Beyond LASIK book by Grace Igh

Information Guide on TransPRK

BEYOND LASIK

TransPRK Laser Vision Correction For The New Generation by Dr Tony Ho

Copyright ÂŠ October 2017 by Dr. Tony Ho All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the publisher, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. Other books by the author: The Complete Eye Care Book. Published in 1994. National Book Development Council Merit Award Winner 1996. 18 Steps To Myopia Control. Published in 1997. Clear Vision. Published in 2001. Published by: ICARE Publishing (UEN No: 49044000B)

3 Mount Elizabeth #03-08 Singapore 228510 Designed by:

Vinci GALLERY

www.vinciarts.com ISBN: 978-981-11-5470-6

Beyond LASIK TransPRK Laser Vision Correction for the New Generation by Dr Tony Ho MBBS, FAMS, FRCS, FRCOphth (UK)

Acknowledgements Firstly, I would ďŹ rstly like to thank my dedicated 3D Imaginations marketing team for their many valuable inputs that made this book possible. Especially to Jolene for her great idea to write this book! To Jencen, for her layout suggestions and text edits; and Grace, for her creative design work that has made this book an attractive read. I wish to also thank my optometrist team at Clearvision LASIK Centre for their help to proofread the book. I would like to express my "grateful thank-you"s to all my patients all over the years, for placing their trust and their eyes in my care. To the Almighty God, for His manifold blessings in my life. Kind thanks to the following companies for their generous contribution towards the cost of producing and printing this book:

All proceeds from the sale of this book will be donated to the Singapore Association of the Visually Handicapped (SAVH).

CONTENTS Introduction By Dr. Tony Ho - 1 Why Clear Vision? - 3 How The Human Eye Works - 5 How Laser Vision Correction Works - 5 Laser Vision Correction As A Lifestyle Choice - 7 The History of Laser Vision Correction - 9 The Advent Of LASIK - 11 Understanding The Pitfalls Of LASIK - 12 Modern Laser Vision Correction - The Progress of Advanced Surface Ablation (ASA) - 13 TransPRK - The Modern “Surface” Laser Vision Correction - 15 How TransPRK Is Done? - 17 About The Schwind Amaris TransPRK Laser - 19 10 Advantages of TransPRK - 21 Case Studies of Advanced Surface Ablation (ASA) - 25 30 Frequently Asked Questions (FAQs) - 35 Your Roadmap To Clear Vision - 45 “The Big Four” Modern Vision Correction Methods - 51 Modern Vision Correction Methods: Comparative Summary Table - 53 About The Author - 61 Epilogue - 62

INTRODUCTION BY

DR. TONY HO 20/20 VISION WITHOUT GLASSES! A DREAM COME TRUE

Over my 20 years of practice as an eye doctor, I have heard from many patients who have had Laser Vision Correction (LVC) done and declare it as “a life changing decision”, “a dream come true”, and even “the best decision of their lives”. In other words, people who have had LVC done tend to gush and rave about how LVC has improved their lives. But those who have yet to go for the procedure are understandably anxious and apprehensive about many things. After all, these are our precious eyes we are talking about!

MAKE AN INFORMED DECISION Today’s technological advancements in Laser Vision Correction (LVC) has brought about the “happy problem” of more choices. Unfortunately, this can also cause more confusion! To the uninitiated, the information on LVC is scattered and can be overwhelming and confusing. This book is specially written to be a concise and easy read. I hope that it will quickly initiate you into a relevant understanding of how the human eye works and the basis of how all LVC procedures work. The history of LVC and modern advanced surface-based LVC is outlined with a detailed description on my current de-facto preferred choice for LVC, that is TransPRK! Whatever your ﬁnal decision may be, I hope that you ﬁnd this book to be a good read, and that it has provided you with a good base foundation of knowledge for you to do your own further research and make your judgement as to whether to proceed for surgery and which surgical procedure is most suited for you. It is my fervent belief and experience that patients armed with information and understanding are more certain and reassured about going for it, which translates to a more relaxed and happy patient experience both during and after the procedure.

1 | INTRODUCTION BY DR TONY HO

A LIFESTYLE CHOICE Laser Vision Correction (LVC) is a special medical procedure that is not done out of a medical necessity but it is really a lifestyle choice - and one that you should make for yourself, not your friends or relatives or even your doctor! Last year, to my pleasant surprise and delight, two of my children told me – without any coaxing from me – that they want to do TransPRK surgery to be free of their glasses. I am happy to say that both my kids are now seeing perfect and are thrilled with their newfound visual freedom. My son has said he feels “reborn” and my daughter said she has a strange satisfaction of not having to search for somewhere to put her glasses when she’s on the plane. If you are keen on making this “life changing decision” to free yourself from your glasses or contact lenses, I hope that this book has been helpful. Have dreams, make proper informed choices and don’t look back! Dr Tony Ho October 2017

INTRODUCTION BY DR TONY HO |

LASER VISION CORRECTION FOR

THE NEW GENERATION

WHY CLEAR VISION? Clear vision is undoubtedly something that we, those who are short-sighted, wish we could regain once more. Just imagine the endless possibilities we could have if only we weren’t burdened with spectacles and contact lenses! In a perfect world with perfect vision, we could wake up fresh every morning and start our day without fumbling for our glasses or contacts lenses. We could go about our sporting activities freely, without being inconvenienced by any form of vision aids. Oh, and if we could travel with clear vision! No more fussing over cleaning and packing our contact lenses. No more suﬀering from dry eyes due to prolonged contact lens wear.

It’ll be like a dream come true, wouldn’t it? 3 | THE LASER VISION CORRECTION FOR THE NEW GENERATION

LASER VISION CORRECTION No longer a wistful dream!

Your second chance at 20/20 vision Most of us started our lives with perfect 20/20 vision. Unfortunately, with the stressful vision demands of the hectic lifestyle we all experience today, we put our eyes through a lot of strain and defective vision begins to set in. Yet regaining clear vision is no longer a wistful dream with todayâ&#x20AC;&#x2122;s technological advances. We now have a choice to opt for laser vision correction with greater safety and accuracy and become free of our dependence on spectacles and contact lenses.

THE LASER VISION CORRECTION FOR THE NEW GENERATION |

HOW THE HUMAN EYE WORKS We rely on our eyesight for almost everything, but most of us have only a vague idea of how our eyes work. Without them, we are unable to see the faces of our loved ones, do our daily chores with ease or experience a beautiful sunset and many other marvels of the world. To see, light rays enter the eye though the cornea, the transparent window of the eye. The cornea shape is curved to impart a refractive power that bends the light so that they pass through the pupil. The pupil is the centre opening or aperture of the iris. The iris color ranges from various shades of blue and green to different shades of light brown to dark brown. After passing through the pupil, the light rays passes through the eye’s natural crystalline lens that further bend the light rays to a focus onto the retina, the so called “film” or “CCD” of the eye, if we are to liken the eye to a camera. The part of the eye in front of the crystalline lens is filled with a constant inflow and outflow of Aqueous Humour and the part of the eye behind the crystalline lens and in front of the retina is filled with a gel-like substance called the Vitreous Humour. To maintain the shape of the eyeball, it is under a normal “intra-ocular eye pressure range” of between 12 to 21 mmHg.

Structure of the Cornea

5 | HOW THE HUMAN EYE WORKS & HOW LASER VISION CORRECTION WORKS

HOW LASER VISION CORRECTION WORKS Laser Vision Correction (LVC) corrects refractive errors such as myopia (short-sightedness), hyperopia (far-sightedness), astigmatism and presbyopia (middle-aged onset far-sightedness). These refractive errors occur when the light rays are brought to a blur focus on the retina. All laser vision procedures such as TransPRK, LASIK and ReLEx SMILE take place at the cornea. The one exception is Implantable Collamer Lens (ICL) that is actually not a laser vision procedure but an artiﬁcial lens implantation procedure that takes place inside the eye, behind the pupil. The basis of all laser vision procedure is to re-shape the cornea curvature either by the sculpting of cornea stroma tissue (as in TransPRK and LASIK) or the cutting and removal of a stroma tissue ﬂap (also called stroma lenticule) as in in ReLEx SMILE. The reshaped cornea curvature will cause the light rays entering the cornea to be bent to a new sharp focus on the retina.

Surface epithelium cells: The transparent surface skin cells that protects the cornea. Epithelium Bowman’s Layer

Stroma

Bowman's layer: The membrane that separates the surface epithelium cells and the stroma. Stroma tissue layer: The transparent body of the cornea that comprises of water and collagen ﬁbres neatly stacked in parallel layers. This is the layer where laser vision correction takes place. Descemet's membrane: Inner-most membrane layer of the eye, and is lined by endothelium. Endothelium cells: Special layer of cells that line the inside surface of the cornea, and is responsible for maintaining the cornea transparency.

Descemet’s membrane Endothelium

HOW THE HUMAN EYE WORKS & HOW LASER VISION CORRECTION WORKS |

GROWTH OF LASER VISION CORRECTION

PARTAKE OF THESE ACTIVITIES WITH VISUAL FREEDOM!

