The Touch Opthalmology

  1. Over the last few years, surgical extraction of a refractive lenticule, or ReLEx®, has evolved as a new treatment in the field of keratorefractive surgery. Currently, the VisuMax® femtosecond (FS) laser (Carl Zeiss Meditec, Jena, Germany) is the only platform to offer this treatment. The 500 kHz VisuMax laser generates very fast pulses (10-15 s range) in the near-infrared spectrum. Depending on the specific laser settings, each pulse conveys approximately 150 nJ, which causes localized photodisruption at the focal point.

    For the last 20 years controlled excimer laser ablation of corneal tissue, either directly from the corneal stromal surface or from the corneal interior after creation of a superficial corneal flap, has become widely used to correct myopia, hyperopia and astigmatism. Recently, an intrastromal refractive procedure whereby a tissue lenticule is cut free in the corneal stroma by a femtosecond laser and removed through a small peripheral incision has been introduced. The procedure avoids creation of a corneal flap and the potential associated risks while avoiding the slow visual recovery of surface ablation procedures. The all-femtosecond-based flap-free intracorneal refractive procedure has been documented to be a predictable, efficient and safe procedure for correction of myopia and astigmatism. Technological developments related to further improved cutting quality, hyperopic and individualised treatments are desirable.

    Tue, 01/07/2014
    Sat, 03/01/2014
    1. Ivarsen A, Hjortdal J, All-femtosecond laser keratorefractive surgery, Curr Ophthalmol Rep, 2014;2:26–33.
    2. Sekundo W, Kunert K, Russmann C, et al., First efficacy and safety study of femtosecond lenticule extraction for the correction of myopia: six-month results, J Cataract Refract Surg, 2008;34:1513–20.
    3. Shah R, Shah S, Sengupta S, Results of small incision lenticule extraction: all-in-one femtosecond laser refractive surgery, Cataract Refract Surg, 2011;37:127–37.
    4. Vestergaard A, Ivarsen AR, Asp S, Hjortdal JØ, Small-incision lenticule extraction for moderate to high myopia: predictability, safety, and patient satisfaction, J Cataract Refract Surg, 2012;38:2003–10.
    5. Blum M, Kunert KS, Voßmerbäumer U, Sekundo W, Femtosecond lenticule extraction (ReLEx) for correction of hyperopia – first results, Graefes Arch Clin Exp Ophthalmol, 2013 251:349–55
    6. Hjortdal JØ, Vestergaard AH, Ivarsen A, et al., Predictors for the outcome of small-incision lenticule extraction for myopia, J Refract Surg, 2012;28:865–71.
    7. Ivarsen A, Asp S, Hjortdal J, Safety and complications of more than 1500 small-incision lenticule extraction procedures, Ophthalmology, 2013 [Epub ahead of print).
    8. Zhao J, Yao P, Li M, et al., The morphology of corneal cap and its relation to refractive outcomes in femtosecond laser small incision lenticule extraction (SMILE) with anterior segment optical coherence tomography observation, PLoS ONE, 2013;8:e70208.
    9. Sekundo W, Kunert KS, Blum M, Small incision corneal refractive surgery using the small incision lenticule extraction (SMILE) procedure for the correction of myopia and myopic astigmatism: results of a 6 month prospective study, Br J Ophthalmol, 2011;95:335–9.
    10. Vestergaard A, Ivarsen A, Asp S, Hjortdal JØ, Femtosecond (FS) laser vision correction procedure for moderate to high myopia: a prospective study of ReLEx FLEx and comparison with a retrospective study of FS-laser in situ keratomileusis, Acta Ophthalmol, 2013;91:355–62.
    11. Kamiya K, Igarashi A, Ishii R, et al., Early clinical outcomes, including efficacy and endothelial cell loss, of refractive lenticule extraction using a 500 kHz femtosecond laser to correct myopia, J Cataract Refract Surg, 2012;38:1996–2002.
    12. Kamiya K, Shimizu K, Igarashi A, et al., Comparison of visual acuity, higher-order aberrations and corneal asphericity after refractive lenticule extraction and wavefront guided laserassisted in situ keratomileusis for myopia, Br J Ophthalmol, 2013;97:968–75.
