Wavefront Optimized Versus Custom-Q Treatments in Surface Ablation for Myopic Astigmatism With the WaveLight ALLEGRETTO Laser

Aleksandar Stojanovic, MD; Ling Wang, MD, MS; Mirko R. Jankov, MD, PhD; Tore A. Nitter, MD, PhD; Qinmei Wang, MD
ABSTRACT
PURPOSE: To compare treatments with wavefront optimized and custom-Q ablations. METHODS: Two consecutive groups of eyes were treated for myopia and astigmatism with surface ablation. One group was treated with wavefront optimized ablation and the second group was treated with custom-Q ablation. Preoperative and 3-month postoperative Q-values, higher order aberrations, low contrast visual acuity, and classic outcome parameters were analyzed. RESULTS: The wavefront optimized ablation group was comprised of 46 eyes of 23 patients with a mean spherical equivalent refraction (SE) of 3.64 diopters (D) (range: 1.15 to 8.25 D); mean Q-value changed from 0.33 preoperatively to 0.06 postoperatively. The custom-Q ablation group was comprised of 42 eyes of 21 patients with a mean SE of 3.24 D (range: 1.47 to 8.00 D); mean Q-value changed from 0.36 preoperatively to 0.03 postoperatively. A statistically signicant difference in postoperative change in Q-values (P=.049) between the two groups was noted, but there was no such difference in higher order aberrations, low contrast visual acuity, or classic outcome parameters. CONCLUSIONS: Custom-Q ablation resulted in a mean postoperative asphericity that was closer to preoperative compared to wavefront optimized ablation, whereas the other outcome parameters showed no statistically signicant differences. [J Refract Surg. 2008;24:779-789.]

ne problem with standard myopic excimer laser treatment is decrease in visual performance manifested by reduction in contrast sensitivity and night vision.1 It has been reported that these treatments induce an increase in spherical aberration2 and that such increase was mainly related to change of corneal asphericity.3,4 The curvature of the anterior surface of an aspheric cornea changes with distance from the apex so that the surface attens towards the periphery in prolate corneas but steepens towards the periphery in oblate corneas. To describe this change in curvature or asphericity, Q-values are used. A negative Q-value describes a prolate surface, and a positive Q-value describes an oblate surface. The standard (non-aspheric) myopic ablation changes the normal prolate corneal shape in an oblate direction,5 and this shift seems to be directly correlated with the amount of correction.6 Modern refractive ablations, with considerations to control asphericity, reduce this oblate shift but typically become progressively less effective towards high degrees of myopia.5,7,8 This study compares the WaveLight ALLEGRETTO (WaveLight AG, Erlangen, Germany) wavefront optimized treatment and its custom-Q treatment. The wavefront optimized ablation has an aspheric prole in which the amount of asphericity is not adjustable (and is the default treatment type on that platform). Similarly, the custom-Q ablation is also an aspheric ablation, but it adds the ability for the surgeon to dene
From the Eye Department, University Hospital of North Norway and SynsLaser Kirurgi, Toms, Norway (Stojanovic); School of Ophthalmology and Optometry and Eye Hospital, Wenzhou Medical College, Wenzhou, Zhejiang, China (L. Wang, Q. Wang); Milos Klinika, Medical Academy US Medical School, Belgrade, Serbia (Jankov); and yelegesenteret, Toms, Norway (Nitter). This study was supported by SynsLaser Kirurgi, Toms, Norway. Dr Jankov is a paid consultant for WaveLight AG, Erlangen, Germany. The remaining authors have no proprietary or financial interest in the materials presented herein. Correspondence: Aleksandar Stojanovic, MD, Flyvn 32, 9020 Tromsdalen, Norway. Tel: 47 90693319; Fax: 47 77647929; E-mail: [email protected] Received: February 26, 2007 Accepted: November 7, 2007 Posted online: March 15, 2008

