Trust your eyes.

SCHWIND ORK-CAM

Treatment Type Decision Tree &

(Re-) Treatment Customization
Disclaimer

This presentation is for information purposes only!

Please refer to officially released product information, such as

marketing brochures or user manuals.

2
 Treatment Type Decision Tree &
(Re-) Treatment Customization
Overview

Introduction
Overview
 Introduction

 Treatment preparations

 Decision Tree criteria

 Optical Zone selection

 Adjustment of laser refraction

 Comparison of ablation depths

 Customized treatment optimization

 Customized treatment planning steps

 Introduction
What is necessary for perfect evaluation and planning of customized treatments?

General: The more information you have the more individual the treatment and the better
Introduction the result could be. Minimum 3 good quality measurements per eye (of each diagnostic
device) allow a valid comparison of examinations.

Treatment
Technological view:
preparations
For an adequate and coherent analysis of the eye both a Corneal Wavefront Analyzer and an
Decision Tree criteria Ocular Wavefront Analyzer (Aberrometer) is advised for wavefront comparison and analysis.
For higher precision and better efficacy of a customized treatment a compensation of
Optical Zone selection possible cyclotorsion movements is recommendable:
 SCC (Static Cyclotorsion Control)
Adjustment of laser  DCC (Dynamic Cyclotorsion Control)
refraction

Equipment needed:
Comparison of
ablation depths • Corneal Wavefront Analyzer (Sirius, Scout, or Peramis)
• Ocular Wavefront Analyzer (Peramis or irx3)
• SCC from Corneal and Ocular Wavefront Analyzer
• SCC and DCC within the AMARIS
 Introduction
What is necessary for perfect evaluation and planning of customized treatments?

Patient evaluation and refractive status

Introduction

• Intensive anamnesis (general information and possibly allergies or eye

Treatment
preparations diseases, quality of vision and night vision)
• Manifest (subjective) refraction (monocular and binocular UCVA / BCVA)
Decision Tree criteria
• Eye dominance

Optical Zone selection • Cycloplegic refraction (especially in hyperopic cases)

• Stability of refraction
Adjustment of laser
refraction

Other recommendations:
Comparison of
ablation depths • SCHWIND Treatment Type Decision Tree consideration
• Use of the SCHWIND CAM <Comparison> module
• Advanced knowledge in CUSTOMIZED treatment planning
 Introduction
Aberrometer measurements (e.g. PERAMIS)

Introduction
Improved pupil recognition of aberrometer examinations:
» Perform minimum 3 measurements per eye
Treatment
preparations » Cover the fellow eye and advise patient to look towards or through the target

» Let the patient adapt again to dark room conditions before starting the next acquisition
Decision Tree criteria

General pupil diameter check:

Optical Zone selection
» Naturally dilated pupil, as wide as possible
» Change of pupil size has influence on
Adjustment of laser
refraction
• aberrometer refraction

Comparison of • higher-order aberrations

ablation depths
 Introduction
Topographic measurements (e.g. SIRIUS/PERAMIS)

Introduction

Improved placido ring recognition of keratoscope examinations:

Treatment » Perform minimum 3 measurements per eye
preparations
» Cover the fellow eye and advise patient to fixate the target correctly
Decision Tree criteria
» Turn and tilt the head of the patient according to the video demonstration (
https://youtu.be/4poCnxVdrRo) for improved placido ring recognition*
Optical Zone selection
» Use a spacer in front of the forehead*

Adjustment of laser
refraction * with use of PERAMIS

Comparison of
ablation depths
 Introduction
What is necessary for perfect evaluation and planning of customized treatments?

1. Select for the best topography and wavefront maps according to the quality criteria
Introduction 2. Do a comparison of OW and CW data within SCHWIND PERAMIS directly or make use of the
SCHWIND Comparison module (after export of diagnostic patient eye data)

3. Use the ‘Export to SCHWIND’ within the SCHWIND diagnostic devices for diagnostic patient file
Treatment
preparations creation

4. Determine the best (treatment) option (AF, OW, CW, no laser treatment) for the individual
Decision Tree criteria patient, taking patient history and anamnesis into consideration  SCHWIND Decision Tree

5. Make use of subjective and objective refraction information to include both refractive, corneal,
Optical Zone selection
and wavefront influences into the treatment plan: “adjusted refraction” (in OW or CW)

6. Do a comparison of Aberration-Free (AF) depth/volume vs. Wavefront-guided (OW, CW)

depth/volume at same (pre-)selected Optical Zone (OZ) size if OW or CW is considered
Adjustment of laser
refraction 7. Make use of the ORK-CAM <Manager> function after final OZ size selection: tissue saving
possible via adaptation in laser refraction “Refraction” and/or in high-order aberrations
Comparison of “Pyramid”
ablation depths
8. Do a comparison between ablation map (=laser profile) and diagnostic map(s) [topography,
wavefront, elevation, …], i.e. validate whether shape and depth/volume plan are plausible.

9. Check the correctness of SCHWIND ORK-CAM input data (“Summary Page”)

10. Create an SCHWIND ORK-CAM export file for treatment with AMARIS laser
 Treatment preparations
Select the best measurement - PERAMIS/SIRIUS - (Keratoscope, Aberrometer, Scheimpflug,…)

‘Reprocess all measurements’ and …

Introduction

Treatment
preparations

Decision Tree criteria

Optical Zone selection … go to ‘Statistics on acquisition’ …

Adjustment of laser
refraction

Comparison of
ablation depths

… to find and select the measurement to be ‘Set as favorite’.

 Treatment preparations
Select the best aberrometer measurement (PERAMIS Ocular Wavefront)

Introduction » Analysis diameter: The bigger the analysis diameter, the more expressive the information
and the larger the OZ for wavefront comparison and treatment. A dark room is mandatory
for aberrometer measurements.  Let the patient adapt to the dark room conditions for
Treatment
preparations several minutes. Min. export diameter is 5.00 mm but the larger the better.

» SCC detection: For more precision and better efficacy of a customized treatment a
Decision Tree criteria
compensation of possible cyclotorsion movements is recommendable.  SCC shall be
suitable (green mark) in case the cylinder refraction >1.25D
Optical Zone selection
» Aberrometer refraction: Check power of Sph.Eq. [D] and Cylinder [D] at 4.0 mm analysis
diameter and compare to manifest (subjective) values  Prefer the measurement with
Adjustment of laser most positive SEq value. Max. standard deviation (SD) should be 0.25D. In case of
refraction
astigmatism >1.25 D the max. deviation in axis should be 10°.
Comparison of
ablation depths  The recommendable best ocular wavefront exam might be a compromise between the
maximum available analysis diameter, the most positive SEq, and the exam with the
lowest higher order aberrations (RMS value).
 Treatment preparations
Select the best aberrometer measurement (PERAMIS Ocular Wavefront)

Introduction

Treatment
preparations
PERAMIS - Aberrometer
Decision Tree criteria

Optical Zone selection

Adjustment of laser
refraction

Comparison of
ablation depths
 The best measurement (quality and reproducibility criteria are met) is set to favorite.

