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Dr. Stephen Slade and Dr. Richard Baker specializes in services such as

By admin on Oct 2, 2010 | In Uncategorized

Laser Vision

LASIK is a laser eye surgery procedure that can improve your vision and quality of life. A key factor in the LASIK outcome is the surgeon. But, most patients in Houston and elsewhere chose a LASIK surgeon based on one or two anecdotal reports. They research a new car purchase more. Other surgeons and LASIK specialists know who to go to. These doctors simply ask their colleagues, read the literature and see the leaders lecturing at meetings. Dr Steve Slade is a LASIK specialist that is indeed a surgeon’s surgeon. He has performed laser eye surgery and refractive surgery on more than 450 other ophthalmic surgeons and hundreds more from other medical specialties. These patients come from not only the Houston and southeast Texas area, but from many other countries.

Learn more about LASIK:

LASIK, as in any other major surgery, has risks. For more Information, please click HERE.

Cataract

Welcome to the Cataract Surgery Center of Slade & Baker Vision Center. If you suffer from cataracts or have lost the ability to see up close, you have come to the right practice. Drs. Slade and Baker are pioneers in the field of refractive cataract surgery. Our patients not only have the choice to see at all distances after surgery they are the only patients in the United States that can have Bladeless Laser Cataract Surgery.

Bladeless Laser Cataract Surgery was first performed in the United Stated by Dr. Stephen Slade within our office surgical suite. Bladeless Laser Cataract Surgery uses the femtosecond laser to do many of the steps currently performed by hand, and is designed to provide a greater level of precision and safety to modern cataract surgery.

“I have been involved in many new technology introductions, and I know from these past experiences that Bladeless Laser Cataract Surgery, will be widely accepted by surgeons and demanded by patients all over the world,” said Dr. Slade after the procedure. “This is the cataract surgery that I would want for my friends, my family and myself.”

Report: First cataract surgeries performed with femtosecond laser in the U.S.

By Stephen G. Slade, MD, Houston TX

During the last week in February, I had the privilege to be the first ophthalmic surgeon in the United States to perform cataract surgery using a femtosecond laser. The procedures that we performed over a 2-day period with the LenSx Laser (LenSx Lasers, Inc., Aliso Viejo, CA) are the beginning of what I believe will be the next evolution in refractive cataract surgery.

The LenSx Laser received FDA clearance for anterior capsulotomies in August 2009 followed by a clearance for corneal incisions in December 2009. During these first surgeries, we used the LenSx laser to create the anterior capsulotomy and corneal incisions for the cataract procedure. Future clearances will allow us to expand the use of the LenSx Laser to include the remaining steps in the surgical process, with the exception of irrigation/aspiration and lens insertion.

Procedure and Patient Acceptance

We performed the first surgeries at our ambulatory surgery center here in Houston with the second laser the company has manufactured. The surgeries turned out even better than I expected. We have done 8 cases and all were 20/25 or better at day one. All of the capsulotomies attempted were perfectly centered and achieved diametric accuracy of ± 0.25 mm. Precise corneal incisions were effectively created by the laser, and all were self-sealing postoperatively. After cataract removal using phacoemulsification, all of the eyes underwent premium IOL implantation. Although anecdotal, both my partner and I independently felt that the corneas at day one were exceptionally clear, perhaps because there is less maneuvering with the corneal tissue and intraocularly.

As exciting as the performance of the LenSx Laser was, the overwhelming response from patients was even more impressive. Then again, patients have always thought that cataract surgery was done with a laser – so perhaps this helped to overcome any concerns about being the first patients to benefit from this new technology. I believe patients will benefit from a lower complication rate and from improved refractive results. The ability of the laser to make reproducible corneal incisions and capsulotomies will allow us to optimize the lens position and astigmatism now. In the future we will be able to make corneal astigmatic incisions to deal with preexisiting or induced cylinder.

I do believe femtosecond refractive surgery will become the preferred method of cataract surgery. This will be both surgeon and patient driven. Patients are extremely excited about "laser cataract surgery". The "get it". Surgeons will find it more precise, reproducible and simply more "fun".

