4/11/2016 DISCLOSURES DR. EIDEN (CONSULTING, LECTURER, RESEARCH, OR FINANCIAL INTEREST*)

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Marianna Doyle
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4th 3rd 2nd 1st ( 1, -1) ( 1, 1) ( 2, -2) ( 2, 0) ( 2, 2) ( 3, -3) ( 3, -1) ( 3, 1) ( 3, 3) ( 4, -4) ( 4, -2) ( 4, 0) ( 4, 2) ( 4, 4) 4/11/2016 ADVANCED REFRACTIVE ANALYSIS, BEYOND JUST BETTER ONE OR

Keratoconus Specialists of Illinois International Keratoconus Academy EyeVis Eye and Vision Research Adjunct Faculty: University of Illinois Medical Center, Dpt. of Ophthalmology Indiana Univ.

EIDEN (CONSULTING, LECTURER, RESEARCH, OR FINANCIAL INTEREST*) Alcon Alden Allergan Bausch & Lomb Brien Holden Vision Institute & Diagnostics Cooper Vision Marco Oasis Medical Oculus Optovue Special

1 4th 3rd 2nd 1st ( 1, -1) ( 1, 1) ( 2, -2) ( 2, 0) ( 2, 2) ( 3, -3) ( 3, -1) ( 3, 1) ( 3, 3) ( 4, -4) ( 4, -2) ( 4, 0) ( 4, 2) ( 4, 4) 4/11/2016 ADVANCED REFRACTIVE ANALYSIS, BEYOND JUST BETTER ONE OR TWO... INCORPORATION OF WAVEFRONT TECHNOLOGY IN VISION ANALYSIS S. Barry Eiden, OD, FAAO North Suburban Vision Consultants, Ltd. Keratoconus Specialists of Illinois International Keratoconus Academy EyeVis Eye and Vision Research Adjunct Faculty: University of Illinois Medical Center, Dpt. of Ophthalmology Indiana Univ., Illinois, UMSL and PCO Colleges of Optometry Zernike Chart Podium Presentations DISCLOSURES DR. EIDEN (CONSULTING, LECTURER, RESEARCH, OR FINANCIAL INTEREST*) Alcon Alden Allergan Bausch & Lomb Brien Holden Vision Institute & Diagnostics Cooper Vision Marco Oasis Medical Oculus Optovue Special Eyes SynergEyes Visionary EyeVis Eye and Vision Research* FOR INFORMATION INCLUDED IN THIS PRESENTATION: SBEIDEN@NSVC.COM HOW WOULD YOU FIGURE THIS ONE OUT? 59yoF: c/o blur, distortion, glare OS over past months increasing gradually. Manifest: OD x100 20/20 OS x080 20/25- Sim-K: OD 43.50/43.62@180 OS 42.50/45.00@160 SLE /Fundus: OD Trace ACC/NS OS +1ACC/+1NS/Trace+ PSC DFE: normal OU Mac OCT: normal OU THE CASE OF: I JUST CAN T SEE! Patient referred to cataract surgeon and has phaco with toric IOL OS presents at 1 mo S/P: I can t see much worse at night sxs of halo, glare +++ Manifest OS: plano-0.25x155 20/20+2 SLE: unremarkable No PCO Fundus and mac OCT normal PERFORM ABERROMETRY (w/ OPD3): LEFT EYE S/P Toric IOL: Note difference in High Order Aberrations Total between right and left eye! Yet acuity is 20/20+ 1

LEFT EYE S/P Toric IOL: Note that Total PSF apx = High Order PSF showing virtually no low order aberrations!

$refractive error but no sig.$ Aberrometry demonstrates in many cases why patients are symptomatic Aberrometry can help differentiate where

in terms of suggested treatment options to address the problem and will also function as an excellent

Will require lens repositioning. Temp. use of miotics at night (A-P no sig help, required P0.

IT: ABERRATION CONTROL: IN THE SPOTLIGHT WHO MIGHT BENEFIT?

