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Laser or Wavefront or....what?
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Laser or Wavefront or....what?

Is Optiwave Refractive Analysis (ORA) Wavefront surgery a boon for cataract patients or just another marketing hype to increase the bottom line?  
Traditional surgery, Laser Assisted surgery, Wavefront surgery....what are the indications that one would be better choice over the others?
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711220_tn?1251894727
I believe that ORA is useful for post refractive cases and I use Femto assisted cataract surgery for premium IOLs.

Dr. O.
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Avatar_f_tn
Hi KayakerNC,

From what I've read about femto assisted surgery and particularly the wavefront component, it sounds like the real deal in terms of giving the best chance for an optimal outcome from cataract surgery, particularly for multifocal IOLs.

That's not to say that a 'traditional' (non laser) surgery isn't just fine for most patients, esp those with low risk and who have chosen monofocal IOLs.  But the laser platform w/ wavefront capability seems like it provides at least two advantages:

-  Ability to map and reduce low level astigmatism in real-time:  The laser can cut limbal-relaxing incisions w/ laser energy and the surgeon can see the corneal topography outcome in real time.  

   Of course, a toric IOL can also be used to reduce or eliminate astigmatism, especially when it's severe.  And some patients can have LASIK after their cataract procedure to 'tune up' any remaining astigmatism or refractive error.  Unfortunately some people (including me) are not candidates for LASIK, and have to rely on having the refractive error and astigmatism corrected by other methods.

    Some patients also have 'higher order' astigmatism where the cornea has some really unusual topography.  I think wavefront treatment is almost always needed for those patients, as the standard toric lens can only correct a simple astigmatism error.  

-  Ability to precisely place the IOL inside the capsular bag:  It's been shown in studies that the size and placement of the 'space' created for the IOL inside the capsule can be shaped and placed more precisely by using the laser to soften the cataract,in comparison to the chopping and manual perimeter formation by the surgeon of the capsular bag space in 'traditional' surgery.  

     The ability to more exactly center a premium IOL seems likely to result in a better outcome for the patient.  However, the risks associated with premium IOLS (halos etc) will still be there.  And more experienced cataract surgeons can probably do nearly as well as the laser at cutting out the cataract and making a space for the new IOL.  But on average I think it's been shown the laser can do it more precisely.  

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Avatar_m_tn
Interesting.  
So if astigmatism was involved (and in my case, it is) and the ORA costs were not prohibitive, it would probably be an advantage to avoid surprises and refractive errors.  It would seem to be very good for placing a toric lens, such as the Trulign, in the optimal position.
Certainly worth considering.
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Avatar_m_tn
They are using it now  to shine in the eye prior to insertion of the new lens after cataract surgery I am concerned that the light may damage the retina or macular - is this a concern?

Peggy
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Avatar_f_tn
The one thing I can't find with a quick web search is whether the ORA system is used intraoperatively in conjunction with any approved femto-laser cataract surgery platform, or whether it's specific to one platform.  

The laser platforms (LensX, Victus, etc) all come with their own software, so I don't know if the ORA is an adjunct module to the base software that comes with each femto platform, or if it's a replacement for whatever software and surgical-computer interface would otherwise be there.  

On the ORA website I read "With ORA’s intraoperative aberrometer, our cataract surgeons can get a precise assessment of the IOL and how much vision improvement can be obtained from it without having to wait or make adjustments weeks after surgery."  So it sounds like their technology can be used during the cataract surgery to assess whether the IOL is providing the correct visual outcome before the surgery is concluded, but I don't know if this is accurate.  I haven't seen a non-company-generated review of the ORA system compared to whatever else would be used.

BTW here is a recent paper comparing the laser platforms and describing the procedure in general, although it doesn't review the software involved:  

http://www.ascrs.org/sites/default/files/resources/Femtosecond%20Cataract%20Surgery%20Review_0.pdf

Still, if you are going to spring for funds for a premium IOL of any sort, you'd definitely want to make sure you had it placed in the optimal location with the minimum chance of complication.  The ORA website 'data' link certainly makes it appear that their system optimizes outcomes.  I just don't know if it's markedly better than other laser-femto computer guidance software, or if it allows the surgeon to assess the outcome during the procedure in a way that's different and better than the alternatives.  

BTW it's great that you are researching the alternatives and how they may benefit your specific case before going for surgery.  good luck!
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Avatar_m_tn
A VERY interesting article on astigmatism, toric lenses, and ORA.  Seems they all work well together.
http://garyfostermd.com/toric-iol-for-astigmatism-after-cataract-surgery/
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Avatar_f_tn
Thanks for the link!  Very interesting indeed, especially the part about astigmatism being generated from the back surface of the cornea. I thought it was primarily driven by the front curvature of the cornea only, unless there had been some kind of corneal trauma or disease process.  Good to know.

It makes sense that with the native lens removed, the ORA device could then measure exactly how much optical aberration remained in the cornea, and what type of toric IOL in which position would yield the best offset for the residual astigmatism.

This technique would require having a pretty broad range of IOLs on hand, so the correct sphere and cylinder correction would be available during surgery (since the surgeon wouldn't know exactly which lens was needed ahead of time).  But it does sound like this system might maximize the chance for the best outcome for a cataract procedure on an astigmatic eye.

Good luck with nailing down your preferred surgical method and implant!  Please keep us posted on how it is going and thanks again for the helpful link.  
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Avatar_f_tn
Interesting article in a recent Review of Ophthalmology where surgeons were interviewed about their plans to adopt - or not - femtosecond cataract procedures.

The article includes a discussion about intraoperative aberrometry.  It was interesting to read that one surgeon had an unplanned outcome (-2D vs plano) even when using ORA.  It does sound like these systems provide a slight improvement in accuracy, although some surgeons clearly think it's just hype:

http://www.revophth.com/content/i/2771/c/46972/

It does surprise me how often I read statements from cataract surgeons who don't believe the femto-assisted procedure provide a benefit to at least some patient groups.  

In my view, the skill of the surgeon in either traditional or femto procedures is clearly a dominant factor in success of any procedure.  But for high myopes with long, long eyeballs and fragile retinas, I don't see how any surgeon could dispute that lower total ultrasound energy disseminated in the eye during cataract surgery isn't safer for those patients.  

Ditto for more accurate placement of multifocal lenses, for patients who can access them. Best possible placement and centering of a multifocal makes it more likely it will 'work' as planned.

It's not to say traditional surgery can't work for these patients, because it often does.  But to say there is no potential benefit to any patient w/ the femto-based procedure seems inaccurate.
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