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Home , Corneal topography, Trabeculoplasty

11/16/2017

Professional Disclosures

• Alcon: Advisory Board, Consultant, Research, Speaker Laser Applications in • Allergan: Advisory Board, Research, Speaker • Bausch & Lomb: Advisory Board, Research, Speaker Clinical • Beaver Visitec: Consultant COPE ID: 49115-LP • Biotissue: Advisory Board, Speaker Walter O. Whitley, OD, MBA, FAAO • Ocusoft: Advisory Board Director of Optometric Services • Science Based Health: Advisory Board, Speaker Virginia Consultants • Shire: Advisory Board, Speaker Residency Program Supervisor • Sun Pharmaceuticals: Advisory Board PCO at Salus University • TearLab Corporation: Advisory Board • Tearscience: Speaker

Virginia Eye Consultants Tertiary Referral Eye Care Since 1963 Today’s Optometrists

• John D. Sheppard, MD, MMSc • Walter Whitley, OD, MBA, FAAO • Stephen V. Scoper, MD • Cecelia Koetting, OD, FAAO • David Salib, MD • Chris Kruthoff, OD, FAAO “To be on the cutting edge of optometry, • Elizabeth Yeu, MD • Jessica Schiffbauer, OD you need to be on the cutting edge of • Thomas J. Joly, MD, PhD • Kelsey Butler, OD science and technology” • Dayna M. Lago, MD • Constance Okeke, MD, MSCE • Jay Starling, MD • Samantha Dewundara, MD

Basic Laser Principles Anterior Segment Applications

• Photodisruption – YAG Laser, Femto • YAG Laser Posterior • Phototherapeutic Keratectomy • Photoablation – PRK • • Corneal Crosslinking??? • Photocoagulation - PRP • Intense Pulse Light????

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YAG Capsulotomy What Do Patient’s Want to Know?

• Indications • What is it? – Decreased visual acuity – Reduced contrast sensitivity • Why did I get it? – Increased glare – Poor view of fundus • How is it treated? – Small anterior – PAM shows improved acuity • ATIOL Considerations

YLC Contraindications Does the BCVA Make Sense?

• Corneal scarring /edema that prevents a clear view during the procedure • Placement of a glass during • Presence of iritis • Macular edema • Previous retinal tears or detachments • Early postoperative period • patients

YLC Procedure Follow Up

• Dilation • 90 day global period • Apraclonidine 1% • Consider medications – inflammation/IOP • Power setting • Check refraction – Mild haze - 0.8 mJoules – Moderate haze – 1.5 mJoules • IOP – Dense haze – 2.2 mJoules • Presence of inflammation • Q-switched vs. mode-locked • Dilation • Focus just deep to the capsule/IOL interface • Anything else? • Create window through posterior capsule

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YLC Complications Applications

• Transient elevation • LASIK • Iritis • PRK • Retinal tears and detachments • Cataract Surgery • Macular edema • Lenticule Extraction • Corneal edema • Intrastromal Corneal • Intraocular lens dislocation into the vitreous Reshaping • Pitting of the intraocular lens • Corneal inlays • Lens Bleaching

High Patient Expectations in Cataract Refractive Surgery The Femto Phaco Market Cataract Outcomes*** • Patient expectations are at an all-time 100% high for refractive surgery 90% 97% • Positive experiences with LASIK have 80% produced high expectations, at a 70% minimum achieving: 71% 60% – 92.6% of LASIK patients with vision of 20/40 or better* 50% – 95.4% of patients satisfied with their 40% outcome after LASIK surgery** 41% 30% • Cataract surgery outcomes may not

20% be meeting the target of ±0.5D that is considered the standard 10%

0% ±0.25D ±0.5D ±1.0D

*“LASIK Surgery Statistics.” Docshop.com. http://www.docshop.com/education/vision/refractive/lasik/statistics **Solomon, K et al. (2009) “LASIK world literature review: quality of life and patient satisfaction.” . 16(4):691-701 ***Graph: Data from Dr. Warren Hill & Behndig A, et al. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg. 2012;38(7):1181-6. 8/13 VRN13066SK 16

