Curtin G. Kelley, M.D. Director of Vision Correction Surgery Arena Eye Surgeons Associate Clinical Professor of Ophthalmology The Ohio State

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1 Curtin G. Kelley, M.D. Director of Vision Correction Surgery Arena Eye Surgeons Associate Clinical Professor of Ophthalmology The Ohio State University Columbus, Ohio

2 Refractive Errors Myopia (nearsightedness) Hyperopia (farsightedness) Astigmatism Presbyopia (loss of accommodation)

3 Refractive Surgery: Approaches Corneal: surface curvature altered to change focal strength Lens Based: internal optics changed with or without lens removal

4 Corneal Refractive Surgery Incisional: relaxes corneal power in axis of incision Laser (excimer, femtosecond) Surface, lamellar Inlay (presbyopia)

5 Corneal Relaxing Incisions Diamond blade, 80-90% stromal depth On steep axis of cornea Age dependent (older = more effect/mm) Limited range Can be done at slit lamp or under scope Combined with cataract surgery often =/- reliable, titratable

6 Excimer lasers Excited Dimer 193 nm wavelength Breaks C-C bonds, no heat Programmed to sculpt stroma Refraction or wavefront guided All refractive errors Physics limit candidacy

7 Excimer Lasers Example: MR x 090 SE = Ablation depth = 15 microns x 7.75 (116 microns) Residual bed depth Pachymetry flap ablation = 304 microns

8 Femtosecond lasers Penetrate transparent tissue Programmed at target nanometer focal point, bubble layer separates tissue Flap making, stromal collapsing Incision making Lens fragmenting Transplant prep Future apps??

9 Corneal Inlays Synthetic or tissue based Myopia, keratoconus, aphakia: human epikeratophakia Presbyopia inlays in use Nutritional corneal issues Centration/ migration concerns

10 Lens Based Refractive Surgery Phakic IOL s Anterior chamber Iris fixated Posterior chamber Clear Lens Extraction (CLE) Multifocal Monofocal Accommodative Toric (mono and multi) Telescopic (low vision)

11 Phakic IOL s: Anterior Chamber

12 Phakic IOL s: Iris Plane

13 Phakic IOL s: Ciliary Sulcus

14 Lens Replacement CLE or cataract surgery patients IOL options rapidly expanding Full range of myopia, hyperopia, and astigmatic correction available Presyopia correcting lenses Multifocal (diffractive and bifocal) Pseudoaccommodating Multioptic

15 CLE lenses Accommodative multifocal

16 CLE lenses Diffractive multifocal

17 CLE lenses Bifocal optic

18 CLE lenses Multioptic

19 Toric Lenses Preoperative marking required

20 Lens Based Refractive Surgery Trulign Toric

21 Lens Based Refractive Surgery Acrylic Toric IOL s AMO ZCT Alcon SN6AT

22 Surgical Technique: CLE Standard cataract workup, surgery Meticulous surgical technique Capsulorhexis centered, round, adequate Intact capsule Healthy ocular surface and retina

23 Surgical Technique: video

24 Lens Based Refractive Surgery Multifocal IOL s

25 Future Developments Increased near and toric options More predictable accommodative IOL s Laser adjustable IOL s

26 Patient Workup Preoperative Perioperative Postoperative Complication Management

27 Preoperative Evaluation Complete eye examination Corneal topography Corneal pachymetry Biometry (ultrasonic or laser) Discussion of lifestyle issues, goals Informed Consent

28 Preoperative Evaluation Lifestyle issues: Vocation Avocation Sports Computer, reading style, importance Night driving, flying interest Commit to goals, approach to each eye determined Ready for Surgery!

29 Perioperative Preparation Time out Anesthetic Antibiosis Betadine prep Postoperative protection Bandage lens for PRK, shield for IOL s and LASIK Pain management One day postop visit scheduled

30 Postoperative Management Visual Acuity, near and far Antibiotics, corticosteroids Evaluate epithelial integrity Anterior chamber reaction and IOP

31 Operative Technique: LASIK (video)

32 Operative Technique: PRK (video)

33 Operative Technique: ICL (video)

34 Operative Technique: LRI (video)

35 Operative Technique: CLE Multifocal (video)

36 Operative Technique: CLE Toric (video)

37 Conclusions Numerous refractive surgical procedures Wide range of candidacy, options Rapidly expanding lens based options Laser vision correction remains viable, safe Lens based options potent, growing; more invasive Multiple techniques can be paired to achieve goals

38 Conclusions Thorough preoperative evaulation and discussion mandatory for patient/surgeon alignment Meticulous perioperative process required, surgical perfection key Postoperative care and ability to enhance results critical to long term success

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