The initial clinical evaluation of the LenSx Laser began in 2008 with Professor Dr. Zoltan Nagy of Semmelweis University in Budapest, Hungary. He has now successfully performed over 500 surgeries with the LenSx Laser, and the first image-guided refractive cataract surgeries with the laserin December 2009. This surgery included lens fragmentation, capsulotomy and corneal incisions.

My initial experience with creation of the capsulotomy and corneal incisions has been extremely positive. In my years as a refractive and cataract surgeon, I have had the good fortune to be involved in the introduction of a number of new technologies – including the first customized ablation for LASIK and the femtosecond laser for corneal flaps – without a doubt, these first surgeries were as textbook as you could hope to have.

In the past 15 years, there have been a number of attempts to deliver a laser for cataract surgery.With the LenSx Laser, I believe that we may be on the way to having a cataract technology that allows us to deliver technique that matches our premium IOLs, enabling us to deliver even better outcomes.

The Advantages of Laser Cataract Surgery - By Stephen G. Slade, MD

What excites me the most about femtosecond laser-assisted cataract surgery are the benefits that the technology offers to our patients. Safety will be enhanced by reduced phaco time and power, less surgical time in the eye, and finer, more elegant incisions, among other innovations. Precision may be increased by an exactly sized, shaped, and positioned capsulotomy that will better control the IOL’s final resting place as well as by precise, reproducible primary incisions and standardized, quantifiable astigmatic keratotomies. Femtosecond lasers could also enable and make possible many other technologies, including polymer IOLs that can be injected through a tiny capsulotomy.

Most of the heated debate about femtosecond laser-assisted cataract surgery has not been about the capabilities of the technology, however, but rather its real-world practicality. Will patients seek it out? Is it economical? Who will pay for it? I have a unique perspective here. I have been performing laser cataract surgery commercially in Houston for nearly a year now on all of our practice’s premium IOL patients and most of our other cataract patients.

Since LenSx Lasers Inc. (Aliso Viejo, CA) delivered the platform to us in February 2010, we have not been part of an FDA trial or subject to other investigational device restrictions. The laser already had 510(k) clearance for anterior capsulotomy when we received it, and clearance for incisions and lens fragmentation quickly followed. In my experience, patients easily understand and prefer “laser” cataract surgery, and they seek it out. Yes, there are added costs. This advanced technology is not covered by Medicare, however, so patients can assume these costs if they so choose. In other words, patients can elect to pay for what they decide is better care, safety, and efficiency.

On January 1, 2011, the first baby boomers turned 65 and entered Medicare, with an estimated 10,000 hitting that milestone each day now. The US population over the age of 65 is projected to double in 7 years. I believe the development and availability of laser cataract surgery are right on time.

This piece was adapted with permission from Dr. Slade’s editorial “Thoughts on 2010”, which appeared in Cataract & Refractive Surgery Today’s February 2011 edition.

Stephen G. Slade, MD, is a surgeon at Slade and Baker Vision in Houston. He serves as the medical director for LenSx Lasers Inc. Dr. Slade may be reached at (713) 626-5544; sgs@visiontexas.com.

For complete details about Laser Cataract Surgery, please click HERE.

Near Vision Solutions

Slade & Baker Vision Center specializes in helping patients see young again by providing them with a full range of vision without glasses or contact lenses. This can be accomplished with contact lenses, laser vision correction or with Intra Ocular Implants.

Near Vision If a person had normal vision when they were young, they could easily shift their focus from near objects to distant objects, seeing clearly at all distances. But around the age of 40 – 45, the lens inside the eye begins to lose its ability to change focus and most people become dependent on reading glasses or bi-focal lenses to see close objects. This condition is called presbyopia.

One of the Near Vision procedures we perform is called monovision or blended vision. Monovision is created when one eye (usually the dominant eye) is corrected for clear distant vision while the other eye is corrected for clear near vision. The visual cortex of the brain learns to only pay attention to the image that it wants to see in focus and ignore the image that is not in clear focus. Most people who have monovision are able to see well enough at all distances to do things at any age without corrective lenses.You may be using this now with contact lenses. If so, you can likely have the same correction with LASIK.