DIVING

TREKKING

PARAGLIDING TRAVELING

7 | GROWTH OF LASER VISION CORRECTION AS A LIFESTYLE CHOICE

AS A LIFESTYLE CHOICE LASER VISION CORRECTION IS NO LONGER NEW! In fact, laser vision correction was ďŹ rst introduced some 25 years ago! It has been estimated that to date, well over 50 million people around the world have undergone laser vision correction surgery. Today, all of us probably have some friends or family members who have already gone for laser vision correction to get rid of their myopia (short-sightedness), astigmatism, hyperopia (long-sightedness) or presbyopia.

Laser vision correction see clearly, live freely

GROWTH OF LASER VISION CORRECTION AS A LIFESTYLE CHOICE |

The History of Laser Vision Correction HOW IT ALL BEGAN – EARLY PRK The very ﬁrst laser vision correction started as a surface-based procedure known as early PRK (PhotoRefractive Keratectomy). It was made available in many countries in 1992 and gained US FDA approval in 1995. Early PRK was done using an ultra-violet light laser called the excimer laser. The procedure is done with the patient lying down and using only numbing eyedrops. The concept is simple. After removing the cornea epithelium cells, the excimer laser beam is applied onto the central cornea stroma tissue to re-shape its curvature, much like the way spectacles lenses are made. The epithelium will spontaneously heal over the treated surface within a week. Today’s advanced laser vision procedures including LASIK and TransPRK utilizes advanced generation models of the excimer laser.

THE EXCIMER LASER This is a high energy ultraviolet light laser that is commonly used in the production of microelectronic devices including semi-conductor based integrated circuits or “computer chips”. When applied to biological tissue, the excimer laser adds explosive energy to disintegrate tissue into the air rather than burning, a process called “tissue ablation”. The excimer laser can thus remove microscopic amounts of tissue very precisely, a process that has been described as precision micro-machining or micro-sculpting.

9 | THE HISTORY OF LASER VISION CORRECTION

How early PRK was done 1. Numbing eye drops are instilled to the eye

2. A blunt blade is used to scrape the cornea surface cells to expose the underlying cornea tissue

3. The patient is asked to look straight ahead at a blinking light and the excimer laser is used to reshape the curvature of the exposed cornea surface.

Why early PRK did not take off.

Despite its then high tech appeal, early PRK did not take oďŹ&#x20AC; mainly because the recovery process was often slow and painful. Visual recovery was also slow and unpredictable. This is due to a number of reasons:

1. The lasers used then were ďŹ rst-generation, broad beam lasers that tends to cause uneven tissue ablation. 2. There were no advanced NSAID eye drops to help reduce pain and swelling. 3. There were no eye drops to prevent scarring. 4. There were no special high oxygen permeability contact lenses available to help the treated cornea surface to heal.

THE HISTORY OF LASER VISION CORRECTION |

The Advent of LASIK It can be said that modern laser vision correction began with the advent of LASIK or Laser-assisted in-Situ Keratomileusis around the mid-nineties. It was discovered that by cutting open a flap in the cornea and applying the excimer laser treatment beneath the flap, the initial discomfort and slower visual recovery of early PRK could be avoided. At around the same time, newer and better lasers were introduced, with advanced features like iris registration, multi-directional eye trackers, faster and better ablation profiles with narrow flying spot laser beam and wavefront measuring machines that allow customised eye treatments. And so, LASIK (also known as the suck, cut, flap and zap method of laser vision correction) was born and it quickly grew in popularity to become the household word it is today.

SUCK & CUT

FLAP

ZAP

11 | THE ADVENT OF LASIK

1. Numbing eye drops is administered to the eye. A suction ring clamp is applied to the eyeball and a corneal ﬂap is then cut using either a microkeratome blade or femtosecond laser.

2. The cut corneal ﬂap is lifted up in preparation for the reshaping of the corneal stroma tissue.

3. The excimer laser is used to sculpt a new cornea curvature to correct the vision. When the treatment is completed, the ﬂap is repositioned. It’s held in place by only a tissue pressure.

Understanding the Pitfalls of LASIK While LASIK is perhaps still recognized today as the de-facto standard for laser vision correction, other modern laser vision correction methods are available today and starting to gain traction over LASIK. This is because eye doctors are becoming increasingly uneasy with the medical complications associated with the “suck, cut, ﬂap and zap” LASIK.

Clamp

Loss of suction is a serious complication that is more commonly seen with the smaller and shallower eye sockets of Asians. It is also not uncommon to abort cases because the suction ring cannot get a good suction.

A poorly cut flap, flap wrinkles or dislodgement can lead to a loss of best corrected vision. The incidence of flap complications is conservatively estimated at 1 to 2%.

Flap and ﬂap interface complications can occur months to years after LASIK surgery. These include the “Sands of Sahara” and “Recurrent Epithelial Ingrowth” syndromes.

Other medical complications of LASIK include prolonged to permanent dry eyes due to cornea nerve ending being cut and Keratectasia (cornea protrusion) problems due to excessive cornea thinning from the cut corneal ﬂap and corneal stroma tissue ablation.

UNDERSTANDING THE PITFALLS OF LASIK |

MODERN LASER VISION CORRECTION THE PROGRESS OF ADVANCED SURFACE ABLATION (ASA) Laser vision correction did not ﬁrst begin with LASIK but began as a surface-based procedure known as PRK (Photorefractive Keratectomy) back in 1992. Since then, the surface-based procedure has evolved and improved though the years as a result of doctors searching for ways to minimize or avoid the pitfalls of LASIK.

Today, laser vision procedures that are surface-based are collectively grouped and given the scientiﬁc name of Advanced Surface Ablation (ASA). 5 . Here is a road map showing the progress of Advanced Surface Ablation (ASA):

LASEK

Advanced PRK START

Early PRK

EARLY PRK was first done in 1992. However, it did not take off as the excimer laser used back then was first generation lasers that tend to overheat the cornea surface. Also, bandage contact lens and the current eye drops to prevent eye pain, swelling and scarring were not available then.

13 |

MODERN LASER VISION CORRECTION

ADVANCED PRK was a major upgrade from early PRK with the use of the more advanced generation excimer lasers, equipped with active eye tracking and sophisticated laser ablation proﬁles. NSAID pain-killing eye drops, anti-scarring MMC (Mitomycin-C) medications and high oxygen permeability bandage contact lenses are additional improvements.

6 TransPRK is now the frontier of Advanced Surface Ablation (ASA) techniques. It is an ideal surface-based procedure as only a single laser removes the epithelium cells and then goes on to reshape the cornea tissue stroma to correct refractive error in one seamless and eďŹ&#x192;cient step.

TransPRK

epiLASIK

Suction Ring Epithelium Separator

LASEK was done by applying a LASEK ring and 20% alcohol solution onto the cornea surface for 20 seconds to remove the surface epithelium cells. Excimer laser ablation is then carried out and bandage lens placed over to promote healing. The results are outstanding and LASEK is still widely used by eye doctors around the world today.

EPILASIK was another improvement, enabling the removal of epithelium cells by a high-speed vibrating epithelium separator unlike LASIK. It is a true surfacebased procedure as there is no cut made into the cornea stromal tissue. In 2004, Dr Tony Ho did the ďŹ rst epiLASIK surgery in Singapore and has since then been a leading advocate of Advanced Surface Ablation (ASA) laser vision correction techniques.

MODERN LASER VISION CORRECTION |

TransPRK - The Modern “Surface” It All Began At The Surface! Laser vision correction first began as a surface-based early PRK procedure in 1992. But early PRK was not well received as the excimer laser used then was the first generation model that was not so technically advanced. Furthermore, there were no eye drops to prevent pain, eyelid swelling and cornea scarring. High oxygen permeability contact lenses to protect the treated cornea surface and promote healing were also not available back then. In the mid-1990s, LASIK became popularised due to its relatively painless and fast vision recovery. However, LASIK also brought about problems such as cornea cut flap related complications, cornea thinning issues and LASIK-induced dry eyes that is oftentimes prolonged and sometimes permanent.

Advanced Surface Ablation ( ASA ) Back to Where It All Began With advancements in laser technology and medications today, laser vision correction (LVC) has come full circle to where it all began! Eye doctors around the world are increasingly moving towards and/or incorporating Advanced Surface Ablation (ASA) techniques such as Advanced PRK, LASEK, epiLASIK and TransPRK in their surgical armamentarium. Even surgeons who are proponents of flap-based LVC will find occasions and need to resort to ASA techniques where there is fear of keratectasia due to thin corneas, fear of flap-induced dry eye, fear of traumatic flap dislodgment for those involved in contact or rugged sports and those patients who are simply afraid to have their eyes cut ! It is also interesting to note that when enhancement surgery is needed in ReLEX SMILE, ASA techniques are used.