 Decide whether full pupil (øMin) is large enough for analysis and a possible OW treatment
 Treatment preparations
Select the best aberrometer measurement (PERAMIS Ocular Wavefront)

Check for objective refraction ø = 4.0 mm in ‘Comparison’ mode:

Introduction

Treatment
preparations

Decision Tree criteria

Optical Zone selection

1. vs. 2. vs. 3.
Adjustment of laser
refraction

Comparison of
ablation depths

 Look for the most positive refraction (to minimize accommodative effects)
 Treatment preparations
Select the best aberrometer measurement (PERAMIS Ocular Wavefront)

Check for higher order aberrations (RMS [Eq.D.] HOA):

Introduction

Treatment
preparations

Decision Tree criteria

Optical Zone selection

Adjustment of laser
refraction

Comparison of
ablation depths

 Reconsider the pre-defined favorite measurement in case of high differences in HOA RMS:

ideally includes the most positive refraction AND the lowest RMS HOA at full pupil.
 Treatment preparations
Select the best aberrometer measurement (PERAMIS Ocular Wavefront)

Interesting parameters “customized treatment”:

Introduction
» Ocular wavefront astigmatism:

• An ocular wavefront astigmatism is calculated based on higher-

Treatment
order aberrations of evaluated Zernike polynomials. Make use of
preparations
<normative data> if you want to view the bar graph (like used to

Decision Tree criteria in SIRIUS device).

• The astigmatism with reference to 4.0 mm analysis diameter

Optical Zone selection provides the refractive effect in photopic-like light conditions.

Consider the Cyl [D] + Ax value (WF Ast @ 4mm) for refractive

comparison/calculation purposes.
Adjustment of laser
refraction • The astigmatism with reference to 6.0 mm analysis diameter

provides the refractive effect in mesopic-to-scotopic-like light

Comparison of
ablation depths conditions. Consider the Cyl [D] + Ax value (WF Ast @ 6mm) for

refractive comparison/calculation purposes.

 These outputs are important and of interest for

possible refraction adjustments, in particular in
customized treatments (OW, CW)
 Treatment preparations
Select the best aberrometer measurement (PERAMIS Ocular Wavefront)

Summary of ocular wavefront information

Introduction
» The evidence of a wavefront analysis is based on the corresponding analysis diameter.
» The bigger the analysis diameter, the more expressive the information and the larger the
Treatment OZ of an ocular wavefront treatment can be.
preparations
» Wavefront information (e.g. RMS) are compared taking the lowest common analysis
Decision Tree criteria
diameter. Take care not to mix up lower order (LOA) and higher order aberrations (HOA).
RMS values are distinguished: Total, LOA, and HOA.
» The ocular wavefront measurement selected to be best might be a compromise between
Optical Zone selection available analysis diameter, most positive refraction, and lowest RMS HOA.

Adjustment of laser Summary of aberrometer refraction

refraction
» Choose aberrometer refraction at 4.0 mm analysis diameter to be compared to manifest
Comparison of (subjective) refraction.
ablation depths
» Measurements are performed with the device close to the head / eyes which affects
accommodation reflexes and causes ‘instrument myopia’. To reduce possible
accommodation influence decide for the exam with most positive refraction (SEq).
 Treatment preparations
Select the best topographic measurement (PERAMIS/SIRIUS Corneal Wavefront)

Introduction » Keratoscopy quality [%]: OK if green check mark (for sufficient centration and coverage)
exists  discard measurement for analysis if attention sign is shown
» Placido coverage [%]: OK if no attention signs are visible. Otherwise, perform new
Treatment measurements with eyes wide open  ideally, take the highest value in %
preparations
» Section (Scheimpflug) coverage [%]: OK if no attention sign is visible. Otherwise, perform
new measurements with eyes wide open  ideally, take the highest value in %
Decision Tree criteria
» SCC Check (Static Cyclotorsion Control): For more precision and better efficacy a
compensation of possible cyclotorsion movements is recommendable  SCC shall be
Optical Zone selection suitable (green mark) in case the cylinder refraction >1.25D and for customized treatments
» Check Meridians 3mm (Avg) [D]  max. SD (standard deviation) 0.25D
» Check Meridians 3mm (Cyl) [D]  in case cylinder >1.25D the max. deviation in axis 10°
Adjustment of laser
refraction » Check CCT [μm] (Central Corneal Thickness)  max. SD 10 μm
» Pupil center [mm] to check offset information: The crosses shall be inside the yellow
Comparison of
ablation depths
dotted ellipse and as close together as possible  prefer the smallest offset out of
reproducible measurements
» Keratoscopy center [mm]: The crosses shall be inside the yellow dotted ellipse and as close
together as possible  prefer the closest out of reproducible measurements
 Treatment preparations
Select the best topographic measurement (PERAMIS/SIRIUS Corneal Wavefront)

SIRIUS - Scheimpflug
Introduction

Treatment
preparations

Decision Tree criteria

PERAMIS - Keratoscope

Optical Zone selection

Adjustment of laser
refraction

Comparison of
ablation depths

 The best measurement (quality and reproducibility criteria are met) is set to favorite.
 Treatment preparations
Select the best Scheimpflug measurement (SIRIUS Corneal Wavefront)

Introduction

Treatment
preparations

Decision Tree criteria

Optical Zone selection

Edit Scheimpflug

Adjustment of laser  Check whether detection of anterior and

refraction
posterior surfaces is correct:
Comparison of i. Surface is correctly displayed in the 25
ablation depths cross sections?
ii. Large coverage, i.e. no eye blink visible?

 Correct Scheimpflug detection is also essential for wavefront calculation processes and purposes
 Treatment preparations
Select the best topographic measurement (PERAMIS/SIRIUS Corneal Wavefront)

» Homogeneity: The best topography should be homogeneous with no artefacts (e.g. eyelid,
eyelashes, tear film, stripes due to movement ).  exclude unstable tearfilm and eyelid
Introduction artefacts

» Check Offset values on consistency and magnitude  if the offset ≥ 0.50mm repeat
Treatment measurements and take care to cover the fellow eye and advise patient to fixate the target
preparations correctly

Decision Tree criteria » Check pachymetry map and minimum thickness

» Check for indication of keratoconus (KC)  check KC screening and the summary of KC
Optical Zone selection indices. The individual cornea can be classified:

Adjustment of laser
refraction

Comparison of »
ablation depths
Go to Export “Refractive Export to SCHWIND” to check for placido rings, pupil & limbus:

• Check amount of placido rings  Ideally ≥ 14 full Placido rings are available (minimum: 12 rings)

• Check correct pupil detection  circle fits with pupil margin

• Check correct limbus detection  red half circles fit with limbus
 Treatment preparations
Select the best topographic measurement (PERAMIS/SIRIUS Corneal Wavefront)

