Refractive Surgery: Vance Thompson, MD, FACS Refractive Surgeon. Oculeve Wavetec Zeiss Mynosys LRG Equinox Precision Lens ORA Amaken EXCELLens

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$Refractive Surgery: My Way Vance Thompson, MD, FACS Refractive Surgeon Vance$ Avedro Calhoun Euclid Systems EyeBrain Medical Forsight Versant AcuFocus

Avedro Calhoun Euclid Systems EyeBrain Medical Forsight Versant AcuFocus

1 Refractive Surgery: My Way Vance Thompson, MD, FACS Refractive Surgeon Vance Thompson Vision Sioux Falls, SD Disclosures Abbott Medical Optics Alcon Avedro Calhoun Euclid Systems EyeBrain Medical Forsight Versant AcuFocus Ophthec Oculeve Wavetec Zeiss Mynosys LRG Equinox Precision Lens ORA Amaken EXCELLens 1

Investigator Experience Vance Thompson, MD PTK (medical monitor) LTK (medical monitor) PRK (principle investigator) LASIK (principle i investigator) i Phakic IOL s (principle investigator) Corneal

2 Investigator Experience Vance Thompson, MD PTK (medical monitor) LTK (medical monitor) PRK (principle investigator) LASIK (principle i investigator) i Phakic IOL s (principle investigator) Corneal Collagen Crosslinking (U.S. co-medical monitor) Femtosecond Laser Cornea (principle investigator) Femtosecond Laser Lens (principle investigator) Zeiss Femtosecond SMILE Procedure Just finished our 50 th FDA monitored clinical trial The Comprehensive Refractive Surgery Practice Technology Advancements 2

Technology Advancements Maximize Accuracy Minimize Risk

wants to see great without them ok with wearing readers

75 X 175 20/20 crisp Topography, tear film testing, SLE

laser Objective evaluation: Quantifies optical

3 Technology Advancements Maximize Accuracy Minimize Risk 62 years old Caucasian male Sees great with glasses and wants to see great without them ok with wearing readers Mrx: OD: X /20 crisp OS: X /20 crisp Topography, tear film testing, SLE normal, retinal exam all normal HD Analyzer Double pass laser Objective evaluation: Quantifies optical performance Comprehensive Ocular surface, cornea, lens, capsule HD Analyzer 3

4 Unique Measurement of Optical Scatter Objective: patient or doctor input not required Numerical output: quantifies and measures severity Optical Scattering Index (OSI) Good Poor OSI = 0.4 OSI = 2.3 OSI = 3.2 OSI = years old Caucasian male Sees great with glasses and wants to see great without them ok with wearing readers Mrx: OD: X /20 crisp OS: X /20 crisp Topography, tear film testing, SLE normal, retinal exam all normal OSI: OD 2.5 OS years old Caucasian male I am not super comfortable with LASIK Not like you have a cataract per say but you have enough changes in your lens that it is affecting how light travels through your lens Your next step (if you want surgery) is lens surgery whether it is 1 month, 1 year, or 10 years Good Poor OSI = 0.4 OSI = 2.3 OSI = 3.2 OSI = 6.2 4

$real comfortable 42 year old female LASIK done 10 years ago eyes they now have some astigmatism developing Refraction OD: plano -1.25 X 88 20/20 crisp OS: +0.75-1.$

5 62 years old Caucasian male His wife then said tell him 62 years old Caucasian male His wife then said tell him She is doing all the night time driving now because I am just not real comfortable 42 year old female LASIK done 10 years ago eyes they now have some astigmatism developing Refraction OD: plano X 88 20/20 crisp OS: X 88 20/20 crisp 5

6 42 year old female LASIK done 10 years ago eyes they now have some astigmatism developing Refraction OD: plano X 88 20/20 crisp OS: X 88 20/20 crisp Doc am still seeing pretty good without my glasses I would like to just get a pair for night time driving 42 year old female? What would you LASIK done 10 years ago eyes they now have some astigmatism developingdo next? Refraction OD: plano X 88 20/20 crisp OS: X 88 20/20 crisp Doc am still seeing pretty good without my glasses I would like to just get a pair for night time driving Pupils, Confrontation fields, IOP, Slit lamp and retinal exam normal both eyes 42 year old female LASIK done 10 years ago eyes they now have some astigmatism developing Refraction OD: plano X 88 20/20 crisp OS: X 88 20/20 crisp Doc am still seeing pretty good without my glasses I would like to just get a pair for night time driving Pupils, Confrontation fields, IOP, Slit lamp and retinal exam normal both eyes 6