2 LEFT EYE S/P Toric IOL: Note that Total PSF apx = High Order PSF showing virtually no low order aberrations! RIGHT EYE (no surgery, no sig cataract): Note Total PSF is greater vs High Order PSF due to uncorrected refractive error but no sig. HOAs TAKE HOME FROM THE CASE: There can be significant symptoms in the presence of excellent visual acuity Aberrometry demonstrates in many cases why patients are symptomatic Aberrometry can help differentiate where the source of high order aberrations are coming from (cornea vs internal) Aberrometry can guide the clinician in terms of suggested treatment options to address the problem and will also function as an excellent educational tool for patient s to understand their situation. RETRO IMAGE from OPD3: OOPS decentered IOL! Will require lens repositioning. Temp. use of miotics at night (A-P no sig help, required P0.5% at dusk to help) NOW LETS GET A BETTER UNDERSTANDING OF WHAT ABERROMETRY IS ALL ABOUT AND HOW WE CAN USE IT: ABERRATION CONTROL: IN THE SPOTLIGHT WHO MIGHT BENEFIT? My glasses/cl s are great during the day, but boy do I have problems night driving. My doctor told me that I have 20/20 vision with my contacts but things just seem out of focus! I have very big pupils and I was told that is why my vision is never very clear with my glasses and contacts. 2

ABERRATIONS Lower order aberrations Spherical component Astigmatism Higher order

HIGH ORDER ABERRATIONS 4th 3rd 2nd 1st Zernike Chart Podium Presentations ( 1, -1) (

$4, 0) ( 4, 2) ( 4, 4) HIGHER ORDER ABERRATION Defined as: Any refractive error that$ trefoil, spherical aberration, chromatic aberration, etc.

eyes 20/10 UNCORRECTED PATIENT Ref +0.04 + 0.

3 ABERRATIONS Lower order aberrations Spherical component Astigmatism Higher order aberrations Coma Trefoil Spherical aberration Etc. LOW ORDER VS. HIGH ORDER ABERRATIONS 4th 3rd 2nd 1st Zernike Chart Podium Presentations ( 1, -1) ( 1, 1) ( 2, -2) ( 2, 0) ( 2, 2) ( 3, -3) ( 3, -1) ( 3, 1) ( 3, 3) ( 4, -4) ( 4, -2) ( 4, 0) ( 4, 2) ( 4, 4) HIGHER ORDER ABERRATION Defined as: Any refractive error that cannot be corrected by sphero-cylindrical lens combinations Examples include coma, trefoil, spherical aberration, chromatic aberration, etc. Higher order aberrations make up approximately 15% of the total aberrations of normal eyes 20/10 UNCORRECTED PATIENT Ref X 110 Lower Higher SIMPLE REFRACTIVE ERROR EG. WHERE 99% OF TOTAL ABBERATION IS LOWER ORDER ABERRATIONS Lower Keratoconus WITH SIGNIFICANT LOW & HIGH ORDER ABERRATIONS Higher RMS = 11µm 3

4 SOURCES OF ABERRATIONS Induced: Corrective Therapies Spectacles Contact Lenses Intra-Ocular Lenses Refractive surgery Inherent: Ocular System Tears* Cornea* Aqueous Lens* Vitreous Retina ABERRATION-FREE EYE If a parallel bundle of rays enter an eye focused for optical infinity and they are perfectly focused on the retina, the rays exiting the eye from the point source on the retina will be parallel, forming a flat wave-front. IDEAL VISION IDEAL VISION Parallel Light Rays Sharp Focus on Retina Plane Wavefront RE-EMITTED WAVEFRONT FOR AN IDEAL EYE WAVEFRONT Perfect wavefront would look like a sheet of paper standing on end. Ideal Plane Wavefront Eye World/ Nov 2000 Refractive Surgery Wavefront property: Appraising the numbers 4

WAVEFRONT DISPLAYS FOR IDEAL VISION WAVEFRONT Any deviation from that flat plane configuration in the wavefront analysis is called an

$Deformed 3-D Representation 2-D Color Map Eye World/ Nov 2000 Refractive Surgery Wavefront property: Appraising the numbers Astigmatism$ cylinder) High Order (Coma, Trefoil, S.A., then others.) Optical Path Difference (OPD) Root Mean Square (RMS) Total vs. Low vs.

cylinder) High Order (Coma, Trefoil, S.A., then others.) Optical Path Difference (OPD) Root Mean Square (RMS) Total vs. Low vs.