Limitations of Traditional Traditional Cataract Surgery: Cataract Surgery Common Complications • 10-40% Posterior capsule opacification • 2-12% Transient cystoid macular edema • 4-10% Corneal endothelial cell loss • 1-5% Vitreous prolapse or loss • 1-2% Persistent cystoid macular edema • 0.6-2% Retinal detachment • 0.3% IOL Malposition • 0.3% Consecutive corneal transplantation • 0.1% Endophthalmitis

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Improved Refractive Quality = Safety Cataract Surgery

• Fewer Wound Leaks • Address Major Requirements for Improved Refractive • Lower Endophthalmitis Rates Procedure • Fewer Corneal Abrasions, Less PO Pain • More Predictable PO • LRIs arcuate & without induced Dry Eye IOL Position Corneal Early Wow Factor • Less IOL Decentration & IOL Tilt Predictability Astigmatism • Reduced Phaco • Fewer YAG • Uniform Shape and • Reproducible Power and Corneal • Less Phaco Time Size Capsulotomy Corneal Entry and Edema Arcuate Incisions • Fewer Ruptured Posterior Capsules Norrby SJ, J Cataract Refract Hill WJ, J Cataract Refract Devgan U, Current Opinions in Surg 2008;34:368–376 Surg 2008;34:364–367 Ophthalmology 2011;18:19–22. • Lower Endothelial Cell Loss

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Manual Clear Corneal Incisions Laser Corneal Incisions

• Dynamics of wound architecture created with hand- held instruments1 – Imprecise tunnel length and geometry – Frequently require stromal hydration to seal – May result in cascading intraoperative difficulties (fluid control, anterior chamber maintenance) – Incisions may be unstable at low IOPs • Recent literature suggests an increased incidence of post-op infection2

Customized wound architecture and placement Self-sealing incisions 1Behrens A, Stark WJ, Pratzer KA, McDonnell PJ. Dynamics of small-incision clear wounds after surgery using optical coherence tomography in the early postoperative period, J Refract Surg, 2008;24(1):46-9. 2Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, McDonnell PJ. Acute endophthalmitis following cataract surgery: a LSX11513SK systematic review of the literature, Arch Ophthalmol. 2005;123(5):613-20. 12

Effective Lens Position (ELP) Does Capsulotomy Size Impact

• “The key to highly accurate IOL power calculation is being able Effective Lens Position? 1 to correctly predict ELP for any given patient and IOL”

• ELP is assumed value, from empirical data – A constant and surgeon factor

• A significant source of IOL power error and key to post surgery refraction3

• Size of capsulorhexis effects ELP4

1Haigis W, Lege B, Miller N, Schneider B, Comparison of immersion ultrasound biometry and partial coherence interferometry for IOL calculation according to Haigis, Graefes, Arch Clin Exp Ophthalmol, 2000;238:765-773. 2Norrby S, Sources of error in intraocular lens power calculation,J Cataract Refract Surg, 2008;34:368-376. 3Hill WE, Does the Capsulorrhexis Affect Refractive Outcomes? In Chang D, editor: Cataract and Refractive Surgery Today, LSX11513SK 2009:78. 4Cekiç O, Batman C, The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic Surg Lasers, 1999;30(3):185-190. Erratum in: Ophthalmic Surg Lasers,1999;30(9):714 13

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1 Factors Affecting IOL Predictability Laser Capsulotomy Results

If IOL is 0.5 mm posterior to the If IOL is 0.5 mm anterior to the assumed plane, a 21 D lens will assumed plane, a 21 D lens will produce only 20 D of correction produce 22 D of correction Myopic Hyperopic

• Perfect centration • Precision diameter: < ± 0.25 mm • No radial tears • Easy and complete removal of capsule • No adverse events • Less PCO formation 1Norrby S, Sources of error in intraocular lens power calculation,J Cataract Refract Surg, 2008;34:368-376. LSX11513SK 14

Laser Fragmentation

• Cylinder pattern, utilized for the softer lens, enables removal with I & A only, no phaco power • Chop pattern efficiently fragments the lens for removal with reduced phaco power and time1

Only 20% of manual rhexis achieved diameter accuracy of +/- 0.25mm

Astigmatism More Prevalent than Recognized

Lane, Stephen, M.D. Toric IOLs Pearls for Success. Cataract & Refractive Surgery Today. August 2009. Pgs. 59-61.