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Wavefront Optimized vs Custom-Q Ablation/Stojanovic et al

the intended Q-shift (postoperative Q-value minus preoperative Q-value) by specifying a desired asphericity target. Unlike wavefront- or topography-guided custom treatments, which attempt to achieve an ideal optical/ corneal surface based on detailed preoperative aberrometry and topography maps, the only preoperative data that custom-Q treatment uses (in addition to refractive data) is a value of the mean corneal asphericity. It does not attempt to achieve a given asphericity at all points within the optical zone because no data on local values in preoperative asphericity are taken into account in programming of the ablation; it aims only to change the mean asphericity by symmetrically adjusting the number of mid-peripheral laser pulses. This study compares the effect of these two types of treatments by evaluating Q-values, higher order aberations, low contrast visual acuity, and classic outcome parameters. PATIENTS AND METHODS One hundred eyes of 50 patients seeking laser correction at SynsLaser Clinic in Troms, Norway, were enrolled in a retrospective, consecutive case study. Inclusion criteria were age 20 years; no contact lens wear for 2 weeks before baseline examination; manifest refraction spherical equivalent (MRSE) between 1.00 and 10.00 diopters (D) with 3.50 D of refractive astigmatism; stable refractive error for 2 years; and best spectacle-corrected visual acuity (BSCVA) of 20/25 or better. Exclusion criteria were eye pathology, including keratoconus or keratoconus suspect; corneal thickness 480 m; previous eye surgery; glaucoma; diabetes; and systemic diseases that could affect corneal wound healing (eg, collagen vascular diseases). Every patient provided an informed consent before being enrolled in the study. The rst 50 eyes were treated with WaveLight ALLEGRETTO wavefront optimized ablation, representing one group, and the remaining 50 eyes were treated with custom-Q ablation, representing the second group. Preoperative examination consisted of slit-lamp microscopy, uncorrected visual acuity (UCVA), manifest refraction and BSCVA (RT 2100 system; NIDEK Co Ltd, Gamagori, Japan), low contrast visual acuity (Optec 3500; Stereo Optical Co Inc, Chicago, Ill), Goldmann applanation tonometry, central ultrasound pachymetry (Corneo-Gage Plus; Sonogage Inc, Cleveland, Ohio), and corneal tomography (Orbscan II; Bausch & Lomb, Rochester, NY). Asphericity values for two orthogonal hemi-meridians covering the apical 30 (a circle with a diameter between 3.8 and 4.4 mm, depending on the corneal curvature) were provided by placido disk based corneal topography (Allegro Wave Topolyzer, WaveLight AG). These measurements were performed 780

three times for each eye, and the mean was used as a basis for calculation of the preoperative Q-value (done by the laser software) in the custom-Q group. Wavefront analysis was performed at 6-mm pupil diameter with WaveLight Allegro Wave Analyzer. This ray-tracing device uses mathematical analysis of a retinal spot pattern captured by a video camera. The rst derivative of the wavefront is calculated from the deviations of spot positions from their ideal position. Wavefront aberrations are expressed in 27 Zernike coefcients up to the 6th order, as proposed by Optical Society of America (OSA) and its Vision Science and Its Applications (VSIA) taskforce. The laser treatments were performed with the ALLEGRETTO excimer laser. This laser performs at a repetition rate of 400 Hz and produces a Gaussian beam prole with spot size of 0.68 mm (as measured by the full-width, half-maximum [FWHM] method, established by the Alliance for Telecommunication Industry Solutions [ATIS]). An infrared pupillary eye tracker with latency of 6 ms was used. Optical zone diameter of 6.5 mm and transition zone of 1.0 mm were used in all surgeries in both groups. The target refraction in all eyes was emmetropia. Manifest refraction, adjusted with a modied manufacturers nomogram, was used as the programming basis of all treatments. Regarding the choice of ablation type, the ALLEGRETTO wavefront optimized ablation was used in the wavefront optimized ablation group, whereas the custom-Q ablation was used in the custom-Q ablation group. The Q-target in the latter group was set to either 0.5 or 0.6, depending on the patients preoperative asphericity and age. If the preoperative Q-value was between 0 and 0.2, and if the patients age was 45 years, the Q-target was set to 0.5, whereas in all other cases the Q-target was set to 0.6. NOMOGRAM ADJUSTMENT FOR CUSTOM-Q TREATMENT Before the custom-Q ablation was programmed, the central ablation depth for the same refractive treatment was calculated by use of the standard wavefront optimized software. After setting the Q-target in the custom-Q software, the myopic correction component was reduced until the central ablation depth decreased to the level previously computed by the wavefront optimized software. Finally, a 10% increase of the astigmatic component was made. All surgeries were performed as surface ablation procedures. A specic protocol was used to reduce postoperative pain and haze, by minimizing the inammation reaction and minimizing the increased sensibility to ultraviolet radiation.9 A detailed protocol is described in a previous study.10 In addition, any tendency towards
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Wavefront Optimized vs Custom-Q Ablation/Stojanovic et al

