9/27/2016

A Brief History of Optometry Technology… Times, they are a-changin’ Technology in Optometry New and Emerging Technologies in Optometry History Spectacles: 1268-1289

Keratometer: 1851

Tonometer: 1865

 THOMAS WONG, O.D. Phoroptor: 1921 MATTHEW D. BOVENZI, O.D., F.A.A.O. (COPE Course #xxxxx-GO)

A Brief History of Optometry Technology… Times, they are a-changin’ Direct Ophthalmoscopy: 1850’s New and Emerging Technologies in Optometry Fundus Photography: 1926 Indirect Ophthalmoscopy: 1950’s luorescein Angiography: 1 F 959 CT (first in vivo images): O 1 993  Time Domain OCT: 2002  Spectral Domain OCT: 2007 Thomas Wong, O.D. Matthew D. Bovenzi, O.D., F.A.A.O. (COPE Course #xxxxx-GO)

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A Quick Introduction A Quick Introduction • Thomas A. Wong, OD (SUNY Optom ’89 & GU ’82) • Matthew D. Bovenzi, OD, FAAO (SUNY Optom ’14 & Cornell ’06) • Director of New Technologies SUNY Optometry • Assistant Chief of Primary Care (University Eye Center) • Past—Chief of Adult & Pediatric Primary Care SUNY Optom • Assistant Clinical Professor (SUNY Optometry) • Past– Chief of Optometry Kaiser Perm Mid-Atlantic States • U.S. Navy Veteran; Surface Warfare Officer (2006-2010) • I have no consulting agreements or financial relationships with any ophthalmic companies, or any products to be discussed.

T h e Evolu t io n of O p t o m e t r y A p r imary h ealt h c ar e p r ofess o n

•

The Class of 2020 Thomas Wong, OD, FAAO May 6, 2016 Director of New Technologies 12:30-5:00 PM SUNY College of Optometry SUNY Optometry The World has Changed

SAVE THE DATE: MAY 6, 2016 SUNY COLLEGE OF OPTOMETRY INVITATIONS TO FOLLOW: ATTENDANCE LIMITED TO 60 Come join SUNY Optometry faculty, residents, students, researchers, practic ing optometrists & ophthalmologists, and industry leaders in designing the Eye Exam of the Future.

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The Future Student The World is Changing The World is Changing 2000 2000 2016

• 361 million people used the • 361 million people used the • 3.4 billion people use the ―65% of today’s grade Internet Internet Internet school kids will end up (5.8% of the world’s (5.8% of the world’s (46% of the world’s at jobs that haven’t population) population) population) been invented yet.‖ - U.S. Department of Labor • 720 million mobile • 720 million mobile • 6 billion mobile subscribers subscribers worldwide (12% subscribers worldwide (12% worldwide (87% of the of the world’s population) of the world’s population) world’s population)

Mobile + Mobile + Social Boundary-less & Connected

90% of all phones in 90% of all phones in Africa are mobile Africa are mobile

1 out of every 7 people 75% of people in China 75% of people in China on Earth use Facebook use mobile devices use mobile devices

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SUNY Optometry What is Hacking?

Students Alumni Taking something apart and rebuilding it to make it better, give it a new function, or just do Creating an Ecosystem something surprising and disruptive Researchers Innovation Through Collaboration Faculty

What is a Hackathon? It’s not only tech companies… An event where participants ―hack‖ on a problem or focus area for an allotted period of time, with the goal of building or creating a 2. Identify solution (via a product, service, tool) Opportunity Areas Understanding the user experience

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IdeaScale An Ecosystem of Innovation

Ideas + Action = Hackathon 3. Ideate Solutions Creativity Loves Constraint

Challenge Challenge Goal

Design The Future Eye Exam Optometry is a Team Sport Design a model eye care unit that will transform and better the SUNY Optometry student experience

Improve Patient Outcomes

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Design Implementation Prototype – Test – Refine After we hack

New and Emerging What’s wrong with BLUE? What’s wrong with BLUE? Ophthalmic Lens Tech/Trends: Blue light Blocking Lenses  Blue light is short wavelength, HIGH ENERGY light.  Blue and violet light have the highest energy of visible light on the electromagnetic spectrum: Gamma Rays X-Rays Ultraviolet Infrared Radar FM TV Shortwave AM

1X10-14 1X10-12 1X10-8 1X10-4 0.01 100 10000 (wavelength in meters)

Visible Light Spectrum

400nm 500nm 600nm 700nm 4S00hnomrt Waveleng5t0h0nm 600nm 7L00onnm g Wavelength  High Energy Low Energy 

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What’s wrong with BLUE? Sources of Blue Light Insults Blue Light – Blocking Lenses/Coatings

 High Energy light creates free radicals and oxidative stre ss  HOYA within RPE  Compact Fluorescent light bulbs  RECHARGE Coating  ↓Blue light transmittance by 10% compared to standard  Environmentally and economically superior to traditional AR coatings incandesc ent lamps, but…  BluTech Lenses

 Intrinsically photosensitive Retinal Ganglion Cells (Mercury 0  Ocular lens pigment derived from auto-oxidation of 3- 2800K energy 5000K hydroxykynurenine (ipRGC); neurotransmitter: melanopsin Incandescent spikes) fluorescent house lamp light  Pigment combined with melanin and infused in optical  Maximally responsive to short wavelength (blue) lenses

light (inhibits melanopsin release; promotes 400nm 55 700 400nm 550 70 0  Essilor wakefullness)  Transmit much more high-energy blue light (due to Mercury in  Crizal Prevencia  Artificial ―Light At Night‖ (LAN) proven to affect fluorescent bulbs) Circadian Rhythm via ipRGC pathway  LCD Screens (on phones, tablets, personal computers,  Zeiss televisions) also emit high amounts of blue light  DuraVision BlueProtect  Blue wavelengths and LAN also linked to mood and depression via ipRGC pathway

42 Poll Question • Do you utilize wavefront aberrometry in your screening procedure? • If yes please send the message ―Wavefront‖ to my twitter account: @tawong Wavefront Refraction An Integrated Measurement of the Optical Pathway with Wavefront Analysis

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Technology/Gadgets Helmholtz Invented the Ophthalmoscope in the 1860’s Optometry’s History  1st Tenet of the Hippocratic Oath is • Optometry has a long history of providing quality eye care  Do what is in the best interest of • Optometrists are eye measurers  Your Patient! • Technology has made a major impact on Glaucoma Tx • Technology has made a major impact on CL care • Technology has made a major impact on Low Vision care • Many optometrists practice very differently than how they  ―Medicine begins where the were taught in Optometry School  Technology ends.‖ • Optometry needs to move from ―Data Collection‖ to ―Data  Edmund D. Pellegrino, M.D. Analysis‖  The Father of Modern ClinicalBioethics

3. Ideate Solutions

The Future Eye Exam Creativity Loves Constraint •

Biomedical Informatics Pre-Screening Tests

Imaging Pt Education & Outcomes

-.....,._...... _ ...... _.. _...... -...... !:: :.='!:-...... - 1 --...... ,_...... :; :_ . - . ... .,...... _...._,., _----- .,,..._.-· ,.... _.-_-...- .. _

.._,.,. ·-=·==' l.: . . = == =:;... ,, --- a - ... -=- -- - t:-h=- -== ·----=--

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•Trans tion of care Outcome measure: 1 CUnical Ca re measures 1comm1unity healtt1 • Me,asures should be •Health behaviors •Acute care •Admission and patient centered •Chironic care •Access to care A .measure that indicates the result of t.he perf ormance (or readmission measures and outc:ome •Prevention •Prov ider communication •Social and economic fact ors non-performance) of afunct ion(s) or process(es) •ClirnicaI effectiveness •Phy sical envirooment oiriented whenever •D sparit ies in care (oould also possible ., Outcome: Diabetiic retinopathy-associated blindness ply across domains) ., Intermediate Outcomie: HbAlC levels Person- and caregiver !Effic iency and cost • Measure concepts, in centered experience and Safety reduction each of the six •Annual spend measures outcomes domains t hat are •Patient exper ience •Pat ent safety le.g.1 per cap ta spend) -.Caregiver experience • Health care acquired •Episode cost measures coimmon across •Patient reported and infect ions and conditions •Quality to cost measures providers and functional outcomes •PrO'IJider safety sett iings can form a core set of measures

[From presentation given by CMS Dr. Kate Goodrich]

Smart Vision Labs • attachment to iPhone that does a refraction in secs

., Department of Health and Human Services (HHS) seeks to

hav1e 85% of Medicare payments t ied to quality 1or value by 2016 and 90% by 2018 f.R.A!;IJ.QN (MARCO ) KR- t W (:f.Qf.C.Q.N) ., The Merit-Based Incentive Payment System (MIPS) !PROFILER (ZEISS ) - Physician Quality Reporting System (PQJRS), Value-Based M odi'fi'er Y.R (REICHART ) (VM ), and EHR M eani'n,gful Use (EHR-MU) program payments 'Will Y.MA-.K PSF REFRACTOR sunset Dec. 31, 2018, w ith M IPS and A lternate Payment M odel E."XENE.T.M (APM.) incentive payments beginning Jain. 1, 2019 - Specif ic empha sis on outcome measures - EP performance iis calculated as a composite score using 4 categories: quality, resource use, cHnicail practice improvement activiities, and meaningful use of certified EHIR techn-ology (CEHRT)

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Phoropter Advancements Automated Refracting Systems Phoropter Advancements • KR-1W • Phoroptor® VRx Digital Refraction System ▫ Wavefront Aberrometer ▫ Pre-programmed tests for astigmatism, phoria, ▫ Rx Reliability binocular balance and near vision ▫ Dry Eye Assessment ▫ Interface with pretest equipment ▫ Early pathology determination (aberrations; ▫ Transfers data to EMR trefoil, coma, peripheral aberrations) ▫ Transfers to the BV-5000

PSF Technology PSF Technology PSF Refractor (cont.)

 VMax PSF Refractor obtained equal (63%) or better (28%) VA • Based on Point Spread function principles • Research results  90% of patients preferred VMax PSF Refraction to phoropter • Diamond Point™ Digital cutting technology ▫ Statistical significance PSF Refraction preferred to ▫ 5X more precise than phoropher’s 0.25D Phoropter Rx increments (0.05D steps) ▫ 900 subjects at 7 US study locations (ARVO 2012) • True night time subjective refraction and Rx ▫ 26 KC eyes ▫ Background of PSF target is darkened to stimulate 69% achieved higher VA with PSF Refactor night time vision conditions Lai ST, Vmax Vision. A Multi-center Study Of Visual Acuity Measurements And Patient Satisfaction With A Novel Subjective Point Spread Function Refractor And Standard Manifest Refraction. Presented at: ARVO 2012; 8 May 2012. Fort Lauderdale, FL.

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PSF Technology Refraction: Taking a Golf Lesson The Eye’s Optical Integrity • Short refraction time (3-5 minutes) • The Eye as an Optical Instrument • PSF target easier for patients compared to • The Eye is not a camera. Snellen chart (faster and more reliable) • The retinal image is not the endpoint, as with a camera. • However, a better analysis of the optical pathway is crucial. • It will give us better objective data for better refractions and improved patient management. • Optical Pathway=Tear Film—Cornea—Aqueous Humor— thru Iris/Pupil—Crystalline Lens—Vitreous Humor • Angle Kappa=Angle between pupillary and visual axis—Can often be important in strabismus patients.

Xfraction Technology Marco Automated Refracting Lane TRS 5100 OPD Scan III

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OPD-Scan OPD-Scan Waveform Measurement To measure the refractive error of the 4x360-degree rotation Measuring Principle ① point by 180-0. OPD map is Wavefront Methods obtained based on the data of The principle of the OPD-Scan Aberrometry measurement 1440 total points。

Lens Photo Diode Eye Pupil Iris Array

OPD Map Manufacturer Principle Wavelength # Points Measurement Range(D) Zernike Alignmentト Infrared LED Alcon HartmmanSchack 820nm 190 / 7mm S-15 to +15 / C-6 8th middle of the pupil 0 180 360 Bausch&Lomb HartmmanSchack 785nm 75 / 7mm S-12 to +6 / C-6 7th middle of the pupil Visx HartmmanSchack 785nm 240 / 7mm S-8 to +6 / C-5 6th middle of the pupil NIDEK DynamicSkiascopy 880nm 1440 / 6mm S-20 to +22 / C-12 8th optical axis of the eye Slit Illumination Projection Chopper Wheel Zeiss/Meditek HartmmanSchack 850nm 800 / 7mm S-14 to +6 / C -5 10th middle of the pupil Lens (Rotating Drum) Schwind Tscherning 650nm 98 / 7mm ??? / ??? 6th optical axis of the eye 180 0 Wavelight Tscherning 650nm 96 / 7mm ??? / ??? 6th fixation beam

Photo Diode Light receiving element 4, Topcon HartmmanSchack 840nm 125 / 7mm S-15 to +15 / C-6 6th middle of the pupil Array which covers up to 359- 180 degrees 67

Rotating the pair of four photodetector arrays 180 How wavefront aberration shown degrees measures the entire area of 2.0 to 6.0 OPD-Scan refractive power – axis graph mm on the cornea ranging from 0 to 360 degrees.