Introduction

Treatment
preparations

Decision Tree criteria

1. Edit rings 2. Edit pupil

Optical Zone selection

Adjustment of laser
refraction

1. 14 full rings are available, 12 rings

Comparison of
ablation depths
recommended to be minimum
2. Pupil size & margin correctly detected
3. Limbus area correctly shown
3. Edit limbus
 Correct pupil detection (round and fitting to pupil margins) is essential for pupil offset and wavefront calculation purposes.
 Treatment preparations
Select the best topographic measurement (PERAMIS/SIRIUS Corneal Wavefront)

Interesting parameters “customized treatment”:

Introduction

Treatment
preparations

Decision Tree criteria

Optical Zone selection

Adjustment of laser
refraction

Comparison of
ablation depths
 Treatment preparations
Select the best topographic measurement (SIRIUS Corneal Wavefront)

Introduction Interesting parameters “customized treatment”:

Treatment
preparations

Decision Tree criteria

Optical Zone selection

Adjustment of laser
refraction

Comparison of
ablation depths
 Treatment preparations
Select the best topographic measurement (PERAMIS/SIRIUS Corneal Wavefront)
Interesting parameters “customized treatment”:
Introduction » Pupil offset:

• The pupil offset describes the position of the pupil center in

Treatment reference to the corneal vertex
preparations
• An objective measured pupil offset value can be used for
Decision Tree criteria treatment planning. The coverage of the fellow eye and the
request for correct target fixation is recommendable to avoid bad
repeatability (especially when phoria or strabism is present)
Optical Zone selection
• With use of pupil offset values, the aspheric correction of manifest
refraction power is aligned to the corneal vertex whereas the
Adjustment of laser
refraction compensation/correction of HOA keep linked to the pupil center

• Clinical evaluation proved that a pupil offset ≥ 0.2 mm has a

Comparison of
ablation depths significant influence on the post-OP visual performance

 To check repeatability of the pupil offset value and axis which is important
for corneal vertex (i.e. visual axis) treatment alignment make use of
“Statistics on acquisition” or the “Comparison” function within Phoenix SW
 Treatment preparations
Select the best topographic measurement (PERAMIS/SIRIUS Corneal Wavefront)

Interesting parameters “customized treatment”:

Introduction

» Topographic astigmatism:

Treatment A topographic astigmatism is calculated based on differences in

preparations
perpendicular meridians of the keratometry. The selection of Meridians
Decision Tree criteria at 3-mm provides a “best-fit to corneal shape” in terms of corneal
power calculation, with separate display of cylindrical power and axis
» Corneal wavefront astigmatism:
Optical Zone selection
• A corneal wavefront astigmatism is calculated based on higher- order
aberrations of evaluated Zernike polynomials
Adjustment of laser
refraction
• The astigmatism with reference to 4.0 mm analysis diameter provides
the refractive effect in photopic-like light conditions
Comparison of
ablation depths
• The astigmatism with reference to 6.0 mm analysis diameter provides
the refractive effect in mesopic-to-scotopic-like light conditions

 These outputs are important and of interest for possible refraction

adjustments, in particular in customized treatments
 Treatment preparations
Select the best topographic measurement (PERAMIS/SIRIUS Corneal Wavefront)

Summary of best topography and its values

Introduction
» Only several exams (at least 3 in good quality) allow a valid comparison of
topographies.
Treatment » Select and export the topography with best homogeneity and adequate quality of
preparations several parameters.
» The entry of the pupil offset value aligns the aspheric correction of the manifest
Decision Tree criteria
refraction to the corneal vertex whereas the compensation / correction of HOA keep
linked to the pupil center.
Optical Zone selection

Summary of topographic influences on refraction and astigmatism evaluation

Adjustment of laser » Due to higher-order aberrations present the manifest refraction might be influenced.
refraction
This reduces the predictability of refraction evaluation and thus, of the laser refractive
outcome in customized cases itself.
Comparison of
ablation depths » The topographic astigmatism and corneal wavefront astigmatism with analysis
diameters of 4 mm and 6 mm support finding an appropriate laser refraction.

 Refer to “refraction adjustment” for an adapted (laser) refraction which is useful as starting
point in the evaluation process and the final treatment decision of complex customized cases
 Treatment preparations
Select the best topography and corneal wavefront measurement (Keratron Scout)

Overview about topographies (OD/OS) and its importance - select the best image
Introduction
» SCC detection » Homogeneity » Pupil detection

» Repeatability » K-readings » Pupil offset value

Treatment
preparations

Decision Tree criteria

Optical Zone selection

Adjustment of laser
refraction

Comparison of
ablation depths
 Treatment preparations
Select the best topography and corneal wavefront measurement (Keratron Scout)

Overview about topographies and its importance - select the best image
Introduction

Treatment » Homogeneity:
preparations
The best topography should be
Decision Tree criteria homogeneous with no artefacts
(e.g. stripes due to movement,
eyelid, eyelashes, tear film)
Optical Zone selection

Adjustment of laser » K-readings:

refraction
Compare the exams and prefer
Comparison of the topography with k-readings
ablation depths close to the mean value
 Treatment preparations
Select the best topography and corneal wavefront measurement (Keratron Scout)
Overview about topographies and its importance - select the best image
Introduction
» SCC check:

Treatment
To guarantee the efficacy of a customized treatment a compensation
preparations of possible cyclotorsion movements is recommended
» Repeatability check:
Decision Tree criteria
• Comparison of the pictures on a mathematical way.

Optical Zone selection • Accept “good” or “very good” reports only as reliable exams

» Placido ring check:

Adjustment of laser
refraction • The more available rings are detected at the cornea the larger
the coverage of the topography and corneal wavefront will be
Comparison of
ablation depths • Up to ring number 20 (corresponds with an OZ of approx. 7mm),
a round shape is given without significant spikes (in any ring)
» Pupil check:

For a correct pupil offset calculation a sufficient pupil detection

(round and centered) is necessary
 Treatment preparations
Select the best topography and corneal wavefront measurement (Keratron Scout)

Overview about topographies and its importance - select the best image
Introduction
» Pupil offset:

• The pupil offset describes the position of the pupil center in

Treatment
preparations reference to the corneal vertex

• The objectively measured pupil offset value can be used for

Decision Tree criteria
treatment planning. The coverage of the fellow eye and the
request for correct target fixation is recommended to avoid bad
Optical Zone selection
repeatability (especially when phoria or strabism is present)

• The entry of the pupil offset value aligns the aspheric correction
Adjustment of laser
of the manifest refraction to the corneal vertex whereas the
refraction compensation / correction of HOA keep linked to the pupil
center
Comparison of
ablation depths • Clinical evaluation proved that a pupil offset ≥ 0.2 mm has a
significant influence on the post-OP visual performance. Check
always the repeatability of pupil offset value and axis
 To check repeatability of the pupil offset value and axis which is important for corneal vertex
(i.e. visual axis) treatment alignment compare the offset readings of the single acquisitions
 Treatment preparations
Select the best topography and corneal wavefront measurement (Keratron Scout)

Overview about topographies and its importance - select the best image
Introduction

» Topographic astigmatism:
Treatment • A topographical astigmatism is calculated
preparations
based on differences in perpendicular
meridians of the keratometries
Decision Tree criteria

• The selection of Best Fit (Maloney)

Optical Zone selection provides corneal refractive power and
cylindrical power (diff.)