    13. Ang M, Chaurasia SS, Angunawela RI, et al., Femtosecond lenticule extraction (FLEx): clinical results, interface evaluation, and intraocular pressure variation, Invest Ophthalmol Vis Sci, 2012;53:1414–21.
    14. Demirok A, Agca A, Ozgurhan EB, et al., Femtosecond lenticule extraction for correction of myopia: a 6 month follow-up study, Clin Ophthalmol, 2013;7:1041–7.
    15. Blum M, Kunert KS, Engelbrecht C, et al., Femtosecond lenticule extraction (FLEx)—results after 12 months in myopic astigmatism, Klin Monbl Augenheilkd, 2010;227:961–5.
    16. Gertnere J, Solomatin I, Sekundo W, Refractive lenticule extraction (ReLEx FLEx) and wavefront-optimized Femto-LASIK: comparison of contrast sensitivity and high-order aberrations at 1 year, Graefes Arch Clin Exp Ophthalmol, 2013;251:1437–42.
    17. Kamiya K, Shimizu K, Igarashi A, Kobashi H, Visual and refractive outcomes of femtosecond lenticule extraction and smallincision lenticule extraction for myopia, Am J Ophthalmol, 2014;157:128–34.
    18. Gazieva L, Beer MH, Nielsen K, Hjortdal J, A retrospective comparison of efficacy and safety of 680 consecutive lasik treatments for high myopia performed with two generations of flying-spot excimer lasers, Acta Ophthalmol, 2011;89:729–33.
    19. Blum M, Kunert K, Schröder M, Sekundo W, Femtosecond lenticule extraction for the correction of myopia: preliminary 6-month results, Graefes Arch Clin Exp Ophthalmol, 2010;248:1019–27.
    20. Shah R, Shah S, Effect of scanning patterns on the results of femtosecond laser lenticule extraction refractive surgery, J Cataract Refract Surg, 2011;37:1636–47.
    21. Riau AK, Ang HP, Lwin NC, et al., Comparison of four different VisuMax circle patterns for flap creation after small incision lenticule extraction, J Refract Surg, 2013;29:236–44.
    22. Kunert KS, Blum M, Duncker GI, et al., Surface quality of human corneal lenticules after femtosecond laser surgery for myopia comparing different laser parameters, Graefes Arch Clin Exp Ophthalmol, 2011;249:1417–24.
    23. Kamiya K, Shimizu K, Igarashi A, Kobashi H, Time course of optical quality and intraocular scattering after refractive lenticule extraction. PLoS One, 2013;8:e76738.
    24. Yao P, Zhao J, Li M, et al., Microdistortions in Bowman’s layer following femtosecond laser small incision lenticule extraction observed by Fourier-Domain OCT, J Refract Surg, 2013;29:668–74.
    25. Tomita M, Waring GO 4th, Magnago T, Watabe M, Clinical results of using a high-repetition-rate excimer laser with an optimized ablation profile for myopic correction in 10,235 eyes, J Cataract Refract Surg, 2013;39:1543–9.
    26. Farjo AA, Sugar A, Schallhorn SC, et al., Femtosecond lasers for LASIK flap creation: a report by the American Academy of Ophthalmology, Ophthalmology, 2013;120:e5–20.
    27. Dong Z, Zhou X, Irregular astigmatism after femtosecond laser refractive lenticule extraction, J Cataract Refract Surg, 2013;39:952–4.
    28. Kunert KS, Russmann C, Blum M, Sluyterman VLG, Vector analysis of myopic astigmatism corrected by femtosecond refractive lenticule extraction, J Cataract Refract Surg, 2013;39:759–69.
    29. Ivarsen A, Hjortdal J, Correction of myopic astigmatism with small incision lenticule extraction, J Refract Surg, (accepted for publication, 2014).
    30. Reinstein DZ, Carp GI, Archer TJ, Gobbe M. LASIK for presbyopia correction in emmetropic patients using aspheric ablation profiles and a micro-monovision protocol with the Carl Zeiss Meditec MEL 80 and VisuMax, J Refract Surg, 2012;28:531–41.