New way of measuring Diopter Refractive error (AR) data is converted to the colored OPD map as shown below. ■Wavefront aberration 4 rings x 360 degrees = 1440 points ※Wavefront Aberration = Difference between ideal and actual result. Difference is Wavefront Aberration )

described in μm 3

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* With the OPD-Scan and OPD-Scan II, there is ：Now wavefront aberration(Ideal) 2

no photodetector within the 2 mm-diameter area in- on the cornea. The data within the 2 mm-diameter

1 area is interpolated. If photodetectors are added ferior 0 180 360 er outside the 2 to 6 mm-diameter area, the s( meas uremenOt PareaD onM thea corneap can be

ior 0 m Photodetectors that expan ded. OPD

mp measures the 0 to 179 u -1 degree area

-2 0 -3 ２D Color Map 180 -3 -2 -1 0 1 2 3 Photodetectors that mm (right-left) measures the 180 to 71 359 degree area Abberation (μm) A Review of Optics

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Scheimphlug Principle Topography & Map Displays Axial Map • Geometric rule that describes the orientation of the plane of • Axial • The Axial Map represents the anterior corneal topography. It focus of an optical system (such as a camera) when the lens • Instantaneous color codes the corneal refractive powers or curvature plane is not parallel to the image plane. In this scenario, an • Gradient radiuses. The higher the refractive powers, the steeper the oblique tangent can be drawn from the image, object and • Refractive cornea, and the warmer the colors on the map. It measures lens planes, and the point of intersection is the Scheimpflug • Elevation the corneal curvature relative to the measurement axis intersection, where the image is in best focus. • Eye Image • Rotating & Dual Imaging Systems available • OPD (Marco’s OPD SCAN III—Optical Path Difference) • Examples: Pentacam, Astramax, Galilei (Placido tech also) • Internal OPD • Applications: Corneal Ectasia, CL Evals, Corneal Diseases • Advantages: Irregular Corneas, Pachymetry, High Resol • Disadv’s: Corneal Power, Sensitivy to movement • Placido based technology based on reflection principle

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Instantaneous Map Gradient & Refractive Maps • Represents the actual geometry of the cornea. • Gradient Map shows the amounts of variation in corneal • Calculates radiuses of localized areas along the meridians. curvature radii in the form of corneal refractive power. • Also referred to as the Tangential Map. • The Refractive Map demonstrates the distribution of corneal • Shows local irregularities: e.g. ecstasias, edema, scars. refractive power using Snell’s Law. Warmer colors in the periphery of a normal cornea, and and cooler colors in the center.

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Elevation Map Eye Image OPD & Internal OPD Maps • The difference in elevation between the cornea and an • To check alignment & focus of captured measurement. • OPD Map=Refractive error at each point within a 9.5 mm overlaid reference sphere (usually best fit sphere) • Placido Disc diameter taking into account the cornea and all internal • 3-D Shape of the Cornea • Photopic Pupil refractive powers. • Useful in monitoring progression of keratoconus, S/P tissue • Mesopic Pupil • Internal OPD Map=The distribution of internal refractive removal, assessing post surgical visual concerns, and • Retro Illumination error obtained in the OPD measurement. planning & monitoring surgical procedures

Wavefront Maps Wavefront Total & WF/OPD/HO Zernike & PSF Maps • Wavefront Total Map • Wavefront Total Map displays the difference in wavefront • Zernike Graph shows aberration components using the • Wavefront OPD Higher Order Map aberration from the wavefront of an aberration-free Zernike Polynomials. • Zernike Graph emmetopic eye. • Point Spread Function Map simulates how a point source of • Point Spread Function Map • Wavefront OPD Higher Order Map displays only higher light appears to the patient as a separate map or as a • Corneal Images order aberrations thumbnail in maps. • Retro Illumination Images

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Diagnostic PSF Summary Toric Simulation Diagnostic PSF Summary Explaining lenticular astigmatism.

1 2 3

4 5

1.The OPD map is the entire visual system from the front of the cornea to the retina. This patient has 2.50 total cylinder correction. 2.When we divide the OPD into two maps (Axial and Internal OPD) we actually uncover -1.22D of astigmatism on the cornea. 3.The Internal OPD map shows -1.28D cyl. When the cataract is removed this patient will still have 1.22D of corneal astigmatism that will need to be corrected. The Axial + Internal OPD = OPD. 4.The center map shows how a patient will see if they are supplied a standard IOL and leave the astigmatism uncorrected. They will need to wear correction. 5.The Toric map shows the patient’s vision with the astigmatism corrected or if they get a Toric IOL. This makes it much easier for the patient to understand that they will need correction, if the astigmatism is not addressed with the surgery.

SM Optical Path DiagnostixSM Diagnosis and Guiding Therapy Optical Path Diagnostix Ocular Surface Disease (OSD): Day Night Summary Wave Front Optimized Refraction: Day Night Summary Placido

Begin with the Placido disc image.

Question 1: Is the tear film competent? Good Consistently ―Bad‖ Tear Film Tear Film Competent Compromised

Next Check the RMS (Maps or Tape) RMS OSD

Question 2: RMS > 0.43 D or RMS < 0.43 D and Are the aberrations primarily 2.6 and 4mm different 2.6 and 4mm same Low or High Order Wavefront Optomized Refraction

High Order Low Order High RMASberrations Aberrations Low RMS (AR se nt) WOR (WF se nt)

Check the Topography and OPD maps (Total and Internal) or text Topography Compare AR anCd hec k Photopic vs Mesopic box “HOA / Refractive OPD Mesopic ctions refractivReefra data

Question 3: Are the HOA’s primarily internal or exteCronrnael?al HOA Refract or not? Internal HOA Different: Same: Two or Modified One Rx 57 yo wm. C/O increasing blur (OS>OD), variable acuity without discernable timing pattern. No pain or discomfort. 22 YO WM, c/o lost primary glasses, using sun Rx as spare but DV blurry, NV not compromised. No other significant history. Wearing: Sent To TRS: Subjective: Therapeutic Options CL’s Surgical approaches Surgical Non-Surgical OD: -2.25 -1.25 x 170 (20/40) OD: -2.75 -1.25 x 169 (20/20) OD: -2.75 -1.50 x 169 (20/15) (Refractive Sx). approaches Treatment Placido Image shows abnormal tear film OS > OD. This patient’s dry eye therapy was OS: -2.50 -1.00 x 26 (20/40+2) OS: -3.00 -1.50 x 23 (20/20) OS: -3.25 -1.50 x 22 (20/15) Question 4: started immediately rather than proceed with refraction. Looking at the Placido discs, tear film is normal, as is Angle Kappa. The retro illumination images are clear. The 2.6mm and 4.0 mm (and 6.0 mm) pupil zone Is the therapeutic intervention surgical or refractions are within 0.5 D for sphere and cylinder power, and the axis within 10 degrees. High order aberrations are low, therefore the RMS values within 3 non-surgical? mm, 4 mm, 5 mm, and 6 mm pupil zones are also low.

Placido disc image OS shows irregular tear film, the pattern This is the patient expected to be correctable to 20/20 or better with minimal refractive adjustments from the wavefront opti mized starting point (WF) and was. The right eye required an additional -0.25 D cylinder power, and the left -0.25 D more sphere to the subjective endpoint. The patient has correction options of changes from measurement to measurement, but never is spectacles, contact lenses or refractive surgery. New spectacles were provided. regular, without distortion.

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SM Optical Path Diagnostix SM Optical Path Diagnostix SM Wave Front Optimized Refraction: Wave Front Optimized Refraction: Optical Path Diagnostix Toric SCL fitting OD -- Standard 2 Summary Toric SCL fitting OS -- Standard 2 Summary Wave Front Optimized Refraction: Toric SCL

Refractive Triage With OPD

HOA (high RMS) LOA (low RMS) Diagnose further 2.6mm = 4mm = meso

Spectacles Contact Lenses Refractive Sx.

OD Initial fit of toric lens, with lens in place. 20/20, OD F/U of toric lens, with lens in place. 20/20. Additional -0.50 OS Initial fit of toric lens, with lens in place. 20/15. OS F/U of toric lens, with lens in place. 20/15-2. Additional - Looking at the process graphically, the OPD selected the wave front value as the refractive 20/15 with -.25 sphere. Dispensed this lens, F/U 2 = 20/15. Included the additional -.50 in final lens, ordered the 6 0.25 slightly better- 20/15. Included the additional -.25 in month supply. Note the stability from the fit, axial map showing Dispensed this lens, F/U 2 weeks. weeks. final lens, ordered the 6 month supply. Note the stability starting point which was verified by the subjective refraction in the TRS, and prescribed as the toric lens surface, OPD showing minimal aberrations remain. from the fit, axial map showing the toric lens surface, OPD a soft toric contact lens. Placido shows peripheral fitting curves of lens. showing minimal aberrations remain. Placido shows peripheral fitting curves of lens.

Optical Path DiagnostixSM Diagnosis and Guiding Therapy Optical Path DiagnostixSM Diagnosis and Guiding Therapy Pupil size effects: Day Night Summary Optical Path DiagnostixSMDiagnosis and Guiding Therapy Ptosis / Cataract: Day Night Summary Pupil size effects: Day Night Summary Cooper Biofinity MF

Progressive MF in two designs. D lens minus center increasing plus peripherally. N lens plus center becomes more minus in the peripherally. Anything familiar about that? I fit her with the low add version of the Biofinity MF which is fit utilizing an approach called ―reverse centrad‖ where the dominant eye gets a ―D‖ lens with the most minus power (least plus) in the center, and increasing plus as you traverse the lens from the center to the edge, the non dominant eye gets the ―N‖ lens. She has been fit with the lenses at -75 sphere low add ―D‖ lens OD 20/20 (in both rooms) and -

2012 exam: 58 yo WF, C/O blur that is either occasional or intermittent, worse at night, with early (incipient) cataract OD. She works as a 1.25 low add N lens OS 20/20 (also in both medical technologist, caring for two parents, both under Hospice care. rooms. At f/u she was no longer plagued by OD: Plano Sphere (20/20) OS: -2.00 – 1.00 x 110 (20/20) the fluctuations, and is still 20/20. Under the influence of the Phenylephrine, the second OPD results were much more reliable, and in OD shows significant axis shift from 2.6 zone to 5 mm zone, and increasing + PLUS Rx. RMS worse at 3 mm than 5 mm and trefoil based fact resulted in a Wavefront Optimized Refraction. internal HOA indicates cataract as the cause. OS shows significant axis shift from 2.6 mm to 5 mm zone and increasing – MINUS Rx. The cylinder power is low, not clinically significant, but the shift explains her night and variable blurring. Her work as a medical technologist has her working in variable lighting, and driving in to work in photopic, home in mesopic conditions. Explained the situation, and set F/U 6 months based on the cataract OD.

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Optical Path DiagnostixSM: Diagnosis and Guiding Therapy Optical Path DiagnostixSM Diagnosis and Guiding Therapy Cataract: Day Night Summary Optical Path DiagnostixSM : Diagnosis and Guiding Therapy- Cataract Ptosis / Cataract Retro-illumination Image Diagnostic PSF Summary

HOA

Internal Corneal surface

Retina Vitreous Iris (pupil) Lens Posterior OSD Irregular Cornea surface

Cataract IOL related Capsule Primary Secondary Related

Surgical Patient Ed. Trauma Ptosis Planning

Angle Kappa Astigmatism Spherical Ab. Pharmacology Surgery The comparison of the total OPD, Internal OPD and Viewing the retro images confirms the presence of a Axial maps show where the problem is, and why she central cataract as the reason for the acuity limiting can’t be corrected with contacts or spectacles. 50 yo wf, successful SCL MF wear x 10 years. C/O increasing blur (OD>OS), MF not working as well. high order aberrations. Graphically the left eye followed the light green path: HOA > Internal > Lens > Cataract > Sx Planning The two eyes of this patient illustrate the OPD scan III refractive triage. The right eye 3mm RMS value of 0.69 D indicates she would be unlikely to achieve 20/20 The associated PSF maps show her the optical (Angle Kappa / Astigmatism / Spherical Aberration). 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 OPD sent the auto refraction to the TRS effects of uncorrectable distortion, and cataract 5100 as a starting point for this refraction based on the right eye results. However, the OPD map indicates irregular and asymmetric astigmatism in both eyes, the surgery is scheduled: OD first, then OS one week 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 The right eye’s diagnostic path is represented in the light purple path: HOA > Corneal surface > Irregular trefoil, and it is internal (behind the corneal surface). Essentially ALL the aberration comes from the internal optical elements. Internally located trefoil is often later. seen in cataract cases. surface > Secondary > Ptosis > Surgery.

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

HOA

Internal Corneal surface

Retina Vitreous Iris (pupil) Lens Posterior Cornea OSD Irregular surface

Cataract IOL related Capsule Related

Surgical Planning Patient Ed.

Angle Kappa Astigmatism Spherical Ab. After dilating with 2.5% phenylephrine, the WF was sent, indicating a low 67 yo wm. OD 20/40, OS 20/30. No retinal disease. Tool and die • Again, looking at the process graphically, the OPD selected the Auto-refractor value as the refractive RMS and predominantly LOA affecting the vision , when the pupil is maker, recently started noticing difficulty reading the micrometer and starting point (HOA arm of the decision tree), and the OPD maps provided the diagnostic pathway to larger. scale on Bridgeport.

discover the cause of the high order aberrations limiting her acuity. Retro shows the cataracts are mostly centrally concentrated. Dilation Retro shows the cataracts. Diagnosis is done, referral is in order. He • The PSF maps helped the patient understand her condition and accept the prescribed treatment modality. exposes optical areas not significantly affected by HOA from cataract, so refused because about to embark on a vacation for a month that has Angle Kappa, corneal spherical aberration, and the corneal cylinder values directed the selection of the his visual performance improves with the larger pupil. The new Rx was been planned for six years. Needs to see better, without Sx. specific IOL for each eye. developed with 20/20-2 and 20/25 results. He was given PE to use during his trip with the Rx. He is scheduled for Sx. on his return.