High Total, External and Internal OPTICAL PATH DIFFERENCE (OPD): Describes the variation of the optical path length (OPL) or optical

In essence OPD describes the variation of the optics within the area of the visual system being measured.

5 WAVEFRONT DISPLAYS FOR IDEAL VISION WAVEFRONT Any deviation from that flat plane configuration in the wavefront analysis is called an Aberration. Deformed 3-D Representation 2-D Color Map Eye World/ Nov 2000 Refractive Surgery Wavefront property: Appraising the numbers Astigmatism Defocus (Refraction) Higher Zernike Images 2 nd Order 3 rd Order 4 th Order 5 th Order KEY TERMS: Aberrations Low Order (sphere and cylinder) High Order (Coma, Trefoil, S.A., then others.) Optical Path Difference (OPD) Root Mean Square (RMS) Total vs. Low vs. High Total, External and Internal Point Spread Function (PSF) Total vs. Low vs. High Total, External and Internal OPTICAL PATH DIFFERENCE (OPD): Describes the variation of the optical path length (OPL) or optical distance of the path light follows through the system. In essence OPD describes the variation of the optics within the area of the visual system being measured. This is a total optical performance measure that takes into account the entire optical system. A perfect optical system will have no variation or zero OPD, however this is never the case in the human eye. ROOT MEAN SQUARE (RMS) Takes all of the wavefront elevations above and below the reference plane, squares them, and takes the root mean Quantifies the magnitude of deviation from a planar wavefront i.e.: RMS Quantifies Aberrations 5

ROOT MEAN SQUARE (RMS) TOTAL ROOT MEAN SQUARE Analogy: Spherical equivalent combines sphere and cylinder RMS does the same for all aberrations Total RMS error allows us to calculate the: Total

light that is focused through an optical system. The PSF can be differentiated in terms of Total, Corneal, Internal and Total vs.

6 ROOT MEAN SQUARE (RMS) TOTAL ROOT MEAN SQUARE Analogy: Spherical equivalent combines sphere and cylinder RMS does the same for all aberrations Total RMS error allows us to calculate the: Total Aberrations vs: Low Order RMS & High Oder RMS Can be differentiated between total, corneal, and internal Etc POINT SPREAD FUNCTION (PSF) Pictorially demonstrates what happens to a point source of light that is focused through an optical system. The PSF can be differentiated in terms of Total, Corneal, Internal and Total vs. High Order Excellent Educational Tool AUTO-CALIBRATION Aberrations of the cornea and lens can partially compensate for one another. In other words: The whole is greater than the sum of it s parts the whole eye often has better optical quality than the individual optical components alone. The Whole Eye is Better than the Sum of Its Parts Artal, Guirao, Berrio, and Williams, Journal of Vision,1, 2001 ABERRATIONS AND PUPIL SIZE Varying Pupil Size Cornea Internal Optics Whole Eye In a typical normal eye, wavefront aberrations become more apparent as the pupil size increases (> 3mm) As pupil size approaches 6.0 mm high order aberrations (HOA s) have the most debilitating impact on vision C. of Williams Lab - CVS 6

CORNEAL TEAR FILM Significant optical aberrations appear when the tear

44 fold compared with HOAs prior to tear film breakup AGE RELATED

aberrations probably remain static between 20 and 40 years of age.

