Disclosures. Refractive Surgery. PRK vs LASIK. Case # 1. Refractive Error. Navigating the Refractive Surgery Menu 9/11/2015

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1 Navigating the Refractive Surgery Menu Disclosures TLC Vision Employee Alcon Advisory board Bill Tullo, OD, FAAO Diplomate AAO Cornea, CL & Refractive Surgery Vice-President of Clinical Service TLC Laser Eye Centers Corneal LASIK Surface Ablation PRK LASEK Epi-LASIK AK - Femto ICRS - Intacs Refractive Surgery Intraocular Phakic IOL Verisys Visian CLE Cataract Surgery Toric IOL Multifocal IOL Accommodative IOL Femtosecond Assisted PRK Advantage No flap Less tissue removed PRK Disadvantage Slow visual recovery Some pain/discomfort PRK vs LASIK LASIK Advantage Fast visual recovery Minimal Discomfort LASIK Disadvantage Flap complications More tissue removed Myopia Astigmatism Hyperopia Presbyopia Refractive Error Case # 1 Dry Rx DS OU 1

2 Femtosecond LASIK Flap ifs Advantages of Femtosecond Flap Independent specific diameter Independent specific thickness Better flap centration Variable hinge size/location Beveled edge Smooth evenly hydrated stromal bed Conserve tissue Planar shape Safer Less complications Less loss of BCVA More gain of BCVA Biomechanically stronger Lower risk of keratectasia Better Efficacy Induce less HOA Smoother beds Even hydration Faster visual recovery Better Low Contrast vision PRK vs LASIK Ocular Health Dry Eye EBMD Corneal Degeneration FFK (irregular topography) Terrian s Corneal Dystrophy Meesman s Avellino Fuch s Case # 2 Dry Rx DS OU PRK vs LASIK Systemic Disease Keloids Rheumatoid Arthritis Crohn s Disease IBS Lupus Fibromyalgia HIV 2

3 Case # 3 Dry Rx DS OU PRK vs LASIK Corneal Thickness Minimal CCT Central Corneal Thickness Minimal RSB - Residual Stromal Bed Corneal Topography Occupation Case # 4 Dry Rx DS OU STAAR Visian ICL (Implantable Collamer Lens) FDA approval in December 2005 Safety Quality of Vision Biocompatibility Versatility Simplicity Cosmetic Appearance Rapid Recovery Removable Patient History and Qualifications Careful questioning and gauging expectations History of contact lens wear D/C soft lens for 3 days D/C rigid lens for 3 weeks Opportunity for the patient to ask questions and counseling provided by the professional/staff Contraindications Patients under age 21 Progressive refractive error Cornea/Endothelial pathology Glaucoma Narrow AC angle Cataract or capsular opacification History of: Iritis Synechiae Pigment dispersion Pseudoexfoliation Previous corneal/refractive surgery? Keratoconus? (Toric ICL) 3

4 Exam and Testing Manifest and cycloplegic refraction Unaided and aided visual acuities Keratometry or corneal topography Gonioscopy (grade 2 or greater) Pachymetry-corneal thickness Pupil size in normal and mesopic conditions (6mm or under mesopic) Exam and Testing Anterior chamber depth Intraocular pressure (IOP) Biomicroscopy-dilated and undilated Ophthalmoscopy-dilated Horizontal white to white- UBM / caliper / Orbscan Endothelial cell count Peripheral Iridotomy Visian Video Necessary to avoid pupillary block Laser vs Surgical One or two If laser performed one-week prior to surgery Post-op Pred-Forte qid Post-op medications Follow normal cataract routine First 2 weeks: NSAID, steroid, antibiotic TID Next 2 weeks: NSAID and steroid BID ICL Post-op Care IOP is critical Over-refraction A/C exam for inflammation Evaluate the vault of the ICL.5-1x corneal thickness is ideal Under.5 observe for anterior capsule haze Over 1.5 observe for narrowing angle Dilate for crystalline lens evaluation 4

5 Vault of the Visian ICL Slitlamp Exam ICL Unchanged Cornea ICL vault Most common complication is early pupillary block Pupillary Block - Treatment Dilate pupil Topical Combo Combigan CoSopt Oral med Diamox Repeat PI Exchange ICL lower vault Initial IOP check is 2-4 hours after surgery Post-op Day 1, 7 and month 1 &3 Uncorrected Visual acuity Dry Refraction (Day 7 & beyond) Biomicroscopy ICL Vault (Vault.5 to 1.5 ct) PI Patency Inflammation Tonometry Evaluation of crystalline lens DFE Yearly Case # 5 Dry Rx x 010 DS OU 5

6 Incomparable safety Femto- AK Decisive control of all surgical parameters Fully computerized control Maximal patient comfort Minimal learning curve Precision & predictability in the creation of AK resections + 10 Microns Femtosecond AK and Incisions Case # 6 Dry Rx DS OU Patient Discussion Dry eyes Steep keratometry Regression Enhancements Hyperopia Case # 7 Dry Rx DS OU Case # 8 55 yo male Dry Rx DS OU 6