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SM SM Optical Path Diagnostix Diagnosis and Guiding Therapy Optical Path Diagnostix Diagnosis and Guiding Therapy Optical Path DiagnostixSMDiagnosis and Guiding Therapy Corneal Scar: Day Night Summary / Retro / Placido image Corneal Scar: Day Night Summary / Placido image Corneal scar

HOA

Internal Corneal surface

Retina Vitreous Iris (pupil) Lens Posterior OSD Irregular Cornea surface

Ablation Sx. Contact Lenses

RGP Hybrid Piggy Back Scleral 48 yo wm. History of HSV keratitis OS 2 years With a -3.50 Synergize Hybrid contact lens in place, the OPD shows minimal ago. Unsuccessful with RGP’s, was successful irregular astigmatism remains, the placido disc image is now regular, with piggy-back fit, but difficult to keep SCL clean. reflecting the smooth surface of the rigid portion of the contact lens. HOA’s Wearing glasses, not happy with VA. are significantly reduced. The RMS value is also improved but is still OD: -3.50 -0.50 x 98 (20/20) reflecting the optical effect of the corneal scar at 0.72 D. OS: -0.25 – 0.50 x 120 Interestingly, the over-refraction indicates the Rx required in the contact lens is (20/40) -2.50, even through he started with a plano refraction from the scar- flattened central cornea. Before the scar, he was myopic. VA is 20/25+2 with the over- OS OPD shows flat central area with irregular refraction astigmatism. Placido disc confirms the surface is The left eye’s diagnostic and therapeutic path is represented in light purple: HOA > irregular, and HOA’s of Trefoil and Coma, mostly Retro illumination shows mild opacity Corneal surface related > Irregular surface > Contact Lenses > Hybrid CL corneal, are responsible for the 0.99 D RMS. from corneal scarring.

Olag: Ciag : Left Com: Com :

- 0.00@ 0. 06@1 0 .06@ 0 CPD 0.00@ 0 Axial 0.07@333 Int ernal CPD 0.07@153 OPD Axial Internal OPD 0 80 9J APf' 4 .06 sci 0.33 @3.0mm 50 APP 45.28 SO 0.49 @3.0mm - Ui 105 5 ...... -4J5 10 \ , , I , , /5' ' \ • I I I ' / ..... 120\ \ Patient A 120\ \. I /e- ' ' / 'J 12 )\ '\ -3.15 /J -351 -315 l'° , / '5 -3JI -2.15 -3.25 ·2.51 -115 -2.15 -lJI .1.75 15 ()-_ -l.25 -t.50 • 53 yr old Asian Male -t.11 165' 15 -f.51 -0.75 -1.25 5.02 45 2:i. . . - 165- 0.46 0.84 - 15 I tJS -t.25 I ' • Former glasses and contact lens wearer 1@0 180 1.25 1!0 1.lS I 7S - - : IJS 1.25 • Wears no correction currently except for very small print u s •, 5.M I illi.8J,' 0.38 2J5 s : --0.25 , s: -1.00 - -0.28 45.05 0.93 c : -0.50 c : .0.25 -- A : 72 • Uncorrected Distance VA OD 20/20-; OS 20/15 A : 174 ' V0 : 1l.75 / / VO : t l.75 / .... 3mmZone: ' 10' 10' SmmZone: 10' 3mmZone: 5mmlone: 3mmZone: 3mmlone: s : +0.00 ' .0.3 go 0 .43(Bl11' ' \ s: -1.00 ' 43.41 • \ ' . .0.27@!1800 o. 1800 • ' \ A@t7• .i.@96• ; , , ,SA·[email protected] / Orde r.8 c : .0.25 ' ' \ \ 0.73@99° 1.36@101• , , I • • \ c :.0.00 \ D.40@90° 1.24@9-0t ' , I , • \ CYL +1.12 CYL >-0.93 Pwr : -120 I PM: 45.02(7.501 PM : 0.59 A : 84 P\11': • 0.36 A : 0 • CYL +0.67 CYL .0.84 • ilMS: 0.230 RMS:0 .3 70 Dist : 0. Di st : o.o o• Dist : 0.0 00 RMS:0.250 RMS:0.250 Dist : 0. Refraction : VD = 13.75mm L L L Refraction: VD = 13.75mm R Cornea R Cyl: VD = O.Omm R Cornea Cyl: VD = O.Omm Sph Axis Sph Cyl Axis RMS Steep Flat Astig Total Cornea Internal Cyl RMS Steep Flat Astig Total Cornea Internal [email protected] +0.00 -0.50 74 0.150 [email protected] -0.75 -0.25 171 0.20D SimK 45.55@ 62° 45 .18@152° 0.37 -0.25@174° -0.37@152° -0.67@ 90° SimK 45.18@102° 44.47@ 12° 0.71 -0.50@ 72° -0.71@ 12° -1.12@ 99° [email protected] +0.25 -0.50 85 0.230 [email protected] -0.75 -0.00 0 0.37D ( 7.41mm) (7.47mm) (7.47mm) (7.59mm) Diff +0.25 0.00 11 Diff 0.00 +0.25 Corneal asphericity e: 0.71 Corneal asphericity Q: -0.37 e: 0.61 Q: -0.50 Pupil Inf ormation Irregularity @4.00mm (HO RMS) Pupil Information Irregularity @4.00mm (HO RMS) Cornea SA 0.190µm @6.0mm Cornea SA 0.178µm @6.0mm j Photopic , 3.47mm I dist 0.33@356° r - : ; - r,:;-:: ; Photopic, --- r-=- I Total 1 Cornea , :Internal ,, 1. Total .1 1,Cornea J ernalJ ' Mesopic 5.09mm I dist 0.33@358° I 1 1 0.184µm 0.166µm 0.233µm iMesopic, 5.50mm dist 0.34@149° 0.139µm 0.112µm 0.126µm Dist to P/M ••• Dist to PIM 0.01@ 95° rContras r - --i ;Contras] Retro , 1 Retro , 20/20: 95% 20/40: 88% @4.00mm 20/20: 88% 20/40: 70% @4.00mm

18 9/27/2016

Oiag: Olag: Com: Com:

R efraction V0137!fno VOQCl'./Tlm " Refractive" 0.07@ J J 3 Axial 0.07@JJJ "Refractive" 0.06@180 Refraction W ll75mm OO'lln Axial 0.06@180 s A R S mmm A 00 c s c WI 75 90 1 \ ' , I , , I -100 -0.25 174 OPD -0.75 -0.00 0 105 75 OPD ws !SJ5 12".l 4UI M .0 25 -0.50 72 0.00 .0.25 84 \ .., ... 120 \ ' ' I ' I 4115 Internal J \ !4.75 J m -1.00 --0.00 0 0.20 +0.67 180 41.!I I 4US !US ' Cornea -047 154 4Ut Patient B 135, ' -0.25 -0_50 82 0.47 ' Cornea .0.76 15 41.IS !3.15 m 4UI 13-,, ' , / 46 rn 0.50 -0.50 120 0.56 [ ]mm s c A H AO 4111 !l.21 1!>0, 1!>0, mmm s c I \ 46J > OPD !2.15 52.98 / 5\ _57 -0.25 -0.50 82 16.10 .•44.05 / 45.40 12•zr•11 150 OPD 46JI !1.25 I 0.50 .0.50 120 ., Internal -0.84 90 11 11 !1.75 1111 Internal +0 93 11 51.10 51.37.-;----- Cornea 165- • 25 yr old Hispanic Male HJ5 ..() 47 14 Cornea .0.54 165 - 45 -- 50.25 ------c;JI..,, ' I nternal OPD 180' 31 52.89 0 • Wears glasses only - - - -! ' ' - y2------.: 025 Internal OPO 0. 06@ 0 ' ' 51.08 0.07@15 , I !li\.83, 41JS . a t 90 5.@' 4125 .ue 105 75 ..ut 3 ' I I I _..JI 120 \ ' • Not interested in wearing contact lenses - 2.58 -3.SI .J.;1 \ I ' /'" .JAt .JJI -1.S• 1l5 , ' , / .i.;1 / 45 , ,52.04 -2.110 • Best Corrected Distance VA OD 20/25; OS 20/25 ,.-3() .-51.41 .JJI -1.50 1.37 .uo 150, ,..30 , I ,52I.07, . \ ' -UO I ' 51.23 ' \ -4.SI Pwr : 50.10 15 Pwr : 50.15 .t,;1 Pv.r : 45.07 (7.491 Di st : 0. o• 0.84 165- - 15 0.50 Dist : 0. o• - D ist : 0. o• - 0 0.50 0.00@ 0 fSO- -0 OPD 0.00@ D I.it 2JI U5 00 0:-38 0.05 105 75 ....,, 105 O P 75 J.il 41 5 12(1 \ I ' ' I ' 6:> ' ' I I _..JS 120 \ .fJS \ i 0.93 D\ t ' 160 -l.75 .J/S J 26 1", ' 90 , / 4.0 -lJS -115 -1.15 3rrrnZone: 150-.. ,.JO 5mmZone: -125 3mmZone: 5mmZone: ' -1.21 -0.27(6'!180. 0.4 1.80° ' \ -1 15 -0.39@) 9• 0.4 11• 0.40@ 90· 1.24@ 907 , , I , , \ n .• •·. 1.36@1'D1° · ' \ 1es- ·1s ,:;,'?J':!,u CYL +0.67 CYL .ll.S4 " " ' I ' -1.25 !U.83 IDf.l4 Nonn50 NL CYL <-0.93 ' RMS: 0.250 RMS:0.250 Dist : 0.0 -0.75 rndv · RM S:0 130 ..JS RMS:0.370 Keratometry Sph. Aber. 4.0mm um (D) I ll t J! 180- - 0 IH Kerstometry Sph. Aber. 4.0mm um (D) 180 t ! SimK s11,. .n : 45.55@ 62 Ornl>1r 0.0'18 ( 0.72 ) us SimK Steep 1 J5 : 45. 18@102 Ocular : -0.058 ( .0.76 ) -1.26 SimK Flat : 45.18@152 Corneal: 0.109 ( 0.51 ) 115 tJS Z.H SimK Flat : 44.47@ 12 C o r n e a l: 0.035 ( 0.42 ) CYL : -0.37 Pupilometry CYL s: .1.00 , UI s: .0.25 : - 0.71 Pupilometry c: -0.25 Aspf1ericity 6

0

Refraction V0137!

19 9/27/2016

Oiag: Oi ag: Com: Com:

OPD 0.00@ 0 Axial 0. Internal OPD 0.06@ 90 OPO 0.07@333 Axial 0.08@315 Internal OPD 0.03@ 90 90 06@270 90 APP 46 .63 SO 1.83 @3.0mm 93 APP 46.C'9 SO 2.56 @3.0mm .U5 I ' I • , l 4U5 105 I I I ' .f. i t 105 -tU5 StM 105 , , I 75 -IJ5 120 411' I I .... !i. I ' , I lfYJ ..... -IU5 60 SIJS 120 \ I f t eo ...... ' ;oo \ I -7.75 \ 41J 5 -3.51 -9.75 ; 51.tl -125 ' -3.tt ' I -l.SI 135, • ,,. / 45 .925 ,, / & 49l5 -lJ I -'-75 -2.51 -US OSI -415 , 47.25 , -251 -2.GO -'J -l .H -I.II 150, A:> -1.50 ,30 150,' -I.SO - .8() -IAO 47.00 -7.25 45St -4.75 t M - - 1s - 15 .us 44!5 -3.15 .us' HJI -31 5 100- Ol5 -2.75 100 -"-75 181'.l OSI .1J5 -4JS 41JS .tJ, .315 4UI , s: -5.75 • c : -3.00 ,, A : 76 ' 10' / 10' VO:13.75 10' ' 10' 3mmZone: 5mmZone: 3mmZone: 3mmlone: 5mmlone: -0.27jil 46° .o. 94• -5.75 SIM K's: .(),68@1589 _ { ' a@2n• ' , \ A @252" s: 5mmZone: ' , \ \ -0.01@136° -0.21@'4•1 ' , I • • \ c: -2.50 \ 46.11 (7.32)@!175• .0.06@68" I I • I I I ' ' I ' ' I Pvvr : -0.21 P'M:.7.01 I'\<.\': -0.14 Pvvr : -4.83 CYL t-0.26 +0.13 A : 73 44.35 (7.61)@! 85' CYL .0.62 CYl \ • CYL • RMS:2 . 450 Ois l: 0. 0 C° Oi st : 0. 00 o· RMS:0.890 RMS:0.710 Dist: 0.0 D ist : 0. 00 o• dk. 1.76 +0.29 RM S -

Refraction : VD = 13. 75mm R R Refracti on: VD = 1 3. 75mm L L L Cornea R Cyl: VD = O.Omm Cornea Cyl: VD = O.Omm Sph Cyl Axis RMS Steep Flat Astig Total Cornea Internal Sph Cyl Axis RMS Steep Flat Astig Total Cornea Internal REF -5.75 -3.00 76 REF -2.25 -5.25 84 SimK 43.27@ 80° 4.40 -4.50@ 84° -4.40@ 80° -0.26@136° SimK 46 .11@175° 44.35@ 85° 1.76 -2.50@ 76° -1.76@ 85° -0.62@ 68° [email protected] -5.25 -2.75 74 0.840 (7.61mm) [email protected] -1.75 -5.00 82 0.400 47.67@170° (7.80mm) {7.32mm) Diff +0.50 +0.25 -2 Diff +0.50 +0.25 -2 (7.08mm) Q: -1 .36 e: 1.17 Corneal asphericity Q: -1.10 e: 1.05 Cornea l aspheri city Pupil Information Irregularity @4.00mm (HO RMS) Pu pil Information Irregularity @4.00mm (HO RMS) -0.635µm @6.0mm;-Photopic, 2.70mm I dist 0.34@105° Cornea SA -0.623µm @6.0mm r - ; --- Cornea SA L_ Photo 2.84mm I dist 0.19@121° Total fCOrnea ' T otal ' C ornea 'ln terilar --1 . 1 flrrternal , r - Mesopic . - Mesopic 4.85mm I dist 0.25@ 83° 0.208µm 0.350µm 0.273µm 5.00mm I dist 0.11@133° 0.492µm 1.162µm 0.772µm Dist to P/M Dist to P/M 0.14@326° 0.08@284° ontr fContra s j Retro Retro 20/20: 100% 20/40: 99% @4.00mm 20/20: 100% 20/40: 99% @4.00mm