Study conducted by researchers at Osaka University Medical School,

from changes occurring in the crystalline lens as we age.

is often helpful in diagnosing in OSD observe Placido rings

$Autorefractor/Autokeratometer ABERROMETERS Topcon KR 9000 T/A/A Zwave$ A/A Allegro-1 A/A itrace T/A/A Ophthonix Z View A/A Optical Path

lens consultation and Pentacam analysis due to reduced BVA at recent

is a religious orthodox Jewish kid and reads virtually all waking

7 CORNEAL TEAR FILM Significant optical aberrations appear when the tear layer becomes disrupted. HOAs after tear film breakup increased 1.44 fold compared with HOAs prior to tear film breakup AGE RELATED INFLUENCES ON ABERRATIONS Studies have revealed that optical aberrations probably remain static between 20 and 40 years of age. After the age of 40, aberrations have been shown to increase. Study conducted by researchers at Osaka University Medical School, Japan The primary degradation from trefoil and spherical aberration is from changes occurring in the crystalline lens as we age. *Ocular surface influence on HOAs must be considered and aberrometry is often helpful in diagnosing in OSD observe Placido rings distortion, location, repeatability, etc. Discovery Marco/Nidek OPD3 Aberrometer/Topographer Autorefractor/Autokeratometer ABERROMETERS Topcon KR 9000 T/A/A Zwave A/A Allegro-1 A/A itrace T/A/A Ophthonix Z View A/A Optical Path Diagnostic Decision Matrix CASES 13 YOM - History Referred for contact lens consultation and Pentacam analysis due to reduced BVA at recent exam by an ophthalmologist. Desired to R/O KCN. Prior told had bilateral amblyopia! Full time FT28 Bifocal Spec Rx wear, first given bifocals 1 yr ago (he is a religious orthodox Jewish kid and reads virtually all waking hours and bifocal helps him. Feels DV is not as good as it could be. NV excellent (uses FT bifocal). No other visual/ocular sxs incl: (-) dryness, itch, flashes, floaters, diplopia. Last year prior attempts at SCL and corneal GP CLs failed due to comfort (GPs) and vision quality/stability (SCLs). LEE: 2 weeks ago Pt began spec wear in 1st grade. Father very nearsighted. 7

Clinical Findings Clinical Findings BCSVA OD 20/25-2 -7.00-2.00x12 OS 20/30+2-6.50-2.

motilities, VF normal OU Fundus: unremarkable OU, including macula OCT OU Pentacam:

steep, normal anterior and posterior elevation (astigmatic), thin pachy but normal PTI

primarily coma Question: is this simply a case of naturally occurring irregular

$0 design Blanchard Labs) and achieved 20/20+ over refraction VA with good comfort,$

8 Clinical Findings Clinical Findings BCSVA OD 20/ x12 OS 20/ x180 Biomicroscopy: unremarkable OU Spec Microscopy: Normal OU Pupils, color vision, motilities, VF normal OU Fundus: unremarkable OU, including macula OCT OU Pentacam: asymm. bowtie sup. steep, normal anterior and posterior elevation (astigmatic), thin pachy but normal PTI (pachymetric progression) and BAD3 (Belin Ambrosio Ectasia Analysis) OU OPD3 Aberrometry: OD: Brdln. HOAs 3 and 6mm corneal pattern OS: Mild elevation HOAs 3 and 6mm corneal pattern, primarily coma Question: is this simply a case of naturally occurring irregular astigmatism (asym. bowtie pattern) vs. early indication of development of KCN? Management Fit patient in scleral GPs (Onefit 2.0 design Blanchard Labs) and achieved 20/20+ over refraction VA with good comfort, vision and physical fit OU. Plan for Ongoing Management Close monitoring (Q-6mo) for progressive ectasia using: Pentacam OPD3 ASOCT (epithelial thickness software) Corneal Biomechanics (Corvis technology) 8

$Superior right is OPD map of total refractive power of vision system, Axial shows power$ RMS (root mean square) is a measure of total high order aberrations (normal limit at

RMS (root mean square) is a measure of total high order aberrations (normal limit at

OS is greater. HOAs are relatively greater OS vs OD and primarily corneal origin.