15 | TRANSPRK - THE MODERN “SURFACE” LASER VISION CORRECTION

Laser Vision Correction

The Frontier Of Laser Vision Correction permeability contact lenses to protect the treated cornea surface

After more than 25 years of progress and evolution, we are ﬁnally approaching tthe frontier Surface Ablation (ASA) laser about problems of suchAdvanced as cornea cut flap related complications, vision correction techniques with the all-laser, one-step, no-touch TransPRK! began! Eye doctors around the world are SIK and TransPRK in techniques those involved at when

TRANSPRK - THE MODERN “SURFACE” LASER VISION CORRECTION |

TRANSPRK How TransPRK Is Done? TransPRK is a revolutionary laser vision correction that is safe and minimally-invasive as it is surface-based. Here's a simple step-by-step explanation of how TransPRK procedure is done:

Epithelium cells Patient lies down and simply looks ahead at a blinking ďŹ xation green light. No suction ring nor surgical instrument touches the eye.

Epithelium cells are removed Epithelium cells are removed with the Schwind Amaris 1050RS laser.

17 | TRANSPRK- HOW TRANSPRK IS DONE?

TREATED ZONE

Laser goes on to reshape the cornea curvature to correct the refractive power in one step seamlessly.

Bandage Contact Lens

Epithelium cells healed

A transparent, high-oxygen permeability content soft contact lens is then placed over the cornea to act as an artiďŹ cial cornea ďŹ&#x201A;ap to protect the treated surface while the epithelium cells regenerate.

Bandage contact lens still on

Epithelium cells healed

The epithelium cells then take 3 to 5 days to regenerate and heal. It is important to use the eye drops medications prescribed and stay away from strong sunlight for good healing. The high-oxygen permeability contact lens is removed after 5 days.

TRANSPRK- HOW TRANSPRK IS DONE? |

About The AMARIS SCHWIND

ABOUT THE

The Schwind Amaris laser is an excimer laser specially developed to perform TransPRK in a safe, fast and eﬃcient manner.

Schwind Amaris 1050RS It is equipped with the SmartSurfACE system, which leaves patients with greater corneal smoothness and more rapid recovery of visual acuity with minimum wastage of corneal tissue. Combined with its ability to perform a seamless, one-step, “no-touch” TransPRK treatment, this innovative excimer laser technology is the frontier of modern surface laser vision correction.

19 | ABOUT THE SCHWIND AMARIS TRANSPRK LASER

TransPRK Laser TransPRK Laser The Schwind Amaris 1050RS is the top-end model in its range. It has the following outstanding features: • One-step laser vision correction, performed using a single laser • "No Eyeball Touch" technology • Iris registration for accurate astigmatism treatment • Zero latency eye tracking • Actively tracks the eye in all 7-dimensions of gaze, including eye rotation • Unsurpassed speed (ablation time) that can treat every 100 degrees of myopia in only 1.3 seconds. This enables actual laser treatment time to be completed in 10 to 50 seconds per eye (depending on eye power to be corrected) Vertical Displacement 2nd Dimension

Vertical Rolling 4th Dimension

Axial Displacement 6th Dimension

Horizontal Rolling 3rd Dimension

Horizontal Displacement 1st Dimension

Cyclotorsion 1st Dimension

Time: 7th Dimension

7-Dimensional Eye Tracking Technology in Schwind Amaris 1050RS TransPRK Excimer Laser

ABOUT THE SCHWIND AMARIS TRANSPRK LASER |

MODERN LASER VISION CORRECTION

No Cut, No Flap (Thus No Fear Of Cutting The Cornea) & Eliminates Risk Of Flap Dislodgement The most feared and common complication of flap-based surgeries, such as LASIK & ReLEx SMILE, are flap-related problems, such as flap dislodgement, flap wrinkles and flap misalignment, as well as flap interface problems, such as the Sands of Sahara (where there is an inflammation between the corneal flap and stroma) and epithelial ingrowth (where epithelial cells invade the space between the corneal flap and stroma). Even though the risk of flap-related problems are touted as low, they are a real and present fear. As TransPRK is fully surface-based and does not cut a cornea flap, there is ZERO RISK of flap-related complications.

Due to the absence of a cut flap, TransPRK completely eliminates flap and flap interface related problems that can be present with LASIK & ReLEx SMILE.

True Surface-Based Procedure (Hence Minimally-Invasive & Less Weakening Of The Cornea) As TransPRK is surface-based and minimally-invasive, there is relatively less cornea weakening as the resulting cornea bed will be thicker. Cornea strength is better preserved, as compared to LASIK, which wastes cornea tissue to create a ﬂap. Thus, the feared medical complications of keratectasia (a condition of progressive thinning of the cornea with time) is better kept at bay.

In TransPRK, about 55 um of surface epithelial cells are removed by the laser followed by cornea stroma tissue sculpting to correct the eye power. These surface epithelial cells will grow back fully after 5 days.

21 | 10 ADVANTAGES OF TRANSPRK

In LASIK, a cornea flap is first cut. This flap can be anywhere from 110 to 160 µm thick i.e. up to 30% of the cornea thickness. Cornea stroma tissue sculpting then takes place. Once cut, the cornea flap never fully heals.

Advantages of TransPRK

All-Laser, No-Touch TransPRK is an all-laser procedure performed using a single excimer laser (Schwind Amaris 1050RS). There are no surgical devices applied onto the eyeball, unlike the suction ring clamps used in LASIK & ReLEx SMILE. Thus, there is no fear of a major surgical complication from loss of suction ring clamp pressure.

One-Step Procedure – Simple & Fast TransPRK requires the shortest treatment time among the diﬀerent laser vision correction procedure, requiring only about 3 to 5 minutes per eye from start to ﬁnish. The actual laser sculpting time is from 10 to 50 seconds per eye only, depending on the eye power to be corrected. This greatly enhances the patients' comfort and reduces the fear of the procedure.

TransPRK

Actual laser sculpting time: 10 to 50 secs per eye Total procedure time: 3 to 5 mins per eye

10 ADVANTAGES OF TRANSPRK |

MODERN LASER VISION CORRECTION

Allow True Customised & Wavefront Correction Advancements in Laser Vision Correction (LVC) now allow customized correction of wavefront and topographical refractive errors. Advanced Surface Ablation (ASA) procedures such as TransPRK can perform true corrections, unlike LASIK where new wavefront and topographical errors are introduced from the cut cornea ďŹ&#x201A;ap. ReLEx SMILE is unable to perform customized wavefront or topographical corrections. Orbscan & Sirius are two high-tech instruments used by eye doctors to measure wavefront errors and map out the topographical features of the cornea.

Reduced Risk Of Permanent Dry Eyes

Cornea ďŹ&#x201A;ap based surgery, in particular LASIK, is associated with dry eye that can be prolonged and permanent in some cases. As no cutting of cornea nerve endings take place in TransPRK, there will be reduced complaint of dry eyes.

23 | 10 ADVANTAGES OF TRANSPRK

Advantages of

TransPRK

Suitable for More Eyes

Suitable For The Active Sports Person Or Military Personnels

There is hope yet for those who have been rejected from LASIK or ReLEx SMILE because of dry eye, high myopia and/or thin cornea problems! As laser sculpting begins right at the surface in TransPRK, candidates who have been previously rejected can now have hope.

With TransPRK, there is no longer the need to fear dislodgement injury when participating in active sports or military duties because there is no cut cornea ďŹ&#x201A;ap to worry about. Go about your rugged sports, be it rugby or boxing with absolute freedom!

9 Prepare For The Future With TransPRK, less cornea tissue is wasted because there is no cut ďŹ&#x201A;ap. The precious cornea tissue saved can useful to allow for future procedures, e.g. secondary enhancements and presbyopia correction as our eyes age.

Longest Track Record (Since 1992) Advanced Surface Ablation (ASA) has come a long way since the days of early PRK in 1992. TransPRK is the surface laser vision correction for the new generation. With advances in laser technology, intra-operative and post-op care medications and avoidance of sunlight exposure in the early post-operative care period; excellent results are now achievable with ASA. 10 ADVANTAGES OF TRANSPRK |

Case Studies of ANDREA CHONG • Model and blogger

Getting epiLASIK done is probably one of the best decisions I've ever made. I am able to have the amazing feeling of waking up seeing my room in clear vision, and I don't have to worry about my dry eyes aﬀecting my vision and mood when I wear contact lenses. I can travel with so much ease - that is so important - I no longer need to pack or worry about forgetting to pack my contact lenses/contact lens solution/contact lens casing/glasses… My life is so much more convenient after epiLASIK! I've been wearing spectacles since I was 7, and my myopia kept worsening till I was about 17 or 18, where I reached an all-time high of 900 degrees on my right eye, and 800 degrees on my left. My degree has been stabilised since I was 18, and I've been wanting to go for epiLASIK surgery since. Having myopia and wearing spectacles has really been one of the annoying banes of my life.

25 | CASE STUDIES OF ADVANCED SURFACE ABLATION (ASA)

Advanced Surface Ablation (ASA)

THERESA GOH • Paralympic Swimmer I train full time - 8 times a week in the pool, and 3 times a week in the gym. My epi-LASIK op was much easier a procedure than I'd thought i would be. I think I stressed over the procedure too much and was worried about being able to keep calm during the whole process but it was done extremely quickly and I felt no pain at all! It's made me more conﬁdent and one thing I'm really pleased about is being able to wear sunglasses or shades without any degree! I would deﬁnitely recommend epi-LASIK to others and I already have! It's over before you know it and it's the best purchase I've made in my life!