Adjustment of laser • For positive cylinder notation take the

refraction
axis of the steepest meridian / highest
refractive power.
Comparison of
ablation depths • For negative cylinder notation take the
axis of the flattest meridian / lowest
refractive power
 Treatment preparations
Select the best topography and corneal wavefront measurement (Keratron Scout)

Overview about topographies and its importance - select the best image
Introduction

» Corneal wavefront astigmatism:

Treatment
preparations • A corneal wavefront astigmatism is
calculated based on higher- order
Decision Tree criteria aberrations of evaluated Zernike
polynomials

Optical Zone selection • For corneal wavefront calculation

and display of higher-order
aberrations only, the entry of the
Adjustment of laser
refraction manifest refraction and deselection
of the LOW (order aberrations) is
Comparison of necessary
ablation depths
 Treatment preparations
Select the best topography and corneal wavefront measurement (Keratron Scout)

Introduction
Overview about topographies and its importance - select the best image

» Corneal wavefront astigmatism:

Treatment
preparations

Decision Tree criteria

Optical Zone selection

Adjustment of laser
refraction

Comparison of
ablation depths
The astigmatism with reference to 4.0 mm The astigmatism with reference to 6.0 mm
analysis diameter provides the refractive analysis diameter provides the refractive
effect in photopic-like light conditions effect in mesopic-to-scotopic-like light
conditions
 Treatment preparations
Select the best topography and corneal wavefront measurement (Keratron Scout)

Summary of best topography and its values

Introduction
» Only several exams (at least 3 in good quality) allow a valid comparison of
topographies.
Treatment » Select and export the topography with best homogeneity and adequate quality of
preparations several parameters.
» The entry of the pupil offset value aligns the aspheric correction of the manifest
Decision Tree criteria
refraction to the corneal vertex whereas the compensation / correction of HOA keep
linked to the pupil center.
Optical Zone selection

Summary of topographic influences on refraction and astigmatism evaluation

Adjustment of laser » Due to higher-order aberrations present the manifest refraction might be influenced.
refraction
This reduces the predictability of refraction evaluation and thus, of the laser outcome
in customized cases itself.
Comparison of
ablation depths » The topographic astigmatism and corneal wavefront astigmatism with analysis
diameters of 4 mm and 6 mm support finding an appropriate laser refraction.

 Refer to “adjusted refraction” for an adapted (laser) refraction which is useful as starting point
in the evaluation process and the final treatment decision of complex customized cases
 Export of Ocular Wavefront data
Refractive export display

PERAMIS – Aberrometer

PERAMIS - TopoAberrometer
Export of Corneal Wavefront data
Refractive export display
SIRIUS - Scheimpflug

PERAMIS - Keratoscope

Keratron SCOUT - Keratoscope

 Treatment Decision
SCHWIND ORK-CAM Treatment Options

» Aberration-Free (AF)
Introduction
Only spherical and cylindrical refraction values are corrected. As the patient is used
to his preoperative existing aberrations he retains his normal visual perception if
Customized treatment these aberrations are kept. This procedure is suitable for patients whose vision is
preparations not impaired by pronounced higher-order aberrations.

Decision Tree criteria

» Corneal Wavefront (CW)

Optical Zone selection Besides the spherical and cylindrical refraction corneal wavefront data is additionally
taken into account. This procedure is suitable for patients whose vision is impaired by
pronounced higher-order aberrations on the corneal surface without internal
Adjustment of laser
refraction
compensation.

Comparison of » Ocular Wavefront (OW)

ablation depths
Besides the spherical and cylindrical refraction ocular wavefront data is additionally
taken into account. This procedure is suitable for patients whose vision is impaired by
pronounced higher-order aberrations of the complete eye.
 Decision Tree criteria
Differences between the types of treatment - part I

Aberration-Free Corneal Wavefront Ocular Wavefront

Introduction (AF) (CW) (OW)

Aspheric ablation profile Yes Yes Yes

Customized treatment
preparations
Simultaneous correction Yes Yes Yes
Decision Tree criteria of sphere + cylinder

Correction of high order HOA preserved Yes Yes

aberrations (HOA)
Optical Zone selection

Compensation of flap-cut
Adjustment of laser induced aberrations Yes Yes Yes
refraction (biomechanical effect)

Comparison of Compensation of ablation

ablation depths induced aberrations Yes Yes Yes
(biomechanical effect)

Compensation of energy Yes Yes Yes

loss of the laser beam
 Decision Tree criteria
Differences between the types of treatment - part II

Aberration-Free Corneal Wavefront Ocular Wavefront

Introduction Treatment Treatment Treatment

Change of Q-Value Change of Q-Value

depending on Target in SCHWIND depending on SEQ +
Customized treatment Q-value CAM:
preparations correction of the ∆Z(4,0)+ ∆Z(6,0)+
SEQ Q-Value = -0.25 ∆Z(8,0)
Decision Tree criteria
Target: 0 µm for Z(4,0)
+ Z(6,0) related to
an eye model with
Optical Zone selection Preservation of Q-value of
Spherical aberration existing -0.25. Target: 0 µm
(SphAb) spherical
aberrations  diagnosis SW
Adjustment of laser displays ~0.2 µm @
refraction 6 mm for Z(4,0) in
the cornea
Comparison of
Target: All
ablation depths Preservation of all coefficients / Target: 0 µm for all
Higher-order existing higher- aberrations close to higher-order
aberrations (HOA) order 0 µm for the given aberrations
aberrations eye-model
Treatment Type Decision Tree V4
Flow chart
 Decision Tree criteria
Treatment Type Decision Table to distinguish the appropriate patient treatment

Level of Aberration Aberration-Free Corneal Wavefront Ocular Wavefront

(RMS HO)

Corneal AND
Ocular Wavefronts Always No No
< 0.25 D

If CDVA < 20/20 OR If CDVA < 20/20

If CDVA ≥ 20/20
Corneal OR complaints in OR complaints in
AND no
Ocular Wavefront quality or night quality or night
complaints in
between vision AND vision AND no
quality or night
0.25 D and 0.50 D Internal Wavefront lenticular
vision
< 0.375 D problems

Corneal AND If wavefront maps

If Internal Wavefront If no lenticular
Ocular Wavefronts smaller than
< 0.375 D problems
> 0.50 D scotopic pupil
 Comparison of OW and CW data
PERAMIS TopoAberrometry at 6 mm analysis diameter

OW CW IW
 Comparison of OW and CW data
SCHWIND CAM Comparison Module

OW
CW
IW

 After import of the two wavefront files, the information refers to the smallest common import diameter.
Take 6 mm (as default) for analysis or even the diameter which is equal to your optical zone size selection.
 Decision Tree criteria
SCHWIND CAM Comparison module
» Functional Optical Zone (FOZ):

• FOZ can be selected on the referring icon on the left side of the
Introduction
Comparison module and is defined as the area where the RMS HO
value exceeds 0.375D