Di ag; Diag: Com: co : m

I OPD 0.07@333 Internal OPD 0.03@90 OPO 0.00@ 0 Axial 0.06@270 lntemalOPD 0.116@90 R Axial 0.06@270 A PP 46.63 SO 1.83 @3.0rrvn 90 50 90 Retro image ...,, 100 1 100 15 100 15 10 \ . , I , 15 ...... \ ' I I I . .JS I ' ...... \ . ' I ' ' I ' eo M 120\ ' /t.O ' 123\ \ -1.15 -3.!t , ,eo ' 1u,' -IJ5 -3Jt 135, / 45 ·US -ZJI -4J5 - Ut ,...30 ,.JO 150-....' -1.SO 150-.. -5.15 .u. ·1.35 0.00 IM - -0.59 -1.13 - 15 Ut - 0 1Jt 100- - 2JI -6.89 -8.99' JJe .5.75 s: -2.25 - .3.00 _., / c : -5.25 A : 84 ' 76 VO : UH ' , / / JmmZone: SmmZone: SmmZone: ' 3mmZooe: SmmZone: ' JmmZone: ' ' .o. 158° _ f , s: -2.25 .o.21A 46" -0. 94· t. @252' s : L.., , ' a @2n• -4.5-0 .0.01! t1J6• .o. 68° c : -O.Z1@ 4 , I \ ' ' . - I , ' I " \ Pwl.0: .14 ' ' Pow : -0.21 CYL-0.ol CYL A : 82 CYL .26 C'l'L '-0.13 Dist: RMS:2.450 RMS:- Dist: 0. o• ;a.no RMS:M 90 RMS:0.710 o. a-

0.07@333 L VAJOPD/HO 0.07@333 0.00@ 0 R VAJOPD/HO 0.00@ 0 Photo size wr enor : 0.492 pm so· 7or;,, :4.00 nun Orlk>r : 4 noxssomm @Sm lzernike 1

Steep: 170° Flat: 80° Astig: 4.98

Steep

Dist: 0.00@ o· Flat P01st : 0.19@121' Photo si.::e Photo size w F error : 0.208 pm wr errm : 3.917 }lm M01st : 0.1 1 @133' 770X550rrm@5m 60' n o x 550nTI@5tn 60 ' LandMark 7onf>: 4.00 mm Orrlf>r : 4 770X5&Jmm@Sm 60' Lone :4.00 mm Oraer : 4

20 9/27/2016

Diag: Oiag: Diag: Com: Com : Com:

Retro image

o-f>o 1-20 1_1; () 2.00 100 4.00

jzernike 5.866 f .(4 6 ·I I 4.237 @95 Steep: 170° I 1.575 @73 Flat: 80° I 0.467 Astig: 2.32 I 0.460 Steep I 0.077 Flat O.llOO ( c12 +0.000 ) LandMark I Sil! K's: 46.11(7.32)@r w 44.35 (7.611@. 85• 001 r - - I II <> I dk -1 .76 +-0. 2 o ,IT T

Dag: Oiag: Diag: i rtf Left Com: Com: Com:

CPD 0.00@ 0 Axial 0.06@270 Internal CPD 0.06@ 90 OPO 0.07@ 333 Axial 0.08@315 Internal OPD 0.03@ 90 W F/OPD/HO 0 .00@ 0 WF/Corn/HO 0.06@270 W F/lnt/HO 0.06@90

90 A PP 46.63 SD 1.83 @3.0mm 90 90 90 APP 46.09 so 2.56 @3.lllmm 90 75 a.Ji 90 -t.il 75 75 105 7 IM ...,. 105 I ' , 105 75 .fUI 105 49JS 105 I ' , ...... I ' , I ' , ( , I , , I ' U I ,l5 .us \ 4U5 I .u t \ ' ' I ' , I -I U S ' I 051 \ ' I , I ' I .... 120\ ' 75 120\ , Jf!J t20\ ...... 120\ • lf!JJ -1.15 , /JJ 41.15 .J.51 .u s ' lt!iJ ' l flJ -351 ',tKJ IJS t.71 ... ' 1.31 ..,, ' ' .JJI ' ' UI -7J5 135, .. , ,...45 1l5, .. ' , ,...45 -US 13.5,' ,, / ..!> -3AI 13.!r, ' ... / 45 UI -'.15 . iJ s -1.SI ll5 151 151 47.25 Oll , -iJ5 .iis ' , -1.80 , 150 ' o. o 150, ' , ,30 150, ' , ,30 ISO ,...30 47.0 150, ..-30 0.15 AO 0..38... 150-....' -5.75 0 -1.50 /; -2; - 0.30 ·7.25 -1.11 0.11 0.20 ,.. 71 u s 165- ·- 15 e.10 15 -4.75 11»·- - 15 165- -0.59 -1\.1J - 15 1M - - 1 5 1M - -2.56 - 15 I J t 0.10 1 .u1Ut ..u ..u ..u . ..2• - - 0 -0 180- -0 - 0 18C (f ' - 0 ISO 180 180 180 - .0.30 . . I -5.30' ·* 0.25 -0.89 .a...... O.ffi \ .."' ::J ,' s: .s.1s ,, - .48,9:1 ·" c : .3.00 , s/ / A : 76 f / / / / / VD:117S / / ' 5mmZone: ' 5mmZone: 3mmlone: ' SmrnZone: ' I I - 0. 94° I 10' \ 10' ' \ 10' ' \ ' \ 6 @ 52• s:·5.75 \ - 1 I ' \ d Tr ' ' , ' ' , , , ' I ' ' .0.21@'4•1 ' ' \ -2.50 I ' ' I I ' ! , I I I \ I c: ' \ ' ' ' ' \ PYK : ..0.21 ' I ' Hgt :-0.202 Hgt :-0.348 Hgt: 0.145 CYI .:0.13 A : 73 Pl•'.-: .14 ,'. oo RMS:0.710 Dist : 00 o• Dist : O. Dist : 0.0 Di st : 0. 0 0° Dist: O. Q° Z: 4.00 0: 4 Zernike/Corn Z: 4 .00 0: 4 Zernike/lnt Z: 4.00 0: 4 QSO 1.60 2 .40 0.80 1 60 0.80 1 ro 2 .40 O.Piston O.Piston 1.Tilt -0.094 1 1.Tilt -0.814 1.Tilt 0.720 2.Tflt 10.019 2.Tf lt 2.Tflt 0.251 3.Astigmat srn --0.426- 3.Astigmatisrn -0.68 • 3.Astigmatism 0.261 4.0efocus 2.400 4.0efocus -0.613- 4.0efocus • 3.013 5.Astigmat srn 5.Astigmatisrn • 1.897 5.As tigmat sm -0.111 6.Trefoil -0.1621 6.Trefoil -0.121; 11 6.Trefoil -0.034 7.Coma -0.036j 7.Coma -0.274. 7.Coma 0.238 8.c.oma -u.uuJi 8.c oma -U.Ut81 8.c oma l u.ur:. 9.Trefoil -0.0461 9.Trefoil -0.0041 9.Trefoil ..0.04 10.Tetrafoil IO.o15 10.Tetrafoil -0.001I 10 Tetrafoil Jo.016 11.A•tigmati•• -0.0141 11.A•ti9mati,-;1 I0.014 11.A,-;tigmatisr ..0.02 12.Spherical -0.088' 12.Spherical -0.1511 12.Spherical lo.063 ' \ Dist : 0.00@ o• 13.Ast gmatisi -0.0671 13.Astigmatisi -0.0041 ' \ 13.AstigmatiSI ..0.06f ' PD1I : 0.19@121• MOist : 0. 11 @133° 00[[] 00 OO@J ITJOO 001 a 1[ 2 ] [3]! = lo

21 9/27/2016

Diag: Com:

OPD 0.06@180 lntemalOPD 0.22@326 \ ...., 90 90 105 I , 15 ...... 105 75 -4J5 120 ' I .... 120 ' I ' • I • , I ' eo \ Patient B Patient C . ).75 . -lJI ' -3.25 1/1,22 -lAI 1 , ' , ,•5 -2.IS -ZH -l.25 -1AO · -1.H 1.85 44.95 -1 0 <1.02 1.28 ' , -115 t.49 -UI • Keratoconus—A condition characterized by corneal thinning, • 59 yr old AA Female .t.15 0 .27 44.91 44.49 1 6S :0.32 0.09 - 11 .tJS 1.0' -•s ''" · { protrusion, and irregularity. It is often bilateral and • Wears PAL’s 180 -3.86 - 0 0.75 z 1eo· 7i 180 1_'°8 - 0 .0.48 .0.13 45.62 5.23 - . .0.11 .().14 asymmetric in presentation. Etiology is sporadic or • Drives mostly during the day time - ! .0.52 45.58 f46.50 --- .20 0.95 autosomal dominant with incomplete penetrance. • Best Corrected Distance VA OD 20/40; OS 20/40 ' 5ffimZo : &4,' ) 6.02 S .69 , ' \ t\ @30' c:.1. • \ I , T • Pellucid Marginal Degeneration—an uncommon bilateral A :105 PvK : 0.51 ' ' P.,•1 : 0.06 RMS: 1.030 01s1: 0. 0151: 0. condition with inferior corneal thinning, protrusion, and irregularity. Presents in early adulthood. Etiology is sporadic. Inferior crescent-shaped band of peripheral corneal thinning extending from 4 and 8 o’clock positions separated from limbus by normal cornea. Fleischer’s ring and Vogt’s striae are absent.

Diag: Diag: Diag: Com: Com: Com:

Retro image R Axial 0.06@180 WF/OPD/HO 0.17@315 W F/Corn/HO 0.06@180 WF/lnt/HO 0.22@326 .... l-00 9() 75 Mi w U I \ ' I I I ' f U t t .71 us... IJS UI 120, ' ' ------/ 131 t.31 ,45 151 125 1.25 UI OJI 020 1W OJC g \ · 0.11 0.2( 0.10 \ . us 1tl5 "-f/ - 10 1{ " .Q.17 -0.05

100 1311 \ 0.31 I :\ ' - , \ '---- .--; ' ' '"lAzc'" : 0781. 000 ' '/' \/ > Hgt : 0.026 Hgt : 0.081 ' ' ' ' Hgt :-0.054 VO: 1l-15 Dist : 0.0 0- Dist : 0.00@1 0° Dist : o. O" R Zernike/OPD Ze rnike/Corn Z: 4.00 O: 4 Z: 4.00 O: 4 Total - 0 40 - 0.20 0.20 0 40 - 0 40 - 0.20 0 0.20 0 40 0 40 0.80 1.20 O.Pis ton O.Piston .0.126 ' 1 lzemike Tl 1.Tnt -0. 1O..TiltPis ton -0.38 1.Tilt -0.0531 -0. = 2..Tilt 0.171 0.223@282 -0.094. 3.Astigmatisrr -0.0121 Steep: 100° 44.95 3.Astigmatism 3.Astigmatism 4.0efocus 4.Defocus -0.177- 4.Defocus -0.101. 5.Astigmatism Flat: 10° 44.91 44. 0.176 5.Astigmatism 0.384 5.Astigmatism -0 · 0.834 6.Trefoil -0.003[ "0.0101 6.Trefoil 10.001 - Astig: 1.13 4$. 9 6.Trefoil iiil 0.131 7.Coma -0.171- 7.Coma -0.164- 7.Coma -0.007[ 45.62 45.23 8.Coma -0.055. 8.Coma -0.07- 8.Coma 10.017 9.Treloil -0.092. 9.Trefoil -0.0101 9.Trefoil ..0.082. Steep 46.50 0.118 I 1O.Tetrafoil • 0.059 10.Te traf oil ..0.0181 10.Te tra foil 1 0.011 Flat 11.Astigmalis1 I0.019 11.Astigmatisi l o.031 11.Astigmatisi -0.012f I0.000 ( C12 +0.000 ) 12.Spherica l I0.030 12.Spherical • 0.052 12.Spherical -0.0221 LandMark 13.Astigmatisi -0.0271 13.Astigmatisi -0.0081 13.Astigmatisi -0.019f 001 o I ., 0 <> 001 1[2 C11C?J 00[ J2] 00@] [ 3 ] - ' - ---'

22 9/27/2016

Diagnostic PSF Summary 0 IJ

OPD HOA [µm): [email protected] R so Patient C-1 105 75 • Total, lnternal@4 .00mm I Order = 4 -ti.II .17.28 M .-,1.1..5.1 .1u 1 -II.II T.Sph T.Coma T.Tre HO -II.It • 47 yr old AA Male -1i O Total: 0.065 0.088 0.122 0.180 -16.66 Cornea: 0.071 0.118 0.084 0.197 -15.50 -14.53 - 15 • Wears SV Specs -1451 Internal: 0.006 0.039 0.051 0.155 IUI - 0 -ll.11 180 . -ll.ff o Refraction: VD = 13.75mm • Prison Guard—Wants Refractive Surgery -IUI .u .97 Cyl .14.00 Sph Axis RMS • Best Corrected Distance VA Specs OD 20/50; OS 20/50 -17.25 -6.00 27 -17.00 -3.00 20 0.950 .\ Diff +0.25 +3.00 -7

HOA [l!m]: [email protected] L .u na.. Total, lnternal@4 . 00mm I Order = 4 .ZUI -IUI T.Sph T.Coma T.Tre HO -1UI -llJI -1UI Total: 0.067 0.290 0.288 0.453 -l>JI Cornea: 0.096 0.037 0.087 0.320 IM- -12.7,1 - 15 Internal: 0.163 0.268 0.210 0.461 IUI - - 0 .1u1 liO · .UI 1 Refraction :VD = 13.75mm UI ·12.96 -11.65 S:.14.50 , Sph Cyl Axis RMS c: .J.00 - ·13.00 A : 6 VD :U.7! REF -14.50 -3.00 6 Jmmlone: 5m One: s :.15.00 s : ,11-.25 WF@6 .00 -13.25 -3.00 154 2.810 I • c: .J.00 C : -ti.00 I I A : 12 A : 127 Diff +1.25 0.00 -32 IA : .1 .1 :4.