In a person who is nearsighted and around the age of 40 – 45, correcting both eyes with LASIK or PRK to see clearly for distance vision means they would probably become dependent on reading glasses to see up close unless they have the monovision procedure.

Cataract Woman For slightly older patients around the age of 55 – 60, the lens inside the eye is usually showing signs of cataracts. For this age group, removal of the natural lens inside the eye with a procedure called Refractive Lens Exchange (RLE) can be a better alternative to laser vision correction. After the natural lens is removed, there are a number of Intra Ocular Lens options that can provide patients with a full range of vision. These options include: monovision with monofocal IOLs or one of the more advanced multifocal or accommodating IOLs such as ReSTOR or Crystalens.

Patient who have significant cataracts are not candidates for laser vision correction. Instead, they should have cataract surgery to restore vision. The same IOL options are available to cataract patients as they are for refractive lens exchange patients.

Eye Diseases

Common Eye Diseases:

Contact Lenses

There are many types of contact lenses and many reasons to wear contact lenses.

At Slade and Baker Vision Center we offer: Soft Contact Lenses , Multi-Focal Lenses, Gas permeable Lenses, Synergeyes Lenses, a hybrid soft gas permeable, Plateau Lenses, and Wave Front Contact Lenses

Disposable Soft Contacts are the most popular, compatible, and the most economical. Options include single vision, toric, and bifocal to correct a wide range of vision problems. When vision cannot be corrected to an acceptable level with soft contact lenses, Gas Permeable Lenses can be customized to each patient’s refractive error. If comfort is a problem with Gas Permeable Lenses, we are a provider for Synergeyes Contact Lenses. Synergeyes Contact Lenses are a unique design of a gas permeable center with a soft lens skirt. This gives the comfort of a soft lens with the crisper vision of a “hard” lens. These lenses now come in a wide range of parameters to maximize both fit and vision and are customized and manufactured individually for each patient.

For patients who have unusual vision problems not correctable by standard type contact lenses whether from a corneal dystrophy, a previous corneal surgery, or corneal injury, we have Plateau Lenses. These lenses are individually customized design for unusually shaped corneas. Dr Baker helped with original design of these lenses for post Radial Keratotomy (RK) patients. Dr Baker has over 25 years experience fitting contacts for these type patients.

Slade and Baker are also providers of Wave Touch Contact Lenses. Wave Touch Contact Lenses are soft contact lenses with a unique in-optical design. These lenses are used for patients who want the absolute best vision available in a soft contact lens, patients who have had previous refractive surgery, or patients who have lenticular astigmatism. Lens parameters are selected for fit by a trial lens method. Then a Wavefront Map is taken over the lens while on the eye with the Tracey Aberrometer. The lens is manufactured with the prescription from the wavefront map to include correction for lower order and higher order aberrations.

We can also provide trial contact lenses for patients who want to try monovision. If you are considering monovision as a refractive procedure such as with LASIK or monofocal IOLs, trying it out first with contacts is usually a good idea.

Contact lenses can be used for both cosmetic and therapeutic purposes. Contacts can also offer advantages to athletes and younger patients who are not ready for refractive surgery. Older patients who do not want to wear bifocal glasses also benefit from contact lenses.

Advanced contact lens technology can now correct Astigmatism, Nearsightedness, Farsightedness, Presbyopia, or any combination of these refractive errors.

They can also be used in the treatment of Keratoconus. Other uses include correcting vision after a corneal transplant and bandaging the cornea after PRK.

There are a number of keys to wearing contact lenses successfully:

#1 MOTIVATION: Ask yourself why you want to wear contact lenses. Is it to look better, to see better, or to reduce your dependence upon glasses? Whatever the reason contact lens patients have to be motivated and have realistic expectations. Finding the ideal contact lens for you may take several tries and adjustments. Lenses selected and worn in the office for 30 minutes may feel different after several full days wear. The actual shape of your cornea can change after wearing them for a while. Blink patterns and tear film can change as patients adapt to wearing contacts. If you understand there is always a bit of a trial and error method to obtain the best fit, chance are you will be a successful contact lens wearer.