Customized treatment • A white ring indicates the FOZ within the wavefront map. The exact
preparations
value of FOZ is mentioned below the slider bar for optical zone (OZ) size
adjustment
Decision Tree criteria
• FOZ function might be useful to analyse the change in HOA between
pre- and post-surgery (aberration-free concept), possible night vision
Optical Zone selection problems andOrder
othersAberrations (HOA):
» Level of Higher

Adjustment of laser • The significance of HOA for selected OZ is shown via traffic light
refraction
• HO refraction with sphere, cylinder and axis is displayed and expressed in
diopters. This refraction reflects the effect of HOA at selected diameter (optical
Comparison of
ablation depths zone) - expressed in spherical and cylindrical power – that is automatically
compensated for in the SCHWIND refractive treatment The software treatment
plan with ORK-CAM tries to be on patient target by this compensation

 The compensation of HOAs (sphere & cylinder) is often more powerful than the treatment of HOAs (=efficacy) themselves.
Thus, reduction in sphere/cylinder (to more positive refraction values) is typically needed in OW-/CW- treatment plans.
 Decision Tree criteria
SCHWIND CAM Comparison module

Workflow following the Treatment Type Decision Tree with COMPARISON module
Introduction » If the analysis diameter (OZ) is >6.0 mm change it to 6.0 mm and press <Apply> to set
all wavefront information to a standard wavefront reference diameter
Customized treatment » Wavefront A provides data of the first imported file (e.g. ocular wavefront)
preparations
» Wavefront B provides data of the second imported file (e.g. corneal wavefront)
Decision Tree criteria » Combined maps shows the difference (A-B) of the two imported files
» By choosing the <Aberration Info> button a summary of aberrations is available
Optical Zone selection
» The clinical relevance of aberration terms
Adjustment of laser can be classified as equivalent defocus
refraction (DEq). This DEq metric is identical to the
power vector notation for low order
Comparison of
ablation depths
aberrations and allows defining optical blur
in dioptres [D]. To follow the flow chart
“Treatment Type Decision Tree” take the
RMS HO of the Aberration Info.
 Depending on optical zone size selection for treatment, you may change and use the same (OZ) size for analysis (diameter)
 Decision Tree criteria
SCHWIND CAM Comparison module

Overview of ‘Aberration Info’ (analysis diameter 6.0 mm)

Introduction

» Ocular Wavefront Aberrations:

Customized treatment
preparations OW RMS HO = 0.29D

Decision Tree criteria

» Corneal Wavefront Aberrations:

Optical Zone selection
CW RMS HO = 0.44D
Adjustment of laser
refraction

» Combined/Internal Wavefront Aberrations:

Comparison of
ablation depths Combined RMS HO = 0.53D

 Because of positive and negative aberration

coefficients and possibly different axes the result of
combined/internal RMS HO is not simply: “3 – 2 = 1”
 Decision Tree criteria
Analysis by PERAMIS TopoAberrometry or SCHWIND CAM Comparison module

Following the first steps of the flow chart:

Assumption:
Introduction » OW RMS HO = 0.29D
CDVA < 20/20 or <1.0 (decimal)
» CW RMS HO = 0.44D
Customized treatment
preparations » Combined/Internal RMS HO = 0.53D

Decision Tree criteria

CW
YES RMS HO < 0.25D

NO
Optical Zone selection
CW
RMS HO > 0.50D YES

Adjustment of laser NO

refraction
Complaints about quality
CDVA = 1.0
NO or night vision YES
Comparison of YES NO
ablation depths

AF Customized
Aberration-Free Treatment
 Decision Tree criteria
Analysis by PERAMIS TopoAberrometry or SCHWIND CAM Comparison module

» OW RMS HO = 0.29D
Continue with next steps in case of
Introduction Customized Treatment decision: » CW RMS HO = 0.44D

» Combined/Internal RMS HO = 0.53D

Customized treatment » OW = 7.48mm
preparations
Customized
Treatment » CW = 7.87mm
Decision Tree criteria

Assumption:
Difference OW – CW Indication and age
Optical Zone selection RMS HO > 0.375D For IOL exchange
YES YES  Patient age: 30 years
NO NO
 No signs of cataract
Adjustment of laser
refraction Æ OW > Æ CW
YES

NO

Comparison of
ablation depths

CW OW NO TREATMENT
Corneal Wavefront Ocular Wavefront with Excimer Laser
 Decision Tree criteria
Alternative flow chart if an aberrometer-link to SCHWIND is missing

Introduction
CW
YES RMS HO < 0.25D
NO

Customized treatment CW
preparations RMS HO > 0.50D YES

NO

Decision Tree criteria Complaints about CDVA

visual quality or night vision YES ≥ 20/20 = 1.0
NO
YES NO

Optical Zone selection

Improved CDVA
with RGP CL NO

Adjustment of laser YES

refraction

Comparison of
ablation depths

AF CW NO TREATMENT
Aberration-Free Corneal Wavefront with Excimer Laser
 Decision Tree criteria
Summary

» Aberration-Free (AF) treatment is the “easiest” or “most conservative” in any

Introduction
case
» AF is the first choice when CDVA is at least 20/20 or 1.0 and no visual
Customized treatment disturbances are existing (at dawn or night)
preparations
» Customized treatments – either Ocular Wavefront (OW) or Corneal Wavefront
Decision Tree criteria (CW) - are favored when CDVA is lower than 20/20 or 1.0 and significant higher-
order aberrations (HOA) are evaluated by diagnosis
» A CW-treatment is indicated or preferred whenever internal HOA (combined
Optical Zone selection
map) are determined to be lower than 0.375 D (reference diameter of 6 mm
preferred)
Adjustment of laser
refraction » An OW-treatment is indicated or preferred with internal HOA (combined map)
to be larger than 0.375 D and with no age-related symptoms to undergo intra
Comparison of ocular lens (IOL) surgery soon.
ablation depths » Rigid Gas Permeable (RGP) contact lenses can help to distinguish whether a CW-
treatment may improve patient’s vision without SCHWIND aberrometer
diagnosis available
 Patient exam and family history have to be considered in any case and may finally
result in: “no treatment with eximer laser”
 Optical Zone selection
Treatment type decision dependent

Initial Optical Zone selection

» General: Optical Zone (OZ) selection should cover the scotopic pupil size as minimum
Introduction

» The following default OZ should be considered as a guideline for OZ as a compromise

Customized treatment between tissue removal and biomechanical stability
preparations
» It is recommended to increase OZ sizes whenever
Decision Tree criteria patient’s scotopic pupils are larger than the OZ size
proposed

Optical Zone selection Example for astigmatism dominance:

Sph -1.50D Cyl -2.50D Ax 175°

Adjustment of laser
refraction Re-Treatment situation
» Whatever laser system performed the previous
Comparison of ablation take the OZ of the initial treatment into
ablation depths
account
» In case no patient history is available the OZ size of the initial d = 6.19mm
treatment might be determined with the use of <FOZ> or
estimated with topography information, e.g. measure the
diameter of the “myopic red ring” in the tangential map
 Optical Zone selection
Re-treatment in Aberration-Free (AF) mode

