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13 At baseline, mean preop sphere in the iDesign group was –2.80 D and mean preop cylinder was –0.81 D; mean preop sphere in the WaveScan group was –2.60 D and mean preop cylinder was –0.78 D. We looked at uncorrected visual acuity (UCVA), preservation of best corrected visual acuity (BCVA), refractive outcomes, patient satisfaction, and visual symptoms. At month 1, 95.4% of the iDesign eyes were within 0.5 D and 93.9% of the WaveScan eyes were within 0.5 D (more than 99% in each group were within 1.0 D of intended correction). The correction ratio stratified by the intended cylinder correction was better in the iDesign eyes (Figure 1). Besides having an improved correction ratio, there was slightly less axis shift with the iDesign—61.4% of eyes were within 5 degrees, compared to 59.2% with the WaveScan. In terms of refractive outcomes, all eyes in both groups were 20/40 or better, 95% of the iDesign eyes and 94% of the WaveScan eyes were 20/20, and 84% of the iDesign eyes and 80% of the WaveScan eyes were 20/16. Of note, binocular uncorrected vision was 20/20 or better in 99% of patients in both groups. There was no difference in the change in BCVA between groups, and more patients gained one or more lines of vision than lost. An important component of this study showed that patient satisfaction was higher for iDesign, with a better patient-reported quality of vision. An overwhelming 96.5% of iDesign patients were satisfied or very satisfied with their uncorrected vision. Visual symptoms were slightly better with iDesign— patients reported less difficulty with glare, halo, starbursts, and night driving in the iDesign group than in the WaveScan group, although neither group reported more than a moderate level of difficulty in any category or in night driving capability. For these treatments, we used the AMO recommended iDesign nomogram, which made a slight sphere adjustment based on the amount of cylinder. Our WaveScan treatments used the refined Optical Express nomogram where we matched the manifest sphere and added a 5% boost. At Optical Express, we're looking to further improve iDesign outcomes, but clinicians need to remember the outcomes we are already getting with the iDesign are exceptional. Overall, I think the diagnostic capabilities of the iDesign are re- markable. The wavefront measure- ment takes the entire optical system into consideration when planning treatments, and we have seen excel- lent results with this new device. Topography-guided ablations also on the horizon There are additional exciting technologies on the horizon, with topography-guided ablations. The FDA approved the WaveLight System (Alcon, Fort Worth, Texas), and it uses both Placido disk and Scheimpflug technology, and captures between 22,000 and 25,000 elevation points. Preliminary data shows promising results for treating virgin eyes: 92.7% of all study eyes achieved 20/20 or better, and 68.8% achieved 20/16 or better after 3 months. Almost 30% gained at least one line of BSCVA 3 months postop, and 98% said they would undergo continued from page 12 continued from page 11 recovery times in PRK may also add up to $300 for pain medications, the costs of which are borne by the prac- tice or passed along to the patient. 2 LASIK also may be a compelling choice for enhancements, especially in premium IOL patients. In general, that patient population is older and already likely to have even slower healing times than the traditional laser vision correction patient. If premium lens patients need an enhancement, they're not likely to be satisfied with the initial sur- gery, and surface ablation will only prolong the healing process (again, likely to result in fewer referrals). Reference 1. Randleman JB, Woodward M, Lynn MJ, Stulting RD. Risk Assessment for Ectasia after Corneal Refractive Surgery. Ophthalmology. 2008; 115:37–50. 2. Javitt JC, Chiang YP. The socioeconomic aspects of laser refractive surgery. Arch Ophthalmol. 1994;112:1526–1530. Dr. Dell is a cataract and refractive surgeon in Austin, Texas. He can be contacted at steven@dellmd.com. the procedure again. Topography- guided ablations have advantages in that ophthalmologists are very familiar with topography maps, and there can be less fluctuation com- pared to a wavefront measurement, as there is less worry about accom- modation. Overall, this looks to be a promising treatment option for virgin eyes as well as for therapeutic needs. The future: Beyond 20/20 There are exciting technologies on the horizon for laser vision cor- rection, and we are moving closer to truly customized ablations. Both ad- vanced wavefront and topography- guided ablations have their benefits, and I believe the future of visual outcomes for our patients is beyond 20/20. We need to adapt our tech- nology and measurement standards for delivering these results and provide this high-quality vision to our patients. Dr. Schallhorn is the medical director of Optical Express and is in private practice in San Diego. He may be contacted at scschallhorn@yahoo.com. Figure 2. How satisfied are you with the outcome of your refractive procedure? Data courtesy of Optical Express Corneal refractive surgery

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