in 50% of cases and PRK in the other 50%. But now, with the VisuMax, we perform LASIK in well over 90% of cases simply because we have so much confidence in the laser. No. 4: Our refractive surgical volume is growing. For the first time in our practice's history, we are now performing more than 100 refractive surgeries per month. In comparison, in years past, it was typical for us to perform between 30 and 50 refractive surgeries per month. When you think about it, as a glaucoma and anterior segment surgeon, 100-plus refractive surgeries per month is a pretty Figure 1. Dr. Vold creates a corneal pocket with the VisuMax femtosecond laser and implants the Raindrop inlay. crazy number. Honestly, it will not shock me if we end up eventually doing more than 150 to 200 eyes per month with the VisuMax. No. 5: There is greater potential to perform other procedures. I have also used the VisuMax in conjunction with corneal inlay implantation (Figure 1), specifically the Raindrop (ReVision Optics). We just started performing this procedure in Spring 2017, and we have been rolling it out carefully. Our numbers are not huge at this time, but eventually I see our inlay volume growing. I don t think I would be as confident with this procedure had it not been for the VisuMax. No. 6: SMILE is an attractive procedure. At Vold Vision, we have also been performing SMILE since Spring 2017 (Figure 2), and it has been a powerful experience. What initially attracted me to the procedure was its safety, especially in that it causes potentially NOVEMBER/DECEMBER 2017 SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY 5

6 often makes more sense to perform SMILE because there is no risk of flap-related complications and because there is a reduced risk for dry eye disease postoperatively. These are the patients we have targeted in our early experience with SMILE, but as I mentioned previously we do envision performing the procedure more often once there are wider indications for its use. In short, we have found an added layer of safety and comfort with SMILE compared to LASIK, and we envisionn our use of the procedure growing. Figure 2. Dr. Vold performs SMILE with the VisuMax. less symptoms of dry eye than LASIK. Second, I like that it achieves LASIK-like results. THE FUTURE OF SMILE At this time, we are cautiously rolling SMILE out to our patients; however, we expect our use of the procedure to increase once indications for astigmatism and hyperopia are approved in the United States. In our experience, patients love that SMILE is performed with only one laser instead of two like with LASIK. Further, we like that it is a very efficient and accurate procedure and is intuitive to perform. In very active patients those who play sports or who have physicially demanding jobs, like police officers for instance it CONCLUSION The VisuMax femtosecond laser is the finest laser that I have used in my career, hands down. In our clinical practice, having the VisuMax has helped us to go from performing LASIK in 50% of cases to more than 90% of cases, and the vast majority of our patients 70% or more are 20/20 uncorrected on postoperative day 1. I am convinced that the reason for our recent successes is that the VisuMax is an excellent tool for flap creation. It has given us the confidence that we need to perform more LASIK procedures and the tool that we need to grow our overall refractive surgery volume. The VisuMax is much more than a tool for SMILE, it is a tool for success with refractive surgery procedures of all types. n Steven D. Vold, MD n Vold Vision, Fayetteville, Arkansas n svold@voldvision.com n Financial disclosure: Consultant (Carl Zeiss Meditec) 6 SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY NOVEMBER/DECEMBER 2017