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Addressing Astigmatism Basics of Corneal Incisions • Differentiate corneal • Corneal coupling – 1:1 ratio cylinder from refractive cylinder – Corneal • More flattening – Lenticular – Mixed – Larger incisions • Accurate / consistent – Central incisions measurements – Penetrating incisions – Manual keratometry – – Deeper cuts – IOL Master – Paired incisions – Lenstar – Cassini

Arcuate Incisions Arcuate Incisions

• Manually executed by “tracing” corneal marks with handheld diamond knife

• Inconsistent depth control

• Unpredictable effect due to imprecise wound architecture • Square edge and depth • Uniform depth (no ripples)

• No image-guided surgical • Precise, reproducible planning or visualization – Arc shape – Arc length – Diameter LSX11513SK 20 Steinert RF, Application of the Femtosecond Laser in Cataract Surgery for the Creation of Multi-Planar, Self-Sealing Incisions, ASCRS 2010, Boston 22

Prediction Error Distribution

Frequency Distribution (%) of Hyperopic Myopic

32% More

27%27%

23% Less

18% More Less

LenSx…

15% 15% Manual…

12% 9% 9%

0% 0% 0% 5% 4% 0% 4%

≤ -1 -0.75 -0.5 -0.25 0 0.25 0.5 0.75 ≥ 1 LSX11513SK Spherical Equivalent Prediction Error (D) = Pred. Ref. - Actual 1M PostOP Ref. 27

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Femtosecond Laser Companies: Value Postoperative Considerations Added Indications • Normal postoperative course • Cataract Surgery: – One day – Anterior & Posterior Capsule Polishing – Posterior Capsulotomy – One week – Paracentesis – One month – Vitreolysis – Three months • : – Goniotomy, Trabeculotomy & • Educate patients on postoperative • Corneal Surgery: expectations – DSEK: Stripping ring, Stromal polishing – Mild subconjunctival hemorrhage due to suction – Lasik Flaps, Intacs Tunnels, Intrastromal Ablation – Mild corneal edema at wound – Improved precision of the procedure

KAMRA® Inlay Raindrop® Near Vision Inlay First US approved corneal inlay; commercially available in 50 countries Effective, Reliable and Safe Presbyopia Solution

 Improves near vision with minimal impact to distance vision

1.6mm − Achieves long-lasting results even as presbyopia 3.8 mm Central Total Aperture progresses Diameter  Implanted into corneal pocket created with femtosecond laser • Physiologically transparent, biocompatible hydrogel corneal inlay − Implanted monocularly into non-dominant eye • Size: 2 mm diameter, 30 microns thickness 8,400 micro-perforations (5-11 μm) allow nutrient flow  Highly biocompatible material • Similar water content and refractive index as the cornea − Made from Polyvinylidene Fluoride (PVDF) • Implanted under a femtosecond laser corneal flap (30% of the corneal thickness) 6 μm and centered over light-constricted pupil Thick  Removable via low-risk procedure with recovery of Inlay matches corneal pre-inlay vision • Placed in the non-dominant eye curvature • Removable, if needed

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Glaucoma Surgical Options

• Laser Therapy – SLT/ALT / MLT – LPI – ELT – Cyclophotocoagulation • Surgical Options – GLAUCOMA APPLICATIONS – Trabectome – Express Shunt – Tube shunt – Canaloplasty – Endoscopic Cyclophotocoagulation

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Glaucoma Clinical Trials Glaucoma: Medications • Collaborative Normal Tension Glaucoma Study (CNTGS) • When COMPLIANCE with drops is low • Advanced Glaucoma Intervention Study (AGIS) • When MEDICAL THERAPY FAILS • Collaborative Initial Glaucoma Treatment Study (CIGTS) • Ocular Hypertensive Treatment Study (OHTS) • When the PROGRESSION continues to WORSEN • Early Manifest Glaucoma Trial (EMGT) • Treatment options • Glaucoma Laser Trial (GLT) – Medications – Laser therapy – Surgical intervention

Poor Adherence To How Adherent are Glaucoma Patients Glaucoma Therapy with QD Medication?

