Over the past 25 years, a variety of technological advancements have helped to improve quality of vision while decreasing the incidence of adverse effects, such as glare and halos, with conventional laser in-situ keratomileusis (LASIK). These include topography- (topo-) and wavefront-guided LASIK surgery.

Here, we compare and contrast topo-guided LASIK with wavefront-guided LASIK by reviewing recent outcomes data, and we provide our perspectives on when and why to use topo- or wavefront-guided LASIK surgery.

TOPO-GUIDED LASIK

Karl Stonecipher, MD
(StoneNC@aol.com)

Over the past quarter-century, laser vision correction surgery has been established as an effective and safe surgical intervention, with LASIK being the main technique used worldwide to correct refractive errors.¹ Topo-guided LASIK is one of the latest advancements in laser eye surgery technology, providing surgeons with more detailed information about the corneal structure than measured with traditional technology and allowing for the individualization of LASIK surgery to each patient’s vision-correction needs.

Specifically, using topo-guided LASIK, each eye is imaged and analyzed using 22,000 unique elevation points on the cornea, with the data sent to a surgical-planning computer that creates a custom profile to optimize the patient’s vision correction. As a result, topo-guided LASIK has been shown to improve vision equal to or better than glasses or contact lenses, and the surgical outcomes of topo-guided LASIK for correcting myopia and astigmatism and treating irregular corneas have been reported with immediate and long-lasting results.^2-7 Topo-guided LASIK results in excellent accuracy, efficacy, and safety, with improved postoperative subjective quality of vision and reduced night vision disturbances in virgin eyes.⁶

Direct comparison studies have demonstrated that topo-guided LASIK results in fewer higher-order aberrations (HOAs) and improved visual outcomes.^8-10 In fact, a recent study showed that 88.9% of patients who underwent topo-guided LASIK surgery had uncorrected distance visual acuity (UDVA) of 20/20 or better at 6 months after surgery, compared with 82.6% who underwent wavefront-guided LASIK surgery.¹⁰ In addition, the patients who underwent wavefront-guided LASIK had a decrease in UDVA over time due to refractive regression.¹⁰ Further, a contralateral-eye comparison study of topo-guided vs wavefront-guided LASIK revealed that 19% of eyes in the topo-guided group gained more than one line of UDVA vs 12% of eyes in the wavefront group.⁸ In another study, 28% of eyes in the topo-guided group had better UDVA postoperatively compared with preoperative-corrected distance visual acuity (CDVA) vs. 17% of eyes in the wavefront-guided group.⁹ Something else to consider is that topo-guided LASIK induces less ocular trefoil, fewer corneal total HOAs, and a lower incidence of corneal coma.^8,9

For patients who have astigmatism, topo-guided LASIK is an especially efficacious procedure, as it provides a personalized procedure. Specifically, it addresses astigmatism variations more accurately, provides topographic adjustment of the amount and axis of astigmatism treated, and offers improved outcomes.⁶ For example, in a recent study, topo-guided LASIK demonstrated efficacy and safety in treating patients who had mixed and myopic astigmatism, while preserving their optical performance without significant induction of HOAs.¹ In eyes with primary myopic astigmatism and a small axis discrepancy between anterior corneal astigmatism and refractive astigmatism of 5° to 20°, topo-guided LASIK provided 20/20 UDVA in 90% of eyes, with 95% having postoperative cylinders of 0.50 D or less.¹¹

In another study of symptomatic myopic patients reporting night vision problems who were undergoing retreatment, topo-guided LASIK was effective in increasing the optical zone by 11%, recentering the optical zone, and reducing HOAs by 39%, spherical aberrations by 44%, and coma by 53%.⁷ Also, 93% of these patients reported improvement in their night vision symptoms.⁷ In an additional study, topo-guided LASIK was shown to be effective and safe, with significant stability in the refractive error correction from the first postoperative day throughout the 1-year follow-up (from 59.1% at 3 months to 71.4% at 1 year).¹²

Although the advantages of topo-guided LASIK are well documented in the literature, some surgeons believe that topo-guided LASIK is complex, time consuming, and not worth the time and effort.² In my practice, I prefer to use topo-guided LASIK as often as possible due to its increased efficacy and individualized treatment approach. In fact, my practice recently reviewed outcomes data from more than 1,000 LASIK procedures to assess the various treatments, including visual recovery rapidity, and we found a significant increase in 20/15 or better postoperative vision, favoring topo-guided LASIK over wavefront-guided LASIK.¹³ As a result, I feel that topo-guided technology provides surgeons with the best tool to perform individualized ablations based on the unique topography of each patient’s eyes. That said, the use of topo-guided LASIK is limited by the current range of FDA approval for the technology, which is currently approved only for myopic patients with and without astigmatism.