$42 year old female LASIK done 10 years ago Refraction OD: plano -1.25 X 88 20/20 crisp OS: +0.75-1.$

7 42 year old female LASIK done 10 years ago Refraction OD: plano X 88 20/20 crisp OS: X 88 20/20 crisp 42 year old female big thinking a topography before prescribing glasses just to make sure. 42 year old female big thinking a topography before prescribing glasses just to make sure. 7

8 42 year old female big thinking a topography before prescribing glasses just to make sure. Ask yourself Why? Ask yourself Why? Increase in myopia and astigmatism changes in a 14 year old Why? 8

Ask yourself Why? Increase in myopia and astigmatism changes in a 14 year old Why? Is it axial length elongation? Is it corneal curvature increasing? Ask yourself Why?

9 Ask yourself Why? Increase in myopia and astigmatism changes in a 14 year old Why? Is it axial length elongation? Is it corneal curvature increasing? Ask yourself Why? Increase in myopia and astigmatism changes in a 14 year old Why? Is it axial length elongation? Is it corneal curvature increasing? adf Changing corneal astigmatism should always have a topography Whether they have had surgery or not 9

10 Changing corneal astigmatism should always have a topography Whether they have had surgery or not Patient had Phakic IOLs 10 years ago Hmmm Patient had Phakic IOLs 10 years ago Endothelial Cell Anterior chamber depth 10

11 that s Big Thinking Postop Visante 2.0 mm central clearance 1.5 mm peripheral clearance Endothelial Cell Density Monitor yearly when stabilizes monitor every two years 11

$! Comprehensive Refractive Surgery Optimizing the Ocular Surface Prior to Cataract or Refractive Surgery Why is it$

12 Patient had Phakic IOLs 10 years ago Endothelial Cell Anterior chamber depth Importance of Yearly Eye Exams!! Comprehensive Refractive Surgery Optimizing the Ocular Surface Prior to Cataract or Refractive Surgery Why is it important? 12

13 The tear film is the most powerful refracting element of the eye 13

Light focusing (or light bending) Light A

variation or abnormality of the tear film

14 Light focusing (or light bending) Light A good tear film is necessary for high quality visual functioning and precise highquality retinal images Even any small variation or abnormality of the tear film will create optical aberrations in the visual system 14

15 Refractive Surgery (Lens or Cornea) Success Target optimal vision Aim for patients desired refractive endpoint Minimize HOAs Maximize visual quality Refractive Surgery Success High quality refractive results mandate high quality pre-operative imaging for all calculations High quality pre-operative imaging is dependent on a good quality tear film Pre-operative Imaging potentially affected by the tear film Wavefront Aberrometry Topography Keratometry measurements/biometry Astigmatism (axis and degree) used to calculate AK/LRIs and toric lenses 15

16 HOAS AND THE TEAR FILM Affect of the BLINK HOAs, Tear Film, and the Blink After a blink, the tear film begins to become irregular, optical aberrations increase, light scattering increases, and the optical quality of the eye decreases. Improve Pre-Operative Imaging Efficient timing in capturing images Testing time for biometry and wavefront images can be from 2-10 seconds Mean TBUT in a DES patient is seconds 16

17 Improve Pre-Operative Imaging Improve Pre-operative Imaging Use of eye drops can improve visual acuity and reduce HOAs Wavefront Aberrations and the Tear Film 17

18 Wavefront Technology Retina Lens Iris Cornea Dry Eye and Topography Error 18

19 HD Analyzer OSI (Objective Scatter Index), indicates the degradation of the retinal image. HD Analyzer OSI (Objective Scatter Index), indicates the degradation of the retinal image. Recommendations for capturing images All imaging taken after asking the patient to blink Attempt to secure images within 2-6 seconds after the blink Take consecutive images and compare the quality before deciding which one to use If questionable image/result occurs, place an artificial tear and repeat and/or begin patient on DES treatment and have return to clinic for repeat testing Take into account time for biometry and wavefront imaging with individual models if purchasing new equipment 19

20 20

21 Refractive Surgery 2015 Cornea Lens replacement Phakic IOL Refractive Surgery 2015 Cornea Lens replacement Phakic IOL How Do We Decide: Refractive error Corneal health Corneal thickness Refractive Surgery 2015 Cornea Lens replacement Phakic IOL How Do We Decide: Refractive error Corneal health Corneal thickness Lens status 21

