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Disclosures Refractive Surgery PRK Vs LASIK Refractive Error Case

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Disclosures Refractive Surgery PRK Vs LASIK Refractive Error Case 9/11/2015 Disclosures Navigating the Refractive • TLC Vision – Employee Surgery Menu • Alcon – Advisory board Bill Tullo, OD, FAAO Diplomate AAO Cornea, CL & Refractive Surgery Vice-President of Clinical Service TLC Laser Eye Centers Refractive Surgery PRK vs LASIK • Corneal • Intraocular • PRK Advantage • LASIK Advantage – LASIK – Phakic IOL – No flap – Fast visual recovery • Verisys – Less tissue removed – Minimal Discomfort – Surface Ablation • Visian • PRK • LASEK – CLE • Epi-LASIK • PRK Disadvantage • LASIK Disadvantage – Cataract Surgery – Slow visual recovery – Flap complications – AK - Femto • Toric IOL • Multifocal IOL – Some pain/discomfort – More tissue removed • Accommodative IOL – ICRS - Intacs • Femtosecond Assisted Refractive Error Case # 1 • 25 yo male • Myopia • Ocular/Systemic health history unremarkable • Astigmatism • No medications • Hyperopia • Dry Rx -3.00 DS OU • Presbyopia • BCVA 20/20 OD/OS/OU • Pachymetry 545 OU • Normal Topography OU • What procedure would you recommend? 1 9/11/2015 Femtosecond LASIK Flap iFS Advantages of Femtosecond Flap PRK vs LASIK • Ocular Health • Independent specific • Safer diameter – Less complications – Dry Eye • Independent specific – Less loss of BCVA – EBMD thickness – More gain of BCVA – Corneal Degeneration • Better flap centration – Biomechanically stronger • FFK (irregular topography) • Variable hinge size/location – Lower risk of keratectasia • Terrian’s • Beveled edge • Better Efficacy • Smooth evenly hydrated – Induce less HOA – Corneal Dystrophy stromal bed – Smoother beds • Meesman’s • Conserve tissue – Even hydration • Avellino • Planar shape – Faster visual recovery • Fuch’s – Better Low Contrast vision Case # 2 PRK vs LASIK • 25 yo male • Systemic Disease • Ocular/Systemic health history unremarkable – Keloids • No medications – Rheumatoid Arthritis • Dry Rx -6.00 DS OU – Crohn’s Disease – IBS – Lupus • BCVA 20/20 OD/OS/OU – Fibromyalgia • Pachymetry 545 OU – HIV • Normal Topography OU • What procedure would you recommend? 2 9/11/2015 Case # 3 PRK vs LASIK • 25 yo male • Corneal Thickness • Ocular/Systemic health history unremarkable – Minimal CCT – Central Corneal Thickness • No medications – Minimal RSB - Residual Stromal Bed • Dry Rx -9.00 DS OU • Corneal Topography • BCVA 20/20 OD/OS/OU • Pachymetry 545 OU • Occupation • Normal Topography OU • What procedure would you recommend? Case # 4 STAAR Visian® ICL (Implantable Collamer Lens ) • 25 yo male • Ocular/Systemic health history unremarkable • FDA approval in • No medications December 2005 • Dry Rx -12.00 DS OU • Safety • Quality of Vision • BCVA 20/20 OD/OS/OU • Biocompatibility • Pachymetry 545 OU • Versatility • Normal Topography OU • Simplicity • Cosmetic Appearance • Rapid Recovery • What procedure would you recommend? • Removable Patient History and Qualifications Contraindications • Careful questioning and gauging • Patients under age 21 • History of: expectations • Progressive refractive – Iritis • History of contact lens wear error – Synechiae – D/C soft lens for 3 days • Cornea/Endothelial – Pigment dispersion pathology – Pseudoexfoliation – D/C rigid lens for 3 weeks • Glaucoma • Previous corneal/refractive • Opportunity for the patient to ask questions • Narrow AC angle surgery? and counseling provided by the • Cataract or capsular • Keratoconus? (Toric professional/staff opacification ICL) 3 9/11/2015 Exam and Testing Exam and Testing • Manifest and cycloplegic refraction • Anterior chamber depth • Unaided and aided visual acuities • Intraocular pressure (IOP) • Keratometry or corneal topography • Biomicroscopy-dilated and undilated • Gonioscopy (grade 2 or greater) • Ophthalmoscopy-dilated • Pachymetry-corneal thickness • Horizontal white to white- • Pupil size in normal and mesopic conditions UBM / caliper / Orbscan (6mm or under mesopic) • 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 ICL Post-op Care • Follow normal cataract routine • IOP is critical • Over-refraction • A/C exam for inflammation • First 2 weeks: NSAID, steroid, antibiotic • Evaluate the