How to Drive the ALLEGRETTO WAVE Keeping pace with new technology is key to growing a refractive practice By Michael Gordon M D Paul H Hughes M D Keith Liang M D and Charles R Moore M by lhh12385


									How to Drive the ALLEGRETTO WAVE
Keeping pace with new technology is key to
growing a refractive practice.
By Michael Gordon, M.D., Paul H. Hughes, M.D.,
Keith Liang, M.D., and Charles R. Moore, M.D.

For those of you committed to expanding and enhancing your refractive practices, the
purchase of a new laser has many benefits, but it comes with a learning curve. How steep
the curve is depends on the surgeon’s experience, skill and ability to adapt, but the goal
can clearly be realized. Four leading surgeons share insights regarding their old and new
technology and provide valuable advice about how to make the transition proceed more
quickly and seamlessly.
                                                                                               Figure 1. The ALLEGRETTO
                                                                                               WAVE features a compact
                                                                                               design and is very low

From the Alcon to the ALLEGRETTO WAVE
In 1989, Dr. Michael Gordon performed among the first treatments in the United States
with the Summit broad beam laser and was involved in all the clinical trials for this laser.
When Summit acquired Autonomous, he transitioned to the newer technology, which
featured a small scanning spot beam. The Autonomous laser became his laser of choice,
right through the approval of wavefront-guided treatments, and he served on the Alcon
Medical Advisory Board. Today, he has performed thousands of procedures with both the
LadarVision and the ALLEGRETTO WAVE.

I became an investigator for WaveLight in 2001 and it quickly became apparent that the
ALLEGRETTO WAVE was not only faster, but more accurate. Further, it featured an excel-
lent tracker, required no dilation, had minimal service requirements, and was more cost-
effective for my practice. This newer generation laser was an all-around better choice for
my patients and my practice.
How to Drive the ALLEGRETTO WAVE                                                                           2

            Initial Impressions
            In the beginning, I had to prove to myself that the wavefront-optimized platform would
            provide satisfactory results. After FDA approval of the ALLEGRETTO WAVE, my in-house
            study clearly revealed that the outcomes with this laser were as good as or better than
            the wavefront-guided program of the LadarVision in almost every category studied. Why
            pay more for a wavefront-guided procedure when I could achieve superb results with the
            ALLEGRETTO WAVE standard program?

            The LadarVision custom treatments took up to two minutes to complete, provided the
            same or worse results, resulted in a higher enhancement rate, and cost my practice
            more money. When patients have significant, pre-existing higher order aberrations (HOA
            >0.30 to 0.40 microns), I now use the VISX WaveScan for custom treatments. I gradually
            abandoned the use of the Alcon laser completely. Currently, I use the ALLEGRETTO WAVE
            on 95% of my cases and use the VISX WaveScan on 5% of cases.

            The only difficulty I experienced in making the transition to the ALLEGRETTO WAVE was
            ergonomic - the laser sits relatively low to the ground. However, this inconvenience
            was more than compensated for by the very rapid treatment times, which created more
            efficient patient flow.

            As with all lasers, surgeons must follow their cases and develop a nomogram based
            on their technique, individual laser, and operating environment. It is critical that new
            users obtain a good software package to facilitate a precise nomogram development.
            Surgeons should also check the alignment of the patient’s head carefully for accurate
            astigmatic corrections.

            The ALLEGRETTO WAVE is a precise, high-speed workhorse laser, which provides
            exceptional results and a very high patient satisfaction rate. In my experience, the transi-
            tion was straightforward and uncomplicated as this laser proved very easy to use.

            From the Bausch & Lomb Technolas 217C and
            the Meditec Mel-70 to the ALLEGRETTO WAVE
            and the WAVE Eye-Q
            Dr. Paul Hughes is Cataract and Refractive Surgeon at Southline Eye Centre in Sydney,
            Australia and has been practicing since the early 1980’s. In 1985, he began to specialize
            in refractive eye surgery. He initially performed radial keratotomy using the Fyodorov
            technique and subsequently adopted the Charles Casebeer system. With the advent of
            the excimer laser in the early 1990’s, he had no doubt that this technology represented
            the future.

