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Driving laser vision correction outcomes, category growth, and confidence in today's turbulent environment 60 New laser vision technology on the way by Edward E. Manche, MD wavefront-guided—deliver higher- quality vision. We need to adapt our technology and measurement standards to achieve these results. Reference 1. Lazon de la Jara P, Erickson D, Erickson P, Stapleton F. Visual and non-visual factors associated with patient satisfaction and quality of life in LASIK. Eye (Lond). 2011; 25:1194–1201. guided ablation, combining manifest refraction and corneal to- pography. Designed to treat corneal aberrations only, it can be used for primary and therapeutic treatments (an off-label use). The advantages of topography- guided ablations are familiarity and consistency of capture. We can center the refractive treatment wherever we prefer, and we can use topography-guided ablations when corneal aberrations are too high for accurate wavefront capture or when we cannot or do not want to per- form wavefront-guided treatments. The U.S. Food and Drug Administration clinical trial for topography-guided ablation showed excellent outcomes. Approximately 93% of eyes had 20/20 or better UCVA and nearly 70% had 20/16 or better (WaveLight Allegretto Wave Eye-Q, Alcon, Fort Worth, Texas). 2 Patient satisfaction was approxi- mately 98%. Advanced wavefront-guided ablation treats aberrations of the entire eye, not just corneal aberra- tions, and its diagnostic capabilities take into account the entire optical system. We hope to see approval at the end of this year. The latest wavefront-guided technology offers a higher-reso- lution aberrometer. It provides increased dynamic range, more precise torsional alignment, and corneal curvature compensation (Figure 1). In a study of nearly 9,000 eyes with low to moderate myopia, 95% of patients had 20/20 or better vision and 84% had 20/16 or better (analysis by Dr. Schallhorn and Biostatistics Department, Optical Express, not yet published). Ap- proximately 97% were satisfied with their vision (Figure 2; courtesy of Dr. Schallhorn). Conclusion The future of LVC is topography- guided ablation and advanced wavefront-guided ablation. They will allow us an unprecedented level of customization, enabling us to combine treatments. The future is beyond 20/20. Higher-resolution diagnostics—both topography-guided and advanced Evolving diagnostics will help surgeons achieve a new level of outcomes N ew technology is on the horizon, imple- menting advanced diagnostics that will continue to improve the excellent outcomes we achieve with laser vision correction (LVC). In November 2013, topography- guided ablations were approved. We hope to see commercial launch soon, as well as the approval of advanced wavefront-guided tech- nologies. Higher standard The gold standard of 20/20 uncor- rected visual acuity (UCVA) is no longer acceptable when patients expect high-quality vision. Patient satisfaction is highly correlated with UCVA, and quality of vision and quality of life surveys are increasing- ly important in assessment. 1 Patient satisfaction is also nega- tively correlated with visual distur- bances, which usually result from residual sphere and cylinder. Furthermore, even patients with 20/15 or better vision will be unhappy if they have chronic irritation and dryness. We must aggressively treat dry eye and ocular discomfort. Satisfaction levels According to research by Steven Schallhorn, MD, and his col- leagues, patients are pleased with 20/20 vision, but satisfaction increases dramatically as vision im- proves to 20/16, 20/12.5, and 20/10 (analysis by Dr. Schallhorn and Biostatistics Department, Optical Express, not yet published). In the United States, we hope to soon have access to topography- Figure 1. Advantages of latest wavefront-guided ablation 2. Allegretto Wave Eye-Q Scanning Spot LASIK Laser System Patient Information Booklet, pgs. 40, 47. www.accessdata.fda. gov/cdrh_docs/pdf2/p020050s012c.pdf. Dr. Manche is professor of ophthal- mology, and director of the cornea and refractive surgery division, Byers Eye Institute, Stanford School of Medicine, Calif. He can be contacted at edward. manche@stanford.edu. • Improved ablation profile based on whole eye optical aberrations • Higher quality aberrometer • Increased dynamic range • More precise torsional alignment • Corneal curvature compensation Figure 2. Responses when patients were asked: "Thinking about your vision during the last week, how satisfied are you with your vision (without the use of glasses or contact lenses)?" Courtesy of Steven Schallhorn, MD, Optical Express Thinking about your vision during the last week, how satisfied are you with your vision (without the use of glasses or contact lenses)? 80% 60% 40% 20% 0% Very satisified Satisified Neither Dissatisfied Very dissatisfied 74.3% 22.2% 1.8% 1.3% 0.3% 96.5% satisfied

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