L Retro image 0.03@ I

.. .

OPD A xi al 0. 06@ Internal OPD 0.11@214 Internal OPD 0.04@135 ...... 0 • - U t APP 44.27 so 1.04 @3.0mm -1151 , - , - , . . . 15 -tu• -17.5• -17.1• -Ii.SI .16.66

-15.50 -14.53 0.50

180 - O -t1ff .tut ISO- ISO- -$ -14.97 0.52 .-.U..t. -12.96 -11.65 0.48 0.14 S :-17.25 - -14.00 1.60 c: -0.00 / s:-14.50 - -13.00 1.18 A : 27 c . .3.00 / VD: 1 115 10' A . 6 ' JmmZone: 5mmZone: 5mrrrZone: 2:54, ' VO: 13.75 3mmZone: s :-17.50 s:'1 l.(19 ------' 0.86{1!.ff ...... 3:97- ".° ' \ L\ @3' 3mmZooe: 5mmZOlle: 5mmZone: c : .J.50 1.72@131" • , I ' ' I Pv.1', -0 s :-15.00 11.2.5 ---- - ' .1.3 138' 0.21 20·· - ' ' \ A @303' A : 21 f ;2{25 1 • , I , ' I Pv.1': -15.60 18 s : CYL-O.ss o· t . o'oo o• c : -3.00 C ; -6.00 I • ' I ' ' I 0.89'1!48' 1.n@1'10- • , I o • I RIAS: 0. 58 MS:1.1 20 D ist : 0.0 0' RM S:1.020 IS : . A : 12 A : 127 l'wr :-12.81 CYL -2.27 CYL-1.56 l'Y6: .V.66 R M S: 1. 1 20 R MS: 4.48[) Dist: 0. 0' RM S: 0.880 RMS:3.90D Dist: o.o o• Refraction: VD = 1 3.75mm R R R Cornea Cyl: VD = O.Omm Refraction: VD = 13.75mm L L L Sph Cyl Axis RMS Cornea Cyl: VD = O.Omm Steep Flat Astig Total Cornea Internal Sph Cyl Axis RMS REF -17.25 -6.00 27 Steep Flat Astig Total Cornea Internal SimK 44.58@108° 42 .51@ 18° 2.07 -3.75@ 27° -2.07@ 18° -0.63@ 63° REF -14.50 -3.00 6 [email protected] -17.00 -3.00 20 0.95D SimK 44.64@ 70° 42.35@160° 2.29 -2.00@ 6° -2.29@160° -2.27@ 48° (7.57mm) (7.94mm) [email protected] -13.25 -3.00 154 2.810 (7.56mm) (7.97mm) Diff +0.25 +3.00 -7 Diff +1.25 0.00 -32 Corneal aspheric ity Q: -0.47 e: 0.69 Irregularity @4.00mm (HO RMS) Pupil Information Corneal asphericity Q: -0.37 e: 0.61 -0.016µm @6.0mm Irregul arity @4.00mm (HO RMS) PupilInformation Cornea SA L P hotopic ' 8.13mm I dist 0.33@113° 0.051µm @6.0mm r Total rc o rnea rlnternal Cornea SA L Photop 7.30mm I dist 0.26@262° r - Mesopic ' 8.20mm I dist 0.28@111° L !otal Corn rIntern Pupil[ 0.180µm 0.197µm 0.155µm C Mesopic..1 7.78mm I dist 0.11@102° Dist to P/M 0.05@307° 0.453µm 0.320µm 0.461µm photo-·r---··- Contras r - Retro' Dist to P/M 0.36@ 88° Meso r "' 20/ 120: 100% @4.00mm 1 RetroJ 20/120: 100% @4.00mm MPDis

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Photos •l l>iag: Patient D Com: • • 15 yr old AA Female • Wears glasses but unhappy with Vision • Uncorrected Distance VA OD 20/100; OS 20/100 • Best Corrected Distance VA OD 20/40-; OS 20/40-

Refraction: VD = 12.00mm Steep Flat Avg Astig Sph Cyl Axis RMS Tota l Cornea Internal Sim K 7.38@ 99° 7.98@ 9° 7.68 0.60 Center -8.75 -6.50 12 -5.00@ 12° -3.44@ 9° -1 .03@ 19° APP 7.63 SD 1 .14 @3.00mm 3.00mm -6.25 -4.75 10 1.320 7.73 SD 1.29 @Mesopic Mesopic -2.00 -5.00 12 0.44D ECCP 7.65 @4.50mm HOA [µm]: [email protected] 1 Me s o p i c 8.10mm I A0.33@156° ( + ) Cornea SA 0.246µm @6.0mm Total, [email protected] I Order = 6 Dist to P/M 0.04@255° Cornea l asphericity Q: -0.14 e: 0.37 T.Sph T.Coma HO Total: 0.640 0.328 0.767 WTW Cornea: 0.056 0.052 0.095 11.87mm (Photopic) Internal: 0.696 0.366 0.839

Diag: . Com: - .

Refraction ID1'0Chm \0 0!1'.lnm OPD Interna l OPD 0.06@180 Internal OPD 0.0618'180 s c A RMS !Imm s c A 90 OPD 105 75 -9.00 -4.75 16 -0.25 -3.00 172 \ ' I I I • • 12\ 6.30 9 • -I U I -11J5 ' ' .-5 ,02 -11.tt Internal 135, -11.25 -8.75 -3.75 172 1.43 --0.57 4 -U.51 \/.ltnl' 2.91 -11.51 3.00 3.50 173 0.62 171 .$.15 , I "9H. !Imm s c A -9.00 .8.41 44.88 "9Jt 44.88 - '1 5 -a.25 OPD 173 -1.50 Ir -300 -325 165- 1a.::.- -7.51 -6.05 '4.66 42.80 I 4i\.57 le 5- lntern;ll --0 .31 23 .us .u, -6.05 4 .66 42.80 43'57 -UI I I Cornea -6J5 . U t -3.05 172 - 180- 0 S.25 -Ut 180 -mt? 4 1- - .u . 180- 7 7 -3.75 -311 -5.71 -3.06 43,55 I lf3:11 .J IS -5.71 -3.06 43.55 43.11 -3.11 l 45.26 6.01 45.26

Refraction: VD = 1 3. 75mm L L L Cornea Cyl: VD = O.Omm Sph Cyl Axis RMS Steep Flat Astig Total Cornea Internal REF -9.25 -5.00 169 SimK 45.24@ 81° 42.67@171° 2.57 -3.75@169° -2.57@171° -0.57@ 5° [email protected] 4 r 171 1.470 Keratometry Sph. Aber. 8.3mm um (7.46mm) (7.91mm) S lmK Stl'l'P : 45.24@ 81 Ocular : -1.124 ( -5.39) SimK Flat : 42.67@ 171 Cornea: 0.540 ( 1.22 ) Diff +5.00 +1.00 2 Corneal asphericity e: 0.34 CYL · -? 57 Pupilometty Q: -0.12 Pupil Information Aspnericit'{ SO!lm tmf P h:>topic :7.83 Irregularity @4.00mm (HO RMS) Avg Steep M eso pic :8.26 Cornea SA 0.289µm @6.0mm e: R0at.34 { 0 .42 , 0 . 22 ) Mf"Di3t r Photopic 7.83mm I dist 0.27@348° :0.1Q@ !i0 L-Tot Orn ter a: -0.12 ( -0.18. -0.05 ) Pdtst :0.27@348 8.26mm I dist 0.34@ 4° Mdist 0.734µm 0.100µm 0.809µm Mesopic :0.34@ 4 0.10@ 50° Dist to P/ M I Order: 6 ,ContrasJ ( Zone: I Mesopic I Retro 1¥1 20/20: 99% 20/40: 99% @4.00mm 1¥1 s. m m r 26

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Diag: OPD 0.03@ 90 Axial 0.12@166 Internal OPD 0.12@ 0

Com : 00 105 75 41.H .us 41JS -12JS 120 - .), " I I -IUI ::.. ' /f!iJ 41J S .u...s -1125 I 4U5 -I.SI OPD 0.03@ 90 0.12@166 Internal OPD 0.12@ 0 4615 .J.15 .,.... 45.75 APP 44.23 SO 1.14 @3.0mm -U S .J0. 0 4LH 75 -9 0 45.2> -1.ll 471§ ' .&15 -t.SD Photos 41J§ -7.51 . . 15 46.1§ .us .... 461 5 1.15 H.75 -6'J5 180 180 -7.58 451 5 --4.St 2.25 .JJS .JM 315 s: -8.75 c : -7.00 .. A : 12 VO : l l.75 3mmZone: s : -6.25 t\ @192° c : 4 .75 I I I .. A : 10 Pwr : 44.06 (7.66} \ P\\f : 2 60 RMS:1.32D Dist : o.o o• D ist : O. O"

A@192° WF!OPD/Tot 1 WF OPD/HO D.<>3@ 90 P lA' ' : 2.60 90 tll 105 75 I I ' , I Dist : 0. O" I.II 120 ' ' UI \ ' /f!i) 1.11 ' , / 45 1.51 1 3 5 , ' IJO , ' 8.10 150-... ,.-30 .e.11 .eJI le.!• - - 115 U I ..,eJI - - 0 180 . 180 -111

1 0' I ' \ I ' \ ' ' I ' ' ' \ Hgt : 0.020 I ' Hgt : -1.488 D,ist· : 0. Dist : o.o er 00

Patient D Diagnosis?? Patient D New and Emerging Technologies Anterior Segment • Lenticonus: Cone-shaped lens due to bulging from a thin lens capsule; Can be anterior or posterior • Anterior Lenticonus: usually males; bilateral. Associations: A D E N O P L U S Alport’s syndrome—autosomal dominant basement IN L FA M M A D R Y membrane disease associated with acute hemorrhagic T E A R LA B nephropathy, deafness, anterior lenticonus, anterior polar or M E IB O GR A P HY cortical cataracts, and albipunctatus-like spots in the fundus. L IP IFL O W • Posterior Lenticonus—More common, slight female B L E P HE X predilection. May have associated cortical lens opacities. A MN IO T IC ME MB R A N E S A L C O N / GO O GL E SM A R T L E N S

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AdenoPlusTM (RPS) AdenoPlusTM (RPS) InflammaDryTM (RPS)

 CLIA-waived Point-of-care Test  Assemble detector with test cassette and sample collector  CLIA-waived Point-of-care Test  Detects all known serotypes of adenovirus  Dab patient’s conjunctiva 4-6 times  Measures MMP-9 concentration in tear film;  Rapid (~2mins to conduct, ~10mins for results)  Immerse detector with sample collector into buffer vial for 15sec positive if >40 units/sample  One-time use  Positive results = both control line AND results line visible  Reimbursable; CPT Code: 83516  High sensitivity/specificity  “immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semi-quantitative, multiple step method.”  Reimbursable; CPT Code: 87809  CMS national limit: $15.74  “infectious agent antigen detection by immunoassay with direct optical observation, Adenovirus.”  CMS national limit: $16.36  Can be useful in dry eye diagnosis/ management

TearLabTM: Osmolarity TearLabTM Osmolarity BlephEx

Osmolarity: proven biomarker of dry eye disease Determines tear osmolarity (mOsm/L) using tear Medical grade micro-sponge at end of electric rotary Clinical Test Criteria PPV fluid collected from eyelid margin tool to exfoliate and remove scurf/debris from lid Osmolarity >317 MOsm/L 86% Osmolarity is indicator of ocular surface health margin Schirmer <5mm/5min 31% Osmolarity > 300mOsm/L: loss of homeostasis TBUT <10sec 25% Staining (RB) Any 31% Inter-eye difference of >8mOsm/L indicates tear film Tear Meniscus ≤0.35mm 33% instability

• Dry Eye Workshop Study (DEWS): Report 5(2). April 2007. • Tomlinson A, et. al. Determination of a referent for dry eye diagnosis. Invest Ophthalmol Vis Sci 2006: 47(10) . Lemp MA, et al. Tear osmolarity in the diagnosis and management of dry eye disease. Am J Ophthalmol 2011; 151:792-8.