            I began performing photorefractive keratectomy using the Alcon Summit laser in 1994.
            In December 1996, I purchased the Bausch & Lomb Technolas 217C as I felt that flying
            spot technology was superior to broad-beam. After performing in excess of 1,000 pri-
            mary procedures annually with this laser, Meditec placed a Mel-70 into my laser suite in
            December 2000 with which I completed approximately 300 cases. After using this laser
            for approximately 3 months, WaveLight placed an ALLEGRETTO WAVE in my practice for
            a similar trial.
How to Drive the ALLEGRETTO WAVE                                                                               3

            With the Mel-70 in one room and the ALLEGRETTO WAVE in the other, I had the unique
            opportunity to compare outcomes. I was constantly evaluating laser technology inclu-
            ding all the newest models and, after extensive research, I was confident that the
            ALLEGRETTO WAVE was the best laser available and so I purchased it. Initially, cases
            were divided equally between each laser. It rapidly became obvious that the results with
            the ALLEGRETTO WAVE were far superior to those of the Mel-70 and so the ALLEGRETTO
            WAVE was placed into primary position. I have since moved on to using the 400 Hz
            ALLEGRETTO WAVE Eye Q.

            Initial Impressions
            I did not experience any difficulties when switching to the ALLEGRETTO WAVE and WAVE
            Eye Q. Not having to deal with fluence plates, which I had to do with the B&L laser, made
            the calibration of the ALLEGRETTO WAVE straightforward, user friendly, and greatly con-
            tributed to the ease of the transition. The ALLEGRETTO WAVE Eye Q is used as a work
            horse in my practice – it is used on all appropriate patients presenting for laser vision

            When I first built my laser suite, the B&L engineers stipulated that it must have a certain
            humidity and temperature, both of which are not required by the ALLEGRETTO WAVE.
            The ALLEGRETTO WAVE operated far more quietly than the B&L laser. Data entry was
            extremely simple as it can be analyzed on my laptop computer anywhere I choose rather
            than being forced to work in the laser suite itself. The outstanding results achieved with
            this laser were a definite plus in terms of marketing my refractive practice. The shorter
            treatment times had a significant impact on the duration of my operating lists allowing
            me more time for leisure.

            When one purchases a new laser, it is best to avoid treating extreme refractive errors.
            Simple myopes and hypermetropes should be completed first to help surgeons become
            accustomed to the nuances of the laser and to guide nomogram adjustments. Secondly,
            it is beneficial to initially do small lists. This will provide the opportunity to better under-
            stand all the features of the laser as well as resulting in a good foundation for future lists.
            Small lists, lower corrections and fastidious follow-up are all pearls for great results and
            happy refractive surgeons and patients.

            With regard to the nomogram, it is prudent to talk to other users who have had expe-
            rience in terms of nomogram adjustments as well as asking for assistance from the
            WaveLight company. However, I would stress to all new users that, while it is helpful
            to have data from other established WaveLight users, the nomogram will always be
            specific to each user’s particular laser and for their environment. I, personally, would not
            be without Dr. Guy Kezirian’s specialized software (Refractive Surgery Consultants, LLC;
            Scottsdale, AZ). With this program, I am more confident in the numbers I enter into the
            laser and the software is constantly upgraded, helping to perfect my surgical outcomes.
            Finally, when choosing a new laser, it is important to check the availability of technical
            support and service. In this regard, I believe that WaveLight is without peer.
How to Drive the ALLEGRETTO WAVE                                                                          4

            Using the Nidek EC-5000 and the

            Dr. Keith Liang is the Medical Director of the Sacramento Eye Surgery Center in Sacra-
            mento, California and specializes in corneal and refractive surgery. He has used multiple
            platforms in PRK and LASIK surgery including lasers by Autonomous, VISX, and the Nidek
            EC-5000, which he acquired in 1998.

            In July 2004, I purchased the ALLEGRETTO WAVE based on recommendations from
            trusted colleagues and friends in Canada and Europe who had transitioned to this laser.
            I was very interested in the evolution of wavefront analyzers and the subsequent inte-
            gration of wavefront measurements into laser treatments. After evaluating each of the
            wavefront platforms, I concluded that the many variables to image acquisition could
            affect treatment outcomes and that the majority of patients would not benefit from
            wavefront-guided treatments. Dr. Seiler and Mrochen’s research demonstrated that
            custom treatments did not always yield better clinical outcomes. They found that wave-
            front-optimized treatments with the ALLEGRETTO WAVE were the best way to address
            the complexities associated with oblate corneas, which is the primary reason I chose
            the ALLEGRETTO WAVE. Another key factor in my decision was that this laser allowed
            wavefront-optimized hyperopic and cross cylinder ablations.