    31. Vestergaard AH, Grønbech KT, Grauslund J, et al., Subbasal nerve morphology, corneal sensation, and tear film evaluation after refractive femtosecond laser lenticule extraction, Graefes Arch Clin Exp Ophthalmol, 2013;251:2591–2600.
    32. Demirok A, Ozgurhan EB, Agca A, et al., Corneal sensation after corneal refractive surgery with small incision lenticule extraction, Optom Vis Sci, 2013;90:1040–7.
    33. Wei S, Wang Y, Comparison of corneal sensitivity between FS-LASIK and femtosecond lenticule extraction (ReLEx flex) or small-incision lenticule extraction (ReLEx SMILE) for myopic eyes, Graefes Arch Clin Exp Ophthalmol, 2013;251:1645–54.
    34. Li M, Niu L, Qin B, et al., Confocal comparison of corneal reinnervation after small incision lenticule extraction (SMILE) and femtosecond laser in situ keratomileusis (FS-LASIK), PLoS One, 2013;8:e81435.
    35. Li M, Zhao J, Shen Y, et al., Comparison of dry eye and corneal sensitivity between small incision lenticule extraction and femtosecond LASIK for myopia, PLoS One, 2013;8:e77797.
    36. Randleman JB, Dawson DG, Grossniklaus HE, et al., Depth-dependent cohesive tensile strength in human donor corneas: implications for refractive surgery, J Refract Surg, 2008;24;S85–9.
    37. Reinstein DZ, Archer TJ, Randleman JB, Mathematical model to compare the relative tensile strength of the cornea after PRK, LASIK, and small incision lenticule extraction, J Refract Surg, 2013;29:454–60.
    38. Agca A, Ozgurhan EB, Demirok A, et al., Comparison of corneal hysteresis and corneal resistance factor after small incision lenticule extraction and femtosecond laser-assisted LASIK: a prospective fellow eye study, Cont Lens Anterior Eye, 2014;37:77–80.
    39. Vestergaard A, Grauslund J, Ivarsen A, Hjortdal J, Central corneal sublayer pachymetry and biomechanical properties after refractive femtosecond laser lenticule extraction, J Refract Surg, (accepted for publication, 2013).
    40. Ozgurhan EB, Agca A, Bozkurt E, et al., Accuracy and precision of cap thickness in small incision lenticule extraction, Clin Ophthalmol, 2013;7:923–6.
    41. Tay E, Li X, Chan C, et al., Refractive lenticule extraction flap and stromal bed morphology assessment with anterior segment optical coherence tomography, J Cataract Refract Surg, 2012;38:1544–51.
    42. Reinstein DZ, Archer TJ, Gobbe M, Accuracy and reproducibility of cap thickness in small incision lenticule extraction, J Refract Surg, 2013;29:810–8.
    43. Ivarsen A, Fledelius W, Hjortdal JØ, Three-year changes in epithelial and stromal thickness after PRK or LASIK for high myopia, Invest Ophthalmol Vis Sci, 2009;50:2061–6.
    44. Patel SV, Erie JC, McLaren JW, Bourne WM, Confocal microscopy changes in epithelial and stromal thickness up to 7 years after LASIK and photorefractive keratectomy for myopia, J Refract Surg, 2007;23:385–92.
    45. Alio JL, Javaloy J, Corneal inflammation following corneal photoablative refractive surgery with excimer laser, Surv Ophthalmol, 2013;58:11–25.
    46. Dong Z, Zhou X, Wu J, et al., Small incision lenticule extraction (SMILE) and femtosecond laser LASIK: comparison of corneal wound healing and inflammation, Br J Ophthalmol, 2014;98:263–9.
    47. Riau AK, Angunawela RI, Chaurasia SS, et al., Early corneal wound healing and inflammatory responses after refractive lenticule extraction (ReLEx), Invest Ophthalmol Vis Sci, 2011;52:6213–21.
    48. Moller-Pedersen T, Cavanagh HD, Petroll WM, Jester JV, Stromal wound healing explains refractive instability and haze development after photorefractive keratectomy: a 1-year confocal microscopic study, Ophthalmology, 2000;107:1235–45.