22 Choosing the Right Procedure for the Right Patient: PRK, LASIK, Custom Ablation, Phakic IOL s, Pseudophakic IOL s Vance Thompson, MD, FACS Sioux Falls, SD Refractive Surgery Options Change corneal curvature example: LASIK Replace crystalline lens example: Refractive Lensectomy Add lens implant example: Phakic IOL Refractive Surgery PAST RK AK ALK Epikeratophakia Keratomileusis Holmium Blade Lasik PRK Broadbeam lasers PRESENT PRK IntraLASIK Scanning AK Intacs PC IOL s CK Phakic IOL s Custom Laser FUTURE Accommodating IOL s Custom Laser Phakic IOL s Adjustable IOL s Microphaco 22

23 Surgical Developments That Have Contributed Positively To My Patient Care: Excimer laser PRK and LASIK Phakic IOL s for Myopia and Hyperopia Intralase Flap Creation Refractive Lensectomy for Hyperopia Striae treatment: smoothing, sutures, PTK Measurement and Treatment of HOA s Restoration of Accommodation Change... in Refractive Surgery Change... in Refractive Surgery constant count on it deal with it patients should be informed of it past present future 23

$surgical) Surgical options Halos & Glare Types of Refractive Error Nearsightedness Farsightedness$

24 Patient Counseling Alternatives discussion (i.e. optical vs. surgical) Surgical options Halos & Glare Types of Refractive Error Nearsightedness Farsightedness Astigmatism Low Order Aberrations 24

25 Types of Refractive Error Nearsightedness Farsightedness Astigmatism High Order Aberrations Low Order Aberrations Glasses and Contact Lenses Only treat low order aberrations Conventional Laser Vision Correction Treats low order aberrations 25

26 Wavefront Measurement Probe Light Beam Re-Emitted Wavefront for an Ideal Eye Plane Wavefront Re-Emitted Wavefront for a Non-Ideal Eye Complex Wavefront 26

27 Re-Emitted Wavefront for a Non-Ideal Eye Complex Wavefront Size of the Pupil is the size of the emitted Wavefront Custom Laser Vision Correction Treats low order and high order aberrations Treats based on the wavefront measurement (the optical fingerprint of the eye) Custom Laser Vision Correction Treats low order and high order aberrations Treats based on the wavefront measurement (the optical fingerprint of the eye) Lessens the chance of inducing HOA s with PRK or LASIK 27

28 Patient Counseling: Surgical Options.Myopia < 3.0 diopters PRK, LASIK, Intacs Patient Counseling: Surgical Options.Myopia < 3.0 diopters PRK, LASIK Patient Counseling: Surgical Options.Myopia < 3.0 diopters PRK, LASIK, If this were my eyes I would do PRK 28

29 Patient Counseling: Surgical Options.Myopia < 3.0 diopters RK,PRK, LASIK LASIK or phakic IOL Patient Counseling: Surgical Options.Myopia < 3.0 diopters RK,PRK, LASIK LASIK or phakic IOL LASIK or phakic IOL Patient Counseling: Surgical Options.Myopia < 3.0 diopters RK,PRK, LASIK LASIK or phakic IOL LASIK or phakic IOL > 9.0 phakic IOL 29

30 Patient Counseling: Surgical Options.Myopia < 3.0 diopters RK,PRK, LASIK LASIK or phakic IOL LASIK or phakic IOL, nothing > 9.0 phakic IOL, nothing Implants Work well Will lessen the amount of Lasik being performed in our country The cornea was not meant to be altered too much (don t thin or flatten it too much) Corneal Limits K s of 35 Posterior untouched cornea: 300 on initial Lasik 250 when maximum 30

31 Phakic IOL s in my practice Lasik and Phakic IOL investigator from the beginning Beginning of LASIK diopter a month club < 12 < 11 < 10 < 9 < 8 < 7 if cornea is thin or flat I will recommend IOL in lower corrections Myopes Phakic IOL s vs Refractive Lensectomy Less risk of retinal detachment with phakic IOL movement of the posterior capsule forward when the crystalline lens is removed posterior capsule vitreous attachments resultant vitreous traction IOL s Risks Corneal decompensation Cataract Infection Glaucoma Retinal Detachment Other risks 31