TABLE 1

Preoperative Demographic and Refractive Data of Patients in the Wavefront Optimized Ablation and Custom-Q Ablation Groups*
Characteristic Age (y) Sex (male/female, %) MRSE (D) Cylinder (D) BSCVA (logMar) Asphericity (Q) Total RMS HOAs (m) Spherical aberration (m) RMS 3rd order HOAs Wavefront Optimized Ablation Group 33.5 8.5 (20 to 52) 69.57/30.43 3.64 1.92 ( 8.25 to 0.92 0.80 (0 to 20/19 0.33 0.10 ( 0.57 to 0.13) 1.15) Custom-Q Ablation Group 34.7 8.3 (20 to 50) 57.14/42.86 3.24 1.47 ( 8.00 to 1.03 0.90 (0 to 20/19 0.36 0.12 ( 0.60 to 0.09) 1.13) P Value .50 .22 .27 .54 .36 .21 .43 .63 .55

3.25)

3.25)

0.20 0.08 (0.10 to 0.51) 0.02 0.06 ( 0.22 to 0.11) 0.16 0.08 (0.05 to 0.47)

0.20 0.06 (0.10 to 0.41) 0.01 0.06 ( 0.10 to 0.09) 0.18 0.09 (0.06 to 0.54)

MRSE = manifest refraction spherical equivalent, BSCVA = best spectacle-corrected visual acuity, RMS = root-mean-square, HOAs = higher order aberrations *Values represented as mean standard deviation (range).