    49. Ivarsen A, Laurberg T, Møller-Pedersen T, Characterisation of corneal fibrotic wound repair at the LASIK flap margin, Br J Ophthalmol, 2003;87:1272–8.
    50. Pradhan KR, Reinstein DZ, Carp GI, et al., Femtosecond laserassisted keyhole endokeratophakia: correction of hyperopia by implantation of an allogeneic lenticule obtained by SMILE from a myopic donor, J Refract Surg, 2013;29:777–82.
    51. Mohamed-Noriega K, Toh KP, Poh R, Bet al., Cornea lenticule viability and structural integrity after refractive lenticule extraction (ReLEx) and cryopreservation, Mol Vis, 2011;17:3437–49.
    52. Riau AK, Angunawela RI, Chaurasia SS, et al., Reversible femtosecond laser-assisted myopia correction: a non-human primate study of lenticule re-implantation after refractive lenticule extraction, PLoS ONE, 2013;8:e67058.
    53. Angunawela RI, Riau AK, Chaurasia SS, et al., Refractive lenticule re-implantation after myopic ReLEx: a feasibility study of stromal restoration after refractive surgery in a rabbit model, Invest Ophthalmol Vis Sci, 2012;53:4975–85.
    54. Liu H, Zhu W, Jiang AC, et al., Femtosecond laser lenticule transplantation in rabbit cornea: experimental study, J Refract Surg, 2012;28:907–11.
    55. Lim CH, Riau AK, Lwin NC, et al., LASIK following small incision lenticule extraction (smile) lenticule re-implantation: a feasibility study of a novel method for treatment of presbyopia, PLoS One. 2013;8:e83046.
    56. Reinstein DZ, Gobbe M, Archer TJ, Coaxially sighted corneal light reflex versus entrance pupil center centration of moderate to high hyperopic corneal ablations in eyes with small and large angle kappa, J Refract Surg, 2013;29:518–25.
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    Ebook Link: 
    Citation override: 
    European Ophthalmic Review, 2014;8(1):31–6 DOI:
  2. There is now an increased recognition by clinicians that dry eye disease (DED) is a common disorder characterised by dryness and damage of the ocular surface. It affects quality of life, including aspects of physical, social and psychological functioning, because it induces ocular discomfort, burning sensation, light sensitivity, visual disturbances or even corneal erosions and infections. DED is also known as keratoconjunctivitis sicca, dry eye syndrome and dysfunctional tear syndrome.

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    Dry eye disease (DED) is a clinically significant multifactorial disorder of the ocular surface and tear film as it results in ocular discomfort and visual impairment and predisposes the cornea to infections. It is important for the quality of life and tends to be a chronic disease. It is also common, as the prevalence is estimated between 5 % to 30 % and this increases with age. Therefore, it is recognised as a growing public health problem that requires correct diagnosis and appropriate treatment. There are two main categories of DED: the deficiency of tear production (hyposecretive), which includes Sjögren syndrome, idiopathic or secondary to connective tissue diseases (e.g. rheumatoid arthritis), and non-Sjögren syndrome (e.g. age-related); and the tear evaporation category, where tears evaporate from the ocular surface too rapidly due to intrinsic causes (e.g. meibomian gland disease or eyelid aperture disorders) or extrinsic causes (e.g. vitamin A deficiency, contact lenses wear, ocular allergies). Management of the disease aims to enhance the corneal healing and reduce patient’s discomfort. This is based on improving the balance of tear production and evaporation by increasing the tear film volume (lubrication drops) and improving quality of tear film (ex omega-3 supplements, lid hygiene, tetracyclines), reducing the tear film evaporation (paraffin ointments, therapeutic contact lenses), reducing tear’s drainage (punctal plugs, cautery) and finally by settling down the ocular surface inflammation (steroids, cyclosporine, autologous serous), as appropriate. In this article we will review the clinical presentation, differential diagnosis and treatment options for DED.