Introduction
» Simple over- / undercorrection without visual complaints and CDVA ≥ 20/20 (feet) or 1.0

Customized treatment
(decimal)
preparations
» No aim to improve CDVA with excimer laser treatment in the individual patient eye
Decision Tree criteria » No information about “internal” eye aberrations and their possible influence on patient
vision, i.e. no aberrometer data available and test with rigid gas permeable contact lens
Optical Zone selection (RGPs) not possible

» The analysis diameter of ocular or corneal wavefront data (HOA) are inefficient or way
Adjustment of laser smaller than the scotopic pupil size, even though an Optical Zone extension by 20% max.
refraction
of the diagnostic export diameter is possible within ORK-CAM software: the peripheral
area is extended by an aspheric (AF) profile fitting as soon as wavefront data are not
Comparison of
ablation depths available anymore, i.e. the diagnostic export diameter is smaller than the selected OZ

Aberration-Free
OZ re-treatment = primary OZ
 Optical Zone selection
Re-treatment in Aberration-Free (AF) mode

Under correction & information about initial OZ available

Introduction
» Myopic under correction
Myopia
• Myopia after initial myopia Myopia
Customized treatment
Myopia
preparations • General: OZ (re-treatment) ≥ OZ (initial)

Decision Tree criteria

• Reason: the periphery (= TZ & untreated area) is more
myopic; i.e. larger OZ reduces peripheral myopia
• Recommendation:
Optical Zone selection
OZ ≥ 6.8 mm or default OZ increase by 0.5 Note:
mm Red colour – Myopic defocus

Green colour – Hyperopic

defocus
Adjustment of laser
refraction » Hyperopic under correction Hyperopia
Hyperopia
• Hyperopia after initial hyperopia Hyperopia
Comparison of
ablation depths • General: OZ (re-treatment) ≥ OZ (initial)
• Reason: the periphery (= TZ & untreated area) is more
hyperopic; i.e. larger OZ reduces peripheral hyperopia
• Recommendation:
OZ ≥ 7.2 mm or default OZ increase by 0.5 mm
 Optical Zone selection
Re-treatment in Aberration-Free (AF) mode

Under correction & information about initial OZ available

Introduction
» Myopic over correction
• Hyperopia after initial myopia Myopia
Customized treatment
preparations • General: OZ (re-treatment) ≤ OZ (initial) Myopia

Hyperopia
• Reason: the periphery (= TZ & untreated area) is more
Decision Tree criteria
myopic whereas within OZ hyperopia exists
• Optimum (default OZ setting):
Optical Zone selection
6.2mm < OZ ≤ 6.3mm
Note: Red colour – Myopic defocus

Adjustment of laser » Hyperopic over correction Green colour – Hyperopic

defocus
refraction
• Myopia after initial hyperopia Hyperopia
Hyperopia
Comparison of • General: OZ (re-treatment) ≤ OZ (initial)
ablation depths Myopia
• Reason: the periphery (= TZ & untreated area) is more
hyperopic whereas within OZ myopia exists
• Optimum (default OZ setting):
6.3mm < OZ ≤ 6.7mm
 Optical Zone selection
Aberration-Free re-treatment / secondary cases

Overview of Optical Zone (OZ) selection in Aberration-Free (AF) re-treatments

Primary treatment Myopia
Introduction OZ ≥ 6.3
Secondary mm
Hyperopia
“overcorrection”
6.2mm < OZ ≤ 6.3mm
Customized treatment
preparations
Secondary Myopia
Decision Tree criteria
“undercorrection”
OZ ≥ 6.8mm

Optical Zone selection

Primary treatment Hyperopia

Adjustment of laser OZ ≥ 6.7 Myopia
Secondary mm
refraction
“overcorrection”
6.3mm < OZ ≤ 6.7mm
Comparison of
ablation depths
Secondary Hyperopia
“undercorrection”
OZ ≥ 7.2mm
 Optical Zone selection
Aberration-Free re-treatment / secondary cases

If no information about initial OZ is existing – take the information of 6 mm corneal

spherical aberration (SphAb, C(4,0)) information for AF (re-)treatment into account.
Introduction
Current situation:

Customized treatment » Myopia with SphAb > 0.25D

preparations
• Typical for a primary myopia treatment that end in undercorrection
Decision Tree criteria
• General: OZ (re-treatment) ≥ OZ (initial)
• Optimum (based on default OZ setting): OZ ≥ 6.8 mm or increase of 0.5 mm
Optical Zone selection
» Myopia with 0.0D < SphAb ≤ 0.25D
• Typical for a virgin eye
Adjustment of laser
refraction • General: OZ (re-treatment) ≥ OZ (initial)
• Optimum (based on default OZ setting): OZ ≥ 6.3 mm
Comparison of
ablation depths » Myopia with SphAb < 0.0D
• Typical for a primary hyperopia treatment that end in overcorrection
• General: OZ (re-treatment) ≤ OZ (initial)
• Optimum (based on default OZ setting): 6.3 mm < OZ ≤ 6.7 mm
 Optical Zone selection
Aberration-Free re-treatment / secondary cases

If no information about initial OZ is existing – take the information of 6 mm corneal

spherical aberration (SphAb, C(4,0)) information for AF (re-)treatment into account.
Introduction
Current situation:

Customized treatment » Hyperopia with SphAb > 0.25D

preparations
• Typical for a primary myopia treatment that end in overcorrection
Decision Tree criteria
• General: OZ (re-treatment) ≤ OZ (initial)
• Optimum (based on default OZ setting): 6.2 mm < OZ ≤ 6.3 mm
Optical Zone selection
» Hyperopia with 0.0D < SphAb ≤ 0.25D
• Typical for a virgin eye
Adjustment of laser
refraction • General: OZ (re-treatment) ≥ OZ (initial)
• Optimum (based on default OZ setting): OZ ≥ 6.7 mm
Comparison of
ablation depths » Hyperopia with SphAb < 0.0D
• Typical for a primary hyperopia treatment that end in undercorrection
• General: OZ (re-treatment) ≥ OZ (initial)
• Optimum (based on default OZ setting): OZ ≥ 7.2 mm or increase of 0.5 mm
 Optical Zone selection
Aberration-Free re-treatment / secondary cases

Additional remarks for OZ selection in AF (re-)treatment due to SphAb judgement:

Introduction

» To evaluate the change in SphAb make use of the <Comparison> module within the
Customized treatment
SCHWIND CAM.
preparations
» The determination of the SphAb value refers to the OZ used (tendency a little smaller)
Decision Tree criteria and must NOT automatically related to 6.0 mm.
» In case the OZ used for primary treatment was selected larger or different than the
Optical Zone selection SCHWIND proposed OZ default, take the difference of these adjustments into account:
• Example: Primary myopia treatment with OZ = 7.0 mm (default OZ = 6.3 mm) initially
Adjustment of laser chosen because of a scotopic pupil size close to 7.0 mm
refraction
‐ Calculated OZ difference (delta between primary treatment and OZ default) is 0.7 mm