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Amniotic Membranes Amniotic Membranes Alcon (Novartis)-Google Partnership: Smart Lens

 Amniotic membrane: part of placenta  Stem cell properties can aid in ocular surface repair Natural growth factors July 2014: partnership announced between  Avascular Prokera povides similar benefits to eye as amniotic Google[x] and Alcon to in-license ―smart lens‖  Prokera: symblepharon ring + CRYOTEK amniotic membrane does to fetus: technology for all ocular medical uses. membrane  Physical barrier DM: continuous blood [glc] monitoring  Treatment for a damaged ocular surface  Anti-scarring  Chemical/thermal burns Presbyopia: Accommodative contact lens  Stevens-Johnson syndrome  Anti-inflammatory  Dry eye syndrome, exposure keratopathy  Anti-angiogenic  Filamentary keratitis  EBMD/RCE  Anti-adhesive  Other epithelial/BM degenerations  Etc, etc… Facilitates tissue regeneration and growth ―Active‖ healing

Smart Lens for Presbyopia Alcon/Google: Smart Lens Sensimed AG: Triggerfish® Sensor Contact Lens

 Soft hydrophilic contact lens that monitors eye Smart Lens for presbyopia Novartis CEO Joe Jimenez: pressure in glaucoma  changes in corneal curvature may correspond  Photo diodes interact with light based on location of eyelid  "The calendar is on track and we are already developing a directly to fluctuations in IOP  Wireless signal sent to liquid crystal embedded between two technological lens prototype (that) should be tested on humans  Data is transmitted wirelessly to a small adhesive layers of contact lens in 2016.― (Le Temps (Swiss Newspaper), 5 Sep 2015) antenna placed on the face near the eye  Anticipates product (smart lens for presbyopia) to market  The antenna then transmits the data to a  Contact lens adjusts power for near or distance portable recorder worn by the patient within 5 years  Can be worn continuously for one 24-hour Apply tech to accommodative IOLs? period.

 Data is transferred from the recorder to the doctor's computer via Bluetooth for immediate analysis.

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ic100 ic100 Features Icare® EasyPos: Intelligent Positioning Assistant Improved forehead support

• New design EasyPos: New Positioning Assistant

• Enhanced Ergonomics Improved forehead adjustment knob

• Clinically robust Large OLED Color Display

EasyNav: New Navigation • Easy to use Interface Green light on the probe The probe should point Red light on the probe base base indicates correct perpendicularly to the center of indicates incorrect vertical • Accurate vertical alignment the cornea (the reflection of the alignment of the tonometer. New Ergonomic AMS Measure light ring is seen symmetrically button • Precise inside the sphere of the pupil).

EasyNav: Advanced Navigation Interface AMS: Automatic Measurement Sequence Rebound Technology • Easy-to-use Select between two modes: The advanced navigation interface includes 3 • Quick, effective routine barely noticeable by the patient buttons and a 128x128 pixel OLED color display • Revolutionizes early glaucoma detection and control • No topical anaesthetics or disinfection for effortless selection and menu browsing. Series mode: Press the measurement button for a sustained period of time needed (more than 2 seconds) and the • Disposable probe touches the cornea tonometer will take six samples in very lightly rapid succession • Suitable also for non-compliant patients and children Single mode: In this mode, the • Proven accurate by several measurement button must be independent studies pressed each time to initiate measurement (six samples = a • Truly portable complete measurement cycle)

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How It Works: Probe Mechanics Revolutionary Technology Measurement Basics Light weight (26.5 mg) probe touches the cornea with low speed (0.25-0.30 Two coils are moving the probe and measuring the probe speed • The probe touches the cornea very gently m/s) • Measurement takes place in 0.1 seconds probe coils • Corneal reflex after 0.2 seconds

contact with cornea probe base • Measurement of motion parameters

probe speed is zero, rebound starts • To be repeated 6 times in order to minimize deviation and to produce a calculated measurement value Light weight probe Low probe speed • Whole procedure (6x both eyes) takes about one minute coil frame time Minimal energy

Clinical Studies How Can We Gather This Data? What is it? REPRODUCIBILITY AND TOLERABILITY OF THE ICARE REBOUND TONOMETER IN SCHOOL ® CHILDREN • Repeated, lab-based diurnal IOP readings over 24 hours • The Icare HOME tonometer is a “Measurement of intraocular pressure (IOP) with the rebound tonometer (RBT) is a An immense effort that is both flawed and handheld, battery operated device highly reproducible method in schoolchildren showing high intraobserver and impractical that measures intraocular pressure interobserver correlation and it seems to be very comfortable when performing IOP (IOP) without the need for topical measurements in schoolchildren without an anesthetic.” anesthetic. Sahin A, Basmak H, Niyaz L, Yildirim N. • Pressure sensors

J Glaucoma. 2007 Mar;16(2):185-8 Invasive • The device is intended as an Expensive adjunct for monitoring IOP of adult AGREEMENT OF REBOUND TONOMETER IN MEASURING INTRAOCULAR PRESSURE WITH Limited patients (self-use) and also by THREE TYPES OF APPLANATION TONOMETERS caregivers in cases where the “iCare agrees well with applanation tonometers” Difficult to justify Nakamura M, Darhad U, Tatsumi Y, Fujioka M, Kusuhara A, Maeda H, Negi A patient is not able to obtain their Am J Ophthalmol, 2006 Aug;142(2):332-4 • Self monitoring own measurements. Has to be accurate Has to be easy to use

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Why 24 Hr Monitoring? Icare® EyeSmart: Automatic Eye Recognition Icare HOME tonometer 24 hour IOP monitoring can reveal higher peaks and • IOP, date, time, eye recognition The tonometer includes an automatic eye recognition system that identifies which eye is wider fluctuations of IOP than those found during (right/left) and measurement being measured. routine office visits. Research reports a steady daily quality are all stored in the internal memory. increase in IOP in some patients being treated for • Two infrared LED transmitters below probe (1) glaucoma. • Data is transferred to a PC for • One infrared LED sensor above probe (2)  Barkana Y, Anis S, Liebmann J, et al. Arch Ophthalmol. 2006;124:793-797. further analysis by the prescribing • The infrared light is reflected from nose back to the physician. sensor Studies have shown IOP rises when a patient is • The sensor knows from which transmitter the supine; IOP peaks were measured upon awakening • New features: positioning light, reflected infrared light came from and thus which automatic eye recognition system, eye, right or left, was measured and declined within 30 minutes. • The resulting eye indication is stored into the  Barkana Y, Anis S, Liebmann J, et al. Arch Ophthalmol. 2006;124:793-797. series or single measurements, memory of the tonometer new user interface panel.

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Icare® HOME Tonometer: Market Clearance Icare® AMS: Automatic Measurement Sequence New User Interface Panel The tonometer can operate in two modes: • USA: ??????? • Simple Indicator Lights • Taiwan: November 2, 2015 and Audible Alerts • South Korea: June 18, 2015 Series mode • China: April 28, 2015 Pressing the measurement button for a sustained • Interpretation only by a • Brazil: April 28, 2015 period of time (more than 2 seconds) initiates the • Japan: October 29, 2014 measurement function and the tonometer takes six health care professional • Canada: July 29, 2014 measurements in rapid succession • Does not display the IOP

Single mode measurement The measurement button must be pressed each o Mitigating concerns that the patient time to initiate the measurement, i.e. six samples for or caregiver might improperly use the whole measurement cycle the information provided by the device

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Commercially available SD- OCTs: 182 5/2/2016

Spectral OCT/SLO iVue (Optovue) Spectralis (Heidelberg) BEYOND OPHTHALMOSCOPY

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Keratoconus HSV Stromal Keratitis 186 5/2/2016

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The Foundation For Ocul ar Surface Health

Meibomian Gland Function

MGD: Prevalent, Progressive, Obstructive Healthy Meibomian Gland Function is Foundational Unstable Ocular Surface to Ocular Surface Health Consequences Beyond Comfort MGD diagnosed in 86% of dry eye2 3 Over 63% of cataract patients have dry eye symptoms Tear film irregularities reduce retinal image Over 30% of all patients > 50 years old have dry eye2 quality by 20% to 40%. Tutt et al, 20001

―If not addressed, tear film dysfunctions can lead to errors in Figure 1. The irregularity and warpage in the rings on this Placido-disc image are indicative biometry and IOL power of significant OSD that should be treated Early Intervention optimizes outcomes prior to preoperative measurements. calculation.‖ Matteo Piovella, MD So Look for MGD EARLY Images courtesy of Cynthia Matossian, MD MGD Assessment requires the evaluation of gland function and/or structure CORE MECHANISM OF MGD IS LEADS TO GLAND ATROPHY Tear film irregularities induce significant higher GLAND OBSTRUCTION 1 AND DROP OUT 1 order aberrations, symptoms of diplopia, starbursts, glare, and shadowing.2 Function Structure Figure 2. Tear film abnormality secondary to dry eye and corneal surface irregularity due to contact lens wear Marjan Farid, MD masquerading as pseudoastigmatism, leading to incorrect lens selection. Blackie CA, Carlson AN, Korb DR. Treatment for meibomian gland dysfunction and dry eye symptoms with a single-dose vectored thermal 1. Knop E, Knop N, Millar T, et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, pathophysiology pulsation: a review. Curr Opin Ophthalmol 2015;26:306-313. of the meibomian glands. IOVS 2011;52(4):1938-1978 Blackie CA, Coleman CA, Holland EJ. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian 2. Lemp M, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478. gland dysfunction and evaporative dry eye. Clin Ophthalmol. 2016 Jul 26;10:1385-96. 1. Refractive index values from Palanker, ONE Network. Tutt R, Bradley A, Begley C, Thibos LN. IOVS 2000;41:4117 3. Trattler WB, et al. Cataract and dry eye: Prospective health assessment of cataract patients ocular surface study. Presented at ASCRS 2011, Sand Diego, CA. 2. The tear film: The neglected refractive interface. Farid M. Eyeworld; Supplement to Eyeworld 2014.

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Rapid HD Meibomian Imaging LipiFlow® : Thermal Pulsation LipiFlow® Thermal Pulsation Pivotal Trial

Effectiveness Parameter Summary LIPIFLOW (9 Site Study) • Inner-lid Heat directed to Baseline 4 Weeks Meibomian glands with (N = 130) (N = 128) Simultaneous Pulsation Mean (SD) Mean (SD) NEW  Rapid image capture • Cornea & Globe Protected Meibomian Gland Secretions Tripled 1.9 (1.6) 5.8 (  High definition • Restores gland function # Glands Secreting Any Liquid (0 to 15) 3.5)* Dynamic Meibomian Imaging(DMI™) In-office procedure -12 mins • Tear Break-up Time (0 to 20 sec) Improved ~ 40% 5.5 (2.9) 7.4 ( 5.5)*  User friendly Dry Eye Symptom Questionnaire Improved ~ 50% 14.3 (4.8) 7.6 ( Total SPEED Score (0 to 28) 5.8)*  Small footprint Total OSDI Score (0 to 100) Improved ~ 50% 32.0 (20.0) 16.6 ( Only single dose treatment achieving long-term improvement in gland function & symptoms 18.1)* 31 Sponsored/Unsponsored Peer-reviewed studies & abstracts. Average improvement1: ~3x Improvement in gland secretion 15 OF 25 GLANDS STUDIED * p < 0.0001, change from baseline to 4 weeks Pretest workup imaging to fit workflow ~Symptom score reduced 50% Lane, et al, Cornea, 2012LipiFlow for treatment of MGD 1. Blackie CA, et al. Treatment for meibomian gland dysfunction and dry eye symptoms with a single-dose vectored thermal pulsation: a Control Group: standardized warm compresses – 5 minutes, QD x 2w NO SIGNIFICANT IMPROVEMENT review. Current Opinion in Ophthalmology 2015, 26:306–313.

The Long-Term Effect of a Single Dose LipiFlow LipiFlow® Thermal Pulsation ® NinTehe-rmcael Pnulstaetiorn,GSrouep GmlanidnSaecrletTionrs ial LipiFlow a Sustained Foundation Results in Cataract and Contact Lens Patients

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* Blackie CA, Coleman CA, Holland EJ. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry 196 Registered randomized controlled trials, expected publishing late 2016 eye. Clin Ophthal. 2016;10:1385-1396.

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® Manage the Ocular Surface LipiScan Indications For Use ® and Labeling & Risks LipiFlow Indications For Use

ASCRS Physician Survey 2013 sician Indications for Use ore

LipiScan Dynamic Meibomian Imager (DMI) is an

ophthalmic imaging device intended for use by a phy ―Eighty-eight percent agree or strongly agree that in adult patients to capture, archive, manipulate and st Indications for Use

digital images of the meibomian glands. mild to moderate dry eye significantly affects The LipiFlow® System is intended for the application

postoperative satisfaction in cataract and refractive of localized heat and pressure therapy in adult Contraindications patients with chronic cystic conditions of the eyelids, ead No contraindications have been identified including Meibomian Gland Dysfunction (MGD), also patients…‖ known as Evaporative Dry Eye or lipid deficiency Dry Precautions Eye. Caution: Disinfect the surfaces of the chin rest, foreh rest and Handheld Near Infrared (IR) Lid Everter with To optimize, maintain or rehabilitate the ocular surface isopropyl alcohol immediately prior to use and prior to storage to prevent cross-contamination and patient healthy meibomian gland function is required* infection. ffects Contraindications Potential Adverse Effects Do not use the LipiFlow® System in patients with the following conditions: Ocular There are no known or anticipated adverse e surgery, ocular injury, ocular herpes of eye or eyelid within prior 3 months associated with use of this device. Active ocular infection or inflammation, or history of chronic, recurrent ocular inflammation within prior 3 months Eyelid abnormalities that affect lid function Eyelid abnormalities or ocular surface abnormalities that may affect/compromise corneal integrity or lid function *Blackie CA, Carlson AN, Korb DR. Treatment for meibomian gland dysfunction and dry eye symptoms with a single-dose vectored thermal pulsation: a review. Curr Opin Ophthalmol 2015;26:306-313. 200 201

LipiFlow® Labeling and Risks Precautions • Severe (Grade 3 or 4) eyelid inflammation (eg, blepharochalasis, staphylococcal blepharitis, or seborrheic blepharitis). Patients with severe eyelid inflammation should be treated medically prior to device use. • In addition, the treatment procedure may loosen previously inserted punctal plugs, which may worsen the patient’s Dry Eye symptoms. Potential Adverse Effects • Eyelid/eye pain requiring discontinuation of the treatment procedure; • Eyelid irritation or inflammation (eg, edema, dermatitis, hordeolum or chalazion); • Ocular surface irritation or inflammation (eg, corneal abrasion, conjunctival edema, or conjunctival injection (hyperemia); and • Ocular symptoms (eg, burning, stinging, tearing, itching, discharge, redness, foreign body sensation, visual disturbance, sensitivity to light). • Potential serious adverse events that are not anticipated because of the device mitigations to prevent occurrence include: – Thermal injury to the eyelid or eye, including conjunctiva, cornea or lens; – Physical pressure-induced injury to the eyelid; – Ocular surface infection.