dry eye that was identied preoperatively was treated with collagen punctal plugs and lubricating gels. Omega-3 fatty acid (1000 mg daily) was used 1 to 2 weeks before surgery and 2 weeks postoperatively. Nonsteroidal anti-inammatory treatment was started with ibuprofen (Weifa AS, Oslo, Norway) 600 mg four times a day two days before surgery and continued through day 3 postoperatively. Prednisolone 50 mg (Nycomed International Management GmbH, Asker, Norway) and alprazolam 0.5 mg (Xanax; Pzer Inc, New York, NY) were given orally as single doses 30 minutes before the surgery. CORNEAL MARKING AND MANUAL FIXATION Corneal marking was used to minimize the initial ablation placement errors. Manual globe xation (14-mm Thornton xation ring; Altomed Ltd, Tyne & Wear, England) was used in addition to the eye tracker to avoid decentrations due to a parallax effect that occurs with patient xation loss during ablation.11,12 Perilimbal marks at 3 oclock and 9 oclock, dening a horizontal line, were placed with the help of a slit lamp, by rotating the slit into the horizontal position. Prior to setting the marks, the patients head tilt was adjusted so that both pupils were leveled along the same horizontal line. The ablation area and its center were dened by a 9-mm circle as well as by a horizontal (x) and a vertical (y) line. All markings were placed simultaneously by use of a single corneal marker (Gebauer Medizintechnik GmbH, Neuhausen, Germany). All ablations were centered on the corneal vertex, whose position was determined by preoperative corneal topography. Therefore, an offset, representing the
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coordinates of the vertex relative to the center of the pupil, was programmed into the eye tracker. After the epithelial removal and before the laser ablation, torsional, x, y, and rotational positions of the eye were checked with respect to the peripheral rests of the x and y marking lines and the calibrated projected laser cross. The patients xation was then conrmed by identication of the position of the rst Purkinje image and the globe xation ring was gently applied and held during the entire ablation. Frozen balanced salt solution (BSS) popsicle (frozen sterile merocel sponge soaked in BSS) was applied with an Amoils brush (Innovative Excimer Solutions, Toronto, Canada) on the cornea for 15 seconds before epithelium removal, for 5 seconds after deepithelialization, and for 15 seconds after laser ablation. After the refractive ablation, a short phototherapeutic keratectomy ablation, 5-m depth and 8-mm diameter, was applied on the wet cornea (hydrated with a thin layer of hyaluronic acid 0.025%) for smoothing purposes.13 Mitomicyn C 0.02% was applied for 12 seconds if ablation depth exceeded 100 m, followed by irrigation with 30 mL chilled BSS. Patients were evaluated on postoperative day 4 to 7 (upon bandage contact lens removal) and 1 and 3 months after surgery. At 1-month follow-up, examination included slit-lamp microscopy, Orbscan tomography, manifest refraction, UCVA, and BSCVA. At 3-month follow-up, examination was identical to preoperative. Pre- and postoperative parameters as well as the preoperative versus postoperative changes were analyzed using NCSS 2004 (Statistical Systems, Kaysville, Utah) software. Paired t-test was used to evaluate the difference 781

Wavefront Optimized vs Custom-Q Ablation/Stojanovic et al

Figure 1. Safety in the wavefront optimized ablation group (group 1) and custom-Q ablation group (group 2) 3 months after surgery showing the gain/loss of lines of best spectacle-corrected visual acuity.

Change in Snellen lines of visual acuity Figure 2. Efficacy in the wavefront optimized ablation group (group 1) and customQ ablation group (group 2) 3 months after surgery showing the cumulative uncorrected visual acuity.

between pre- and postoperative parameters. Two-sample t test was used to evaluate the difference between the two groups. A P value .05 was considered statistically signicant. Pearson test was used for testing of correlations. Vector analysis was used for calculating the changes between the spherocylinders before and after surgery, whereas all calculations concerning visual acuity were done by converting Snellen values to logMAR. RESULTS The wavefront optimized ablation group was treated from September 1, 2005 through February 28, 2006, whereas the custom-Q ablation group was treated from March 1, 2006 through August 31, 2006. Forty-six (92%) eyes from the wavefront optimized ablation group and 42 (84%) eyes from the custom-Q ablation group were available for evaluation at 3-month follow-up. Preoperative demographic and refractive data are presented 782

in Table 1, along with the manifest refraction data, BSCVA, asphericity (expressed as Q-factor), spherical aberration, 3rd order higher order aberrations, and total root-mean-square (RMS) higher order aberrations. Four (8%) eyes from the wavefront optimized ablation group and 8 (16%) eyes from the custom-Q ablation group were lost to follow-up. Their baseline data differed insignicantly from their respective groups. At 3 months after surgery, no eye in either group lost lines of BSCVA, whereas 41 (89.1%) eyes in the wavefront optimized ablation group and 35 (83.3%) eyes in the custom-Q ablation group gained 1 or more lines of BSCVA. Safety index (ratio between the mean postoperative BSCVA and mean preoperative BSCVA) was 1.26 for the wavefront optimized ablation group and 1.29 for the custom-Q ablation group (Fig 1). No statistically signicant difference between groups was noted (P=.63).
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Wavefront Optimized vs Custom-Q Ablation/Stojanovic et al

Figure 3. Predictability in the wavefront optimized ablation group (group 1) and custom-Q ablation group (group 2) 3 months after surgery showing manifest refraction spherical equivalent outcome.