References

1. Biscevic A, Bohac M, Pjano MA, Grisevic S, Patel S, Pidro A. Treatment of high astigmatism with WaveLight Allegretto Eye-Q Excimer Laser Platform. Acta Inform Med. 2019;27(3):177-180.
2. Kanellopoulos AJ. Topography-modified refraction (TMR): adjustment of treated cylinder amount and axis to the topography versus standard clinical refraction in myopic topography-guided LASIK. Clin Ophthalmol. 2016;10:2213-2221.
3. Tan J, Simon D, Mrochen M, Por YM. Clinical results of topography-based customized ablations for myopia and myopic astigmatism. J Refract Surg. 2012;28(11 Suppl):S829-S836.
4. Stulting RD, Fant BS, T-CAT Study Group, et al. Results of topography- guided laser in situ keratomileusis custom ablation treatment with a refractive excimer laser. J Cataract Refract Surg. 2015;42(1):11-18.
5. Knorz MC, Jendritza B. Topographically-guided laser in situ keratomileusis to treat corneal irregularities. Ophthalmology. 2000;107(6):1138-1143.
6. Wallerstein A, Caron-Cantin M, Gauvin M, Adiguzel E, Cohen M. Primary topography-guided LASIK: refractive, visual, and subjective quality of vision outcomes for astigmatism ≥2.00 Diopters. J Refract Surg. 2019;35(2):78-86.
7. Reinstein DZ, Archer TJ, Carp GI, et al. Incidence and outcomes of optical zone enlargement and recentration after previous myopic LASIK by topography-guided custom ablation. J Refract Surg. 2018;34(11):121-130.
8. El Awady HE, Ghanem AA, Saleh SM. Wavefront-optimized ablation versus topography-guided customized ablation in myopic LASIK: comparative study of higher order aberrations. Ophthalmic Surg Lasers Imaging. 2011;42:314-320.
9. Jain AK, Malhotra C, Pasari A, Kumar P, Moshirfar M. Outcomes of topography-guided versus wavefront-optimized laser in situ keratomileusis for myopia in virgin eyes. J Cataract Refract Surg. 2016;42:1302-1311.
10. Schallhorn JM, Seifert S, Schallhorn SC. SMILE, Topography-guided LASIK, and wavefront-guided LASIK: Review of clinical outcomes in premarket approval FDA studies. J Refract Surg. 2019;35(11):690-698.
11. Wallerstein A, Gauvin M, Qi SR, Bashour M, Cohen M. Primary topography-guided LASIK: Treating manifest refractive astigmatism versus topography-measured anterior corneal astigmatism. J Refract Surg. 2019;35(1):15-23.
12. Kanellopoulos AJ. Topography-guided LASIK versus small incision lenticule extraction: long-term refractive and quality of vision outcomes. Ophthalmology. 2018;125(10):1658-1659.
13. Stonecipher K, Parrish J, Stonecipher M. Comparing wavefront-optimized, wavefront-guided and topography-guided laser vision correction: clinical outcomes using an objective decision tree. Curr Opin Ophthalmol. 2018;29(4):277-285.

DR. STONECIPHER is clinical professor at the UNC School of Medicine Department of Ophthalmology and is medical director of TLC Greensboro. He has practiced ophthalmology in North Carolina for more than a decade and has performed more than 77,000 refractive procedures. Dr. Stonecipher has been certified by the American Board of Ophthalmology since 1992 and is a well-published opinion leader and expert speaker on refractive, cataract, presbyopic, and corneal surgeries. He discloses relationships with Alcon and Visx.

WAVEFRONT-GUIDED LASIK

Edward E. Manche, MD
(edward.manche@stanford.edu)

The FDA approved customized wavefront-guided LASIK in 2003. Wavefront-guided technology has significantly improved the safety, predictability, and postoperative results associated with LASIK surgery.¹ Specifically, it is effective and results in low postoperative induction of HOAs and a high rate of patient satisfaction.^2-5

Additional technological advancements and improvements in wavefront aberrometry have led to an increased ability to correct refractive errors, and these advances are largely responsible for the improved visual outcomes recently reported in the medical literature.⁶ Specifically, wavefront-guided LASIK uses detailed, wavefront-generated measurements to create a laser treatment that is personalized for each patient’s eye and vision-correction needs, while wavefront-optimized LASIK uses detailed measurements of the curvature of the front surface of the eye to preserve the cornea’s natural aspheric shape.⁷ Although wavefront-optimized LASIK and wavefront-guided LASIK provide similar visual outcomes, wavefront-guided LASIK demonstrates greater efficacy in achieving higher visual acuity, less residual refractive error, mean postoperative UDVA by approximately one line, less trefoil, and fewer induced HOAs in head-to-head comparisons.^8-10

A number of studies have demonstrated that wavefront-guided lasers significantly improve patient outcomes.^11-13 One such study shows that wavefront-guided LASIK demonstrates a reduced rate of both postoperative glare and induction of HOAs, compared with traditional LASIK.¹² This study was conducted to compare the visual and refractive outcomes in myopic LASIK between wavefront-guided and traditional treatment in 162 eyes of 81 myopic patients undergoing LASIK by one surgeon. In another study, wavefront-guided LASIK was effective and well tolerated, and at 3 months 100% of 58 eyes (29 patients) achieved a UDVA of 20/20 or better (74.1% of eyes achieved UDVA of 20/16), with clinically insignificant changes in ocular aberrations at 3 months postoperatively.¹³

Patient satisfaction is highly correlated with UDVA; therefore, the large percentage of eyes that have excellent visual acuity may be the main reason for such high patient satisfaction with wavefront-guided LASIK surgery reported in the literature.^2,3,11,14 In a prospective study I conducted evaluating quality of vision and quality of life using a validated questionnaire, at 1 year after wavefront-guided LASIK surgery, 90% of 42 patients had a UDVA of 20/20 or better and significantly improved refractive status and vision profile scores, and most patients (88.1%) reported satisfaction with their visual function without correction, compared with 4.7% preoperatively.¹⁴ Moreover, preoperative Refractive Status & Vision Profile (RSVP) scores for visual function, perceptions, and problems with corrective lenses all significantly improved at 1 year.¹⁴ Specifically, 76 eyes (90.5%) had a UDVA of 20/20 or better, and total refractive status and vision profile scores improved from a mean of 30.9 points at baseline to 20.7 points at 1 year postoperatively. An additional prospective analysis of 127 patients (253 eyes) who underwent wavefront-guided LASIK shows that the surgery was effective (99% UDVA of 20/20) and led to high levels of patient satisfaction.³ Also, patients reported a significant decrease in difficulty performing daily activities and in glare while driving.³ Still another study reveals a significant postoperative reduction in light sensitivity, nighttime driving difficulty, reading difficulty, double vision, glare, and halos.¹¹ This study compared three different wavefront-guided lasers on overall changes in visual symptoms and patient-reported outcomes.¹¹

Since wavefront-guided technology is easy to use, allows for streamlined patient work-up and treatment and can be used for the majority of patients, some surgeons prefer to use it over topography-guided LASIK. Topography-guided LASIK requires additional measurements and calculations and can be very time consuming to integrate into a busy refractive practice. Topo-guided surgery has traditionally been used outside the United States primarily as a therapeutic modality for irregular corneas, such as postcorneal cross-linked eyes with keratoconus and eyes that have undergone previous keratorefractive surgery with complications, such as decentered ablations or steep central islands. Topo-guided surgery was approved by the FDA for patients who have naturally occurring myopia with and without astigmatism who have not previously undergone keratorefractive surgery. Both topo-guided LASIK and wavefront-guided LASIK are shown to be equally efficacious treatments for patients with astigmatism.^15,16,17

Topo-guided LASIK is precise and customizable to each case, but wavefront-guided LASIK is also shown to have advantages.¹⁸ For example, one study reveals advantages in quality of vision. This randomized study evaluated the visual performance of wavefront-guided LASIK and topo-guided LASIK in 35 patients (68 eyes), with both wavefront-guided and topo-guided surgeries providing excellent results in predictability and visual function.¹⁹ Studies conducted to compare clinical outcomes between topo-guided and wavefront-guided LASIK demonstrate that LASIK procedures using different technologies safely and effectively provide similar refractive visual outcomes, including UDVA, residual SE refractive error, and astigmatism results.^9,20-23 Despite the similar efficacy, in some patients, such as those with nonreproducible topography images, topography-guided treatment would be minimally effective and could potentially make vision worse, so wavefront-guided LASIK should be considered instead.^18,24-25

Laser vision correction remains an active area of research, and there have been many recent advances in the field, with both wavefront-guided and topography-guided LASIK continuing to improve patient outcomes.^25,26 Wavefront-guided LASIK is associated with outstanding efficacy, predictability, and patient satisfaction. It has demonstrated advantages in visual acuity, predictability, astigmatism correction, and subjective visual symptoms.⁶ CP

High-resolution Aberrometer

HIGH-RESOLUTION SENSOR MAXIMIZES CAPTURE RATES

• High-resolution Hartmann-Shack wavefront sensor (5 x higher than previous generation)
• Fourier reconstruction algorithms using up to 1257 micro-refractions over a 7-mm wavefront
• Improved accuracy and ability to measure complex wavefronts and highly aberrated eyes

INCREASED RESOLUTION PROVIDES

• Ability to capture images of more eyes
• Improved spot quality, reduces spot crossover effect
• Detection of HOAs
• Better reconstruction

References

1. Liu T, Thibos LN. Variation of axial and oblique astigmatism with accommodation across the visual field. J Vis. 2017;17(3):24.
2. Xia LK, Ma J, Liu HN, Shi C, Huang Q. Three-year results of small incision lenticule extraction and wavefront-guided femtosecond laser-assisted laser in situ keratomileusis for correction of high myopia and myopic astigmatism. Int J Ophthalmol. 2018;11(3):470-477.
3. Moussa S, Dexl AK, Krall EM, Arlt EM, Grabner G, Ruckhofer J. Visual, aberrometric, photic phenomena, and patient satisfaction after myopic wavefront-guided LASIK using a high-resolution aberrometer. Clin Ophthalmol. 2016;10:2489-2496.
4. Lee WS, Manche EE. Comparison of simulated keratometric changes following wavefront-guided and wavefront-optimized myopic laser-assisted in situ keratomileusis. Clin Ophthalmol. 2018;12:613-619.
5. Schallhorn SC, Farjo AA, Huang D, et al; American Academy of Ophthalmology. Wavefront-guided LASIK for the correction of primary myopia and astigmatism: a report by the American Academy of Ophthalmology. Ophthalmology. 2008;115(7):1249-1261.
6. Manche E, Roe J. Recent advances in wavefront-guided LASIK. Curr Opin Ophthalmol. 2018;29(4):286-912.
7. Thompson V. Custom Wavefront LASIK: Personalized vision correction. All About Vision. 2019. Available at: https://www.allaboutvision.com/visionsurgery/custom_lasik.htm . Accessed January 30, 2020.
8. Sáles CS, Manche EE. One-year outcomes from a prospective, randomized, eye-to-eye comparison of wavefront-guided and wavefront-optimized LASIK in myopes. Ophthalmology. 2013;120(12):2396-2402.
9. Roe JR, Manche EE. Prospective, randomized, contralateral eye comparison of wavefront-guided and wavefront-optimized laser in situ keratomileusis. Am J Ophthalmol. 2019;207:175-183.
10. He L, Liu A, Manche EE. Wavefront-guided versus wavefront-optimized laser in situ keratomileusis for patients with myopia: a prospective randomized contralateral eye study. Am J Ophthalmol. 2014;157(6):1170-1178.
11. Moshirfar M, Shah TJ, Skanchy DF, Linn SH, Durrie DS. Meta-analysis of the FDA reports on patient-reported outcomes using the three latest platforms for LASIK. J Refract Surg. 2017;33(6):362-368.
12. He R, Qu M, Yu S. Comparison of NIDEK CATz wavefront-guided LASIK to traditional LASIK with the NIDEK CXII excimer laser in myopia. J Refract Surg. 2005;21(5 Suppl):S646-2649.
13. Shetty R, Matalia H, Nandini C, et al. Wavefront-guided LASIK has comparable ocular and corneal aberrometric outcomes but better visual acuity outcomes than SMILE in myopic eyes. J Refract Surg. 2018;34(8):527-532.
14. Chen SP, Manche EE. Patient-reported vision-related quality of life after bilateral wavefront-guided laser in situ keratomileusis. J Cataract Refract Surg. 2019;45(6):752-759.
15. Liu HT, Zhou Z, Luo WQ, et al. Comparison of optical quality after implantable collamer lens implantation and wavefront-guided laser in situ keratomileusis. Int J Ophthalmol. 2018;11(4):656-661.
16. Wallerstein A, Gauvin M, Qi SR, Bashour M, Cohen M. Primary topography-guided LASIK: Treating manifest refractive astigmatism versus topography-measured anterior corneal astigmatism. J Refract Surg. 2019;35(1):15-23.
17. Durán JA, Gutiérrez E, Atienza R, Piñero DP. Vector analysis of astigmatic changes and optical quality outcomes after wavefront-guided laser in situ keratomileusis using a high-resolution aberrometer. J Cataract Refract Surg. 2017;43(12):1515-1522.
18. Reinstein DZ, Archer TJ, Gobbe M. Improved effectiveness of trans-epithelial phototherapeutic keratectomy versus topography-guided ablation degraded by epithelial compensation on irregular stromal surfaces [plus video]. J Refract Surg. 2013;29(8):526-533.
19. Toda I, Ide T, Fukumoto T, Tsubota K. Visual outcomes after LASIK using topography-guided vs wavefront-guided customized ablation systems. J Refract Surg. 2016;32(11):727-732.
20. Chang Y, Chen Y. A randomized comparative study of topography-guided versus wavefront-optimized FS-LASIK for correcting myopia and myopic astigmatism. J Refract Surg. 2019;35(9):575-582.
21. Kim J, Choi SH, Lim DH, Yang CM, Yoon GJ, Chung TY. Topography-guided versus wavefront-optimized laser in situ keratomileusis for myopia: Surgical outcomes. J Cataract Refract Surg. 2019;45(7):959-965.
22. Shetty R, Shroff R, Deshpande K, Gowda R, Lahane S, Jayadev C. A prospective study to compare visual outcomes between wavefront-optimized and topography-guided ablation profiles in contralateral eyes with myopia. J Refract Surg. 2017;33(1):6-10.
23. Ozulken K, Yuksel E, Tekin K, Kiziltoprak H, Aydogan S. Comparison of wavefront-optimized ablation and topography-guided contoura ablation with lyra protocol in LASIK. J Refract Surg. 2019;35(4):222-229.
24. Reinstein DZ, Archer TJ, Dickeson ZI, Gobbe M. Transepithelial phototherapeutic keratectomy protocol for treating irregular astigmatism based on population epithelial thickness measurements by Artemis very high-frequency digital ultrasound. J Refract Surg. 2014;30(6):380-387.
25. Vinciguerra P, Azzolini C, Vinciguerra R. Corneal curvature gradient determines corneal healing process and epithelial behavior. J Refract Surg. 2015;31(4):281-282.
26. Myrowitz EH, Chuck RS. A comparison of wavefront-optimized and wavefront-guided ablations. Curr Opin Ophthalmol. 2009;20(4):247-50.

DR. MANCHE is the director of Cornea and Refractive Surgery at the Stanford Eye Laser Center and professor of ophthalmology at the Stanford University School of Medicine. He is a world-renowned expert in laser and surgical techniques for vision correction and has personally performed more than 50,000 LASIK procedures. He is recognized as one of the top-performing laser vision correction surgeons in the U.S. Dr. Manche discloses relationships with Alcon, Allergan, Avedro, Carl Zeiss Meditec, Johnson & Johnson Vision, Presbia, RxSight and Vacu-Site.