LASIK. Complications. Customized Ablations. Photorefractive Keratectomy. Femtosecond Keratome for LASIK. Cornea Resculpted

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1 Refractive Surgery: Which Procedure for Which Patient? David R. Hardten, M.D. Minneapolis, Minnesota Have done research, consulting, or speaking for: Alcon, Allergan, AMO, Bausch & Lomb, Inspire, Medtronic, TLCV, Zeiss Some of the information may represent off-label uses of approved drugs or devices Ph: Fax: Reduction of Handicaps Ophthalmology Prevalence of myopia, hyperopia, and astigmatism (refractive error) has given it the status of a normal variant Non-interventional means of overcoming refractive error is spectacles Slightly more invasive way of overcoming refractive errors is contact lenses Refractive Procedures Diverse Patients to to to to to to to Astigmatism Presbyopia LASIK, Intacs, PRK, RK LASIK, PRK with MMC Lens Implant, LASIK Lens Implant LASIK, CK, PRK LASIK, Lens Implant Lens Implant LASIK or AK LASIK, CK, Lens Implant Mini - RK PRK for Myopia Incisions Round area of treatment Page 1

2 Photorefractive Keratectomy LASIK Cornea Resculpted Complications LASIK Significant Early Dry Eye 10-15% Epithelial Defect 1-5% Epithelial l Ingrowth 011% 0.1-1% Inadequate Suction/Poor Flap <1% Significant Decentration <1% Significant Irregular Astigmatism <1% Femtosecond Keratome for LASIK Potential Advantages of Intralase Potentially less buttonholes Recut immediately in suction loss cases Thinner flaps in periphery Laser to cut flap Planar cut Dryer bed Intralase vs. Mechanical Keratome for LASIK Potential Disadvantages of Intralase Waiting time for bubbles to dissipate Increased inflammation Potentially increased epithelial ingrowth Thicker flaps in center Laser to cut flap Cost Time of surgery Customized Ablations WavePrint is the patients individual acuity map Best Uncorrected Vision This acuity map shows the eye uncorrected for sphere, cylinder, and higher order aberrations Uncorrected Higher Order Aberrations This aberration map shows some slight aberrations, while the periphery shows larger wavefront errors Page 2

3 Uncorrected Visual Acuity Post-Op UCVA Compared to Pre-Op BSCVA 100% 80% 69% 92% 70% 88% 74% 94% 70% 98% 100% 80% 75% 75% Same or Better 79% 80% 60% 60% 40% 24% 27% 23% 40% 0% 1 Month 3 Months 6 Months 12 Months 20/12.5 or better 20/16 or better 20/20 or better At 12 m 70% of eyes were 20/16 or better and 98% were 20/20 or better 0% 1 Month 3 Months 6 Months 12 Months At 12 Months, 80% of eyes had either the same or better post-op UCVA compared to their pre-op BSCVA Patient Satisfaction Vision at Night Expectations 100% 80% 65% 60% 40% 24% 10% 1% 0% Pre-Op Very Satisfied/Satisfied Somewhat Dissatisfied 85% 6% 7% 2% 6 Months Not Sure Very Dissatisfied How do we counsel based on this data for Wavefront guided ablations 99% of the time 20/40 or better 90% of the time 20/20 or better 65% of the time you will see as well as you do in our trial frames in the office of the time 20/12.5 or better 10% of the time will gain >1 line BCVA Expectations How do we counsel based on this data for Wavefront guided ablations On average you will see similar levels of glare or halo at night as you do now, yet some patients will have more, some will have less Still the higher your correction or if you have confounding issues you will be less likely to achieve your goals We have adopted 100% wavefront when appropriate to reduce unrealistic expectations Phakic IOLs Types Anterior Chamber Angle fixated Anterior Chamber Iris fixated Posterior Chamber Unique Problem in Hyperopia is shallow anterior chamber Becomes a problem if AC Depth < 3.2 mm Page 3

4 STAAR Visian/ICL STAAR Visian Nuvita Lens Anterior Chamber Lens Verisyse Lens Verisyse Lens AMO/Ophtec Visian Phakic IOL Myopia & Hyperopia Preserves accommodation Retains corneal asphericity Potential Damage to angle Endothelial concerns Risk of endophthalmitis Pigment dispersion Over 90% 20/40 or better New imaging methods may improve results Page 4

5 Natural Lens Replacement Myopia and Hyperopia Retains corneal asphericity Accurate Endophthalmitis risk RD risk Posterior capsular opacity No accommodation Natural Lens Replacement Extreme Myopia Standard cataract technique Allows for no retention of accommodation Risk of RD greater than for phakic IOL May require retinal laser prophylaxis Complications Natural Lens Replacement Endophthalmitis Endothelial Cell Loss Glaucoma Wound Leak Posterior Capsular Opacification Intraocular Lenses Refractive Surgery Allow normal corneal optics Lens design extremely important Retinal detachment risk probably higher Multifocal IOL possible management of presbyopia Presbyopia Well Accepted Options available Multifocal & Accommodative IOLs ReZoom, Restor, Tecnis MF, Crystalens Monovision still a useful tool New options in development Scleral relaxing incisions/implants Still short term follow-up on studies Presbyopic Lens Exchange Options (Prelex) Array ReSTOR Crystalens Tecnis MF ReZoom Page 5

6 3 year US Clinical Trial - Bilateral Uncorrected Distance Visual Acuity - Crystalens 100% 80% 60% 40% 0% 79% 84% 1 Year 3 Year n=38 100% 98% 100% 98% 100% 91% 20/20 20/25 20/32 20/40 Reports of Wearing Glasses More than 84% of subjects reported never wearing glasses post-implantation. No. of Subjects, % N= Never Occasionally Always Note: Residual Astigmatism not corrected in the study, so results likely improvable with correction of astigmatism 1.00D Astigmatism = 20/30 UCVA; 0.75D Astigmatism = 20/25 UCVA; 0.50D Astigmatism = 20/20- UCVA Tecnis MF Presbyopic IOL Refractec Conductive Keratoplasty CK Shrinks tissue in the cornea using a radiofrequency probe Steepens central cornea to reduce hyperopia Able to correct to D of hyperopia Use for Hyperopia or Presbyopia Intrastromal Corneal Ring Intacs Intrastromal Corneal Ring Intacs Used to correct myopia or keratoconus Two semicircular rings placed into cornea Rings made of biocompatible plastic Main current use is for Keratoconus Page 6

7 Intacs KCN with CK/Intacs then PRK/MMC 20/20 UCVA Advances in Technology Vision Correction Continuous incremental improvements in laser and IOL technology New techniques for extreme levels of correction Methods to improve vision in patients with other reasons for vision loss - irregular astigmatism, scars Advances in Technology Vision Correction Presbyopia still a major hurdle in vision correction Improvement of vision over natural state may someday be possible 20/10 vision 20/6 vision Custom LASIK most common current technique 2010 Portfolio of Options 2010 Portfolio of Options to to to to to to to to Astigmatism Presbyopia LASIK, PRK, Intacs LASIK, PRK LASIK, PRK, IOLs IOLs, LASIK IOLs LASIK, CK, PRK IOLs, LASIK IOLs LASIK or AK Monovision, Multifocal IOL, Accommodating IOL Page 7

8 THANK YOU!! David R. Hardten, M.D. Contact Information: Minnesota Eye Consultants 710 E. 24th Street, Suite 100 Minneapolis, MN Page 8