32 Phakic Implants Artisan Lens Staar ICL Visian ICL Scheimpflug Photo 32

33 Verisyse 33

34 Preop Visante Postop Visante Postop Visante 2.0 mm central clearance 1.5 mm peripheral clearance 34

35 Endothelial Cell Density Monitor yearly when stabilizes monitor every two years Mean Spherical Equivalent Manifest Refraction Stability D D from 6 mos. to 1 yr D from 2 yr. to 3 yr. Preop 1 d 1 wk 1 mo 3 mo 6 mo 1 yr 2 yr 3 yr Time After Surgery yes Percent of E Change in BSCVA at Three Years First Eyes (n=228) % % > +2 Snellen Lines Gained/Lost 35

36 Patient Counseling: Surgical Options Hyperopia <3.0 PRK or LASIK Patient Counseling: Surgical Options Hyperopia <3.0 PRK or LASIK D PRK, LASIK, phakic hki IOL, Refractive Lensectomy Patient Counseling: Surgical Options Hyperopia <3.0 PRK or LASIK 3040D D PRK, LASIK, phakic hki IOL, Refractive Lensectomy Over 4.0 D Phakic IOL, Refractive Lensectomy 36

37 Hyperopia Refractive Lensectomy > 50 years of age Over 3.0 D of hyperopia Don t like to do this for myopia unless there is early NS or significant spherical aberration In hyperopia there is not the same retinal/vitreous issues as in myopia If no NS and no significant SA Phakic IOL The Crystalline Lens As we age the spherical aberration of the lens changes from negative to positive This is in addition to the positive spherical aberration that the cornea often has Result: reduction in contrast sensitivity (may still see 20/20) The Crystalline Lens As we age the spherical aberration of the lens changes from negative to positive This is in addition to the positive spherical aberration that the cornea often has Result: reduction in contrast sensitivity (may still see 20/20) This is why I am very wary about laser vision correction in a patient over 55 y.o. with a lot of spherical aberration 37

38 Over 55 y.o. Laser Candidate Are you happy with your glasses or contact lens corrected vision? How is your night time image quality? Wavefront: is there a lot of HOA s? Over 55 y.o. Laser Candidate Are you happy with your glasses or contact lens corrected vision? How is your night time image quality? Wavefront: is there a lot of HOA s? After this line of questioning if I think there is something going on in their lens I am less excited about doing something over that lens i.e. laser or phakic IOL. I would then lean towards nothing or refractive lensectomy. HD Analyzer OSI (Objective Scatter Index), indicates the degradation of the retinal image. 38

39 Over 55 y.o. Laser Candidate HD Analyzer OSI (Objective Scatter Index), indicates the degradation of the retinal image. HD Analyzer OSI (Objective Scatter Index), indicates the degradation of the retinal image. 39

40 HD Analyzer OSI (Objective Scatter Index), indicates the degradation of the retinal image. A Refractive Surgery Mindset Optics Reduced best corrected vision: X X /25 blurry 40

41 X X /25 blurry 20/20 crisp A Refractive Surgery Mindset Optics Reduced best corrected vision: Corneal irregularity Cataract A Refractive Surgery Mindset 41

$Unhappy Refractive Surgery$ custom if there is another

42 Unhappy Refractive Surgery Patient Don t treat with custom if there is another cause Tempting to do wavefront guided rx I do if BCVA is reasonable and the case is not too unusual Corneal limitations: thickness Be careful in these situations 42

43 Surgical Developments That Have Contributed Positively To My Patient Care: Excimer laser PRK and LASIK Phakic IOL s for Myopia and Hyperopia Intralase Flap Creation Refractive Lensectomy for Hyperopia Striae treatment: smoothing, sutures, PTK Measurement and Treatment of HOA s Restoration of Accommodation Modern Day Refractive Surgery PRK LASIK Laser Flaps Ability to treat HOA s Intacs CK AK Phakic IOL s Refractive Lensectomy Choosing the Right Procedure for the Right Patient: PRK, LASIK, Custom Ablation, Phakic IOL s, Pseudophakic IOL s Don t treat too deep with surface ablation Don t treat too high with Lasik Be aware of the limitations of treating HOA s 43

44 Refractive Surgery: My Way Thank You! 44

Causes of refractive error post premium IOL s 3/17/2015. Instruction course: Refining the Refractive Error After Premium IOL s.

$Causes of refractive error post premium IOL s 3/17/2015. Instruction course: Refining the Refractive Error After Premium IOL s.$ Instruction course: Refining the Refractive Error After Premium IOL s. Senior Instructor: Mounir Khalifa, MD Instructors: David Hardten,MD Scott MacRea,MD Matteo Piovella,MD Dr. Khalifa: Causes of refractive