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Meibomian Gland Morphology LipiView® II: Adaptive Transillumination

Gland truncation

Normal Meibomian gland structure

Central dilation Gland drop out Changes the light intensity across the surface of the illuminator to compensate for lid thickness variations between patients

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LipiFlow® Thermal Pulsation

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LipiFlow® is the only FDA-cleared device for Meibomian Gland Dysfunction (MGD), shown to restore gland function.

LipiFlow® is an in- office procedure, taking only 12 minutes per eye.

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Belin ABCD System in Oculus Pentacam Keratoconus Keratoconus • Keratoconus: first described in detail in 1854 as a chronic, • Global Consensus on KC and Ectatic Diseases (2015) non-inflammatory ectasia of the cornea. reports there is no consistent or clear definition of ectasia • Annual Incidence of 2 per 100,000 progression • Prevalence of 54.5 per 100,000 • Kmax (maximum anterior saggital curvature) is the most • No universally recognized classification system commonly used parameter to detect or document ectatic • The Amsler-Krumeich is one of the oldest and most widely progression and is regularly used as an indicator of used classification system grading KC from stage 1-4 using crosslinking’s efficacy spectacle refraction, central keratometry, presence of • The ―Belin ABCD‖ KC Grading system uses anterior and absence of scarring and central corneal thickness (CCT) posterior radius of curvature taken from the 3 mm zone centered on the thinnest point ( A for Anterior, B for Back Surface, C for Corneal thickness, and D for Distance Visual Acuity.

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!DO!l'IT1f'l1l n's M.!!

CORNEAL COLLAGEN CROSS• - LINKI NG ' Liquid riboflavin (Vit B2) applied Central 7-9mm of epithelium removed . De cemet' / \ •, M 11Jlir:m ,,/ • to surface of eye, followed by Riboflavin B2 in 20% Dextran applied every 5 -· Cornea End1;1t tu;-li1,1m i controlled application of UV light minutes, while UVA (365-370nm) applied for Goal is to prevent progression of 30min - - - - ,..-- ectasia by increasing number of . Typical post-op: bandage CL + topical cross-linking bonds in stroma antibiotics/steroids x2-4wks Bf FOl'tE CXL : LESS C : OSS:LINK ING AF e n :MORE CROSSU NKilt•f.'G Ideal candidate  Cornea thins slightly after CXL (mean change 24m), but = yn;;U

"'- ...... I { t i , I Caprorossi A, Mazzotta C, Baiocchi S, Caporossi T. Long-term results of riboflavin ultraviolet A corneal collagen cross-linking for keratoconus in Italy: The Siena Eye Cross Study. Am J Ophthalmol 2010; 149(4):585-93.

Collagen Cross Linking Collagen Cross Linking •

The US Food and Drug Administration (FDA) has approved a riboflavin ophthalmic solution ( Photrexa, Avedro) that treats a corneal disease called progressive keratoconus with corneal collagen crosslinking, the manufacturer announced today.

The approval extends to a version of the riboflavin ophthalmic solution that contains dextran (Photrexa Viscous) and an electronic device (KXL System) that irradiates the solutions with ultraviolet A light after they have been applied to the cornea.

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Ancillary Techniques in Tx of Microbial Fundus Autofluorescence (FAF) New and Emerging Technologies Keratitis Posterior Segment Non-invasive imaging modality using cSLO • Topical Corticosteroids Pictoral representation of metabolic activity • Collagen-Cross Linking (CXL)—PACK-CXL or photoactivated FU N D U S A U T O FL U O R E SC E N C E chromophore for infectious keratitis—Experimental SW E P T - SO U R C E O C T High activity: hyperautofluorescence • Intrastromal Antimicrobials W ID E FIE LD O C T • Amniotic Membrane Transplantation SW E P T - SO U R C E O C T Low activity: hypoautofluorescence • IVP for Acanthamoeba O C T A N GIO GR A P HY

Fundus Autofluorescence (FAF) Widefield OCT (Heidelberg Engineering) Swept-Source OCT (SS-OCT)

ONH Drusen Current field of view with SD-OCT: 30  Visualization of choroid (deeper)  Faster scan rate (and  wider field width)  Spectralis OCT with widefield module: 55   Equal/higher resolution to SD-OCT Retinal degenerations Macula, ONH and periphery in one examination TD-OCT SD-OCT SS-OCT Widefield lens attachment + software upgrade to Scan Rate 400 27,000-50,000 up to 1,000,000 (A-Scans/sec) current Spectralis OCT Resolution 10-15 m 3m axial 1-3m B Scan Field Width 6-9mm 6-9mm 12mm

 Zeiss and Heidelberg: prototypes  Topcon: DRI Triton OCT

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' -.-.., 1·

OCT Angiography (OCTA) OCT Angiography (OCTA)

Isolation/extraction of microvascular ciculation from Sequential B-Scans performed repeatedly at same OCT image data using specialized processing location in the retina to detect motion of scattering techniques particles (e.g Layer-by-layer analysis of vascular Visualization of ALL vascular layers without dye anatomy injection  FA does NOT image radial periphery or deep capillary networks well AngioVue (Optovue) Moving structures: phase shift/phase-doppler Cirrus HD-OCT with AngioPlex (Zeiss)  after eliminating excess motion artifacts, residual motion = blood flow Spectralis OCT Angiography (Heidelberg Eng.) • Spaide RF, Klancnik JM Jr, Cooney MJ. Retinal vascular layers imaged by fluorescein • Spaide RF, Klancnik JM Jr, Cooney MJ. Retinal vascular layers imaged by fluorescein angiography and angiography and optical coherence tomography angiography. JAMA Ophthalmol 2015; optical coherence tomography angiography. JAMA Ophthalmol 2015; 133(1):45-50. 133(1):45-50.

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Zeiss AngioPlex Maps Zeiss AngioPlex Maps

2D representation of retinal vasculature in a Color depth map combines superficial, deep and particular region of interest avascular retina maps and allows for depth visualization of retinal blood flow

(Simultaneous infrared cSLO and OCT Angiography imaging with Spectralis OCT2)

Diabetic Retinopathy NVE BRVO wet AMD with CNV (Ziess AngioPlex OCT)

Potential Clinical Applications OCT Angiography (OCTA) Limitations Confocal Imaging Systems

Detection of: r No supportive clinical trial data yet 240 5/2/2016  CNV Interpretation of en-face images depends on accurate  Neovascularization in Macular Telangiectasias segmentation  MA’s and ischemia in Loss of sensitivity with depth Diabetic Retinopathy  Swept Source OCT may address this  Occlusions, shunts and othe abnormalities in RVO’s Cost?  ONH Vasculature abnormalities • Spaide RF, Klancnik JM Jr, Cooney MJ. Retinal vascular layers imaged by fluorescein angiography and optical coherence tomography angiography. JAMA Ophthalmol 2015; 133(1):45-50.

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Centervue Eidon Centervue Eidon

241

• Ultrawide digital • Scanning Laser Ophthalmoscope • Simultaneous, Non-Contact • Single Capture • Up to 82% or 200 degrees of retina displayed in one capture • Autofluorescence features • Angiography & ICG features in 5/2/2C016alifornia

Centervue Compass Centervue Compass

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3. Ideate Solutions 3. Ideate Solutions 3. Ideate Solutions

Creativity Loves Constraint Creativity Loves Constraint Creativity Loves Constraint

3. Ideate Solutions 3. Ideate Solutions 3. Ideate Solutions

Creativity Loves Constraint Creativity Loves Constraint Creativity Loves Constraint

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3. Ideate Solutions Centervue—Superior Wide Field Image Quality with Small Pupil Size Introduction Creativity Loves Constraint There are layers of the retina that we simply can’t see with traditional fundus • examination and photographic means…

Eidon with AF: https://youtu.be/5B1qtu6tdMg The Vitreomacular Interface The RPE The Choroid

Compass: https://youtu.be/m_zP7V9_wQQ

Multi-Spectral Imaging (MSI) with the Annidis RHATM provides access to these layers.

255

The Annidis RHATM Multi-Spectral Imaging (MSI) The Benefits of MSI Optic Cornea Macula Nerve TM • ―Annidis RHA Multi-Spectral Imaging is emerging as the Light most comprehensive technology for the early detection of outer retinal and choroidal disorders, including all forms of AMD and opening a new frontier in non-invasive ocular Pupil Retina imaging.― Lens

• Discrete narrow band light emitting diodes (LEDs) are used to create a series of non-invasive en face ―spectral • Detect more pathology images‖ throughout the entire thickness of the retina and • Identify pathology earlier • Screen for change more frequently choroid • Utilize the Oxy/Deoxy retinal and choroidal images as a form of proactive multi-spectral angiography • Make sure that your ophthalmological referrals are pertinent • Provides an enhanced view of the entire retinal and Discrete monochromatic LED lights are used to create a series of en face ―spectral images‖ • Monitor the effectiveness of treatment choroidal architecture including the RPE throughout the entire thickness of the retina and • Engage your patients with this technology by teaching them the value of assessing all of choroid including the RPE. structures and layers of their retina and choroid 256 258

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Fundus Autofluorescence Clinical Features of MSI “Covering the Full Spectrum of Eye Disease

MSI-FAF (Long Wavelength) Stereo - Melanoma with the Full Spectrum of Light”

Stereo images captured without moving the patient or instrument • Retinal topography • Pigment epithelial detachments (PED) • Edema • Optic nerve head evaluation

Choroidal melanoma deep within Choroidal Crescent Early RPE Disruption Geographic Atrophy Plaquinel Toxicity ocular structures seen with TCI

Stargardt Disease Retinitis Pigmentosa Nerve Head Drusen Vitelliform Degeneration * 260 261

XiidraTM (lifitegrast 5% oph soln) XiidraTM (lifitegrast 5% oph soln) New and Emerging  Lymphocyte [CD4 T-Helper Pharmacological Agents Cell] Function-associated Antigen-1 (LFA-1) antagonist

X IID R A  Activated CD4 T-Cells release GE N E R IC O C U L A R HYP O T E N SIVE S cytokines, exacerbating LA T A N O PR O ST E N E B U N O D inflammation R HO P R E SSA R O C L A T A N  Lifitegrast blocks the binding of B IM A T O P R O ST SU ST A IN E D R E L E A SE CD4 T-Cells, preventing their activation  may block initiation of inflammatory cascade

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XiidraTM (lifitegrast 5% oph soln) XiidraTM (lifitegrast 5% oph soln) XiidraTM (lifitegrast 5% oph soln)

 Received FDA approval July 11, 2016 OPUS-1 Trial OPUS-2 Trial  Significantly reduced corneal fluorescein and conjunctival  Significant improvement in eye dryness as reported using a  Indication: lissamine green staining vs placebo after 84 days visual analog scale as early as 14 days improving through days  ―For the treatment of the  Improvements noted by day 14, persisted through day 84 42 to 84 signs and symptoms of dry  No changes demonstrated in decreasing corneal and eye disease. ‖  Significant improvements in subjective measures of ocular discomfort and eye dryness but not as measured on conjunctival staining

standardized surveys (VR-OSDI) as in Phase 2 trials  Adverse events reported:  Dosage: 1gtt BID  Adverse events reported  Burning on instillation = 28%  Discomfort on instillation at start of Tx = 24%  Dysgeusia (change in taste sensation) = 19%  Packaged in single-use, non- ―Lifitegrast ophthalmic solution 5.0% versus placebo for treatment of dry eye disease: Results of the preserved vials ―LifitegrDasyt sopghetuhaslimaic(scohluatinong5e.0i%nftoar strteeatmseentsoaf tdiroy ney)e =dis1e3as%e: Results of the OPUS-1 phase 3 randomMizedilpdhatsoe ImII oOdPUeSr-a2tsetuidny‖sTeavubeerriJt,yKarpecki P, Latkany R, et.al. Ophthalmology. 2015; study ‖Sheppard JD, Torkildsen GL, Lonsdale JD, et.al. Ophthalmology. 2014; 121:475-483. 122:2423-2431.