Figure 4. Attempted spherical equivalent refraction versus achieved manifest refraction spherical equivalent in the wavefront optimized ablation group (group 1) and custom-Q ablation group (group 2) 3 months after surgery.

Forty-one (89.1%) eyes in the wavefront optimized ablation group and 38 (90.5%) eyes in the custom-Q ablation group achieved UCVA better than 20/20, whereas 32 (69.6%) eyes in the wavefront optimized ablation group and 29 (69.1%) eyes in the custom-Q ablation group achieved UCVA better than 20/16. Efcacy index (ratio between the mean postoperative UCVA and mean preoperative BSCVA) was 1.15 for the wavefront optimized ablation group and 1.13 for the custom-Q ablation group (Fig 2). No statistically signicant difference was noted between groups (P=.94). Forty-one (89.1%) eyes in the wavefront optimized ablation group and 36 (85.7%) eyes in the custom-Q ablation group were within 0.25 D of emmetropia, and 42 (91.3%) eyes in the wavefront optimized ablation group and 40 (95.2%) eyes in the custom-Q ablation group were within 0.50 D of emmetropia (Figs 3 and 4).
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No statistically signicant difference between groups was noted (P=.68). Pre- and postoperative low contrast visual acuity (12.5% contrast) at night and day, with and without glare, for the two groups are shown in Table 2. No statistically signicant difference was noted between groups for any low contrast visual acuity modes. All eyes demonstrated a tendency toward oblate shift after surgery (Fig 5). A marginally statistically signicant difference in oblate shift between groups (P=.049) was seen. Mean Q-value changed from 0.33 to 0.06 in the wavefront optimized ablation group and from 0.36 to 0.09 in the custom-Q ablation group. Figure 6 shows the mean Q-shift for two subgroups treated for low and high myopia (division point spherical equivalent refraction 4.00 D). The oblate shift showed a high correlation to the amount of myopic 783

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TABLE 2

Change in Mean Low Contrast Visual Acuity* for Patients in Wavefront Optimized Ablation and Custom-Q Ablation Groups
Wavefront Optimized Ablation Group Characteristic Night without glare Night with glare Day without glare Day with glare Preoperative 20/27 20/27 20/22 20/23 Postoperative 20/26 20/25 20/20 20/21 P Value .16 .07 .04 .06 Custom-Q Ablation Group Preoperative 20/27 20/27 20/22 20/22 Postoperative 20/26 20/26 20/21 20/20 P Value .46 .57 .31 .13 P Value .79 .48 .09 .18

*Mean Snellen low contrast visual acuity (12.5% contrast), converted from logMAR. Preoperative vs postoperative. Postoperative wavefront optimized ablation group vs postoperative custom-Q ablation group.

Figure 5. Q-shift (postoperative Q minus preoperative Q) in the wavefront optimized ablation group (group 1) and custom-Q ablation group (group 2), where negative Q-shift indicates a postoperative asphericity more prolate than preoperative, and positive Q-shift indicates postoperative asphericity less prolate than preoperative.

Change in asphericity (Q-shift)

correction in the wavefront optimized ablation group, but a low correlation in the custom-Q ablation group (three outliers were excluded in both groups) (Figs 7 and 8). Q-targets (applicable only to the custom-Q ablation group) were not achieved (see Fig 8). Root-mean-square higher order aberrations, spherical aberration, and RMS 3rd order higher order aberrations did not change signicantly (Table 3). Figure 10 shows refractive stability. Figure 11 shows the stability of low contrast visual acuity (12.5% contrast at night without glare) and RMS higher order aberrations at 3 and 6 months after surgery in subgroups of 26 and 18 eyes from the the wavefront optimized ablation and custom-Q ablation groups, respectively. DISCUSSION Data on corneal asphericity in the current study were acquired through WaveLight Topolyzers placido 784