vault of the ICL TID – .5-1x corneal thickness is ideal • Next 2 weeks: NSAID and steroid BID • Under .5 observe for anterior capsule haze • Over 1.5 observe for narrowing angle • Dilate for crystalline lens evaluation 4 9/11/2015 Slitlamp Exam ICL Vault of the Visian ICL Unchanged Cornea ICL vault Most common complication is early Pupillary Block - Treatment pupillary block • 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 Case # 5 • Uncorrected Visual acuity • 25 yo male • Dry Refraction (Day 7 & beyond) • Ocular/Systemic health history unremarkable • Biomicroscopy • No medications • ICL Vault (Vault .5 to 1.5 ct) • Dry Rx -3.00 -4.00 x 010 DS OU • PI Patency • Inflammation • BCVA 20/20 OD/OS/OU • Tonometry • Pachymetry 545 OU • Evaluation of crystalline lens • Normal Topography OU • DFE Yearly • What procedure would you recommend? 5 9/11/2015 Femto- AK Femtosecond AK and Incisions Incomparable safety 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 Case # 6 Hyperopia • 25 yo male • Patient Discussion • Ocular/Systemic health history unremarkable – Dry eyes • No medications • Steep keratometry – Regression • Dry Rx +3.00 DS OU – Enhancements • BCVA 20/20 OD/OS/OU • Pachymetry 545 OU • Normal Topography OU • What procedure would you recommend? Case # 7 Case # 8 • 25 yo male • 55 yo male • Ocular/Systemic health history unremarkable • Ocular/Systemic health history unremarkable • No medications • No medications • Dry Rx +6.50 DS OU • Dry Rx +6.50 DS OU • BCVA 20/20 OD/OS/OU • BCVA 20/20 OD/OS/OU • Pachymetry 545 OU • Pachymetry 545 OU • Normal Topography OU • Normal Topography OU • What procedure would you recommend? • What procedure would you recommend? 6 9/11/2015 Manual Cataract Surgery Today Manual Capsulorhexis • 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. MK-00251 Rev A Manual vs. Catalys Cataract Surgery – Femtosecond Laser Cataract Surgery 1 month postop • 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 Surgery Catalys Surgery MK-00251 Rev A MK-00251 Rev A ENGAGE with Liquid Optics™ Interface VISUALIZE and CUSTOMIZE with Integral Guidance™ • Gentle dock for patient with minimal intraocular pressure (IOP) rise and • Integrated near-infrared video and 3D spectral domain OCT systems minimal hemorrhaging visualize from anterior cornea through posterior lens • No corneal distortion or induced folds • Sophisticated algorithms customize treatment plan in 3D to anatomy of • Clear optical path for precise imaging and laser delivery each patient Liquid Optics Docking Liquid Optics Suction Catalys OCT with Liquid Ring Optics Catalys 3D spectral domain Ocular surfaces mapped and Liquid Optics Advantage: Optical and comfort gains OCT treatment customized even when lens is tilted MK-00185 Rev B MK-00251 Rev A MK-00185 Rev B MK-00251 Rev A 7 9/11/2015 Catalys Clinical Results: Catalys Unique Lens Fragmentation Capsulotomy Shape Reduces Phaco Energy and Manual Capsulorhexis Manipulations More predictable and precise cuts More predictable outcomes Catalys Capsulotomy Better outcomes Images courtesy of OptiMedica Images courtesy of OptiMedica Corp. MK-00251 Rev A MK-00185 Rev B MK-00251 Rev A Catalys Clinical Results: Interface Configurations: IOP rise Impact on Effective Phaco Time 100.00 90.00 Curved Lens Effective 80.00 porcine (n=6) Phaco Time 70.00 (s) Femto 0.16 ± 0.21 60.00 (n=57) 50.00 Liquid Optics porcine (n=3) Standard 4.07 ± 3.14 40.00 (n=52) 30.00 IOP Rise (mmHg) Rise IOP 20.00 Liquid Optics 10.00 cadaver (n=6) Effective Phaco Time (seconds) 0.00 Standard Cataract Surgery Catalys 0 100 200 300 400 500 600 700 Suction Vacuum (mmHg) 96% reduction in effective phaco time compared to standard Liquid Optics has >4x reduction in IOP rise at procedure suction Data courtesy of Prof. Burkhard Dick, MD, PhD. Ruhr University Eye Hospital. Bochum, Germany, Member of pressure OptiMedicaMK-00185 Rev Medical B Advisory Board. MK-00251 Rev A MK-00185 Rev B Data courtesy of OptiMedica MK-00251 Rev A 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 MK-00251 Rev A 8 9/11/2015 Case # 9 Surface Ablation • 25 yo male • PRK – Photorefractive keratotomy • Ocular/Systemic health history unremarkable • LASEK – Alcohol assisted with epi-flap • No medications • Epi-LASIK –
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