JIMMY SIAH • Player, Singapore International, Hockey Association

Ice Hockey is my hobby. Before having my epiLASIK done, I used to have to rely on contact lens when playing. However, whenever I was in the ring, because of the cold temperature, I would always feel that my eyes were very dry and I always found it very uncomfortable. I’d be blinking a lot to moisten my eyes or apply eye drops as much as possible. Contacts were really very inconvenient for me when playing ice hockey. Now that I’ve done epiLASIK, playing ice hockey is a breeze! My performance is no longer inhibited!

CASE STUDIES OF ADVANCED SURFACE ABLATION (ASA) |

Case Studies of JEMMA WEI • Blogger In the three months after opting for perfect vision, I’ve not had to grasp around blindly upon waking up for my glasses, or stumble out of the toilet post-shower looking for them with blurred vision. I’ve not faced the choice of battling laziness (should I get up and hunt for my glasses?) and strain (or should I just squint at my laptop, try to get by reading emails without them?). I’ve not experienced the panic you get when you reach for the contact lens solution bottle at the end of the day only to realise that you’re out. For the ﬁrst time I could sit at length with a glass of wine in hand, chatting about life and shared experiences without worrying about my eyes getting red from strain or having to blink, hard, to stop the contact lenses in my eye from drying up and dislodging. It is a new life, and I can’t believe Ive gone so long without experiencing this. The burden of rented vision is gone. It’s been a short three months, but it feels like forever in the best way possible. My vision now is even better than when I’d worn contact lenses or glasses, I’d say, and I can’t imagine having lived any other way before this. Extract taken from Jemma's blog (www.jemmawei.com)

27 | CASE STUDIES OF ADVANCED SURFACE ABLATION (ASA)

Advanced Surface Ablation (ASA)

MITCH "THE DRAGON” CHILSON ONE FC Featherweight Competitor My vision has always been a concern when fighting or competing professionally in mixed martial arts (MMA). Before using contact lenses, I trained with blurred vision. Sight is the most important sense a fighter must reply on and in some ways I have only been competing at 50% due to my poor vision. I thought I found the answer when I began wearing contacts, but the biggest problem is that even the slightest brush to the eye or face could make the contacts move out of place or worse, drop out. Now most of the MMA organisations have banned contact lenses during fights and conduct stringent vision tests for the safety of the athletes. I decided it was time to look into my LASIK options and I started doing my research and learnt that LASIK is not safe for contact sports. With epiLASIK, I can continue to fight! I found the procedure quick and painless, and fast recovery time. I am looking forward to see and fight through my new eyes!

SOPHIE WILLOCQ • Blogger Myopia has been a pretty big part of my life as I've had to wear glasses since I was about 8 years old! If you don't have a high degree like I do, you don't get how it's like to have a person stand in front of you & not be able to make out who it is… It's that bad! I have worn contact lens on a daily basis since I was 15 years old & anytime I'm not wearing them, I'm in my spectacles. I put them on as soon as I wake up & take them off only right before I sleep. I even wear them into the shower & only take them off when I need to get my face wet! You can say… I'm pretty handicapped due to my low vision. Let's face it, real prescription spectacles generally aren't always that flattering. Especially for girls! I find some guys look pretty good/even better with glasses, but most girls want to be vain & wear contact lens (myself included), which can be tiring + costly. Let me reinforce it again… I DON'T NEED GLASSES ANYMORE! I HAVE PERFECT VISION! *jumps for joy* Extract taken from Sophie’s Blog (www.sophiewillocq.com) CASE STUDIES OF ADVANCED SURFACE ABLATION (ASA) |

Case Studies of BERTILLA WONG Blogger & Co-Founder (The Closet Lover)

I have worn contact lenses since I was primary 6. As a former ballet dancer and sports player, spectacles were extremely inconvenient for me. Can you imagine dancing with spectacles on? One jump and my spectacles will fall off. While playing sports, sweat will also cause my spectacles to slide off and hence contact lenses was a more viable option It was all fine until probably about 3 years ago during a Korea trip, I had difficulties removing the contact lens in my left eye. It was so, so painful like a sharp pain and I used to have such cases before and all I needed was to hydrate the eyes before taking it out. However, I couldn't remove it at all even though I dripped eye drops. To be honest, I was terribly scared that the lens could not be removed. Luckily, after numerous attempts I removed it! I think I tried for like 1 hour. That wasn't the end though as it left me with a sore, red and teary eye over the next few days. I visited a doctor immediately after returning to Singapore and was diagnosed with dry eyes. My cornea wasn't damaged and I was so afraid that it might have been because I had to keep squeezing my eyes to take the lenses out. Even though the doctor said that I could attempt to wear lenses again if my eyes were not dry anymore, I decided it wasn't worth the risk! Eyes are the windows to the world and I wasn't going to ruin that. The standard lasik treatment requires the cornea to be cut, the laser to reshape your cornea and a cornea flap will be put in place. It sounds pretty scary to me when I read that the older treatments required a blade to cut your cornea. It also causes dry eyes which was a big no no for me since I already had dry eyes. This is why I decided to go with Trans-PRK treatment! Extract taken from Bertilla’s blog (www.dayre.me/bertillawong)

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Advanced Surface Ablation (ASA) STEPHANIE WONG - Blogger, TheSmartLocal

Imagine waking up with perfectly clear vision, anywhere in the world and at any time of the day! No more fussing to remember to take out your contact lenses when you get home on late nights, carry spare contact lens cases, or buy travel-friendly bottles of eye solution when ﬂying abroad. I calculated the cost spent on constantly purchasing or changing your glasses and contact lenses, and it easily added up to thousands of dollars in a few years. No wonder everyone claims lasik (SafeSight TransPRK) to be one of their best decisions ever!

Extract taken from Stephanie’s blog (www.heytheredreamerblog.com)

CHRISTABEL CHUA – Blogger

This was the BEST decision, ever! Having perfect vision is beyond amazing, this has changed my life :’) Extract taken from Christabel’s YouTube channel (Bellywellyjelly)

CASE STUDIES OF ADVANCED SURFACE ABLATION (ASA) |

Case Studies of SOPHIA CHONG – Blogger LIFE IS SO MUCH EASIER AFTER TRANS EPI-LASIK! And I mean MUCH easier. Aside from my double eyelid surgery, this has to be the other best decision I’ve made in my life. I DO NOT miss my spectacle/contact lens life at all! Gone are the days of removing lenses before sleeping, wearing goggles to swim etc! As an avid traveller, having my eyesight corrected means convenience for me. No more dry eyes in the plane, packing tons of daily contact lenses for long trips (not forgetting solution, saline, contacts case and glasses). All I need now is a pair of sunnies. I can swim and see clearly underwater for the ﬁrst time. I love waking up to clear vision, not stumbling my way to the toilet in the middle of the night. I cannot imagine being myopic again and I’m baﬄed at myself for not undergoing Trans epi-Lasik earlier. How did I even get through 17 years of my life being a blind bat hahah. Extract taken from Sophia’s blog (www.sophiachong.com)

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Advanced Surface Ablation (ASA) AGGY LOW - Blogger For those that follows my IG stories, you would know that I run on a very frequent basis and yes I do wear my contact lenses while running because it is such a hassle to jog with specs on (joggers would understand!) One thing about this is that when I perspire, sometimes the droplets of sweat goes into my eyes which can sting and irritate them a little during my jog. At this moment I really wished that I have my eyesight corrected so I won't have to go through this. And of course, the hassle of having to take care of your spectacles/contact lenses which can be such a bother when you are really tired after a long day and just want to lie down on your bed & shut your eyes… Not to mention every single time when I travel (and I want to look chio but not blind before taking off in the plane), I tend to wear my contacts on to be always camera-ready but obviously my contact lenses are not very flight-friendly. My eyes can become so terribly dry and irritated and I have to always make sure I remember to pack a small bottle of contact lens solution/case to bring up together with me for my flight. #SUCHAHASSLE So these basically drove me to the point whereby I felt that I NEEDED to correct my eyesight/vision. I wanted to be able to be free from the responsibility of caring for my specs/contact lenses & worryfree when I travel/exercise! Special thanks to Dr Tony Ho for helping me fulfill this little wish of mine! Extract taken from Aggy’s Instagram page (www.instagram.com/aggylow)