7 SMILE: Another Opportunity to Make LVC Great First experiences in the United States. BY GREGORY D. PARKHURST, MD, FACS At Parkhurst NuVision, one of our fundamental philosophies is that refractive surgery is more about meeting the goals and needs of our patients than it is about the particular procedures we offer. We spend a lot of time listening to patients and thinking, examining, and educating them on what their anatomy tells us about the potential upsides and downsides of any given intervention unique to their optical system. Only after we have a good understanding of the patient s needs, desires, and anatomy do we think about selecting a procedure. A FULL MENU OF OPTIONS Because our strategy is fitting the procedure to the patient, rather than the patient to the procedure, having a full menu of options has always been important to the way we approach refractive surgery. Whenever we decide to add a new procedure, first we study it and get a sense for what its advantages are. We read about it, and we talk to, and then visit, surgeons who have experience performing the procedure. For example, I went to Singapore this past year to consult with Jodhbir S. Mehta, BSc(Hons), MBBS, FRCOphth, FRCS(Ed), FAMS, who has been performing small incision lenticule extraction, or SMILE, with the VisuMax femtosecond laser (ZEISS) for several years. I also talked to some surgeons from Southeast Asia about their experiences with SMILE and traveled to Europe to observe more procedures and to collect information on European Figure 1. Dr. Parkhurst (right) performs SMILE with the VisuMax. results with SMILE. After talking with surgeons I trust, I became convinced that SMILE is going to be an important procedure for refractive surgery in the United States, just as it has been in Europe and Asia. I performed my first SMILE in March 2017, and the day was especially memorable because it happened to be my 40th birthday. Being early adopters of advanced technology is part of our core values at Parkhurst NuVision, so we were proud to be one of the first 10 practices in the country to launch the procedure commercially. I had been using the VisuMax laser for LASIK flaps for 1 year prior to that, so I had adequate time to get used to the platform and its nuances, and I really love the platform for making flaps. The VisuMax continues to be the main laser I use, whether I am performing modern LASIK or whether I am performing SMILE. I really like that the platform is so versatile, meaning I can perform a variety of procedures depending on what is best for each individual patient. Thus far in my experience, patient satisfaction has been excellent. I can recall one patient specifically who said that the SMILE surgery was so gentle that it was almost like nothing had happened, except that afterward she could see better. She related the patient experience to going in for an eye exam, but coming out with clear vision. The surgery is so comfortable that it is almost like a nonevent, which is a different experience than what patients are used to on the day of surgery with almost any other refractive procedure. MORE INDICATIONS TO COME Right now, we are finding that only about 25% to 30% of our current refractive surgery patients are eligible for SMILE. That is going to grow dramatically, and it is going to grow soon. The reason that we have not performed SMILE more often thus far is because the current indication in the United States is only for spherical myopia between and D. This means that, in the United States, we are not able to treat patients with greater than 0.50 D astigmatism. As one can expect, that limits the patient pool significantly. Once the astigmatism indication is approved by the US FDA, I expect the volume of SMILE procedures that I perform to increase dramatically. Currently I find that SMILE works best in patients who have moderate to high myopia (-3.00 to D). This is because, when getting used to dissecting and extracting the lenticule, a higher treatment gives you a little more tissue to grasp ahold of and get into. NOVEMBER/DECEMBER 2017 SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY 7

8 MARKETING REFRACTIVE SURGERY Rather than marketing one specific procedure as the best laser eye surgery available, we choose to focus our messaging on the fact that we have all the different options to ensure that the best surgical solution is chosen for each individual patient. There are situations when a patient is better suited for SMILE and others when a patient is better suited for modern LASIK. We want our patients to know what all of their options are before they make the transformative decision to undergo refractive surgery. One thing we have done since we started performing SMILE is to do some TV interviews educating the community about what SMILE is. We have done some optometric seminars to introduce SMILE, so referring optometrists understand what it is, what it can offer their patients, and how it differs compared to some of our other procedures. Our marketing strategy may seem a bit subtle, but it has been very effective. It is different from the way new technologies have been introduced into refractive surgery in the past. Take for instance what happened when the femtosecond laser was introduced for LASIK flap creation. The common messaging across the United States was, "Hey, you should get all-laser LASIK, and you should not trust the surgeon down the street who is still using a microkeratome blade. Come to me, because we do it all by laser." That was an underlying negative message, and it was a marketshare play by the surgeons who invested in that laser technology. But what resulted from that negative messaging was fear and stagnation in the refractive surgery market, not growth. This time around, any marketing should be positive, and surgeons should try to be strategic about not positioning SMILE as the one procedure that everybody should get. Rather they should alert patients and doctors that they need to know about SMILE because it is in fact an optimal procedure for many people desiring to undergo laser vision correction. CONCLUSION There are a lot of people in this world who would benefit from refractive surgery who simply do not know it yet. Anything we can do to educate our patients about the transformative potential of refractive surgery and to bring excitement back into the specialty is beneficial. Introducing a new laser vision correction procedure to augment the surgeon's already expanding toolbox gives people another reason to think about refractive surgery again. I believe SMILE, among other procedures, will be a catalyst of growth for refractive surgery. We have already seen some of this effect, as laser vision correction volume is up in many centers by 20% or more so far in 2017 and there has been a lot more positive messaging and chatter around refractive surgery in the United States in the past 12 to 18 months. I would attribute some of that to the introduction of SMILE, and perhaps even more to the collaboration and positive messaging taking place among refractive surgeons looking to expand the refractive surgery space. I think the future of SMILE will have a much broader scope than it currently has in the United States, mostly because of the limitations in the indications for treatment that we can perform right now. By the time that the procedure has FDA approval for astigmatism correction, SMILE is going to become a really important procedure for refractive surgery patients because of the quick recovery, the comfort during surgery, and the excellent quality of vision it provides postoperatively. n Gregory D. Parkhurst, MD, FACS n Physician-CEO, Parkhurst NuVision, San Antonio, Texas n gregory.parkhurst@gmail.com n Financial disclosure: Consultant (Carl Zeiss Meditec) 8 SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY NOVEMBER/DECEMBER 2017