#2 REFRACTIVE ERROR: The type of refractive error you have can influence your chances for success. Some refractive errors can be corrected with basic or standard lenses. More complex errors may require more complex or specialty contact lenses. Your initial exam will determine if your refractive error is simple or complex and where it is located (cornea or lens inside the eye). Corneal dystrophies, corneal transplant, and post refractive surgery patients are always more complex but we can usually obtain success with one of the many new technology contact lenses available at our offices.

#3 COMPLIANCE: How well patients comply with recommended handling, cleaning, storage, replacement and the prescribed wearing schedule has a significant influence on success. Lenses must be clean to perform their best and eyes are more tolerant to a consistent wearing schedule.

#4 HYGIENE & ENVIRONMENT: Hygiene and environment also have an influence on success. Lid hygiene can affect the chemistry and production of tears necessary for hydration and comfort. Patients with blepharitis, meibomanitis, or other lid abnormalities can affect the secretion of the oil glands that keep our tears from evaporating too quickly. Contact lenses become soiled more quickly if the eyes are dry. Patients who have dry eye can be treated prior to contact lens fitting to improve their chances for success. Wet, lubricated lenses don’t get soiled as quickly. As we age, our eyes have a tendency to become drier and many previously successful CL wears may lose their compatibility with contact lenses. Many of our patients regain their success with contacts by improving their “dry eye” symptoms with therapy. Many contact lens failures however, are able to experience success with refractive or intraocular lens replacement surgery. We can evaluate and recommend your best option if your contacts can no longer be tolerated.

#5 FIT: Physical fit of the contact lens and its alignment and movement when blinking is important in providing tear exchange under the contact. This provides oxygen to the cornea for normal metabolism and eliminates debris and bi-products. There are many different manufactures of contact lenses with many different designs, materials and fitting characteristics. Our state-of-the-art equipment in measuring the dimensions of your cornea allows us to select the very best fit for you

The Fitting Process

Our pre-fitting exam and assessment includes: corneal topography; corneal curvature; refraction; tear testing (volume and chemistry); blink pattern; lid anatomy; pupil size; intraocular pressure; binocular vision; wavefront testing; dilation; retinal exam; trial lens; discussion of expectations; and for current or previous CL wearers an evaluation of previous or current lenses.

If your test results are good and we determine you are a good candidate, most types of lenses can be dispensed to you the same day from our inventory. If a customized lens is necessary it will need to be ordered and dispensed back in our office upon delivery. We will provide you with instructions on handling cleaning, and inserting and removing your contacts at the time of dispensing.

Patients are usually asked to return to the office a week or two after dispensing the contacts for evaluation of compatibility, wearing schedule, fit, quality of vision and performance within the eye. Adjustments to the contact lenses are made when indicated at no additional cost during the fitting period.

ASCRS Live Surgery
now available on eyetube.net

Please click the below link to access the video series.

eyetube.net/series/alconlivesurgery

© 2011 Novartis AG     4/11    MCA11580EMB

Tags: dr. stephen slade, m.d., slade lasik, stephen slade, steve slade

Articles By Dr. Stephen G. Slade, MD

Sub Bowman’s Keratomileusis: The Case for a New “K” in Refractive Surgery

By Stephen G. Slade, MD, Houston, Texas

Whether surface or lamellar excimer laser surgery is better has been a long running debate in Ophthalmology. In general, even though different studies have found LASIK and PRK very similar in longer-term follow-up, in the immediate post-operative of 1 to 6 months, LASIK delivered better results and that drove the move towards LASIK as the procedure of choice. More recently, Allan and Shortt undertook a comprehensive review of all peer-reviewed published literature, as well as the FDA database, comparing outcomes in LASIK vs. PRK.1 The conclusion reached was that LASIK was a better procedure to PRK in safety and efficacy although the majority of the published literature dates prior to 2001., More recently, surface ablation has received a renewed interest as it has been perceived as safer in terms of ectasia. What if there is a better technique, a hybrid of the two procedures, that combined the faster recovery and better patient comfort of LASIK with any safety advantages of PRK? For several years, Drs. Slade and Durrie have worked with customizing the LASIK flap to the patient and the ablation much as we customize the ablation to the patient. We have named this technique Sub Bowman’s Keratomileusis (SBK).

