Eyeworld

54 | EYEWORLD | SUMMER 2026 R EFRACTIVE Dr. Cummings said he didn't participate in the European post-market study, which includ- ed 224 eyes (113 patients), due to a conflict of interest. He described these patients as "not spe- cifically high myopes and people who look dif- ferent from the Gullstrand model." At 3 months, this study found 100% of eyes at 20/20 or bet- ter uncorrected, with 86% at 20/16 or greater, 50% at 20/12 or greater, and 8% at 20/10, Dr. Cummings said. "That was the first crazy statis- tic," he added. "The second was there was no increase in higher order aberrations, including patients who were –5, –6, –7, while there was a significant decrease in spherical aberration." A study that compared data from premar- ket approval trials for both topography-guided LASIK (Contoura and the Allegretto Wave Eye-Q laser, Alcon) and ray tracing-guided LASIK (WaveLight Plus with the WaveLight EX500 ex- cimer laser and Sightmap) found that the topog- raphy-guided procedure "showed superior visual acuity outcomes," but the ray tracing-guided procedure had higher contrast sensitivity. 2 The ray tracing-guided platform also showed a higher rate of achieving 20/20 or better visual acuity. The Teneo platform and integrated nomogram automation Another relative newcomer to the LASIK treat- ment planning space is the Teneo excimer laser (Bausch + Lomb), which received approval in 2024. Karl Stonecipher, MD, said he "[loves] this platform especially for an inexperienced surgeon." He added, "Our out of the box with no nomogram adjustments were some of the best published to date." 3 Dr. Lobanoff said something that sets the Teneo apart from any U.S. laser platform is its active cyclotorsion tracking. It is also currently the fastest laser in the U.S., operating at 500 Hz, treating 1 D per 1.2 seconds. Like the WaveLight Plus, Dr. Lobanoff said Teneo doesn't require nomogram input, simplifying the pro- cess and accuracy for surgeons. "The engineers have built those nomograms into the laser itself," he said. "Whatever the manifest is, that's what you enter, and it does the nomogram on its own and creates that treatment." Dr. Lobanoff said he appreciates the ergo- nomics of Teneo. "They nailed it," he said. "It's designed to fit the surgeon well. It also has a beautiful touchscreen interface, making it easy to understand and putting things where it's log- ical to reach and walk through treatment plan- ning." Dr. Lobanoff said one thing he doesn't like is that when he's changing magnification, it's not a continuous transition. He described a magnification delay as lenses clicking in and out of place. Another limitation of Teneo is that it is not FDA approved to treat under –1 D, meaning it can't be used on-label for little touch-ups on pseudophakic patients. Dr. Lobanoff said this is a disadvantage for practices that want a laser to be able to perform corneal refractive surgery and enhancements post-refractive cataract or refractive lens exchange surgery. Comparing enhancement rates and planning approaches To Dr. Cummings, there is a lot of thinking re- quired in topography-guided procedures. "If you ask 10 specialists, you get 10 different opinions on how to plan a topography-guided proce- dure," he said. With ray tracing LASIK, there are no nomograms, he said, adding later that he has not had any postoperative enhancements with the WaveLight Plus technology. Dr. Stonecipher said his overall enhancement rate in a series of more than 3,000 LASIK cases (followed for at least 1 year) is 0.29%. When he used ray tracing-guided technology, he said, "we have yet to enhance a single person, and we have been treating with this platform for more than 11 months." Dr. Lobanoff said 3% of his Teneo cas- es have required an enhancement within 1 year. When deciding on topography-guided, wavefront-guided, and ray tracing technology, Dr. Stonecipher said to look at the parameters the patient presents with from an anatomical position and their refractive error. He also said that many surgeons are now suggesting ICL at lower levels of refractive error. Wavefront-opti- mized technology is designed to treat up to –14 D of myopia, up to –6 D of myopic astigma- tism, up to +6 D of hyperopia, and up to +6 D of hyperopic astigmatism, but Dr. Stonecipher said the technology is rarely employed at the upper approved limits. He called topography- guided customized ablations and treatment with Phorcides planning software "great options depending on the patient." continued from page 53

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