CASE STUDIES OF ADVANCED SURFACE ABLATION (ASA) |

Case Studies of VANESSA TAN • Blogger

I’ve been wearing different brands of contact lenses since I started modelling. The one thing in common is they’re all colored contact lenses as they’ve always made my eyes look a little rounder and bigger, especially in photos. ? True, they were not exactly unhealthy for eyes, but I didn’t have much choice, For obvious reasons (due to the natural of my job), I can’t wear glasses and since I had a degree is almost 700, and without lenses (or glasses, for that matter), I was effectively blind. For me, I’ve a very serious case of corneal ulcer recently that left me with a scar on one of my eyeballs – and also the fact that I couldn’t wear contact lenses anymore… Behold, my new journey into LASIK! In my mind, I figured that I needed an eye surgeon whom is not only good in this, but also with a solid amount specialty experience. I didn’t want to go ahead with LASIK with uncertainties… Not only Dr. Tony has YEARSSS of experience, but he was also the FIRST specialist that did the bladeless, flapless LASIK in Singapore – the epiLASIK. My LASIK surgery was scheduled the very next morning after my pre-LASIK evaluation! I opted for the Trans-epiLASIK under Dr. Tony Ho from Clearvision. The reason why I wanted to do it as soon as possible was due to the fact I’m no longer suitable for contact lenses. My Trans-Epi LASIK yesterday at @ClearVisionSG was a breeze. Less than 10mins in total?! Throughout the surgery, Dr. Tony was super reassuring! The most and only scary part throughout was… … Waiting for the surgery to start! Extract taken from Vanessa’s Blog (www.yingvannie.com)

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Advanced Surface Ablation (ASA)

MELISSA LEE • Avid Traveller

LASIK was always something I'd considered doing, since it would ﬁnally mean liberation from contact lenses, spectacles and the hassle of packing additional items (contact lens solution, contacts casing, etc) during my holidays. I adore traveling and seeing new places, meeting new people and trying out new experiences, but my short-sightedness was so burdensome. When I went diving in Malaysia, I couldn't view the underwater world as clearly as I wished I could, what a pity! It was so inconvenient to have to wear contact lenses, but wearing spectacles sometimes wouldn't be an option either when playing sports or water activities. I decided to choose epiLASIK as I found out it was less invasive than traditional LASIK as it is surface-based, without cutting the cornea. It was also important to me that the structure of my cornea remained intact for future procedures on my eyes, if need be. *kiasu*. I also heard of dry eyes horror stories from people who did LASIK instead of epi-LASIK. My epiLASIK surgery was quick and completely painless, I would recommend everyone to do epiLASIK and enjoy the same freedom I have today!

ANG JOO KIAK • Motorbike Enthusiast

I wanted to do epiLASIK because wearing spectacles while motorbiking was inconvenient in many ways. Firstly, because of perspiration, the specs would slide down my nose all the time, giving me less than full coverage of the pit lane. Secondly, I have high astigmatism so I’m limited to daylight conditions. Biking in the later part of the day when the sun sets means poor vision for me. My high astigmatism makes it hard for me to get suitable disposable contact lens.

CASE STUDIES OF ADVANCED SURFACE ABLATION (ASA) |

FREQUENTLY ASKED

GENERAL QUESTIONS Q1: Which procedure is best for me? Today, technological advancements have brought about 3 main laser vision correction options - TransPRK, LASIK, ReLEx SMILE. Whilst each technique has its own pros and cons, Dr Ho’s preferred choice would overwhelmingly be TransPRK, the advanced, safe, surface-based method of laser vision correction. Learn more about 10 deﬁnite advantages you can reap from TransPRK on Pg 21 to 24. You may also refer to the Comparative Summary Table (Page 53 to 60) for more information.

Q2: How do I pick a good surgeon? An experienced, capable surgeon is of paramount importance to a successful surgery. A veteran eye surgeon can perform the surgery within a shorter time, ensuring greater comfort and more accurate results. The likelihood of complications will also be better kept in check. You can begin by searching the internet for an eye surgeon who has an established track record and proﬁciency in your procedure of choice. Cross check your ﬁndings with friends or relatives who have undergone the procedure as well as blog posts by those who have had the procedure done. The surgeon’s years of experience and track record of the clinic he practices in are further important points to consider.

Q3: What vision problems can laser vision correction treat? Laser vision correction can be used to correct myopia (short-sightedness), hyperopia (far-sightedness), astigmatism and presbyopia (middle-aged onset far sightedness).

SUITABILITY FOR TRANSPRK PROCEDURE Q4: What is the minimum and maximum age suitable for TransPRK? You must be at least 18 years old to undergo TransPRK, and have a stable degree for at least for the past three years. Parental consent is needed for patients who are 21 years old and below. There is no maximum age limit, but those over 60 years of age may have underlying eye medical problems, for example cataract, and should undergo a medical eye examination ﬁrst.

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QUESTIONS (FAQ) Q5: Can I go for laser vision correction if I am pregnant or breastfeeding? Women who are pregnant or breastfeeding are not advised to go for the procedure because the eye prescription may be aďŹ&#x20AC;ected due to hormonal changes. Medicated eye drops that are prescribed (e.g. antibiotics and steroids) may aďŹ&#x20AC;ect the foetus or infant even if it is in microscopic quantity.

Q6: I am interested to go for TransPRK. How do I know if I am a suitable candidate? You will need to make an appointment for a Laser Vision Correction (LVC) evaluation to determine if you are a suitable candidate for the procedure. The LVC evaluation would consist of detailed tests & eye measurements followed by a medical eye examination & consultation with the eye surgeon himself. Some factors that will determine your suitability include your cornea thickness, cornea curvature, keratectasia risk, total refractive power, and any existing eye conditions such as glaucoma, cataracts,etc.

Q7: Must I stop contact lens wear before the surgery? Yes, you should stop contact lens wear for both the evaluation and surgery. For soft contact lens wearer, you should stop for at least 3 days (or at least 10 full days for hard contact lens wearer). This is to minimize the risk of infection and to ensure that your cornea shape returns to its natural shape.

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Q8: Must I stop contact lens wear before the surgery? As your eyes would be dilated during the LVC evaluation, thus it is not advisable to have both the evaluation and the procedure on the same day. Instead, the earliest date you can have the surgery is the very next day after the evaluation day. If you delay the procedure for more than 6 months after the evaluation, most centres would require you to repeat the tests.

Q9: What is Corneal Cross-Linking (CXL)?

Avedro KXL for Collagen Cross-linking

Corneal Cross-Linking (CXL) is a safe, non-invasive, low-risk cornea strengthening treatment that may be recommended to be incorporated into your TransPRK/ LASIK procedure. Unfortunately, it cannot be incorporated into the ReLEx SMILE or ICL procedure. CXL provides additional safety for patients with thin cornea, high myopia and astigmatism to prevent a corneal medical condition known as keratectasia. CXL is a simple two-minute procedure that involves 2 steps: 1. Riboflavin (Vitamin B2)* eye drops are applied to the cornea and left to soak into the cornea for 1 minute. 2. The riboflavin-soaked cornea is illuminated with ultra-violet A (UVA) light Riboflavin (Vitamin B2) eye drops for 1 minute using advanced technology of the Avedro KXL® System, and this treatment cross-links the collagen fibers within the cornea, thus strengthening the cornea.

Q10: Will I need Corneal Cross-Linking (CXL)? All laser vision correction procedures will result in the cornea being thinner. If the cornea becomes too thin, it might be pre-disposed to a cornea medical condition called keratectasia, in which the cornea progressively become thinner. This will in turn lead to blur and unstable vision. Hence, CXL is indicated for patients whose cornea would be signiﬁcantly thinned out as a result of treatment for high myopia or astigmatism, or who have thin cornea to begin with. Your eye doctor is the best person to advise if you will need CXL or not.

Q11: What are the things that I would need to take note on the surgery date? Do not wear any makeup, aftershave, perfume and deodorants on your surgery day, as the odours and vapours will aﬀect the accuracy of the laser machine. General hygiene is very important as infection is a feared complication of any surgery. Have a good bath before coming down for the procedure, including a good hair wash. There is no need to fast, but avoid having a heavy meal. The laser treatment room might be cold, so you may want to dress warmly, but not in tight-ﬁtting clothes. You can see reasonably well after the procedure, but it is still not advisable to drive.

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THE TRANSPRK PROCEDURE Q12: Is the procedure painful? No. Anaesthetic numbing eye drops are administered just before the procedure, so you would not feel any pain. After the anaesthesia wears oďŹ&#x20AC;, you might feel a slight discomfort. Your eyes might feel scratchy and watery. However, this is only a temporary symptom and does not pose a problem for most patients.

Q13: What happens during the TransPRK procedure? You will be awake and numbing eye drops will be instilled into your eyes. A device will be placed to help keep your eyelids open. Rest assured that with TransPRK, there will be no surgical instruments that will be placed on your eyeball. All you need to do is simply to ďŹ x your gaze at the blinking green light. Try to keep both eyes open and do not be afraid. Try not to squeeze your eyes hard as that will cause the eyes to roll. The actual treatment time is usually short (around 10 to 50 seconds). You will hear some clicking and whirring noise, and you may detect a faint burnt smell. Before you know it, the treatment is over!

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Q14: Should I do both eyes together or one eye at a time? When laser vision correction ﬁrst started, the industry standard was to do one eye at a time. However with advances in technology, it is a common practice now to have both eyes done at the same time. Today, over 98% of patients will opt to do the surgery on both eyes at the same time for convenience in terms of taking medical leave and not having to go through the discomfort of the recovery process twice. If patients opt to do one eye at a time, they should be aware that they will experience the discomfort and disruption of having imbalance vision during the interim period between the ﬁrst and the second eye.

Q15: How long would the TransPRK procedure take? For TransPRK, the total surgery time would only take about 3 to 5 minutes for each eyes. However, the actual laser treatment time is about 10 to 50 seconds per eye.

