Alpins method

The Alpins Method, developed by Australian ophthalmologist Noel Alpins, is a system to plan and analyze the results of refractive surgical procedures, such as laser in-situ keratomileus (LASIK).[1][2][3] The Alpins Method is also used to plan cataract/toric intraocular lens (IOL) surgical procedures.[4]

Introduced in 1993, it has been used in some research studies of LASIK.[1][2][3][5] In 2006 the American National Standards Institute (ANSI) published guidelines based on the Alpins Method, designed to help manufacturers demonstrate the efficacy of refractive surgical lasers.[3][6][7]

The Alpins Method uses vector mathematics to determine a goal for astigmatism correction and analyze factors involved if treatment fails to reach that goal. The method can also be used to refine surgical techniques or correct laser settings in future procedures.[8] The Alpins Method is one of the “more sophisticated” approaches in analyzing surgical results.[1]

Background

In the early 1990s, astigmatism analysis and treatment applied to laser modalities was inconsistent, and did not assess the success of the results or the extent to which surgical goals had been achieved.[9] The advent of excimer laser technology (e.g., laser-assisted in situ keratomileusis, or LASIK) also introduced a conundrum between incisional and ablation techniques; specifically, should treatment be planned according to refractive cylinder values as introduced with laser refractive surgery, or corneal astigmatism parameters as had been customary with incisional surgery.[10][11]

In providing a coherent basis for reporting astigmatism results, the Alpins Method became the standard in the major ophthalmology journals,[12][13][14] accepted worldwide for studies that include refraction and corneal astigmatism measurements.[2][6][7] The method provides a consistent, logical approach to quantifying and comparing the success of various refractive surgical procedures, and refining/planning surgery to achieve even better results, both in individuals and groups of individuals receiving refractive surgery.

Basics

The Alpins Method determines a treatment path and defined astigmatic target that in many instances is not zero, although prior to the Alpins Method zero had been a nearly unanimous, but unachievable, preference.

Golf analogy

The Alpins Method of astigmatism analysis has many parallels to the game of golf.[8] A golf putt is a vector, possessing magnitude (length) and axis (direction). The intended putt (the path from the ball to the hole) corresponds to Alpins' target induced astigmatism vector (TIA), which is the astigmatic change (by magnitude and axis) the surgeon intends to induce in order to correct the patient's pre-existing astigmatism to the derived or calculated target. The actual putt (the path the ball follows when hit) corresponds to Alpins' surgical induced astigmatism vector (SIA), which is the amount and axis of astigmatic change the surgeon actually induces. If the golfer misses the cup, the difference vector (DV) corresponds to the second putt—that is, a putt (by magnitude and axis) that would allow the golfer to hit the cup (the surgeon to completely correct) on a second attempt.[15]

Indices generated

The diagram superimposed on the golf putt image corresponds to a double-angle vector diagram (DAVD), which allows calculations using rectangular (Cartesian) coordinates. Vectors can only be calculated; they cannot be measured like astigmatism. Line 1 in the diagram represents a patient's preoperative astigmatism by magnitude (length of the line) and axis (which in a DAVD is twice the patient's measured axis of preoperative astigmatism). Line 2 represents the target astigmatism—that is, the magnitude and axis of the correction the surgeon would like to achieve. Line 3 represents the achieved astigmatism—that is, the magnitude and axis of the postoperative astigmatism.

The TIA, SIA, and DV and their various relationships generate the following indices, which comprise the essence of the Alpins Method:[15][16]

  • Correction index (CI)—The ratio of the SIA to the TIA—what the surgery actually induced versus what the surgery was meant to induce. The CI is preferably 1; it is greater than 1 if an overcorrection occurs and less than 1 if there is an undercorrection. The CI is calculated by dividing the SIA (actual effect) by the TIA (target effect).
  • Coefficient of adjustment (CA)—The inverse of the CI, the CA quantifies the modification needed to the initial surgery plan to have achieved a CI of 1, the ideal correction. If the surgeon achieves an overcorrection, for example, the CA might be 0.9, indicating that the surgeon should have selected a correction 90% of what was actually selected. The CA can be used to refine nomograms for future procedures.
  • Magnitude of error (MofE)—The intended correction minus the actual correction in diopters.
  • Angle of error (AE)—The angle described by the vectors of the intended correction versus the achieved correction (SIA minus TIA). By convention, the AE is positive if the achieved correction is on an axis counterclockwise to where it was intended, and negative if the achieved correction is clockwise to its intended axis.
  • Index of success (IOS)—The IOS is calculated by dividing the DV (how far the target is missed) by the TIA (the original target effect). The IOS is a relative measure of success; that is, if golfer John attempts a long putt and golfer Bob a shorter one, and each ends up the same distance from the cup, John's putt can be considered more successful because he had the longer initial putt and a lower IOS (zero being perfect). The IOS is a valuable measure of the relative effectiveness of various surgical procedures.

Unlike other approaches to astigmatism analysis, the indices of the Alpins Method can be subjected to conventional forms of statistical analysis, generating averages, mean magnitudes and summated vector means, standard deviations, etc., for each individual component of surgery.