            Initial Impressions
            Because I was achieving very good results with the Nidek laser, my adoption of the
            ALLEGRETTO WAVE advanced more slowly. During the first three to six months, I used
            this new laser on low myopes and slowly incorporated patients with astigmatism. Most
            of my patients were pleased with the results of both lasers, with no perceptible subjective
            differences noted in terms of glare, illumination rings and uncorrected visual acuities.

            Using the Nidek OPD-Scan (Refractive Power/Corneal Analyzer), I observed that patients
            treated with the ALLEGRETTO WAVE had a good, effective optical zone with a lesser
            amount of measurable post-operative spherical aberration, particularly in monovision
            patients. Following the wavefront-optimized treatment in the near vision eye, patients
            had fewer higher order errors such as spherical aberration and coma. My results were
            carefully tracked with the Refractive Surgery Consultant software, allowing me to gain
            confidence in my nomograms and to perfect my outcomes. The ALLEGRETTO WAVE was
            the only laser platform that allows surgeons to treat the near vision eye with wave-
            front technology. More of my patients were able to adapt to monovision following their
            treatment with the ALLEGRETTO WAVE as compared to the Nidek and I now offer this
            treatment option to patients with greater confidence.

            Traditionally, hyperopic treatments have resulted in more induction of higher order
            aberrations than myopic treatments. The ALLEGRETTO WAVE has produced better out-
            comes and resulted in greater patient satisfaction in these more challenging cases. In
            these patients, the wavefront-optimized treatments were a tremendous improvement
            over treatments with any other laser platform.

            I continue to use the Nidek laser to treat simple myopes and patients with myopic
            astigmatism who have low HOA or low spherical aberration. Approximately 70% of
            treatments are conducted with the ALLEGRETTO WAVE and 30% with the Nidek laser.
How to Drive the ALLEGRETTO WAVE                                                                             5

            The main difficulties I experienced when transitioning to the ALLEGRETTO WAVE involved
            ergonomics. The bed moves more slowly and the laser platform itself is positioned lower,
            which can require some adjustment, particularly for taller surgeons. The eye tracker is
            outstanding and very fast, but your laser technician must pay careful attention to the
            tracker illumination ring, making appropriate adjustments, for accurate tracking during
            surgery. I have discovered that it is best to dim the laser light to enlarge the pupil, which
            enhances the performance of the tracker. Patients with large chests will limit the tracker
            illumination ring’s ability to slide easily into position.

            New users must adjust to the lower seating, to the post located on the left-hand side,
            and to the tracker illumination ring, which swings in and out. I easily adjusted to the
            lower seating, as did my staff. The tracker illumination ring movement and the greater
            reliance you must place on your laser technician during the procedure were overcome
            with practice. The magnificent speed of this laser has many advantages as the corneal
            bed stays uniformly hydrated during the procedure, but errors can occur more quickly and
            surgeon’s may have to adjust to the faster speed.

            Negotiating the Move between the VISX STAR
            S4 and the ALLEGRETTO WAVE

            Dr. Charles Moore is Medical Director of the International EyeCare Laser Center in
            Houston, Texas. His practice has been dedicated exclusively to the keratorefractive field
            since 1997. He was a clinical investigator for Summit Technology and the CRS study
            for approval of LASIK. Dr. Moore first used the VISX 20/20 in a multi-user center and
            purchased a STAR S3 in the year 2000, performing several thousand cases. He upgraded
            to a STAR S4 and later added the WaveScan WaveFront System and performed an addi-
            tional several thousand cases.

            My practice was one of ten original United States study sites for the FDA trials for the
            ALLEGRETTO WAVE. My staff and I were immediately impressed by the one day post-
            operative visual acuities and quality of vision as well as by the elimination of halos, glare,
            and night vision complaints.

            Dr. Seiler initially explained to us that the ALLEGRETTO WAVE had been specifically
            designed using wavefront algorithms in order to preserve preoperative asphericity and
            to minimize the induction of spherical aberration. After FDA approval, I purchased the
            first ALLEGRETTO WAVE in the United States. The primary reasons for purchasing this
            200 Hertz (Hz) laser were the magnificent speed and superb outcomes of the wavefront-
            optimized (standard) platform as compared to the more time-consuming and compara-
            tively less predictable results achieved with the wavefront-guided platform furnished by
            the VISX WaveScan system.
How to Drive the ALLEGRETTO WAVE                                                                          6

                                                                                  Figure 2. Post-operative
                                                                                  topography view of a
                                                                                  patient who had a wave-
                                                                                  front-guided VISX Star
                                                                                  S4 C­ustomVue treatment.
                                                                                  This patient required
                                                                                  an enhancement, which
                                                                                  was performed with
                                                                                  the ALLEGRETTO WAVE
                                                                                  platform (Figure 3).

             Patient               Treatment
                                                            ALLEGRETTO WAVE
             TX                    VISX Star S4 CustomVue
             Manifest              -1.39 = -0.72 x. 47      -1.75 = -1.50 x. 45
             Calculated OZ         6.0 x 5.0 mm             6.5 mm
             Measured OZ           3.85 mm                  6.62 mm

                                                                                  Figure 3. Post-operative
                                                                                  topography view of a patient
                                                                                  who had an enhancement
                                                                                  with the ALLEGRETTO
                                                                                  WAVE wavefront-optimized
                                                                                  platform. The topographi-
                                                                                  cal results clearly reveal
                                                                                  the significantly increased
                                                                                  optical zone size following
                                                                                  the wavefront-optimized
                                                                                  enhancement as compared to
                                                                                  her original treatment with
                                                                                  the VISX C­ustomVue program
                                                                                  (Figure 2). Using an advanced
                                                                                  Munnerlyn formula, the
                                                                                  ALLEGRETTO WAVE preserves
                                                                                  the natural aspheric shape of
                                                                                  the cornea with a peripheral
                                                                                  energy adjustment and an
                                                                                  aspheric ablation. This laser’s
                                                                                  peripheral energy adjustment
                                                                                  and pulse control compen-
                                                                                  sate for the energy reflection
                                                                                  at the corneal periphery,
                                                                                  resulting in the creation of
                                                                                  a large, true optical zone.
How to Drive the ALLEGRETTO WAVE                                                                           7

            Initial Impressions

            The transition to the ALLEGRETTO WAVE progressed very smoothly. It was very reassuring
            for patients to learn that their actual “laser time” would be less than 20 to 30 seconds.
            I quickly realized that a 9.5 mm flap was preferable because of the larger treatment zone.
            My enhancement rates decreased significantly and I have never had a tracker failure.
            I have now performed several thousand cases with this laser. The ALLEGRETTO WAVE
            has proved to be much quieter with faster treatment times and the calibration and pre-
            operative data input are made easy with a laptop computer. 100 per cent of my cases are
            now performed with this laser and I have since sold the VISX STAR S4.

            New users must be cautious when initially treating large dioptric amounts of refractive
            error prior to establishing their own nomogram with their particular laser in their specific
            environment. I strongly urge each physician to use an outcome analysis program to cal-
            culate and perfect their own treatment nomogram. Surgeons should learn to use the slit
            lamp immediately after each procedure to evaluate the flap interface, preventing trips
            back to the laser suite.

                Top Five Considerations when Switching to an ALLEGRETTO WAVE

                1. You must develop your own treatment nomogram, specific to your individual
                   surgical technique and the environment in which you are performing procedures.
                   Obtain a good outcome analysis program to calculate and perfect your own
                   treatment nomogram.
                 2. Surgeons should evaluate the flap interface with the slit lamp immediately
                   after each procedure to prevent trips back to the laser suite.
                 3. Check the patient’s head alignment carefully for accurate corrections.
                 4. Surgeons must adjust to the ergonomics of the laser, such as the chair
                    movement, post location, and to the use of the tracker illumination ring.
                    The laser sits relatively low to the ground and requires some adaptation
                    by users and their staff.
                 5. Because the laser is very fast, surgeons may have to adjust to the more
                    rapid speed.

            Driving Forward
            Replacing older technology is critical to the success of your practice, but it has its
            challenges. In some ways, adjusting to new surgical technology is similar to adjusting
            to a new car. The ALLEGRETTO WAVE’s bed height and laser speed are some of the
            factors requiring a transitory adjustment. Developing an accurate treatment nomogram
            as expeditiously as possible is the primary pearl offered to new users.
How to Drive the ALLEGRETTO WAVE                                                                                           8


                Mrochen M, Seiler T. Influence of corneal curvature on calculation of ablation patterns
                used in photorefractive laser surgery. Journal of Refractive Surgery 2001;17:S584-S587.

                Mrochen MC, Kaemmerer M, Riedel P, Seiler T. Why do we have to consider the
                corneal curvature for the calculation of customized ablation profiles?
                Investigative Ophthalmology & Visual Science 2000;41:S689.

            Dr. Gordon’s e-mail address is
            Dr. Hughes’ e-mail address is
            Dr. Liang’s e-mail address is
            Dr. Moore’s e-mail address is

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                                                                                               WaveLight AG
                                                                                               Am Wolfsmantel 5, 91058 Erlangen

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