POSSIBLE RISKS AND COMPLICATIONS Q16: What are the risk and complications of TransPRK? Rest assured that the TransPRK procedure is safe and problem-free in the vast majority of cases. Unlike LASIK & ReLEx SMILE procedures, there is ZERO risk of flap-related complications that is the most frequent cause of serious complications in laser vision correction. The most feared complication common to all the various laser vision correction techniques is infection. The risk of a serious infection as stated in most medical textbooks is 1 in 5000 eyes. But with modern safety standards, the real on the ground experience is significantly less. The next feared complication for TransPRK is corneal haze. Fortunately, this is unlikely to occur if the patient adheres strictly to the prescribed eyedrop regime, and wear sunglasses when outdoors in the sun, especially within the first month after the TransPRK procedure. Other complications such as glare, halos and star-bursts complaints are now much less common with today’s advanced lasers and techniques. Scientific research have proven that these complaints are more common in patients who already have such complaints before undergoing the treatment and also in patients who undergo high power corrections. You may refer to Pg 53 to 60 for detailed comparison of the risks & complications related to the different modern vision correction methods.

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Q17: Can I go blind? In theory, yes, but in practical reality, the chance of going blind from laser vision correction is very unlikely. For TransPRK procedure, we are most concerned with complications from infection and haze due to exposure to uv rays. If the patient adhere to the eyedrops regime that is prescribed, keep good eye hygiene and stay away from excessive sunlight especially during the ﬁrst month, the risk of complications that can lead to blindness is very unlikely.

Q18: What are the things that I would need to take note of after the surgery? For TransPRK procedure, you should refrain from rubbing or squeezing your eyes after the surgery so that the protection bandage contact lens does not become dislodged. For the ﬁrst 5 days, it is not advisable to apply eye make-up and facial lotions close to your eyes. During this period, you also have to take care not to splash water into your eyes when washing your face or during baths. It is important to wear your sunglasses and a cap when you are outdoors for the ﬁrst month to reduce uv exposure to the eyes.

Q19: How many days of medical leave will I be given? For TransPRK, your operation day is considered as Day 1. Your post-operative consultations will be scheduled on Day 3, Day 6 and Week 3. Follow-up consultations after the ﬁrst month will be further advised by the doctor depending on your recovery. Most patients are usually discharged after the third or fourth month.

Q20: When would I need to come back for my follow-up consultations? For TransPRK, your operation day is considered as Day 1. Your post-operative consultations will be scheduled on Day 3, Day 6 and Week 3. Follow-up consultations after the ﬁrst month will be further advised by the doctor depending on your recovery. Most patients are usually discharged after the third or fourth month.

Q21: How soon after the surgery will I be able to see clearly? Your vision will be fairly clear immediately after the procedure, however, it is not advisable to drive for the ﬁrst week. Although the use of handphones and computers are not harmful to the eyes, you may experience some diﬃculty with near-vision work. Some bluriness in vision may be experienced on Day 3 to 5 when the surface healing is nearing completion. Most patients see well enough to return to work on Day 6. Generally, most patients are discharged after the third or fourth month. However, patients with high power treatment may require longer period of post-operative reviews.

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Q22: : How long do I need to wait before I can resume sport activities? After your TransPRK procedure, you can resume light sports activities (e.g. jogging, gym exercises, cycling, etc) after 5 days. However, if you participate in strenuous/ rugged/ contact sports (e.g. rugby, MMA, etc), as well as water sports (e.g. swimming, water polo, diving, etc), you can resume after 2 weeks. However, especially for the ﬁrst month of the recovery period, you should remember to avoid exposure to the sun’s ultraviolet rays. Hence, engage in outdoor sports only before 8 am and after 630 pm.

MISCELLANEOUS QUESTIONS Q23: Can TransPRK be used to correct presbyopia (middle-aged onset far-sightedness)? Yes, TransPRK can be also be used to correct Presbyopia, also more commonly known as middle-aged Farsightedness or “Lao Hua“ in Chinese. The most common strategy is called “Mono-Vision treatment“, but I would personally prefer the term of “Blended Vision treatment“. With this strategy, the dominant eye (yes, we all have a dominant eye same as we all have a dominant hand and dominant leg) will be corrected to see clearly for the distance, and the other eye (your non-dominant eye) corrected to see better for near vision. If the diﬀerence in the refractive power between the two eyes are kept at 1.50 Dioptres and below, the phenomenon of “Blended Vision“ occurs where for distance vision, the dominant eye helps the non-dominant other eye to see well for far also, and for near, the non-dominant eye helps the dominant eye to see better for near. Thus, rest assured that it is thus not a case of having only one eye see for far and one eye see well for far also, and for near, the non-dominant eye helps the dominant eye to see better for near. Thus, rest assured that it is thus not a case of having only one eye see for far and one eye see for near as the term Mono-vision Treatment suggests. Presbyopia Treatment Process: 1. The TransPRK Evaluation - Similar to the general TransPRK evaluation, but you will have to undergo additional tests to assess the severity of your presbyopia condition, binocularity and dominant eye preference. 2. The Trial Lens Test - Think of this as a “try before you buy” trial to allow you to experience and adapt to the corrected vision. Your eye surgeon will provide you with trial extended wear contact lens that do not need to be taken out daily to wash. You will be asked to wear the lenses for about a week. 3. The Laser Treatment - This will proceed only if you are found to be a suitable candidate after the Trial Lens Test and you fully understand the pros and cons of the “Blended Vision Treatment”. Note that presbyopia is not a static eye condition, but a progressively worsening dynamic condition related to the aging process of the human body. It is caused by progressive weakening of the eye’s focusing muscles and loss of the human crystalline lens elasticity. As such, there is no treatment in the world that can directly treat or cure the condition. We can oﬀer at best a compromised solution to the presbyopia problem with “Blended Vision Treatment” and as such, the happiest candidates for presbyopia treatment are those with realistic expectations.

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Q24: What if I am not suitable for TransPRK? If you have very high myopia of more than 11.00 Dioptres (1,100 degrees) and/or astigmatism of over 3.00 Dioptres (300 degrees), you may not be suitable for TransPRK because there will be too much sacriﬁce of cornea tissue needed to correct your power. If you have unusually thin cornea or central cornea scarring, you may also not be suitable. Less commonly, those who suﬀer from severe dry eyes or certain auto-immune disorders on immunosuppressant medications may also not be suitable. For these cases, Implantable Collamer Lenses (ICL), where a crystalline lens is inserted in between the iris and in front of the natural lens, can be considered. Your eye doctor is the best person to advise on this. For more details on ICL, please refer to the Comparative Summary Table on Pg 53 to 60.

Q25: Will going for laser vision correction make future eye surgery such as cataract surgery more diﬃcult? No, as the entry wound for cataract surgery is at a diﬀerent part of the eye. It will also not bring on earlier development of cataract. But your eye surgeon will need to factor in your new cornea curvature shape measurement when he does the calculation and selection of the intra-ocular lens implant for the cataract surgery.

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Q26: How long will the eﬀect of TransPRK last? Following TransPRK, your cornea is re-shaped to put your spectacles lens refractive power onto the cornea curvature. This eﬀect is permanent and very unlikely to change especially for those older than 25 years. Nonetheless, always adopt the good eye care habits listed below:

1. Minimise eye strain Placing too much strain on the eyes can cause discomfort and fatigue. One of the best ways to prevent eye strain when doing near vision work is to follow the rule of 20-20-20. This simply means that every 20 minutes of near vision work, you should look at objects 20 feet away for 20 seconds!

2. Do not hold reading materials too close to the eyes Maintain a comfortable distance between your eyes and reading materials. For reading, the ideal distance is 2/3 of an arm’s length away.

3. Work in well-lit areas It is important for one to work in bright spaces with suﬃcient and suitable lighting. Whilst dim lights will not directly damage your eyes, they can tire them out more quickly and cause eye strain symptoms and headaches. 4. Your sitting posture matters Maintaining a proper sitting posture while working is important as well. Refrain from slouching! You should adopt a correct but comfortable sitting posture with the back straight and shoulders relaxed.

5. Maintain a healthy lifestyle To keep your eyes healthy, it is important to consume nutritious food or supplements that has beneficial effects for the eyes. Spent sufficient time outdoors daily to engage in exercise or leisure activities daily.

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Q27: What is the likelihood that I will still need to wear glasses or contact lenses after TransPRK procedure? TransPRK is a very accurate procedure. For most patients, they will not need to wear glasses or contact lenses anymore! However, for some patients, the doctor may not be able to achieve full correction due to limitations brought about by their high myopia, astigmatism or thin cornea. This category of patients may require low-power glasses to achieve perfect vision.

Q28: Will I still be able to wear soft contact lenses after the TransPRK procedure? Yes. Soft contact lenses, including cosmetic lens, can still be worn but only after one month. Hard lenses cannot be worn as they tend to slip due to the altered cornea curvatures.

