The following article highlights key questions addressed during a roundtable discussion of the role of personalized topography-guided LASIK among today’s selection of refractive treatments. Led by Kerry D. Solomon, MD, the panel included Ronald R.Krueger, MD; Karl G. Stonecipher, MD; and R. Doyle Stulting, MD, PhD.
What are some advantages of CONTOURA Vision topography-guided treatments versus WAVEFRONT OPTIMIZED or wavefront-customized treatments?
Ronald R. Krueger, MD: I think there are two primary advantages. First, topography-guided treatments offer us an opportunity to eliminate most aberrations on the cornea. Because the cornea is the eye’s first refractive structure, it is essential that we do everything we can to ensure that the front surface has the most uniform prolate shape possible, able to bring light to a single focus without bending. In addition to offering patients immediate visual benefits, a clear cornea that is free of aberrations is likely to have good long-term health and clarity until the patient requires lens replacement in the future.
The second advantage of topography-guided LASIK is that it does not induce aberrations. Wavefront-guided treatments allow us to measure and treat aberrations. They reduce the overall induced aberrations compared with conventional LASIK, but they still induce aberrations. Patients are never aberration-free. A myopic patient who has WAVEFRONT OPTIMIZED ablation, for example, is likely to have nearly the same visual outcomes we would expect from CONTOURA Vision, but without the same reduction of higher-order and even lower-order aberrations seen with CONTOURA Vision.1
With topography-guided LASIK, there is a whole new outlook on postoperative aberrations. While most of us focus on visual outcomes and not higher-order aberration reduction, we do see improvements in symptoms and best corrected vision. That tells us the CONTOURA Vision procedure is going beyond the visual outcomes we accomplish with WAVEFRONT OPTIMIZED and wavefront-guided techniques.
Dr. Stulting, you were the medical monitor of the CONTOURA Vision FDA study. How did your research affect your view of this modality?
R. Doyle Stulting, MD, PhD: The study evaluated the efficacy of CONTOURA Vision for myopia and myopic astigmatism.2 It was limited to “normal eyes,” excluding any subjects who had asymmetrical bowties, skewed radial axes, or any other features that could be considered abnormal. When we were planning the study, I was sure that the outcomes for these “normal eyes” would be no different than those we were accustomed to seeing with existing, approved treatments.
To my surprise—and that of everyone involved—the outcomes were much better than we could expect from standard treatments. The visual acuities were superb. For 30% of patients, postoperative uncorrected distance visual acuity was actually better than preoperative best spectacle-corrected distance visual acuity. Furthermore, subjects noted less light sensitivity, difficulty driving at night, reading difficulty, glare, halos, and starbursts than they did before surgery. These findings allow us to tell our patients that CONTOURA Vision may provide them with better uncorrected vision than they have with their glasses.
These exceptional outcomes can probably be attributed to CONTOURA Vision’s lack of dependence on pupil size/location, its ability to measure peripheral corneal aberrations that may be significant in low-light situations, its reproducibility, and its independence from lenticular aberrations. I believe we are seeing the benefits of optical correction of topographical abnormalities that are subtler than those we typically recognize.
What will your selection of LASIK treatment options look like going forward?
Kerry D. Solomon, MD: I am very accustomed to wavefront-guided technology, and most of the surgeons I know are entrenched in the mindset that wavefront-guided, WAVEFRONT OPTIMIZED, or wavefront-customized treatment is best. My one pearl for all of us is to question the status quo. Look at the data for CONTOURA Vision. See if something new and different makes sense in this case. Compared to wavefront procedures, CONTOURA Vision induces fewer aberrations and gives patients a clear cornea with less tissue ablation and possibly better contrast sensitivity.3 It certainly makes sense to me to try a procedure with those outcomes, and I think that a lot of other wavefront surgeons out there would reach the same conclusion.
Dr. Krueger: Ultimately, once we have the CONTOURA Vision technology, we can explain to patients that our practice has a full menu of different customized options, which allows us to choose the best procedure to achieve the results they want. Testing steers us in the right direction. If we obtain good quality topographic (Topolyzer VARIO; Alcon) maps, we will perform CONTOURA Vision for the best results. If the topographic maps are not good, we might choose WAVEFRONT OPTIMIZED LASIK or perform wavefront-guided treatment to address some higher-order aberrations. The patient’s goals and expectations, combined with testing, drive individualized choices drawn from the full menu of options.
Karl G. Stonecipher, MD: To obtain the best possible visual outcomes for all of our patients, we have to design the most effective optical system for each one. That is the great thing about this robust surgical armamentarium. I will still want to do WAVEFRONT OPTIMIZED treatment for some patients, as well as perform wavefront-guided LASIK occasionally when I think it best. By offering another strong tool in this armamentarium, CONTOURA Vision makes customized treatment that much easier.
1. Shetty R, Shroff R, Deshpande K, et al. A prospective study to compare visual outcomes between WAVEFRONT OPTIMIZED and topography-guided ablation profiles in contralateral eyes with myopia. J Refract Surg. 2017;33(1):6-10.
2. Stulting RD, Fant BS; T-CAT Study Group. Results of topography-guided laser in situ keratomileusis custom ablation treatment with a refractive excimer laser. J Cataract Refract Surg. 2016;42(1):11-18.
3. Jain AK, Malhotra C, Pasari A, et al. Outcomes of topography-guided versus WAVEFRONT OPTIMIZED laser in situ keratomileusis for myopia in virgin eyes. J Cataract Refract Surg. 2016;42(9):1302-1311.Important Product Information