XiidraTM (lifitegrast 5% oph soln) Xiidra™ - Pearls Generic Ocular Hypotensives to Market

 Keep unused vials in foil sleeve  Where does it fit in our treatment plan?  Generic Lumigan: bimatoprost 0.03% oph soln  Light sensitive - will turn yellow and spoil  Designed as a chronic therapy  Safety not established <17 years of age  Lupin Pharmaceuticals (Baltimore, MD)  Insurance coverage?  FDA no longer assigns pregnancy categories  FDA-Approved Feb 23, 2016  Safe in rat models  Use professional judgement prescribing for pregnant patients  Wait 15 minutes after instillation before inserting CL’s Generic Travatan: travoprost 0.004% oph soln  Use punctal occlusion with fingers/tissue and head tilt forward after  APOTEX INC instillation to keep from running down back of throat to avoid  FDA-Approved July 10, 2016 dysgeusia

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Latanoprostene bunod RhopressaTM (netarsudil 0.02% oph soln) ROCK Inhibitors: Mechanism of Action

= latanoprost + a ―Nitric Oxide donating moiety‖ Rho-Kinase (ROCK) and  Nitric Oxide: vasodilator via action on smooth muscle Norepinephrine Transporter (NET)  Also suppresses Rho signaling pathway Inhibitor  TM cells and tissue relax, decreasing outflow resistance  Also lowers episcleral venous pressure

 Possible anti-fibrotic effect on TM Currently in Phase 3 Clinical Trials  Research underway to evaluate possible  Two phase 3 clinical trials (APOLLO, LUNAR) already have neuroprotective effects shown latanoprostene bunod 1gtt qHS had higher IOP-lowering effect compared to timolol alone Currently in Phase 3 Clinical Trials (Inhibition of actin cytoskeleton contractile tone of TM smooth muscle)

RoclatanTM (netarsudil/latanoprost 0.02/0.005% oph soln) RoclatanTM (netarsudil/latanoprost 0.02/0.005% oph soln) RoclatanTM (netarsudil/latanoprost 0.02/0.005% oph soln)

Phase 3 Trials COMPLETE 9/14/2016 Efficacy:  IOP lowering exceeded latanoprost by 1.3 to 2.5mmHg  IOP lowering exceeded RhopressaTM by 1.8 to 3.0mmHg

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RoclatanTM (netarsudil/latanoprost 0.02/0.005% oph soln) Bimatoprost Sustained-Release Implants

SCHLEMM'S CHANNEL  Device asymmetrically swells then shrinks to ~ sphere then disappears between 4-6 mo

 Doses: 6, 10, 15, 20 micro grams  91% reached clinical endpoint @

IM P l A NT week 16 FIG. 2  41% @ 6 months

 10% hyperemia

Bim at opr os t Sustained-Re lease Im pla nt is a Sign if icant G lobal Op p o r t u n ity Keratoprosthesis

Bi matoprost Sustained-Re lease Implant is a Noncomplianceis an Issue w ith New and Emerging Si nif icant Innovation Current Treatments • Inability to c o rrectly and Surgical Technologies  Treatment option for severe corneal opacification when reliably inst ill eye d rops (1)( 2 ) • Adverse effects associated PK repeatedly fails or is not possible w it h t aking eye drops (3) • T he num ber of medication  Donor graft + prosthesis and t he c o m plexit y of t he C O R N E A L C R O SS - L IN K IN G ( C X L ) dosing sc hedule (4 )< 5H6H7}  Multicenter study (2006): • U nderstanding of glaucoma K E R A T O P R O ST HE SIS • A sustai ned- re lease, • Dis rupt ive, f i rst- i n-class inc ludi ng t he consequences  57%: BCVA ≥20/200 at 8.5mos prostam ide- lo aded, tec hnology and its t reatm ent l 1H2H8J D R O PLE SS C A T A R A C T SU R GE R Y bioerod ible implant • Data f ro m Phase 2 clinical t r ials • M e d icat io n cost !9l M IC R O P U L SE L A SE R T R A B E C U L O P L A ST Y ( M L T )  Post-op complications: • Inject ed into t he ante rio r suggest s t hat bim a toprost • Patie nt f orget fu lness (2 )(5H8> chambe r sustained- release im plant ef f icacy T R A B E C U L E C T O M E  Retroprosthetic membrane (RPM): 25% • Can be perf o rm ed in t he is com parab le t o daily t o pical o f f ice bi mat oprost w it h dura t io n of 4-6 r ST E N T S, SHU N T S, T U B E S  Ocular hypertension: 15% mont hs Of Patie nts are • Ensures patient complia nce J E T R E A  "' 20 % Not W ell Managed Vitritis: 5% On To pical Drops <10> R E T IN A L IM P L A N T S  Boston KPro Type 2: If approved, b lmatoprost sustaine d-releaseIm plant for glaucoma has potent ial to change th e treatm ent paradigm  Complete tarsorrhaphy performed

(l ) Wu and rm . Cllin f! J Ooh rJtoim ology . 2Cl.1a (6) Olth ohl1 Q u!g!ey. Sunt Op/ltha!m oJ. 2008. 8 Zerbe BL, Belin MW, Ciolino JB. Results from the multicenter Boston Type 1 Keratoprosthesis Study. Ophthalmology (S) Pott!I and Spaeth.. Opltthaim i c Surg. 1995. ( 1.D) Truve.n He.a.lr.h Marlr:ersca11• ReSttlrch O.!Jrab oses, AtJ.ausr 201 3 (D'Ora o.nfi»e r..,it.h Aft"erg-::Jn) & Anwar z er al. Our pursuit. Life's poten tia l.• Current Opinion.s O ohrl 1a 1mo>ogy ZOJ.3 2006;113(10):1779.

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―Dropless‖ Cataract Surgery Dropless Cataract Surgery Micropulse Laser Trabeculoplasty

 Intravitreal transzonular antibiotic/steroid injection Argon Laser Trabeculoplasty (ALT) (1979) concurrent with cataract surgery  High power argon laser, small spot size  Trimoxi (itramcinolone/moxifloxacin, Imprimis Pharmac.)  Injected through incision underneath iris/through zonules/into anterior vitreous after IOL in place, just prior to removing Selective Laser Trabeculoplasty (SLT) (1998) viscoelastic  Lower power (Nd:YAG) laser, larger spot size  Initial recovery VA is poor (due to milkiness of triamcinolone); ~50% BCVA is 20/100 or worse 1day post- op Micropulse Laser Trabeculoplasty (MLT) (2005)   By 3wks, BCVA 20/40 or better in 96% of eyes ―chopping‖ laser in sequence of ON and OFF intervals  CME rates: 2-2.5% (“typical” phaco CE: 14%)  Limits thermal spread to adjacent tissue  Treatment risks reduced, patient comfort increased

Micropulse Laser Trabeculoplasty MLT vs. SLT? MIGS  Micropulse Laser in DME Tx:  MLT: thermally affects—but does not destroy—pigmented TM, without Microinvasive Glaucoma Surgery thermal/collateral damage  Decreased photothermal effects; outcomes equal to or better than  MLT: more titratable than SLT continuous wave (CW) focal laser Tx  Pulse energy control  ON/OFF times; frequency of repetition T R A B E C U L E C T O M E  MLT is effective without signs of thermal damage seen in  Use of micropulse laser for other indications IST E N T ALT  Diabetic macular edema EX - PR E SS MIN I - SHU N T  Suture lysis CY - P A SS/ GO L D M IC R O - SHU N T  potentially lower postoperative inflammation and IOP spikes than SLT  Study forthcoming…

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MIGS Trabeculectome Trabeculectome

 Less disruptive to tissue than traditional glaucoma surgeries  Electrosurgical handpiece used to remove strip of TM and inner (e.g. trabeculectomy) wall of Schlemm’s canal  Shorter surgery and healing time  Minimally invasive  Higher safety profile  Can be done in conj. with  no long-term safety or effectiveness data cataract extraction  Study (2006), 101 patients  ―ab-interno‖ (inside the eye):  Mean IOP: 27.7  iStent  Mean IOP 30 months post-op: 16.3  Trabeculectome  (mean IOP: 40%)  ―ab-externo‖ (outside the eye):  Better safety profile than trabeculectomy  Ex-PRESS mini-shunt

 Minckler D, Baerveldt G, Ramirez MA et al. Clinical results with the trabectome, a novel surgical device for treatment of open-angle glaucoma. Trans Am Ophthalmol Soc 2006; 104:40-50.

iStent iStent iStent

 Trabecular ―micro-bypass ‖ Contraindications  Primary or Secondary Angle  1-mm long stent inserted into end Closure GL (including of Schlemm’s canala using neovascular glaucoma) injection tool through  Diseases that may cause cornea/anterior chamber increased episcleral venous pressure, e.g.:  Retrobulbar tumor  Thyroid eye disease  Sturge-Weber Syndrome

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iStent iStent Ex-PRESS Mini-shunt

Study on mild-to- Designed to augment conventional trabeculectomy moderate POAG patients,  Minimally Invasive?? combined with cataract extraction:  64% had sustained 20% IOP (vs. 47% with cataract extraction alone)  patients who had CE alone were 2x more likely to require GL medication than iStent group

 Samuelson TW, Katz LJ, Wells JM, Duh Y, Giamporcaro JE. Randomized evaluation of the trabecular micro-bypass stent with phacoemulsification in patients with glaucoma and cataract. Ophthalmology 2011; 118(3):459-67.

.P..E..N..E..T..R..A..T..ING TIP Ex-PRESS Mini-shunt -...... - . -...... 3 - TRANSVERSE ... ORIF l v ES

SHAFT 2 1 . . . . . -. 0 _._ 0D Standard Trabeculectomy vs. Ex-PRESS mini-shunt under

SCLERAL S LO T partial-thickness scleral flap · --' - '.... -SPUR -- --  Retrospective study of 100 eyes  50 trab+Ex-PRESS mini-shunt  50 controls  No long-term statistical differences in mean IOP or number of glaucoma medications needed  Fewer post-operative complications in Ex-PRESS mini-shunt group (hypotony, choroidal effusion) Conclusion: Ex-PRESS mini-shunt is as efficacious as traditional trabeculectomy, with less complications

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CyPass/Gold micro-shunt CyPass/Gold micro-shunt

From: Efficacy and Safety of Gold Micro Shunt Implantation to the Supraciliary Space in Patients With Glaucoma: A Pilot Study  99.95% pure gold Micro- Arch Ophthalmol. 2009;127(3):264-269. doi:10.1001/archophthalmol.2008.611 stent delivered with a delivery tool into TM (during cataract extraction)

 Aqueous drains through shunt into suprachoroidal Figure Legend: Postoperative clinical image of a patient after Gold Micro Shunt implantation. Note the good position of the shunt in the anterior space chamber (A), with no shunt-corneal or shunt-iris touching, as seen in the gonioscopic view (B).  (mimics uveoscleral outflow) Copyright © 2016 American Medical Association. Date of download: 9/12/2016 All rights reserved.

Jetrea® (ocriplasmin) Jetrea® (ocriplasmin): Indications

From: Efficacy and Safety of Gold Micro Shunt Implantation to the Supraciliary Space in Patients With Glaucoma: A Pilot Study Arch Ophthalmol. 2009;127(3):264-269. doi:10.1001/archophthalmol.2008.611 Proteolytic enzyme for vitreomacular traction Tx Focal adhesion (<1500 m) vs. broad First and only FDA-approved nonsurgical Tx VMT resolution in 28 days  26.5% of patients (vs. 10.1% with vehicle only)  70% resolved by day 7 No ERM present in addition to VMT

Figure Legend: Anterior segment optical coherence tomography showing the Gold Micro Shunt (GMS) in the suprachoroidal space. Note the spongiform appearance of the sclera, suggesting aqueous humor flow.

Copyright © 2016 American Medical Association. Date of download: 9/12/2016 All rights reserved.

Stalmans P, Benz MS, Gandorfer A, et al. Enzymatic vitreolysis with ocriplasmin for vitreomacular traction and macular holes. N Engl J Med. 2012;367(7):606-615.

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Baseline: 20/40 Day 28: 20/32 Retinal Implants (―bionic eyes‖) Retinal Implants (―bionic eyes‖)

 Argus II (Second Sight Medical Products) Intelligent Retinal Implant System (IRIS)  Video camera Day 7: 20/80 Month 3: 20/25  Transmitter mounted to eyeglasses  Intraretinal implant  Video processing unit (VPU)  Retinal prosthesis (electrode array)  Tx of adults with severe to profound RP Retina Implant AG  2/14/2013: FDA-approved as  Subretinal implant Humanitarian Use Device Day 14: 20/32 Month 6: 20/32  Proven to improve spatial-motor visual performance  Cost: ~$100,000

Ho AC, Humayun MS, Dorn JD et al. Long-term results from an epiretinal prosthesis to restore sight to the Chuang AT, Margo CE, Greenberg PB. Retinal implants: a systematic review. Br J Ophthalmol 2014; 98(7):852- blind. Ophthalmology 2015; 122(8):1547-54. 6.

Virtual & Augmented Reality Augmented Reality in Optometric Education The Eye Exam of the Future

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Augmented Reality in Optometric Education 3. Ideate Solutions Creativity Loves Constraint

Design Prototype – Test – Refine http://prezi.com/whwto9f7lg5m/?utm_campaign=share&utm_medium=copy&rc= ex0share

• “Medicine begins where the technology ends.” Questions? Edmund Pellegrino, M.D. The Father of Modern Biomedical Ethics WOULO T TMT TEAcM...... THE TO .6ELtEVE.· ,.·. l DON'T N"TMI THE'<'Rt " TMtNK . • “Medicine is a moral enterprise, and if you take away TOLO WITHOUT APPLYING ..• ABOUT I ' the ethical and moral dimensions, you end up with a . AN't' " 'ITtCA THlN.lN G? iII.. , THT. · 'J " • . '. t . ' • 1 , ..1 . technique. The reason it is a profession is that it’s . -c :> dedicated to something other than its own self- interests.” Edmund Pellegrino, M.D. Georgetown Magazine, 1996.

Thomas A. Wong, OD ([email protected]) Matthew D. Bovenzi, OD, FAAO ([email protected])

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