Q29: Do I need to undergo enhancement surgery? Enhancement surgery is not common with modern laser vision correction and in particular TransPRK. With TransPRK, the enhancement rate is less than 3 percent. Generally, enhancement is not recommended to be done until after a waiting period of at least six months for full and complete eye healing and eye power stabilization. When indicated, it is also subjected to the pre-condition that the remaining central cornea stroma thickness exceeds the standard safety limits.

Q30: Can I claim medical insurance or Medisave? In general, as laser vision correction is considered as a "cosmetic" op, medical insurance and Medisave will not be claimable.

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Your Roadmap Your Roadmap To Clear Vision I hope that you have gained a better understanding about laser vision correction. If you have decided that TransPRK is your preferred choice for laser vision correction, here are the steps you can take to make your dream come true: an appointment for an evaluation 1 Book to assess your suitability for TransPRK. You should stop wearing your soft contact lens for at least 3 days prior to the evaluation (or at least 10 days for hard contact lens wearers in preparation for the evaluation).

BOOK YOUR EVALUATION

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p To Clear Vision 2

The evaluation is expected to take around 2 to 3 hours. It will include comprehensive eye tests & measurements, a detailed information session on the procedure, and a medical examination & consultation with the eye surgeon himself. Pupil dilating eye drops would be administered as part of the eye examination, and may cause your near vision will be blurry for the next few hours. Hence, it is best not to drive.

If you are found to be suitable, you can proceed to book a date for the TransPRK procedure. You should plan for around 5 days to rest and recover.

pre-op operations book your surgery

evaluation day

You would have to stop wearing your soft contact lenses for at least 3 days prior to your surgery day (or at least 10 days if you are wearing hard contact lenses).

YOUR ROADMAP TO CLEAR VISION |

Your Roadmap To Clear Vision Your Roadmap the surgery day, have a good bath, including a through hair wash. Please have a light meal 5 On before coming down. It is advisable to come to the clinic with warm clothing, as the operating theatre will be cold. Do not wear any perfume, deodorants, aftershave, colognes, etc. It is not necessary to have someone accompany you as you will see well enough to go home by yourself. But you shouldnâ&#x20AC;&#x2122;t be driving home!

6 Prior to the start of the surgery, anaesthetic eye drops would be administered to numb your eyes. will be instructed to lie down on the surgery bed and to look ahead with both eyes open at 7 You a blinking green ďŹ xation light. You can blink softly. Be relaxed. This is all you need to do! Have no fear, there is absolutely no pain. Unlike the other vision correction methods, there is no eyeball ring clamps and nothing touches the cornea except for the laser light.

TRANSPRK PROCEDURE SURGERY DAY

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To Clear Vision TransPRK procedure is performed using 8 The the Schwind Amaris 1050RS excimer laser. Equipped with the SmartSurfACE technology, this state-of-the-art equipment will sculpt your cornea and correct your vision in one single seamless step lasting from 10 to 50 seconds. You would just be required to focus on the ﬁxation light during this period.

VISION CORRECTION COMPLETED!

the procedure is completed, a clear, 9 After high-oxygen permeability bandage contact lens is placed onto the treated cornea surface. It acts as an artiﬁcial ﬂap to protect the treated surface while the surface epithelium cells regenerate themselves fully over the next 3 to 5 days.

Next, you will be brought to the resting area to rest for about half an hour, and you’re good to go home!

Please be reminded once again that you shouldn’t be driving back home after the procedure. During the ﬁrst few days of the recovery period, please keep your area clean, and do follow the prescribed eye drop medications. You should be resting at home. When outdoors in the sun, please wear your uv-protected sunglasses. YOUR ROADMAP TO CLEAR VISION |

Recovery Process Recovery DAY 1 TO DAY 3 You will be given an appointment to see the doctor after 48 hours of rest. During this ďŹ rst follow-up, the doctor will be examining your eyes for any possible signs of infection. Please tell the doctor if you are experiencing any pain, redness, eye discharges, etc. Do not be anxious if your vision is a bit hazy, especially during Day 2 to Day 3, as the surface epithelium cells are healing. During this period, medical leave can be given for you to rest at home. It is safe to use your handphone and computer, however, it may be blurry. You should remember to wear sunglasses when you are outdoors in the day to prevent exposure to the sunâ&#x20AC;&#x2122;s ultraviolet rays.

DAY 5 TO DAY 6 DAY 1 TO DAY 3

Bandage contact lens still on

Epithelium cells healed

| YOUR ROADMAP TO CLEAR VISION

Process

DAY 15 ONWARDS You may safely resume rugged & contact sports (e.g. boxing, rugby), as well as water sports (e.g. swimming, diving, snorkelling). However, please bear in mind that sunglasses should still be worn when you are outdoors in the sun at least for the next 8 weeks.

DAY 15

DAY 5 TO DAY 6 You will be given a second follow-up appointment to see the doctor to remove the bandage lens. You can go back to work on the same day as the removal. Once the bandage lenses are removed, you may resume light sports (e.g. jogging, cycling, gym exercises). You can wash your hair and face without any worries, however, you should remain cautious to not allow any dirty water to splash into the eyes. It is also safe to wear make-up now. Sunglasses should still be worn when you are outdoors in the day to avoid exposure to sunlight.

Congratulations on realising your dream of 20/20 vision! YOUR ROADMAP TO CLEAR VISION |

“The Big Four” Modern Vision Correction Methods Advanced Surface Ablation (ASA) ASA is the modern evolved form of surface-based laser vision correction techniques. ASA encompasses: Advanced PRK, LASEK, epiLASIK and TransPRK that is the current frontier ASA technique. With TransPRK, we ﬁnally have a laser vision correction technique that is: 1) Less invasive as no cuts are made in the cornea 2) Uses only a single laser 3) Done as one seamless single-step 4) A true no-touch technique with no suction clamps applied onto the eyeball. As such, it is also the fastest of the vision correction procedures.

ASA

ReLEx SMILE is also known as the “internal ﬂap” procedure as the cornea is cut internally with a Femtosecond laser to create an internal ﬂap (lenticule). The side of the cornea is then cut to make an opening for the lenticule to be removed from the eye. The front cornea will then collapse into the empty space created, causing a change in the cornea curvature shape to correct the refractive errors.

| “THE BIG FOUR” MODERN VISION CORRECTION METHODS

ReLEx SMILE

Today, with so many vision correction centres offering so many different options with different names, it is no wonder that you’re confused. But when you boil it down, there are actually just four main modern vision correction methods to choose from, namely Advanced Surface Ablation (ASA), LASIK, Small Incision Lenticule Extraction (ReLEx SMILE) and Implantable Collamer Lens (ICL).

LASIK Also known as the “suck, cut, flap and zap” procedure, the eyeball is first held taut by a ring clamp applying high suction pressure. During this time, vision blacks out. Blood supply to the eye is being cut off. The cornea is then cut with a blade device or a femtosecond laser. The corneal flap is then opened up so that the excimer laser can reshape the curvature of the corneal bed below. The flap is then closed back and it is held in position by tissue pressure alone.

LASIK

ICL

ICL ICL is the odd one one out as it not a laser vision correction procedure, but a lens implant procedure. A cut is made at the side of the cornea and an artiﬁcial lens is implanted deep inside the eye, behind the iris and in front of the natural lens. It is the most invasive procedure of all the modern vision correction methods and Dr Ho’s view is that it is best reserved for patients who are not suitable for laser vision correction procedures such as TransPRK, LASIK or ReLEx SMILE.

“THE BIG FOUR” MODERN VISION CORRECTION METHODS |

Modern Vision Correction Methods: Here is a detailed summary table comparing the four modern vision correction procedures:

TransPRK Track Record Since

1992 Longest track record

1994

Procedure Time Per Eye

3-5 mins per eye (fastest)

15 to 20 min

Corneal Thickness Criteria

Cornea must be at least 475 microns thick. Better for thin cornea.

Cornea must be at least 500 microns thick.

Degree Correction Criteria

Myopia: Up to 1,000 deg Hyperopia: Up to 400 deg Astigmatism: Up to 500 deg

Myopia: Up to 800 deg Hyperopia: Up to 400 deg Astigmatism: Up to 500 deg

(Based on average corneal thickness of 550 microns)

53 |

LASIK

ʻNo Eyeball Touchʼ Surgery?

Yes

Invasiveness

Least invasive True no-cut surface-based procedure.

COMPARATIVE SUMMARY TABLE

No A suction ring with high pressure is applied.

Moderately invasive LASIK takes place beneath a cut corneal ﬂap.

Comparative Summary Table

Implantable Collamer Lens (ICL)

ReLEx SMILE 2012 Shortest track record

1993

10 to 15 min

20 to 30 min (Slowest)

Cornea must be at least 500 microns thick.

N.A No corneal thickness requirements (ICL is not a corneal based procedure).

Myopia: 200 to 700 deg ONLY Hyperopia: N.A. Astigmatism: Up to 500 deg

Myopia: Up to 1,800 deg Hyperopia: N.A. Astigmatism: Up to 600 deg

No A suction ring with medium pressure is applied.

Minimally invasive ReLEx SMILE takes place via a removed internal corneal ďŹ&#x201A;ap (lenticule).

No A small side incision is made for insertion of the lens.