Prospective Comparison

In attempt to try and help answer this long-running debate between surface and lamellar, Daniel S. Durrie, MD, Overland Park, Kan., and Stephen G. Slade MD have recently completed a clinical study to compare PRK against SBK. In this study we used a smaller diameter flap (8.0 mm) and a thinner flap (≤100 µm). Our goal was to create a prospective, randomized study with a, contralateral eye design to make it as evenly matched as possible. We also agreed to use newer technology and techniques, so all patients received a customized ablation, PRK was performed using an established technique and all flaps were created with a 60-kHz femtosecond laser (IntraLase Femtosecond Laser, Advanced Medical Optics, Irvine, CA).

In some respects, the results confirmed what many of us had suspected, and it also led us to conclude that SBK may be just what we expected, a hybrid of PRK and LASIK. SBK may give refractive surgeons the biomechanical stability of surface ablation with the quicker visual recovery and relatively pain-free experience of LASIK.

Clinical Results

The study of 50 patients (100 eyes) was conducted at two sites (Slade in Houston, Texas and Durrie in Overland Park, Kansas) last spring, with one eye undergoing a femtosecond-laser assisted LASIK procedure (with an intended flap thickness of 100 µm) and the fellow eye undergoing a PRK procedure. Because it was a contralateral study, the two groups (Slade and Durrie) were almost even matched in terms of pre-operative mean refractive error: the femtosecond laser group was -3.64 D (-2.00 to -5.75 D) (SD = 0.97) and the mean manifest cylindrical refraction was -0.63 D (0 to -3.00 D), while the PRK group was -3.68 D (-2.00 to -5.75 D) (SD = 1.06) with a mean manifest cylindrical refraction was -0.64 D (0 to -2.75 D). The mean preoperative BSCVA was 20/17 in both groups (Slade and Durrie) with a range of 20/12 to 20/20 (SD = 2.47).

Because we wanted to truly analyze the outcomes, as well as to look at the biomechanical effects these two approaches have on the cornea, we utilized both standard, and newer, diagnostic testing. This included corneal topography, wavefront aberrometry (LADARWave, Alcon Laboratories, Inc., Ft. Worth, TX); contrast visual acuity, corneal sensitivity (Cochet-Bonnet aesthesiometer); Visante OCT imaging (Carl Zeiss Meditec, Oberkochen, Germany); corneal hysteresis (Ocular Response Analyzer, Reichert, Depew, NY); and, corneal response factor and, light scatter and optical visual acuity assessment (OQAS, Visometrics, Terrassa, Spain) at Dr. Slade’s clinic. At Dr. Durrie’s clinic, patients underwent two additional tests: Confocal through microscopy and Artemis High-frequency Ultrasound Imaging (Ultralink LLC, St. Petersburg, FL).

The full results from this Slade/Durrie study are due to be published later in the year, however, we can report that the visual results confirm that the femtosecond-laser group had a quicker return to functional vision than the PRK group. In fact, 100% of the femtosecond eyes could see 20/40 uncorrected on the first post-operative day compared to 42% in the PRK group. At 1 month post-op, 88% of the femtosecond eyes were 20/20 or better, uncorrected, compared to 48% of the PRK eyes.

The femtosecond-laser group also had lower levels of higher order aberrations at 1 and 3 months (coma and spherical aberration) compared to the PRK eyes. High and low contrast acuity and retinal image quality also favored the femtosecond group. More importantly, the patients preferred their femtosecond laser eye to the PRK eye citing less pain and better vision during the first three post-operative months.

OCT measurements showed that the femtosecond-laser created flaps had a uniform (planar) thickness with a mean of 112 ± 5 µm (range 87 to 118µm). The average standard deviation in flap thickness was 4 µm.