• By one year after first eye drop Rx, less than 50% are still filling prescription

• Among New Jersey Medicaid seniors, 25% never filled the second prescription

• Average number of treated days = 70

Reardon, Schwartz, Mozaffari. Clin Therap 2003;25:1172 Gurwitz et al. Am J Public Health 1993;83:711-6.

Barriers to Compliance

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Continuous Use

Nordstrom, Friedman, et al. Ophthalmology 2005

Argon Laser Trabeculoplasty Selective Laser Trabeculoplasty

• One of the most common glaucoma procedures • Non-thermal treatment which uses short – Noncompliance pulses of relatively low energy to target and – Unable to instill medications irradiate only the melanin-rich cells in the TM – Expense • Using gonioscopic views thermal burns are placed at the junction of non-pigmented and pigmented

– Burns are evenly spaced two to three widths apart – 50 burns per 180 degrees – Can treat 1800 or 3600

Selective Laser Trabeculoplasty Advantages of SLT vs ALT

• IOP decrease after SLT • SLT has the potential for repeat procedures – Primary Therapy - 28.7% • SLT lacks thermal damage/scaring to the TM – Adjunctive therapy – 19.4% • SLT has less post-operative pain and inflammation – SLT Retreatment – 12.1% – Replacement Therapy – 4.5%

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Glaucoma: Laser Treatment Laser Trabeculoplasty

Five years post-treatment, the • Efficacy mean IOP decrease for the SLT group was 7.4±7.3 mmHg and • Compliance 6.7±6.6 mmHg for the ALT • Diurnal IOP Control group. • Side effects • Economic Issues

Glaucoma: Laser Treatment Glaucoma: Laser Treatment

• Trabeculoplasty -Candidates • Trabeculoplasty – Complications – Primary treatment to lower IOP – Fairly minimal complications – Not responsive to medications – Post op IOP spike (rare <1%) – Target pressure not reached – Peripheral anterior synechiae – Significant side effects with medications – Repeated laser has theoretical long-term risk of – Not compliant with medications accelerating loss of the TM cells – Unable to administer medications – Failure to control IOP – Patient not ready for filtering surgery

– After trabeculectomy if angle open

– MIGS not covered by insurance

Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, Peripheral Iridotomy (PI) randomized trial. • PURPOSE: To compare outcomes of selective laser trabeculoplasty • Indications (SLT) with drug therapy for glaucoma patients in a prospective randomized clinical trial. – Narrow angles • RESULTS: 54 patients reaching 9 to 12-months follow-up. – Acute, angle closure glaucoma – SLT (29 pts) • • Baseline IOP 24.5 mm Hg YAG laser to create opening from posterior to • Mean IOP at follow up 18.2 mm Hg anterior chamber – Med (25 pts) • Baseline IOP 24.7 mm Hg – Superior location??? • Mean IOP at follow up 17.7 mm Hg • – SLT group -> 11% of eyes required additional SLT Procedure / Drop Protocol – Prostaglandin group -> 27% of eyes required additional medication • Re-evaluate in one week

• Treat fellow eye L., Steinmann, W., Kabir, A. J Glaucoma. 2012 Sep;21(7):460-8.

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Dysphotopsia after temporal versus superior laser peripheral iridotomy: a prospective randomized paired eye trial. PI Complications

• PURPOSE: To determine if the location of neodymium:yttrium-aluminum- • Elevated IOP garnet laser peripheral iridotomy (LPI) is related to the occurrence of postoperative visual dysphotopsia. • Inflammation • RESULTS - New-onset linear dysphotopsia • Hyphema – Sup PI - 18 (10.7%) – Temp PI – 4 (2.4%) • Cataract – P = .002 • Inability to penetrate iris • CONCLUSIONS: Temporal placement of LPI is safe and was found to be less likely to result in linear dysphotopsia as compared with superior • Closure of iridotomy placement. Temporal iris therefore may be considered a preferred location for LPI. • Optical aberrations

Vera, V., Naqi, A., Belovay, G. Am J Ophthalmol. 2014 May;157(5):929-35.