diskbased videokeratography, which provides a map of corneal curvature. Unfortunately, measuring the asphericity with current instruments is not standardized; eg, AstraMax (LaserSight Technologies Inc, Orlando, Fla) gives mean asphericity within a circle of 4.6 mm in diameter, centered on the corneal vertex; Topolyzer calculates the mean asphericity along the attest and steepest meridians within the apical 30, providing two values; and Orbscan supplies the information about mean asphericity within a userdened apical circle. According to the American National Standards Institute (ANSI), mean asphericity should be based on the attest apical meridian for the central 5.5 mm.14 All of the mentioned methods provide different values. Additionally, registering asphericity with current technology is more difcult postoperatively than in virgin eyes. This is possibly due to induced corneal morphology changes, resultjournalofrefractivesurgery.com

Wavefront Optimized vs Custom-Q Ablation/Stojanovic et al

Figure 6. Mean Q-shift in the wavefront optimized ablation group (group 1) and custom-Q ablation group (group 2) divided in subgroups treated for low myopia (SE 4.00 diopters [D]) and high myopia (SE 4.00 D). Vertical lines represent 1 standard deviation.

Figure 7. Q-shift versus attempted spherical equivalent refraction correction of myopia in the wavefront optimized ablation group.

ing in decreased reliability of the Q-values (eg, typical measurement error in our material was 0.07 preoperatively and 0.11 postoperatively). Hence, we did not use Q-value data in the current study in any deeper analysis than presented in our results. It is currently known that for most eyes a negative (prolate) corneal asphericity is required to balance the positive (oblate) asphericity of the crystalline lens15 to achieve minimal spherical aberration. However, the current standard (non-aspheric) treatments for myopia result in an oblate shift,5 which disturbs this balance, thereby increasing spherical aberration. A combination of factors such as the decrease in effective radiant exposure to laser
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energy from the corneal center towards the periphery16 (due to inclination of corneal surface), reection losses according to Fresnels law,17 and the corneal biomechanical response3,18 seem to be responsible for the oblate shift. The rst two factors are addressed by modern aspheric ablations that feature a correction matrix, which compensates for the reduced laser ablation efcacy in the mid-peripheral cornea.19 Ablation proles used in both groups in the current study are compensated for by such a correction matrix19 and, therefore, the residual oblate shift that our results show is probably, or at least partially, due to a biomechanical response of the cornea in agreement with the study by Koller et al.7 785

Wavefront Optimized vs Custom-Q Ablation/Stojanovic et al

Figure 8. Q-shift versus attempted spherical equivalent refraction correction of myopia in the custom-Q ablation group.

Figure 9. Percentage of eyes in the custom-Q ablation group showing achieved Q-target proximity. Negative values indicate overcorrection (more prolate than intended), whereas positive values indicate undercorrection (less prolate than intended). Q-target was 0.6 in 39 eyes and 0.5 in 3 eyes.

Q-target proximity

Custom-Q treatments, which were used in the custom-Q ablation group, allowed us to aim for certain asphericity targets. Despite the fact that they were not met (see Fig 9), custom-Q ablations resulted in a smaller mean oblate shift compared to wavefront optimized ablations (see Fig 6), especially for higher degrees of myopia (see Fig 8). This is an improvement compared to ALLEGRETTOs wavefront optimized treatment. The data from the current study concerning Q-shift will help us in building a Q-adjustment nomogram, with the aim of further decreasing the oblate shift in myopic treatments. Study protocol used two separate Q-targets ( 0.5 and 0.6). Only three (7.1%) eyes satised our protocol criteria for Q-value of 0.5. The rationale for using two separate Q-targets was to limit possible excessive shift in prolate direction, especially in younger patients with relatively low preoperative Q-values (0 to 0.2) 786