9 Superior right is OPD map of total refractive power of vision system, Axial shows power of cornea via topography, Internal OPD is primarily lenticular power distribution. RMS (root mean square) is a measure of total high order aberrations (normal limit at 3mm is apx0.35d, at 6mm up to apx 0.6D is normal. Here HOAs are just slightly elevated. OS is greater. HOAs are relatively greater OS vs OD and primarily corneal origin. Point spread function OD mild elevation HOAs shown Point spread function OS mod elevation HOAs shown 9

OD Zernike breakdown of types of HOAs for overall HOAs, Corneal and Internal, Note how HOAs are primarily induced by cornea OS

but overall greater HOAs OS vs. OD 63 yom KCN Keratoconus OD>OS (OS sub-clinical) Manifest: OD -6.50-5.

Ring, no scar Mild lenticular changes - +1 NS and ACC* Diagnostic Scleral GP: significant improvement however not as much as

OPD3 Scan: dramatic elevation of HOAs contributions both from Keratoconic cornea (primary) but also internal due to early

10 OD Zernike breakdown of types of HOAs for overall HOAs, Corneal and Internal, Note how HOAs are primarily induced by cornea OS Zernike breakdown of types of HOAs for overall HOAs, Corneal and Internal, Note how HOAs are primarily induced by cornea again, but overall greater HOAs OS vs. OD 63 yom KCN Keratoconus OD>OS (OS sub-clinical) Manifest: OD x15 20/30-3 SLE OD: Cornea - + V. Striae, F. Ring, no scar Mild lenticular changes - +1 NS and ACC* Diagnostic Scleral GP: significant improvement however not as much as would have been expected based on degree of corneal distortion. OPD3 Scan: dramatic elevation of HOAs contributions both from Keratoconic cornea (primary) but also internal due to early cataracts. Pattern primarily dictated by cornea (similar pattern) OPD3 Scan with diagnostic scleral GP on eye sphero-cylinder over Refraction. Results in acuity of 20/20-3 and dramatic reduction of HOAs total (even greater reduction of corneal HOAs as expected). BVACL limited by lenticular changes and internal HOAs. 10

$worse Manifest Refraction: OD +0.50-1.00x060 20/25 (significant flux w/blink) SLE: + MGD, low TBUT, particulate tear film, desiccation SPK +1, Osmolarity elevated OD 323 OS 311.$ $vision more stable. Repeat Manifest refraction: +0.25-1.25x060 20/20 much more stable. Subsequently did ongoing tx series still under therapy.$ OPD3 Scan following 2 weeks of therapy: shows significant reduction of HOAs from cornea and better stability of mires. This corroborates with improved symptoms.

OPD3 Scan following 2 weeks of therapy: shows significant reduction of HOAs from cornea and better stability of mires. This corroborates with improved symptoms.

$successful SCL MF wear x 10 years. C/O increasing blur (OD>OS), MF not working as well. The two eyes of this patient illustrate the OPD3 scan refractive triage. The right eye 3mm RMS value of 0.$