7 Manual Cataract Surgery Today Ophthalmic surgeon uses hand-held instruments to create a opening in the lens capsule (capsulorhexis) that is as circular as possible The surgeon then breaks up the clouded lens with surgical instruments and ultrasound energy An artificial intraocular lens (IOL) is then placed in the eye. Manual Capsulorhexis Femtosecond Laser Cataract Surgery Using femtosecond (FS) laser technology in cataract surgery makes cataract removal a more predictable and potentially safer procedure by Creating more perfectly sized/shaped/centered capsulotomy Allowing for easier and more gentle break-up of the clouded lens (phacoemulsification) Manual vs. Catalys Cataract Surgery 1 month postop Manual Surgery Catalys Surgery ENGAGE with Liquid Optics Interface Gentle dock for patient with minimal intraocular pressure (IOP) rise and minimal hemorrhaging No corneal distortion or induced folds Clear optical path for precise imaging and laser delivery VISUALIZE and CUSTOMIZE with Integral Guidance Integrated near-infrared video and 3D spectral domain OCT systems visualize from anterior cornea through posterior lens Sophisticated algorithms customize treatment plan in 3D to anatomy of each patient Liquid Optics Docking Liquid Optics Suction Ring Catalys OCT with Liquid Optics Liquid Optics Advantage: Optical and comfort gains MK Rev B Catalys 3D spectral domain OCT MK Rev B Ocular surfaces mapped and treatment customized even when lens is tilted 7

8 Catalys Clinical Results: Capsulotomy Shape Manual Capsulorhexis Catalys Unique Lens Fragmentation Reduces Phaco Energy and Manipulations More predictable and precise cuts CatalysCapsulotomy More predictable outcomes Better outcomes Images courtesy of OptiMedica Corp. Images courtesy of OptiMedica MK Rev B Effective Phaco Time (seconds) Catalys Clinical Results: Impact on Effective Phaco Time Standard Cataract Surgery Catalys Femto (n=57) Standard (n=52) Effective Phaco Time (s) 0.16 ± ± % reduction in effective phaco time compared to standard Data courtesy of Prof. Burkhard Dick, MD, PhD. Ruhr University Eye Hospital. Bochum, Germany, Member of OptiMedica MK Rev Medical B Advisory Board. IOP Rise (mmhg) Interface Configurations: IOP rise Suction Vacuum (mmhg) Curved Lens porcine (n=6) Liquid Optics porcine (n=3) Liquid Optics cadaver (n=6) Liquid Optics has >4x reduction in IOP rise at procedure suction pressure MK Rev B Data courtesy of OptiMedica Femto-Cataract Video Patient Experience Clinical Workup No major changes to standard procedure Things to note: How well patient dilates Is patient able to keep still during procedure Post-Surgery Follow-up Same regimen as existing practices Things to note: Visual recovery may be faster because of reduced ultrasound energy Patient may notice slight hemorrhaging on the conjunctiva 8

9 Case # 9 Dry Rx DS OU Pachymetry 480 OU Surface Ablation PRK Photorefractive keratotomy LASEK Alcohol assisted with epi-flap Epi-LASIK mechanical microkeratome ASA Advanced Surface Ablation -hybrid Remove Epithelium Removal of Epithelium Laser transepithelial Alcohol 20% ETOH Mechanical scrape Brush Amoil s Epi-keratome Epi-LASIK PRK Video Case # 10 OD DS 20/20 OS x /25- Pachymetry 500 OD 465 OS Abnormal Topography 9

10 Early Keratoconus Moderate Keratoconus Severe Keratoconus Femto-Intacs Goals Delay need for corneal transplant Increase BCVA Improve ability to fit/wear CL s Increase UCVA 10

11 Intacs CXL The Use of Corneal Collagen Cross-linking Clinical Studies 670 Peer-reviewed literature citations 96% of eyes show topographic stability Average flattening 1.7D of max-k Flattening effect reduced max-k > 54D The Key Ingredients UVA Dose Continuous or Pulsed Illumination Formulation Composition Method of Application Consumption by Cross-linking Reactions Supplemental Oxygen Delivery Dresden Protocol 0.1% riboflavin Minimal Corneal Thickness 400 microns when using 3.0 mw/cm2 Stromal haze peaks at 1 month post-op and decreases significantly between 3 and 12 months1 UVA dosage 3 mw/cm2 for 30 minutes 1. Greenstein SA, Fry KL, Bhatt J, Hersh PS Natural history of corneal haze after collagen crosslinking for keratoconus and corneal ectasia: Scheimpflug and biomicroscopic analysis. J Cataract Refract Surg Dec;36(12):

12 Intacs with Sequential CXL Effects of both treatments are synergistic Increased K flattening Increased BCVA Increased UCVA Demarcation Line at 1Month 10 minute soak with VibeX Rapid, 30mW/cm 2,7.2J/cm 2, Pulsed [2,1] Kamburoglu G, Ertan A: Intacs Implantation with Sequential CXL Treatment in Postoperative LASIK Ectasia. J Refractive Surg. 2008:24:7:S726-S729 Chan CC, Sharma M, Wachler BS: Effect of inferior-segment Intac with and without C3-R on keratoconus. J Cataract Refract Surg. 2007;33: Credit: Dr. Miguel Rechichi Transepithelial Cross-Linking with ParaCel The corneal epithelium is left in place, and topical anaesthetic applied. ParaCel is applied to completely cover the cornea, and soaked for 4 minutes. VibeX Xtra is applied and soaked for an additional 6 minutes. Riboflavin is rinsed from the eye. Advantages of Epi-ON CXL Faster visual recovery: Return to contact lenses in days Less pain Avoids risk of delays in epithelial healing Reduced risk of infection Reduced development of corneal haze 45mW/cm 2 UVA is applied through the intact epithelium using pulsed Illumination William Trattler, MD Keratoconus Treatment Early Keratoconus progressive topography or tomography minimal reduced BCVA CXL as soon as Dx confirmed Moderate Keratoconus progressive topography or tomography moderate reduced BCVA Consider CXL / Intacs Advanced Keratoconus pachymetry less than 400 microns Intacs if stable + CL refit PK as last resort 12