Glaucoma: Laser Treatment Glaucoma: Laser Treatment

• Open or Narrow Angle Glaucoma • Cyclophotocoagulation - Advantages – Success rate 60-70% – Transcleral Cyclophotocoagulation – Relative ease of technique • Diode Laser – Can be repeated – Recovery 4-6 weeks – Follow up visits not as intensive as filtering surgery • Candidates – Refractive glaucoma – Poor vision – Blind painful eye – Non-surgical end-stage disease

Proliferative Diabetic Retinopathy Laser Retinal Applications

• Diabetic Retinopathy • Neovascularization • • Retinal Vein Occlusion Vitreous hemorrhage • • AMD Fibroglial proliferation • • Ocular Tumors Tractional RD • • Tears and Detachments Neovascular glaucoma

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Early Treatment Diabetic Retinopathy Diabetic Retinopathy Study Study (ETDRS) • Examined when to treat neovascularization • Clinically Significant Macular Edema • High Risk Characteristics – Retinal thickening within 500 um of the foveal center – Neovascularization of the Disc (NVD) greater than – Hard exudates within 50 um of the foveal center, ¼ Disc Diameter (DD) with adjacent thickening – Any NVD or NVE with a vitreous or preretinal – Retinal thickening of at least 1DD, within 1DD of heme the fovea • PRP decrease the incidence of severe VA loss • Severe NPDR at 2 years from 26% to 11% – 4 quadrants of hemorrhages/microaneurysms – 4 years 44% vs. 20% treated – 2 quadrants of venous beading • Argon over Xenon – 1 quadrant of intraretinal microvascular abnormalities

Treatment of Clinically Significant Macular Treatment for PDR Edema • Pan Retinal Photocoagulation • Focal Laser – Equilibrium between retinal oxygen supply vs. demand – Gold Standard (ETDRS) – Recommended treatment for high-risk PDR – ↓ Chance of moderate vision loss by 50% – Resulted in significant reduction in severe vision loss – ↑ Chance of moderate vision gain – Prophylaxis – no benefit – Better for eyes with discreet leakage – May take multiple sessions (1000s of burns) – Effects last longer than other treatments – Side effects: loss of peripheral VF, color defects, nyctalopia – Relatively painless

Photo accessed from http://www.illinoisretinainstitute.com/index.php?p=2_3

Vein Occlusions Age-Related Macular Degeneration

• Branch Vein Occlusion Study *** • Thermal Laser – Established laser treatment as the standard of care for – Best results for extrafoveal CNV (>200 microns the treatment of vision loss associated with macular from fovea) edema and for the prevention of vitreous hemorrhage – Repeatable in this disease – Foveal damage • Central Vein Occlusion Study – Choroidal hemorrhage (high energy into Bruch’s) – Showed that while macular edema was reduced, there – Contraction of fibrous tissue (laser burns too close was no improvement in visual acuity after grid together) treatment and no difference in final visual outcome compared to control eyes – Scatter PRP – recommendation that treatment delayed until there is visible evidence of iris neovascularization

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Age-Related Macular Degeneration Prophylaxis of Retinal Detachment

• Photo Dynamic Therapy • Asymptomatic breaks – Photosensitizing dye (verteporfin) I.V. • Symptomatic breaks – Accumulates in new, leaky blood vessels – Cold laser (689 nm) activates molecules to produce free • Lattice degeneration radicals, destroying neovascular membrane – Best results: classic CNV – Decreases vision loss, but DOES NOT IMPROVE – SEs: temporary visual disturbances, light sensitivity – In combo w/ Anti-VEGF injections, if no improvement with injections alone – Repeat 3 months

Photo accessed from http://www.retinabatonrouge.com/images/RD.jpg

Retinal Tears and Detachments Considerations for Optometry • Laser Photocoagulation • Laser therapy remains a viable option – Formation of scar tissue around the margin

– Choroid and retina form adhesion (1-2 weeks) • Optometric comanagement considerations – Fluid reabsorption – Good for small tears – Comfortable for patient • Practice to the fullest extent of your scope

Photo accessed rom http://www.mvretina.com/presentation/images/tear.jpg

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