Vector planning

Clinical studies support vector planning both in healthy astigmatic eyes[17][18][19] and in eyes with keratoconus.[20]

Additionally, Alpins and Stamatelatos showed that combining refraction (using wavefront measurements) with Vector Planning provided better visual outcomes than using wavefront planning alone.[17][21]

References
  1. Koch, DD (1997). "Excimer laser technology: new options coming to fruition". Journal of Cataract and Refractive Surgery. 23 (10): 1429–30. doi:10.1016/s0886-3350(97)80001-6. PMID 9480341. S2CID 43145363.
  2. Koch, DD (1998). "Reporting astigmatism data". Journal of Cataract and Refractive Surgery. 24 (12): 1545. doi:10.1016/s0886-3350(98)80335-0. PMID 9850884. S2CID 43642730.
  3. Koch, DD (2006). "Astigmatism analysis: the spectrum of approaches". Journal of Cataract and Refractive Surgery. 32 (12): 1977–8. doi:10.1016/j.jcrs.2006.10.001. PMID 17137948.
  4. Borasio, E; Mehta, JS; Maurino, V (2006). "Torque and flattening effects of clear corneal temporal and on-axis incisions for phacoemulsification". Journal of Cataract and Refractive Surgery. 32 (12): 2030–8. doi:10.1016/j.jcrs.2006.09.010. PMID 17137979. S2CID 45492280.
  5. Goggin, M; Pesudovs, K (1998). "Assessment of surgically induced astigmatism: toward an international standard". Journal of Cataract and Refractive Surgery. 24 (12): 1548–50. doi:10.1016/S0886-3350(98)80337-4. PMID 9850888. S2CID 30676358.
  6. Eydelman, MB; Drum, B; Holladay, J; Hilmantel, G; Kezirian, G; Durrie, D; Stulting, RD; Sanders, D; Wong, B (2006). "Standardized analyses of correction of astigmatism by laser systems that reshape the cornea". Journal of Refractive Surgery. 22 (1): 81–95. doi:10.3928/1081-597X-20060101-16. PMID 16447941. S2CID 6400260.
  7. Dupps Jr, WJ (2008). "Impact of citation practices: Beyond journal impact factors". Journal of Cataract and Refractive Surgery. 34 (9): 1419–21. doi:10.1016/j.jcrs.2008.07.001. PMID 18721687.
  8. Alpins, NA; Goggin, M (2004). "Practical astigmatism analysis for refractive outcomes in cataract and refractive surgery". Survey of Ophthalmology. 49 (1): 109–22. doi:10.1016/j.survophthal.2003.10.010. PMID 14711444.
  9. Croes KJ. “The Alpins method: a breakthrough in astigmatism analysis” Medical Electronics, September 1998.
  10. Thornton, SP; Sanders, DR (1987). "Graded nonintersecting transverse incisions for correction of idiopathic astigmatism". Journal of Cataract and Refractive Surgery. 13 (1): 27–31. doi:10.1016/s0886-3350(87)80005-6. PMID 3559948. S2CID 35283485.
  11. Lindstrom, RL (1990). "The surgical correction of astigmatism: A clinician's perspective". Refractive & Corneal Surgery. 6 (6): 441–54. doi:10.3928/1081-597X-19901101-11. PMID 2076422.
  12. American Academy of Ophthalmology website. Author information pack. 17 January 2016. Accessed 20 December 2016.
  13. American Society of Cataract and Refractive Surgery website. Information for Authors. 2016. Accessed 20 December 2016.
  14. Reinstein, DZ; Archer, TJ; Randleman, JB (2014). "JRS standard for reporting astigmatism outcomes of refractive surgery". Journal of Refractive Surgery. 30 (10): 654–659. CiteSeerX 10.1.1.692.4931. doi:10.3928/1081597X-20140903-01. PMID 25291747.
  15. Alpins, NA (1993). "A new method of analyzing vectors for changes in astigmatism". Journal of Cataract and Refractive Surgery. 19 (4): 524–33. doi:10.1016/s0886-3350(13)80617-7. PMID 8355160. S2CID 40460505.
  16. Alpins N, Stamatelatos G. "Chapter 24: The Cornea - Part X: Treatment and analysis of astigmatism during the laser era." In: Boyd BF, ed. Modern Ophthalmology: The Highlights. Clayton, Panama: Jaypee-Highlights Medical Publishers, Inc; 2010. Accessed 6 April 2017.
  17. Alpins, N; Stamatelatos, G (2008). "Clinical outcomes of laser in situ keratomileusis using combined topography and refractive wavefront treatments for myopic astigmatism". Journal of Cataract and Refractive Surgery. 34 (8): 1250–9. doi:10.1016/j.jcrs.2008.03.028. PMID 18655973. S2CID 29819060.
  18. Qian, YS; Huang, J; Liu, R; Chu, RY; Xu, Y; Zhou, XT; Hoffman, MR (2011). "Influence of internal optical astigmatism on the correction of myopic astigmatism by LASIK". Journal of Refractive Surgery. 37 (12): 863–8. doi:10.3928/1081597X-20110629-01. PMID 21739930.
  19. Kugler, L; Cohen, L; Haddad, W; Wang, MX (2010). "Efficacy of laser in situ keratomileusis in correcting anterior and non-anterior corneal astigmatism: comparative study". Journal of Cataract and Refractive Surgery. 36 (10): 1745–52. doi:10.1016/j.jcrs.2010.05.014. PMID 20870122. S2CID 16877048.
  20. Alpins, N; Stamatelatos, G (2007). "Customized photoastigmatic refractive keratectomy using combined topographic and refractive data for myopia and astigmatism in eyes with forme fruste and mild keratoconus". Journal of Cataract and Refractive Surgery. 33 (4): 591–602. doi:10.1016/j.jcrs.2006.12.014. PMID 17397730. S2CID 14881153.
  21. Kohnen, T (2008). "Reshaping the cornea: which laser profiles should we use?". Journal of Cataract and Refractive Surgery. 34 (8): 1225. doi:10.1016/j.jcrs.2008.06.013. PMID 18655955.
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