11 51 yof OSD eg. OD Total PSF Corneal PSF Internal PSF Total PSF w/ Scleral CL Corneal PSF w/scleral CL Presented with c/o blurry vision, fluctuating vision, irritated and red eyes chronic over past year but getting worse Manifest Refraction: OD x060 20/25 (significant flux w/blink) SLE: + MGD, low TBUT, particulate tear film, desiccation SPK +1, Osmolarity elevated OD 323 OS 311. Tx with 2 week FU: Lotemax QID, Avanova BID, Bruder heat mask BID, Oasis + drops QID, First in office Miboflow Tx 2wks: significant but not 100% improvement eyes less red, more comfortable, vision more stable. Repeat Manifest refraction: x060 20/20 much more stable. Subsequently did ongoing tx series still under therapy. OPD3 Scan: elevated HOAs with primarily corneal origin and mild irregularity in Placido mires that varied in degree and location with blink. OPD3 Scan following 2 weeks of therapy: shows significant reduction of HOAs from cornea and better stability of mires. This corroborates with improved symptoms. Patient requires ongoing therapy and has experienced further reduction of sx s and is now able to wear PT DD CLs for social occasions (prior total CL intolerance). Optical Path Diagnostix SM Diagnosis and Guiding Therapy Cataract Optical Path Diagnostix SM : Diagnosis and Guiding Therapy- Cataract Retro-illumination Image Overview Summary OD OS 50 yo wf, successful SCL MF wear x 10 years. C/O increasing blur (OD>OS), MF not working as well. The two eyes of this patient illustrate the OPD3 scan refractive triage. The right eye 3mm RMS value of 0.69 D indicates she would be unlikely to achieve 20/20 or better acuity, while the left eye has an RMS of.20 D, and would be expected to be correctable to 20/20 or better. The right eye s pattern is more defined as that of trefoil. The HOA table confirms that the major high order aberration responsible for the high RMS value is trefoil, and it is internal (behind the corneal surface). Essentially ALL the aberration comes from the internal optical elements. Internally located trefoil is often seen in cataract cases. Viewing the retro images confirms the presence of a central cataract as the reason for the acuity limiting high order aberrations. The comparison of the total OPD, Internal OPD and Axial maps show where the problem is, and why she can t be corrected with contacts or spectacles. The associated PSF maps show her the optical effects of uncorrectable distortion, and cataract surgery is scheduled: OD first, then OS one week later. 11

Optical Path Diagnostix SM Diagnosis and Guiding Therapy Non-surgical Cataract Optical Path Diagnostix SM Diagnosis and Guiding Therapy Non-surgical Cataract: Day and Night Summary / Retro

Diagnosis is done, referral is in order. He refused because about to embark on a vacation for a month that has been planned for six years. Needs to see better, without Sx. After dilating with 2.

He will use the Rx, and the drops for the vacation, and is scheduled for surgery on his return. Retro shows the cataracts. Diagnosis is done, referral is in order.

12 Optical Path Diagnostix SM Diagnosis and Guiding Therapy Non-surgical Cataract Optical Path Diagnostix SM Diagnosis and Guiding Therapy Non-surgical Cataract: Day and Night Summary / Retro Illumination 67 yo wm. OD 20/40, OS 20/30. No retinal disease. Tool and die maker, recently started noticing difficulty reading the micrometer and scale on Bridgeport. Retro shows the cataracts. Diagnosis is done, referral is in order. He refused because about to embark on a vacation for a month that has been planned for six years. Needs to see better, without Sx. After dilating with 2.5% phenylephrine, the WF was sent, indicating a low RMS and predominantly LOA affecting the vision, when the pupil is larger. Rx developed for 20/20-2 and 20/25 results. He will use the Rx, and the drops for the vacation, and is scheduled for surgery on his return. Retro shows the cataracts. Diagnosis is done, referral is in order. He refused because about to embark on a vacation for a month that has been planned for six years. Needs to see better, without Sx. WAVEFRONT REFRACTION WILL IT BE THE NEXT BIG WAVE AS WE RIDE ON OUR JOURNEY IN REFRACTIVE VISION CORRECTION? Thank You! 12

10/25/2017. Financial Disclosures. Do your patients complain of? Are you frustrated by remake after remake? What is wavefront error (WFE)?

10/25/2017. Financial Disclosures. Do your patients complain of? Are you frustrated by remake after remake? What is wavefront error (WFE)? Wavefront-Guided Optics in Clinic: Financial Disclosures The New Frontier November 4, 2017 Matthew J. Kauffman, OD, FAAO, FSLS STAPLE Program Soft Toric and Presbyopic Lens Education Gas Permeable Lens