where the preoperative corneal and lenticular asphericity were in balance.20,21 In retrospect, given the results of the current study where the desired prolateness was clearly not reached, the distinction between Q-targets of 0.6 and 0.5 turned out to be unnecessary. Only 46 (92%) eyes and 42 (84%) eyes from the wavefront optimized ablation group and custom-Q ablation group, respectively, were available for evaluation mainly due to the long traveling distances in North Norway. We believe this loss to follow-up has not inuenced the comparison of pre- and postoperative data as there was not a signicant difference in baseline data between the eyes lost to follow-up and the remainder of the respective groups. This studys 3-month follow-up may appear short, but one must take into account that our treatments were done by surface ablation and the outcomes are expected to change in the course of several months.
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Wavefront Optimized vs Custom-Q Ablation/Stojanovic et al

TABLE 3

Changes in Aberration Characteristics of Patients in Wavefront Optimized Ablation and Custom-Q Ablation Groups*
Wavefront Optimized Ablation Group Characteristic Total RMS HOAs Spherical aberration RMS 3rd order HOAs Preoperative (m) 0.20 0.08 (0.10 to 0.51) 0.02 0.06 ( 0.22 to 0.11) 0.16 0.08 (0.05 to 0.47) Postoperative (m) 0.23 0.09 (0.11 to 0.61) 0.03 0.06 ( 0.15 to 0.16) 0.19 0.09 (0.05 to 0.53) P Value .13 .46 .17 Custom-Q Ablation Group Preoperative (m) 0.20 0.06 (0.10 to 0.41) 0.01 0.06 ( 0.10 to 0.09) 0.18 0.09 (0.06 to 0.54) Postoperative (m) 0.22 0.09 (0.13 to 0.53) 0.03 0.04 ( 0.11 to 0.03) 0.19 0.08 (0.09 to 0.41) P Value* .19 .22 .25 P Value .43 .63 .55

HOAs = higher order aberrations *Values represented as mean standard deviation (range). Preoperative vs postoperative. Postoperative wavefront optimized ablation group vs postoperative custom-Q ablation group.

Figure 10. Stability of mean manifest refraction spherical equivalent in subgroups of the wavefront optimized ablation group (group 1) and custom-Q ablation group (group 2). Vertical lines represent 1 standard deviation.

However, our experience with the current laser, which produces wide and smooth ablations, is that results stabilize before 3 months postoperatively. To support this statement, we analyzed 6-month follow-up of subgroups of 26 eyes from the wavefront optimized ablation group and 18 eyes from the custom-Q ablation group (see Figs 10 and 11). Our protocol included application of frozen BSS popsicle before and after epithelial removal and after laser ablation. Currently, no published study in the peer-reviewed literature addresses the use of the frozen BSS popsicle technique, but various authors have presented this technique at numerous international meetings as well as in non-peer-reviewed literature.22,23
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After receiving conrmation from WaveLight that it would not interfere with the lasers eye tracking, a globe xation ring was applied in the current treatments to maintain the initial eye alignment and prevent decentration due to possible patient xation loss during ablation. Bueeler et al11 showed that an ablation displacement 0.21 mm, which will occur due to parallax effect in a non-xating eye with a globe rotation 3.25, will induce visually signicant higher order aberrations. With the same amount of globe rotation, pupil horizontal displacement (as seen by the eye tracker) will be 0.62 mm. However, the current pupil-tracking eye trackers will not interupt the ablation until a horizontal pupil displacement of at least 1 mm occurs. A detailed analysis of the implica787

Wavefront Optimized vs Custom-Q Ablation/Stojanovic et al

Figure 11. Stability of mean root-meansquare high order aberrations (RMS HOA) and mean low contrast visual acuity (LCVA) in the wavefront optimized ablation group (group 1) and custom-Q ablation group (group 2). Vertical lines represent 1 standard deviation.