Comparison of • Outcome 1: myopic undercorrection and recommended increase of 0.5 mm in OZ size

ablation depths
• Proposed OZ for AF re-treatment = OZ (initial) + 0.5 mm = 7.5 mm

• Outcome 2: myopic overcorrection and recommendation for a smaller OZ than initially

• Proposed OZ for AF re-treatment = the compromise of scotopic pupil size and OZ

decrease proposes a treatment of 6.8 mm to 7.0 mm in this case
 Optical Zone selection
Aberration-Free re-treatment / secondary cases

Summary for OZ selection in AF (re-)treatment:

Introduction

» Most conservative way regarding OZ selection for an Aberration-Free re-treatment is

Customized treatment
to take the same OZ as in the primary treatment
preparations
» Increase the OZ after an unintended post-OP undercorrection after primary treatment
Decision Tree criteria – in both myopia and hyperopia – to prevent an under corrected outcome again
» Caution: A recommended increase of the OZ for re-treatment might be limited due to
Optical Zone selection the initial flap size after primary (Femto-)LASIK treatment.
» Decrease or keep the OZ same after an unintended post-OP overcorrection to prevent
Adjustment of laser changes in the untreated peripheral area, i.e. the periphery should not become even
refraction more myopic or hyperopic, respectively, than initially. This holds for both myopia and
hyperopia.
Comparison of » Caution: A recommended decrease of OZ might be limited by the risk of potential
ablation depths
regression (inefficacy of cornea change over time) if OZ is selected too small, e.g. OZ
<6.0 mm in myopia, OZ <6.4 mm in hyperopia and OZ <6.7 mm in high astigmatism
 Adjustment of laser refraction
Customized OW and CW (re-)treatments

Possible reasons for an unexpected outcome after customized (re-) treatments

Introduction

» High order aberrations (HOA) might have an influence on low order aberrations
Customized treatment (sphere and cylinder) , e.g. coma aberration may contribute to the power/axis of
preparations manifest astigmatism
» HOA reduce the precision of determination of manifest refraction because of
Decision Tree criteria
low(er) image quality (= reduced CDVA) and possibly increased depth-of-focus
(= significant amounts of spherical aberration) due to previous laser treatment
Optical Zone selection » HO refraction compensation in sphere and cylinder power (which is part of the
individual customized treatment profile) increases with bigger OZ sizes and may
Adjustment of laser significantly influence the depth/volume of the treatment profile
refraction

Comparison of  In case of customized OW or CW treatments the primary Optical Zone (OZ) size of the
ablation depths AF treatment does not play a role.
Customized treatments with significant high-order aberrations (HOA) consider
typically an OZ of 7 mm and more (as long as enough corneal tissue is available)
 Adjustment of laser refraction
Customized OW and CW (re-)treatments

When the Treatment Type Decision Tree (flow chart) results in a customized treatment
Introduction planning it is recommended to perform a first refraction adjustment based on the summary
of:
» Manifest refraction
Customized treatment
preparations » Aberrometer refraction @ 4mm

Decision Tree criteria » Topographical astigmatism

» Wavefront astigmatism @ 4mm

Optical Zone selection » Wavefront astigmatism @ 6mm

Adjustment of laser If no aberrometer refraction is available the autorefraction might be useful to take instead.
refraction
The topographical astigmatism is taken from Meridians @ 3mm (SIRIUS, PERAMIS) or „Best
Comparison of Fit Maloney“ (Scout).
ablation depths
The wavefront astigmatism @ 4mm and 6mm is taken from the Topographer (Corneal
Wavefront treatment) or Aberrometer (Ocular Wavefront Treatment), respectively.
Based on the SEQ of the manifest refraction and the mean of the 5 astigmatism values the
adjusted refraction (“vectorial mean”) can be calculated.
 Comparison of ablation depth/volume
Difference in depth/volume: Aberration-Free (AF) vs. Customized (OW/CW) treatment plan

The SCHWIND Decision Tree supports you in making the best decision for each individual
Introduction patient. Nonetheless, patient eyes with previous corneal treatments or injuries are less
predictable than virgin corneas.
Optical Zone Size Depth* Volume Volume
Customized treatment
Myopia* Hyperopia*
preparations
[µm] [nl] [nl]
Decision Tree criteria < 5.25 mm 6-8 up to 75 up to 95
5.25 - 5.75 mm 8 - 10 90 - 125 115 - 160
Optical Zone selection 5.75 – 6.25 mm 10 - 11 125 - 185 160 - 220
6.25 – 6.75 mm 11 - 13 185 - 255 220 - 300
Adjustment of laser 6.75 – 7.25 mm 13 - 15 255 - 350 300 - 400
refraction
7.25 – 7.75 mm 15 - 17 350 - 470 400 - 530
Comparison of *corresponds to a 0.75D-AF-treatment for selected OZ (which is „deviation maximum“ of AF vs. OW/CW)
ablation depths
If the differences between manifest refraction in Aberration-Free mode vs. customized
Corneal or Ocular Wavefront are larger than these for the selected OZ, modify the
spherical and/or cylindrical component with use of <Refraction>, and make use of
<Pyramid> afterwards if even more tissue has to be saved. Otherwise, the risk of a
refractive outcome significantly different from target exists.
 Comparison of ablation depth/volume
Difference in depth/volume: Aberration-Free (AF) vs. Customized (OW/CW) treatment plan

Summary regarding the tolerance in ablation depth/volume difference in

Introduction reference to optical zone selection:

Customized treatment » Wavefront-guided treatments (OW/CW) most likely take more tissue into account
preparations
than Aberration-Free (AF) treatments with equal manifest refraction values. This
Decision Tree criteria leads to the fact that wavefront-guided treatments do have a higher potential of
over corrected outcomes
» A certain depth/volume difference is tolerable if high-order aberrations are part of
Optical Zone selection
the treatment plan but being conservative, i.e. sparing tissue for another possible
optimization, should be a major goal
Adjustment of laser » If accurate refraction (= patient target refraction) is intended, i.e. the treatment plan
refraction
has no therapeutic reason, OW/CW treatment plan should not deviate more than
±0.75D from AF-depth/volume
Comparison of
ablation depths
 Customized Treatment optimization - OPTION 1: Comparison of ablation
depth/volume
CW-guided (manifest) vs. AF (manifest) vs. CW-guided (adjusted)

Type of Treatment Depth Depth Volume Depth Depth Volume

max central max central
[µm] [µm] [nl] [µm] [µm] [nl]

Example Example
Myopic Astigmatism Hyperopic Astigmatism
Re-Lift OZ (mm): 7.00 PRK OZ (mm): 7.20
CW-guided (manifest) 61 59 1911 123 89 4879
AF (manifest) 13 13 367 109 31 2840
CW-guided (adjusted) 70 68 2200 121 87 4916

Treatment Plan Treatment Plan

Refraction adjustment Tolerance (Δ): 14 µm Tolerance (Δ): 15 µm
300 nl 400 nl
Δ (CW (adjusted) – AF (manifest)) 57 55 1833 12 56 2076
Tolerance factor (Δ : Tolerance) 4x 4x 4.5x 1x 4x 5x

Rule of thumb: TF ≤ 1: no change, TF ≤ 2: pyramid (+) only, TF of ≤ 3: Rx optimization (default constraints)

followed by pyramid maybe, a TF > 3: Rx optimisation (extended constraints) followed by pyramid maybe.
63
 Customized Treatment optimization - OPTION 2:
SCHWIND CAM Comparison
Display of High-Order (HO) Refraction with reference to different OZ sizes

Extend the constraints within the ORK-CAM <Manager> for Rx optimisation if

Rule of thumb: TF ≤ 1: no change, TF ≤ 2: pyramid (+) only, TF of ≤ 3: Rx optimization (default constraints)
HO Refraction values are bigger than DEFAULT constraints for Optical Zone given:
followed by pyramid maybe, a TF > 4: Rx optimisation (extended constraints) followed by pyramid maybe.
64
Customized Treatment: The manager function
REFRACTION: Optimization possibilities (depth/volume) in combination with CONSTRAINTS

Default setting

The smaller the ‚Constraints‘ selected the smaller the deviation maximum
(‚Residual‘) from ‚Current‘ refraction can or will be.
Customized Treatment: The manager function
PYRAMID: Optimization possibilities (depth/volume) in comparison
 Customized Treatment: The manager function
Make use of the output from OPTION 1 or OPTION 2 (with very similar results)

The manager function gives the opportunity to individualize Ocular and Corneal Wavefront treatments.
The <Manager> function has to be used after the final adjustment of treatment parameters.
The typical order of the optimization process is from “ROUGH” (Refraction 1 st) to “FINE” (Pyramid 2nd).
 Customized Treatment: The manager function
REFRACTION: Maximum Saving (depth vs. volume) with NO CONSTRAINTS selection

Minimize Depth with NO Constraints = Maximum Tissue Saving (Depth)

Minimize Volume with NO Constraints = Maximum Tissue Saving (Volume)

Δ (Minimize Depth vs. Minimize Volume)

 Customized Treatment: The manager function
CONSTRAINTS: The possibilities

Constraints LASIK and FemtoLASIK (Trans)PRK and LASEK

max. limit range
Myopia and myopic astigmatism Myopia and myopic astigmatism

max. sph. correction: -12 D / -15 D* max. sph. correction: -9 D / -12 D*

max. cyl. correction: ± 6 D / ± 7 D* max. cyl. correction: ± 6 D / ± 7 D*

Hyperopia and hyperopic astigmatism Hyperopia and hyperopic astigmatism

max. sph. correction: +6 D / + 8 D* max. sph. correction: +6 D / + 8 D*

max. cyl. correction: ± 6 D / ± 7 D* max. cyl. correction: ± 5 D / ± 7 D*

CAM Settings Tab

*  Extended limits in the ORK-CAM module

 Customized Treatment optimization - Summary
» Compare the ablation depth/volume of CW-guided (OW/CW) with Aberration-Free (AF)

» Calculate the difference in depth/volume between both treatment types at equal Optical Zone (OZ)

» Look for the tolerance factor (TF) or refer to the HO Refraction- Info (out of SCHWIND CAM Comparison), each
related to the OZ selection for treatment

» If TF is ≤ 1: no change (~14 µm @ 7 mm is acceptable), a TF of ≤ 2: pyramid (+) only, a TF of ≤ 3: Rx

optimization (default constraints) (and pyramid afterwards), a TF > 3: Rx optimisation (extended constraints)
(and pyramid afterwards), … to be close to AF depth/volume

» Increase constraints ‘Sphere’ if tolerance factor is more than 3x,

i.e. the calculation is: tolerance factor multiplied by 0.75 D. Another (easier) option is to take the HO Refraction
value of the spherical component at selected OZ (out of SCHWIND CAM Comparison module)

» Increase constraints ‘Cylinder’ only if a big impact of HO astigmatism and/or Coma aberration is present. Refer
to the HO Refraction value of the cylindrical component at selected OZ (out of SCHWIND CAM Comparison
module)

» Decrease constraints ‘Cylinder’ (close to zero) if cylinder component is repeatable (subjective, topo, wavefront)

» Change constraints ‘Axis’ only if bigger axes differences than 15° exist between subjective, topo, and adjusted

» Decrease constraints ‘Axis’ (close to zero) if cylinder power and axis is repeatable (subjective, topo, wavefront)

 The tighter the constraints selected, the lesser the change (“tissue saving”) of the ‘Current’ can be
 SCHWIND ORK-CAM, Main Menu in OS (V5.2)
Customized treatment – Patient with progressive keratoconus

» Example of a Main Menu that displays a CW-guided treatment (SCHWIND SIRIUS) (Trans-)PRK
proposal for a patient with progressive keratoconus, followed by CXL treatment.
Agreement of the Ablation Profile
Comparison of diagnostic device information and SCHWIND ORK-CAM ablation map

PRK
SIRIUS Tangential Anterior
and Altimetric (Asphero-
Toric) Map show very high
agreement in shape to the
ORK-CAM customized profile

: 7 mm reference diameter

72
 SCHWIND ORK-CAM, Summary Page in OS (V5.2)
CW-guided (SIRIUS) TransPRK with refraction & pyramid (manager) adjustment

Check parameter of treatment planning and <Export> file to AMARIS laser 73

 Customized Treatment planning – The steps

1. Select for the best topography and wavefront maps according to the quality criteria
2. Do a comparison of OW and CW data within SCHWIND PERAMIS directly or make use of the SCHWIND
Comparison module (after export of diagnostic patient eye data)
3. Use the ‘Export to SCHWIND’ within the SCHWIND diagnostic devices for diagnostic patient file creation
4. Determine the best (treatment) option (AF, OW, CW, no laser treatment) for the individual patient, taking
patient history and anamnesis into consideration  SCHWIND Decision Tree
5. Make use of subjective and objective refraction information to include both refractive, corneal, and wavefront
influences into the treatment plan: “adjusted refraction” (in OW or CW)
6. Do a comparison of Aberration-Free (AF) depth/volume vs. Wavefront-guided (OW, CW) depth/volume at
same (pre-)selected Optical Zone (OZ) size if OW or CW is considered
7. Make use of the ORK-CAM <Manager> function after final OZ size selection: tissue saving possible via
adaptation in laser refraction “Refraction” and/or in high-order aberrations “Pyramid”
8. Do a comparison between ablation map (=laser profile) and diagnostic map(s) [topography, wavefront,
elevation, …], i.e. validate whether shape and depth/volume plan are plausible.
9. Check the correctness of SCHWIND ORK-CAM input data (“Summary Page”)
10. Create an SCHWIND ORK-CAM export file for treatment with AMARIS laser
Thank you very
much for your kind attention!
Vielen Dank für Ihre Aufmerksamkeit!

Customer Support

SCHWIND eye-tech-solutions GmbH fon: +49(0)6027 / 5 08-350

Mainparkstrasse 6-10 fax: +49(0)6027 / 5 08-208
63801 Kleinostheim, Germany email: [email protected]
www.eye-tech-solutions.com