Finally, the biomechanical results were evaluated using two relatively new devices: the Optical Response Analyzer (Reichert) and the Pascal Dynamic Contour Tonometer (SMT/Ziemer Ophthalmic Group). Both devices measure how the cornea responds to biomechanical changes. The results showed that the femtosecond group eyes were statistically significantly better than the PRK eyes. Interestingly, none of the tests showed that PRK had a biomechanical advantage over a flap-based approach, although the clinical significance of the ORA and the Pascal tonometer still need to be proven.

John Marshall has led the way investigating the strength of an eye after SBK compared to PRK by studying human cadaver eyes and believes that SBK and PRK are virtually indistinguishable in terms of biomechanical stabiliy. In fact, with the effect of wound healing in a patient, Marshall believes SBK may indeed be stronger than PRK.

The New K in Refractive Surgery

Now many surgeons are already doing laser vision correction with a femtosecond laser or a mechanical microkeratome and creating a flap of ≤100 µm on a regular basis. So what’s the difference between this technique and SBK?

At Slade and Baker we have defined SBK as a customized corneal flap that creates a flap based on the requirements of the patient, as well as the type of excimer laser and ablation being used. The intended thickness is between 90 and 110 µm. In the study discussed above, the corneal flap diameter was 8.5 mm. However, in my practice, I routinely use flaps with diameters of between 7 and 8 mm depending on which of my excimer lasers and what pattern I am using.

Key to creation of an SBK flap is the ability to create a planar corneal flap with a consistent thickness across the entire area. Although there are a number of mechanical microkeratomes that can create a 100-µm flap, the reality is that the method of flap creation used by mechanical keratomes tends to create a flap that is more meniscus in shape, so it is thicker in the periphery and thinner in the center. In my opinion, the most consistent, predictable method for creation of an SBK flap is with a femtosecond laser. This is supported by a number of clinical studies that have compared flap thickness of mechanical microkeratomes with the femtosecond laser.2-5 There are many more parameters in which we can customize flaps. We are looking at shaping the edge to improve strength, controlling the depth by the variations in the epithelium and oval flaps for astigmatism.

What Do Patients Want?

In recent years, refractive surgery volumes have been relatively flat or have even declined. In many respects this is related to the drawbacks associated with the two procedures we currently rely upon. With PRK, patients must cope with pain, haze and slow visual recovery. With LASIK, there is an increased incidence of dry eye, halos and glare, as well as the risk of corneal ectasia.

In this study, we found that there was less sensitivity and fluctuating of vision through one month in the SBK group. There was also less dry eye, double vision and blurry vision, glares/halos, grittiness and difficulty with night driving through three months post-op. Overwhelmingly, patients preferred the vision in their SBK eye out to three months by a margin of 2 to 1.

We know from the longer follow-up that by six months, the two groups, both Slade and Durrie, become relatively equal. This was not a surprise. But the point is that patients will make up their minds about the success or failure of their laser vision procedure in the first few months. More importantly, it’s during this time that they will talk to their family and friends about their experiences. Certainly more study is needed but with SBK, we may now have a technique that enables us to take the best of PRK and LASIK, while avoiding the negatives – giving us the ability bring back the “wow” to refractive surgery.

References

Shortt AJ, Bunce C, Allan BDS. Evidence for superior efficacy and safety of LASIK over photorefractive keratectomy for correction of myopia. Ophthalmology. 2006:113;1897-1908.

Duffey RJ. Thin flap laser in situ keratomileusis: flap dimensions with the Moria LSK-One manual microkeratome using the 100-micron head. J Cataract Refract Surg 2005;31:1159-62.

Taneri S. Laser in situ keratomileusis flap thickness using the Hansatome microkeratome with zero compressions heads. J Cataract Refract Surg 2006;32:72-7.

Flanagan GW, Binder PS. Precision of flap measurements for laser in situ keratomileusis in 4428 eyes. J Refract Surg 2003;19:113-23.

Shemesh G, Dotan G, Lipshitz I. Predictability of corneal flap thickness in laser in situ keratomileusis using three different microkeratomes. 2002;18:S347-51.

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