tions of manual globe xation will be addressed in a future article. According to the calculations of Gatinel et al,24 an intentional increase in prolate asphericity caused by a mid-peripheral increase in ablation depth results in a decrease in myopic correction. To compensate for this, a deeper central ablation is necessary in aspheric ablations. However, in our previous clinical experience with custom-Q ablation, the built-in compensation is too large. Therefore, to avoid overcorrection, we made a nomogram adjustment by reducing the amount of treated sphere, as previously described in Patients and Methods. This provided excellent predictability, which is comparable to recently published LASIK outcomes for low to moderate myopic treatments in virgin eyes.25,26 The nomogram adjustment (ranging from 0.10 to 0.80 D) depended on the desired Q-target, the preoperative Q-value, and the amount of treated myopia/astigmatism. The adjustment increased with the increase of targeted prolateness and the amount of myopic correction, whereas it decreased with the amount of astigmatism correction and with more oblate preoperative asphericity. We believe this nomogram adjustment had an insignicant inuence on the amount of the oblate shift. Because we treated only virgin eyes with good preoperative contrast sensitivity and a low preoperative level of higher order aberrations, our aim was to eliminate the patients spherocylindrical error without disturbing the remainder of the corneal optics signicantly. Koller et al7 used the same laser platform and found a much larger increase in the 3rd order higher order aberrations (from 0.181 0.072 m before surgery to 0.296 0.115 m after surgery) in eyes treated with custom-Q ablation, compared to wavefront-guided 788

treatments (from 0.182 0.094 m before surgery to 0.192 0.088 m after surgery). Tran and Shah27 compared WaveLight wavefront optimized treatments and LADARVision4000 (Alcon Laboratories Inc, Ft Worth, Tex) wavefront-guided treatments and found signicantly more induced 3rd order higher order aberrations with the former. Both of our groups were treated with non-wavefront-guided ablations. The 3rd order higher order aberrations in both groups changed only insignicantly (from 0.163 0.081 m before surgery to 0.191 0.092 m after surgery in the wavefront optimized group and from 0.182 0.092 m before surgery to 0.193 0.085 m after surgery in the custom-Q group). Hence, our results in both groups were more comparable to Koller et al7 and Tran and Shahs27 wavefront-guided treatments than with their wavefront optimized treatments. The reason for this may be our centration of the ablation on the corneal vertex, the implications of which will be addressed in more detail in a future article. Our total RMS higher order aberrations, spherical aberration, and the 3rd order higher order aberrations increased very little and resulted in well-preserved, low contrast visual acuity under light and dark conditions, with and without glare (a nding comparable to the study by Koller et al7), and a statistically signicant correlation between the postoperative Q-values and low contrast visual acuity has not been found. Tuan and Chernyak14 did not nd such a correlation either and concluded that an oblate cornea is as likely to produce high-quality vision as a prolate one. Other explanations may be that low contrast visual acuity is a subjective measurement dependent on a number of interrelated factors and the low quality of postoperative asphericity data.
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Wavefront Optimized vs Custom-Q Ablation/Stojanovic et al

Our results showed almost universal oblate Q-shift in both groups (see Fig 5). The shift was less in the custom-Q group, but the difference between groups was just marginally statistically signicant (P=.049) and did not result in any signicant difference in postoperative spherical aberration or low contrast visual acuity. This may be caused either by the insufcient measurement reliability of our asphericity and wavefront aberrometry, or by a small inuence of the achieved Q-value changes on the spherical aberration and low contrast visual acuity. It is uncertain whether more prolate Q-targets would further diminish or eliminate the remaining oblate shift found in our custom-Q treatments. We are limited to what we can achieve by the Q-target adjustment, especially if we bear in mind that a part of the oblate shift most likely occurs due to biomechanical response of the cornea, which may need to be counteracted by a different approach. However, with the custom-Q treatments we have a new possibility to better control the oblate shift. Hopefully, in the future it will be possible to achieve specic Q-targets resulting in minimal spherical aberration. REFERENCES
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