Most invasive ICL is inserted inside the eye, beyond the cornea and deep behind the pupil.

COMPARATIVE SUMMARY TABLE |

Modern Vision Correction Methods: TransPRK

LASIK

Least invasive True no-cut surface-based procedure.

Moderately invasive LASIK takes place beneath a cut corneal ﬂap.

Flap-Related Complications?

No Zero ﬂap-related complications since no corneal ﬂap cut at all.

Yes This include: flap dislodgement, flap wrinkles, flap inflammations and flap interface problems.

Dry Eyes?

Least likely TransPRK is a surfacebased procedure with no nerve endings being cut, greatly reducing the risk of dry eyes.

Most likely Thousands of cornea nerve endings are cut when the cornea ﬂap is created, resulting in the risk of permanent LASIK-induced dry eyes.

Ability To Achieve True Wavefront/ Topographical Correction

Yes

No The cut corneal ﬂap during Lasik will introduce new Wavefront & Topographical errors.

Ability To Do Crosslinking To Prevent Future Corneal Thinning Problem i.e. Keratectasia

Yes Can be incorporated in TransPRK procedure.

Yes Can be incorporated in LASIK procedure.

Invasiveness

55 |

COMPARATIVE SUMMARY TABLE

Comparative Summary Table ReLEx SMILE

Implantable Collamer Lens (ICL)

Minimally invasive ReLEx SMILE takes place via a removed internal corneal ďŹ&#x201A;ap (lenticule).

Most invasive ICL is inserted inside the eye, beyond the cornea and deep behind the pupil.

Yes Internal ďŹ&#x201A;ap complications can occur.

N.A. The ICL procedure is not a corneal based surgery.

Moderately likely There is no big external cut made in the cornea, thus incidence of dry eyes is lower compared to LASIK.

N.A. The ICL procedure is not a corneal based surgery.

No Current technology unable to correct Wavefront/ Topographical errors.

No There is no wavefront-enabled ICL.

No Cannot be incorporated in ReLEx SMILE procedure.

No Cannot be incorporated in ICL procedure.

OMPARATIVE SUMMARY TABLE |

Modern Vision Correction Methods: TransPRK Can Go Back To Work

Full Visual Recovery

57 |

4 to 5 days

Slower Generally takes around 1 to 3 months.

Resume Light Sports e.g. Jogging, Gym, Cycling

5 days

Can Do More Active Sports e.g. Swimming, Diving, Bungee Jumping, Football

2 weeks (Important to avoid sun’s uv rays for 6 to 10 weeks)

Participate In Rugged And Contact Sports

2 weeks

COMPARATIVE SUMMARY TABLE

LASIK 2 to 3 days

Fast Generally take 2 to 3 weeks.

5 days

1 month

It is not advisable to participate in contact sports as the cut corneal ﬂap will never fully heals.

Comparative Summary Table ReLEx SMILE

2 to 3 days

Slower Generally takes about 1 to 3 months.

5 days

1 month

3 months

Implantable Collamer Lens (ICL) 2 to 3 days

Fast Generally take 2 to 3 weeks.

5 days

3 months

It is not advisable to participate in contact sports as the ICL may dislodge or injure internal structures.

COMPARATIVE SUMMARY TABLE |

Modern Vision Correction Methods: TransPRK Nutshell Summary

Cost For Two Eyes

*Prices indicated are exclusive of 7% GST

59 |

LASIK

Good for anyone who prefers a safe surface-based procedure. Suitable for active sportsperson, especially those participating in contact sports. Suitable for those who are risk adverse to corneal ﬂap complications, wish to minimise risk of dry eye, have thin cornea and high myopia, and those who are afraid of having their eyes cut can also consider TransPRK. Very important to avoid the sun’s uv rays for two months post-op and to use the recovery eye drops provided for six to ten weeks depending on the eye power corrected.

Good for those who wish to have a fast visual recovery. Not suitable for those who are risk adverse to the cut corneal ﬂap complications. Not suitable for those who wishes to participate in contact sports, or suﬀer from dry eye, or who have a fear of having their cornea cut.

From $3,388 at Clearvision Eye Clinic and LASIK Centre; from $3,600 at Singapore National Eye Centre (SNEC).

From $2,988 at LASIK Surgery Clinic; from $2,800 at SNEC.

COMPARATIVE SUMMARY TABLE

Comparative Summary Table ReLEx SMILE An improvement over LASIK, in that it does not cut an open flap, and thus, lowers the risk of flaprelated complications and dry eyes. However, visual recovery is slower. ReLEx SMILE cannot perform Wavefront and Topographical corrections, also no adjunct crosslinking can be done at same time to strengthen thin cornea. If finetuning enhancement is needed in the future, it is done using ASA techniques like TransPRK. Accuracy is a concern for those with high astigmatism. Lenticule flap complication is a concern for those with low myopia.

From $5,288 at LASIK Surgery Clinic; from $4,376 at SNEC.

Implantable Collamer Lens (ICL) This is the most invasive procedure as it is an intra-ocular procedure. It increases the risk of developing cataracts and glaucoma. There is a real 1 in 1,000 eyes fear of the eye going fully blind from a bad post-op infection. Hence, in my opinion, it is an option to consider only for those patients who are found to be not suitable for cornea-based laser vision correction procedures. e.g. patients, with very thin cornea, high refractive errors or cornea scarring.

From $11,460 at SNEC.

COMPARATIVE SUMMARY TABLE |

ABOUT THE AUTHOR Dr Tony Ho Senior Ophthalmologist and Founder Clearvision Eye Clinic and LASIK Centre

Dr. Tony Ho is a well-recognised and respected figure in the Singapore ophthalmology and refractive surgery field, with sub-specialty experience of over 25 years. He is an elected Fellow of the American Academy of Ophthalmology and the Royal College of Ophthalmology U.K., and also an honoured recipient of the prestigious Singapore Public Service Commission Local Merit and double recipient of the Ministry of Health’s Higher Manpower Development Plan Scholarships. Dr. Ho received higher specialist training at three top eye centres around the world: the Tennant Eye Institute of Glasgow, Scotland, the Moorfields Eye Hospital, London and the Bascom Palmer Eye Institute, USA. In 1990, Dr. Ho published described landmark scientific papers on laser iridotomy for glaucoma management. At present, his method of sequential Argon-YAG laser iridotomy is now employed by doctors around the world as the gold standard for laser iridotomy in dark brown irises. He also authored three books on eye care, amongst which the Complete Eye Care Book won the Singapore National Book Council Merit Award in 1994. In 2001, Dr. Ho pioneered the concept of using 1% Atropine Eye Drops on a weekly basis as a therapy to control childhood myopia progression (www.myopia.com.sg). Since 2009, Dr. Ho has been a pioneer and leading advocate of epiLASIK (www.epilasik.com.sg) and he now champions TransPRK as the frontier of Advanced Surface Ablation laser vision correction techniques. (www.lasik.com.sg). His latest project is FLIP (www.flipeyewear.com.sg), an innovative myopia eyewear technology that will help to instantly reduce accommodative eye strain in children wearing myopia glasses. Dr. Ho established Eye Care Clinic at Mount Elizabeth Medical Centre Singapore (www.eyecare.com.sg) offering advanced treatment for patients with eye diseases such as glaucoma, cataracts, macular and retinal degeneration. He also founded Clearvision Eye Clinic & LASIK Centre (www.clearvision.com.sg) as a dedicated LASIK centre to help patients see clearly, safely. Dr. Ho strives to be at the forefront of laser vision correction technology and Clearvision now offers the advanced SafeSight TransPRK procedure using the Schwind Amaris 1050RS SmartSurfACE excimer laser technology.

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ABOUT THE AUTHOR

Epilogue If you have found the information in this book useful, you may wish to refer your family and friends to the online version of this book at www.BeyondLasik.sg. Do you have any questions you'd like to ask? Call us at 6100 2211 or email us at info@beyondlasik.sg and we'll be happy to answer your queries. Special Note: All proceeds from the sale of this book will be donated to the Singapore Association of the Visually Handicapped (SAVH).

ABOUT WWW.BEYONDLASIK.SG |

BEYOND LASIK - TRANSPRK Laser Vision Correction for the New Generation LASIK has become a buzzword for laser vision correction. But with advancements in medical science and technology LASIK is no longer the only option out there for those looking to rid themselves of glasses and contact lens wear. Enter in TransPRK, a break-through laser vision correction procedure that is evolved from early PRK from where laser vision correction all started! TransPRK is the fastest of all the vision correction methods. It is done in one seamless step under just numbing eyedrops and using only a single laser. It is a true blade-less, cut-less procedure. It is also a true no touch procedure as there is no placement of suction ring clamps onto the eyeball. TransPRK has zero incidence of cornea ﬂap complication risk that is a feared complication of other options. There is also less fear of cornea thinning issues and dry eye problems with this technique. With over 20 years’ experience as an eye surgeon, Dr Tony Ho has written this book to be a concise and easy read for those who wants to take the plunge but are understandably anxious and apprehensive and want to ﬁnd out more information. Have dreams, make proper informed choices and don’t look back!