    Thu, 02/27/2014
    Mon, 03/31/2014
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    Citation override: 
    US Ophthalmic Review, 2014;7(2):109–15 DOI:
  3. Patient demand for spectacle independence is growing. The advances in laser and non-laser technology have allowed ophthalmologists to offer their patients the freedom to choose between depending on their glasses, or to go spectacle free. Presbyopia, defined as the age-related loss of the ability to clearly accommodate onto near objects, has become the last frontier for refractive vision correction.


    Presbyopia remains the last frontier for refractive surgeons. With increased demand for spectacle independence at all ages, ophthalmologists are exploring different approaches for presbyopia correction. The idea of adding synthetic material to the cornea for the management of presbyopia has come a long way since its inception. The Raindrop® (ReVision Optics®), KAMRA™ Inlays (AcuFocus™) and the Flexivue Microlens™ (Presbia™) are three very different inlays that attempt to reverse presbyopia through different mechanisms. The Raindrop changes the curvature of the anterior cornea in the plane of the pupil, the Kamra uses the principle of the pinhole to increase depth of focus, while the Flexivue is a refractive annular add lenticule that creates a paracentral zone for near vision. The decreased incidence of complications, ease of insertion, reversibility and potential applicability to patients with various refractive statuses make inlays a powerful addition to the armamentarium in the management of presbyopia.

    Fri, 01/10/2014
    Wed, 03/19/2014
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    US Ophthalmic Review,2014;7(2):123–30 DOI:
  4. Since the introduction of ultrasound phacoemulsification in 1967, cataract surgery has become the most commonly performed outpatient operation in the US. While phacoemulsification has been shown safe and effective, application of ultrasound power within the eye does carry some risk of ocular injury, such as endothelial cell loss.

    The LENSAR® Laser System’s ergonomic design permits flexible functionality in any operating environment. Its low-pressure liquid interface eliminates corneal compression and facilitates accurate and complete capsulotomy construction. The Augmented Reality™ imaging system utilises a variable super luminescent diode for scanning structured illumination to provide high-contrast, high-definition targets, which guide the laser. Real-time imaging adjustments compensate for minute degrees of tissue displacement, permitting unrivalled precision in corneal incision architecture. Precise laser spot application allows fragmentation of all grades of cataract, without the need for unnecessarily large safety margins. Iris registration compensates for cyclotorsion in the construction of arcuate incisions by aligning preoperative corneal biometry to intraoperative imaging. The ability to define the cataract grade intraoperatively facilitates efficient phacofragmentation by permitting surgeon-specified preset patterns for the full range of nuclear densities. The LENSAR Laser System represents the state of the art in femtosecond cataract surgery.
    Tue, 07/22/2014
    Wed, 08/27/2014
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    8. Shin YJ, Nishi Y, Engler C, et al., The effect of phacoemulsification energy on the redox state of cultured human corneal endothelial cells, Arch Ophthalmol, 2009;127:435–41.
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    10. LENSAR data on file.
    11. Fine IH, Hoffman RS, Packer M, Profile of clear corneal cataract incisions demonstrated by ocular coherence tomography, J Cataract Refract Surg, 2007;33:94–7.
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    13. Preferred Practice Pattern for Cataract in the Adult Eye, American Academy of Ophthalmology, 2011.
    14. Xia Y, Liu X, Luo L, et al., Early changes in clear cornea incision after phacoemulsification: An anterior segment optical coherence tomography study, Acta Ophthalmol, 2009;87:764–8.
    15. LENSAR Commercial System Clinical Series data set on file.
    16. Packer M, Uy H, Changes in endothelial cell density in large cohort of patients having laser refractive cataract surgery, intraocular surgery femtosecond laser, ASCRS paper session, at American Society of Cataract and Refractive Surgery (ASCRS), Chicago, IL, April, 2012.
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    European Ophthalmic Review,2014;8(2):93–8 DOI:
  5. Exudative age-related macular degeneration (AMD) develops in approximately 10 of out 1000 people per three-year period in the US, which projects an estimated 125,000 new cases per year. Exudative AMD is the commonest cause of legal blindness in developed countries. Given the increasing size of the aging population, this condition presents a substantial threat to quality of life in this group.
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    Mon, 01/10/2011
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    US Sensory Disorders Review, 2006:5-6 DOI: