Category Archives: Technology

Refractive Surgery

LASIK and PRK, the most commonly performed refractive procedures, are great for a lot of people, but there are many newer procedures now that can help minimize the risk of complications. With regards to Asian patients in particular, there is fairly recent evidence that Asians are much more likely to develop dry eye problems than non-Asians after LASIK, even after factoring out the amount of myopia. It has also been shown that the corneal nerves do not seem to completely grow back to normal like we had once believed. Even if the nerves appear to grow back morphologically, their function is ultimately what must return to equilibrium.

What causes post LASIK dry eyes?

A sophisticated feed-back-loop links the corneal epithelium, stroma, nerves to the central nervous system, then back out through the facial nerve to the lacrimal gland and orbicularis fibers. When corneal nerves are damaged, the feed-back-loop is disrupted. As the sensation of dryness deminishes, the blink rates decrease and tear secretion is slowed.

LASIK induced neurotrophic epitheliopathy (LINE) initially described by Wilson, was found to correlate with blink rate. Because LASIK first requires the creation of a large corneal flap, a larger area of sub epithelial corneal nerves are damaged in LASIK than by PRK. This is believed to be part of the reason why PRK seems to have fewer problems with post operative dry eyes.

For patients especially at risk of developing dry eyes, nasal flap orientation was believed to help save a portion of the nerves (that enter the cornea from 3 and 9 o’clock) and reduce the incidence of dry eye symptoms. A recent prospective randomized clinical trial however found no significant difference in symptoms between the superior or nasal flapped patients, but did however find a correlation with the amount of preoperative myopia and ablative depth.

With this evidence, I believe that it is the deeper stromal corneal nerves that play a greater role in the development of dry eyes. Because LASIK begins ablation deeper within the stroma than PRK, this may also help explain why PRK patients suffer less from dry eyes. I will further discuss how each of the three different types of corneal nerves (cold sensors, nociceptors, and propriocepts) impact the blink rate on my Dry Eye page.

Phakic IOL’s

For people with higher degrees of myopia that require deeper ablations there are now more options that avoid corneal ablation. Phakic intra ocular lenses (P-IOLs) have been used for years in Europe but are starting to be used here in the US. Two types of lenses are currently FDA approved for use in myopic eyes. The Verisyse PIOL by Ophtec BV was approved 9/2004 for implantation infront of the iris. The Visian ICL (Implantable Collamer Lens) by STAAR surgical was approved 12/2005 for implantation behind the iris.

For highly myopic Asian patients who are particularly at risk of dry eyes, I believe this will become the best choice refractive procedure.


Measuring Beauty

Progress in human perception research has revealed the sophisticated process by which faces are recognized and judged for attractiveness. This remarkable ability once believed to be unique to humans has been found in animals and even bees. Despite the universality of this primitive talent to recognizing faces, efforts to mathematically define these facial properties have baffled intellectuals since Da Vinci. Not until the development of photographic imaging technology was there any progress. In 1897, Francis Galton was attempting to predict criminal behavior through patterns in facial morphology using composite photography. By superimposing multiple inmate mugshots into a composite photograph, he noted that the combined face appeared more attractive. In 1990, Langlois et al generated computer averaged composite faces and similarly concluded that mathematically average faces are perceived as attractive. Perret et al discovered that by averaging only a subset of the most attractive faces, an additional non-average property of attractive faces could be isolated. Recent emphasis in biometric technology and computer gaming has nurtured the next generation in facial morphing precision. Applying these technologies, Gruendel et al have generated a photo-realistic template of female beauty, “Virtual Miss Germany” by morphing together all 22 contestants of the final round of the Miss Germany competition, 2002. This image possesses all the characteristics of attractive faces, including average properties of balance and symmetry as well as non average properties of youth and health. The clarity of her image can precisely define anthropomorphic features that are consistent with current perceptions of idealized Caucasian female beauty.

My research during residency with Dr. Jill Foster and some of her colleagues focused on developing a method to measure the success of rejuvenating cosmetic brow lifting and blepharoplasty surgeries. Inspired by the natural human process of judging facial attractiveness, we proposed that the relative aesthetic improvement of brow lifting surgery over blepharoplasty alone could be quantified. We achieved these values by comparing the brow and lid fold positions of patients before and after surgery to the positions of an ideal template: Virtual Miss Germany. I presented these results last year at the 2005 American Society of Oculoplastic and Reconstructive Surgeons meeting.