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Centering corneal laser surgery (LASIK/PRK) with the Alcon/Wavelight EX 500 laser and Topolyzer Vario

Introduction

This page explains the different steps that allow the surgeon to the ablation center we the desired location with the Alcon/Wavelight EX500 excimer laser, while preventing discrepancies between registration data (Topolyzer Vario) and the EX500 laser eye-tracking system.

The EX500 excimer can be linked via local network to the Vario Topolyzer: this enables easy transfer from Topolyzer to the excimer laser.

Topolyzer to 500 ex

The Topolyzer Vario is connected via local network to the EX 500 excimer laser

The Topolyzer catches 2-D images of the anterior segment, while the eye at the center of its fixates Placido patterns.

The eye fixates the center of the Placido rings, and is coaxial with the Topolyzer camera which stands along the same axis.

The eye fixates the center of the Placido rings, and is coaxial with the Topolyzer camera which stands along the same axis.

 

These images include the cornea (tear film Placido image reflection), the pupil and iris. The pupil and limbus rentals are also determined the center. The reflection of the center of the Placido rings locates the intercept of the keratoscopic axis and the cornea, which is called "Vertex" in the ophthalmic literature. However, this point is called "Apex" the EX500 laser software, which is a misnomer for "Vertex", as the Apex should refer to the academically point of maximum curvature.

The rental of the corneal reflex is performed with eyes to the limbus.

The rental of the corneal reflex is performed with eyes to the limbus.

 

For the sake of consistency, we will use the term "Apex" to describe the corneal intercept of the keratoscopic axis (corneal reflex), from which the corneal Placido ring image is referenced. The recognition of the edge of the pupil is important, the pupil margin is detected by the eye-tracker at the laser and used as landmark to the laser treatment center.  The pupil diameter measured by default is obtained while the the Placido rings are illuminated, hence it corresponds to a "photopic" (illuminated) pupil diameter. The pupil rim can be delineated on the picture, and the projection of the center of the entrance pupil (pupil centroid) on the cornea locates the "corneal sighting center"which is the intercept of the line of sight with the corneal surface. In addition, the image of the iris is captured, to allow details for iris recognition and cyclotorsion prevention.

The pupil rim can be delineated and superimposed to the curvature map.

The pupil rim can be delineated and superimposed to the curvature map.

 

Eventually, the distance of the corneal reflex ("Apex") to the center of the "photopic" pupil can be calculated. If the "Apex" is referenced as the center of a Cartesian domain, the X and Y coordinates of the pupil center at the time of registration can be computed.

The center of the pupil defines the origin of a Cartesian domain in which the pupil center coordinates can be computed. Corneal reflex ("Apex") is a fixed landmark, light the pupil center can shift with pupil movements.

The center of the pupil defines the origin of a Cartesian domain in which the pupil center coordinates can be computed. Corneal reflex ("Apex") is a fixed landmark, light the pupil center can shift with pupil movements.

Currently, there are no. clinically available methods to locate the intercept of the visual axis and the corneal surface, which may correspond to the ideal point for laser ablation centering)see this page for additional information about visual axis and other ocular axes for centering corneal refractive surgical treatments). The visual axis, there is minimal lateral/transverse chromatic aberration. Some studies suggest that the visual axis intercept is often located between the pupil and the corneal reflex (= Topolyzer "Apex") center, but close to it. Hence, some authors advocate centering the treatment somewhere between these points.

Because of the angle kappa, the corneal reflex appears usually located on the nasal side with respect to the pupil center. While the position of the corneal reflex does not mark the intersection of the visual axis with the cornea (named "ophthalmometric pole"); However it may be its closest landmark and can be used to center the treatment (Pande M, Hillman JS. Optical area focus in keratorefractive surgery. Entrance pupil center, visual axis, coaxially sighted corneal reflex, geometric gold corneal center? Ophthalmology 1993; 100 (8): 1230-7).

In myopic eyes, the distance of the pupil center and the corneal reflex is usually low (about 100 microns or less). However, in some eyes (with hyperopia or astigmatism high), the distance between these points can be as high as 500 to 600 microns. This reflects the existence of a wide angle Kappa, defined by the angle between the pupillary axis and the visual axis). Defining the proper axis for centring may become of critical importance in eyes which exhibit a wide distance between the center and the "Apex" (corneal reflex) pupil.

Depending on the deviation between the pupillary axis and visual axis (angle Kappa), the rental of the visual axis intercept RK corneal flat may vary.

Depending on the deviation between the pupillary axis and visual axis (angle Kappa), the rental of the visual axis intercept RK corneal flat may vary. A valid assumption is to consider that the visual axis may be located mid way between the corneal reflex and the pupil center.

 

In the light of these recommendations, the EX500 excimer laser software enables to center the excimer profile of ablation on the pupil center (PC), we the corneal reflex (here called "Apex"), gold in between, by 10% steps (ex: 60% of the distance along the line joining the PC and the "Apex").

This video displays the procedure that precedes the laser delivery.

 

Here is a step-by-step description of the procedure shown in the video:

Registration and focus with the EX 500 excimer laser

(1) Vario Topolyzer examination:

This examination allows recording the corneal anterior topography and the pupil center coordinates: the location of the Apex defines the center of was Cartesian coordinates system, in which the (X/Y) pupil center coordinates are located. Several examinations can be taken and averaged. Each examination is verified by the software, and must exceed Topolyzer has quality threshold to be valid for registration and integration in the treatment program sequence (in which the desired correction, optical zone diameter, etc., are manually entered by the surgeon).

The treatment sequence (sphere and cylinder corrections) and the anterior segment image data (iris images, pupil center coordinates relative to the Apex) are transferred to the EX 500 laser system via local network. It is important to realize that the system now "knows" about the distance between the pupil and the Apex center. This distance is comparable to a "vector". It is displayed on the screen of the programming software.

Several measurements are taken and provide information on the pupil diameter and location with respect to the apex (Pupil Dec. X/Y). A median value is computed from the various acquired examinations.  In this example, due to wide angle Kappa, the pupil center at registration is located 410 micron temporally, and 60 micron inferiorly to the apex.

Several measurements are taken and provide information on the pupil diameter and location with respect to the apex (Pupil Dec. X/Y). A median value is computed from the various acquired examinations.
In this example, due to wide angle Kappa, the pupil center at registration with the Topolyzer is located 410 micron temporally, and 60 micron inferiorly to the apex.

 

However, keep in mind that the pupil center may shift with pupil diameter variations: hence, the length and direction of the aforementioned "vector" can change. Such variation can occur between the time and conditions of Topolyzer examinations to that of the excimer laser treatment, which follows flap creation gold epithelial removal. This shift can be compensated for, provided that it is monitored with respect to a stable landmark. Under the EX 500 excimer laser, this landmark cannot be the corneal reflex anymore (it is not clearly visible after flap lift since the exposed corneal stromal surface is dull), but can still be the limbal ring. It is therefore mandatory to accurately locate the limbus, and iris detail for optimal image matching and comparisons.

 

(2) EX 500 excimer laser correction focus:

 

At the time of the surgery, after flap creation and lift)LASIK (surgery), gold central epithelial removal (PRK surgery), three steps must be completed to perform focus to the desired rental after preventing from cyclotorsion and pupil shift:

(a) matching Limbus

The limbus diameter measured by the laser camera (circle delineating the corneal periphery) is compared to the reference image you captured by the Topolyzer and re-normalized to its value.

limbus registration

The diameter of the limbus as seen by the laser camera is compared to the data recorded by the Topolyzer

(b) Pupil diameter match

The diameter of the iris pupil is measured continuously under the laser, the laser microscope illumination should be adjusted so that the live and pupil diameter value gets as close as possible to that of the Topolyzer Vario referenced pupil image.

The comparison between the pupil diameter RK Topolyzer and under the EX 500 excimer laser is performed during registration. It is important to obtain comparable values. This ensure adequate pupil center location and looks to the limbus, in casee of wide pupil center shift when mydriasis or myosis occurs.

The comparison between the pupil diameter RK Topolyzer and under the EX 500 excimer laser is performed during registration. It is important to obtain comparable values. This ensure adequate pupil center location and looks to the limbus, in casee of wide pupil center shift when mydriasis or myosis occurs.

(c) the Pupil center shift compensation

The difference between the rental of the pupil center to the limbus as seen by the laser vs the location you recorded at the Topolyzer Vario (i.e pupil center shift) is displayed in terms of X and there distances. In parallel, the angle of rotation of the eye (cyclotorsion) is calculated and shown in degree. If the (X, Y) distances are less than 100 microns, it is recommended to add their value to the Topolyzer measured distance between the pupil center and apex (pupil shift compensation). If the (X, Y) distances are more than 100 microns, it is recommended not to add their value to the distance between the pupil and apex.

The displacement of the pupil center with looks to the limbus between the Topolyzer reference image and the actual laser image is shown in terms of X and there distances.

The displacement of the pupil center with looks to the limbus between the Topolyzer reference image and the actual laser image is shown in terms of X and there distances. Thesis distance will be used to "relocate" the pupil and recalculate the Apex rental center.

The apparent displacement of the pupil center may be due to some shift of the pupil center with pupil movements to, and/or instrumental inconsistencies; usually, such displacement should be less than 100 microns. The displacement along the X and there distances can be added to the "vector" connecting the pupil center (at Topolyzer) and the Apex.

Relocation of pupil center for vertex distance

 

(d) Cyclo twist activation

IRIS details are taken into account to calculate the angle of rotation of the eye under the laser cyclo. At the time of registration, this angle is used to rotate the treatment orientation accordingly, which is of critical importance for astigmatic correction.

Cyclotorsion angle

The iris image acquired by the Topolyzer is used to calculate the angle of rotation of the eye under the laser, it may have a different orientation.

(e) Deciding on final focus

Finally, a bar selector allows the surgeon to decide where the center of the ablation will be delivered, from pupil center (0%) to the Apex (100%), or anywhere in between (ex: 60%).

As the rental of the corneal Apex relative to the pupil center is known, any point in between these two landmarks can be used to center the laser ablation.

As the rental of the corneal Apex relative to the pupil center is known, any point in between these two landmarks can be used to center the laser ablation.

 

After the completion of these steps, the eye tracker can be activated by pressing the right pedal, before the laser is fired by pressing the left pedal.

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