Disclosures. Refractive Surgery. PRK vs LASIK. Case # 1. Refractive Error. Navigating the Refractive Surgery Menu 9/11/2015

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Navigating the Refractive

Surgery Menu

Bill Tullo, OD, FAAO

Diplomate AAO Cornea, CL & Refractive Surgery Vice-President of Clinical Service

TLC Laser Eye Centers

Disclosures

• TLC Vision – Employee • Alcon – Advisory board

Refractive Surgery

• Corneal – LASIK – Surface Ablation • PRK • LASEK • Epi-LASIK – AK - Femto – ICRS - Intacs • Intraocular – Phakic IOL • Verisys • Visian – CLE – Cataract Surgery • Toric IOL • Multifocal IOL • Accommodative IOL • Femtosecond Assisted

PRK vs LASIK

• PRK Advantage – No flap

– Less tissue removed

• PRK Disadvantage – Slow visual recovery – Some pain/discomfort

• LASIK Advantage

– Fast visual recovery – Minimal Discomfort

• LASIK Disadvantage

– Flap complications – More tissue removed

Refractive Error

• Myopia • Astigmatism • Hyperopia • Presbyopia

Case # 1

• 25 yo male

• Ocular/Systemic health history unremarkable • No medications

• Dry Rx -3.00 DS OU • BCVA 20/20 OD/OS/OU • Pachymetry 545 OU • Normal Topography OU

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Femtosecond LASIK Flap

iFS

Advantages of Femtosecond Flap

• Independent specific

diameter

• Independent specific thickness

• Better flap centration • Variable hinge size/location • Beveled edge

• Smooth evenly hydrated stromal bed

• Conserve tissue • Planar shape

• Safer

– Less complications – Less loss of BCVA – More gain of BCVA – Biomechanically stronger – Lower risk of keratectasia • Better Efficacy

– Induce less HOA – Smoother beds – Even hydration – Faster visual recovery – Better Low Contrast vision

PRK vs LASIK

• Ocular Health – Dry Eye – EBMD – Corneal Degeneration • FFK (irregular topography) • Terrian’s – Corneal Dystrophy • Meesman’s • Avellino • Fuch’s

Case # 2

• 25 yo male

• What procedure would you recommend?

PRK vs LASIK

• Systemic Disease

– Keloids

– Rheumatoid Arthritis

– Crohn’s Disease – IBS – Lupus

– Fibromyalgia

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Case # 3

• 25 yo male

PRK vs LASIK

• Corneal Thickness

– Minimal CCT – Central Corneal Thickness – Minimal RSB - Residual Stromal Bed • Corneal Topography

• Occupation

Case # 4

• 25 yo male

STAAR Visian®

ICL (Implantable Collamer Lens

)

• FDA approval in December 2005 • Safety • Quality of Vision • Biocompatibility • Versatility • Simplicity • Cosmetic Appearance • Rapid Recovery • Removable

Patient History and Qualifications

• Careful questioning and gauging expectations

• History of contact lens wear

– D/C soft lens for 3 days – D/C rigid lens for 3 weeks

• Opportunity for the patient to ask questions and counseling provided by the

professional/staff

Contraindications

• Patients under age 21 • Progressive refractive error • Cornea/Endothelial pathology • Glaucoma • Narrow AC angle • Cataract or capsular opacification • History of: – Iritis – Synechiae – Pigment dispersion – Pseudoexfoliation • Previous corneal/refractive surgery? • Keratoconus? (Toric ICL)

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Exam and Testing

• Manifest and cycloplegic refraction • Unaided and aided visual acuities • Keratometry or corneal topography • Gonioscopy (grade 2 or greater) • Pachymetry-corneal thickness

• Pupil size in normal and mesopic conditions (6mm or under mesopic)

Exam and Testing

• Anterior chamber depth

• Intraocular pressure (IOP)

• Biomicroscopy-dilated and undilated • Ophthalmoscopy-dilated

• Horizontal white to white-UBM / caliper / Orbscan • Endothelial cell count

Peripheral Iridotomy

• Necessary to avoid pupillary block • Laser vs Surgical

– One or two

• If laser performed one-week prior to surgery

– Post-op Pred-Forte qid

Visian Video

Post-op medications

• Follow normal cataract routine

• First 2 weeks: NSAID, steroid, antibiotic TID

• Next 2 weeks: NSAID and steroid BID

ICL Post-op Care

• IOP is critical • Over-refraction

• A/C exam for inflammation • Evaluate the vault of the ICL

– .5-1x corneal thickness is ideal

• Under .5 observe for anterior capsule haze • Over 1.5 observe for narrowing angle

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Vault of the Visian ICL

Unchanged Cornea

Slitlamp Exam ICL

ICL vault

Most common complication is early

pupillary block

Initial IOP check is 2-4 hours after surgery

Pupillary Block - Treatment

• Dilate pupil • Topical Combo – Combigan – CoSopt • Oral med – Diamox • Repeat PI

• Exchange ICL – lower vault

Post-op Day 1, 7 and month 1 &3

• Uncorrected Visual acuity

• Dry Refraction (Day 7 & beyond) • Biomicroscopy

• ICL Vault (Vault .5 to 1.5 ct) • PI Patency

• Inflammation

• Tonometry

• Evaluation of crystalline lens • DFE Yearly

Case # 5

• 25 yo male

• Dry Rx -3.00 -4.00 x 010 DS OU • BCVA 20/20 OD/OS/OU

• Pachymetry 545 OU • Normal Topography OU

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Femto- AK

Incomparable safety

Decisive control of all surgical parameters Fully computerized control

Maximal patient comfort Minimal learning curve

Precision & predictability in the creation of AK resections + 10 Microns

Femtosecond AK and Incisions

Case # 6

• 25 yo male

• Dry Rx +3.00 DS OU • BCVA 20/20 OD/OS/OU • Pachymetry 545 OU • Normal Topography OU

Hyperopia

• Patient Discussion – Dry eyes • Steep keratometry – Regression – Enhancements

Case # 7

• 25 yo male

Case # 8

• 55 yo male

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Manual Cataract Surgery Today

• Ophthalmic surgeon uses hand-held instruments to create a opening in the lens capsule (capsulorhexis) that is as circular as possible

• The surgeon then breaks up the clouded lens with surgical instruments and ultrasound energy

• An artificial intraocular lens (IOL) is then placed in the eye.

MK-00251 Rev A

Manual Capsulorhexis

Femtosecond Laser Cataract Surgery

• Using femtosecond (FS) laser technology in cataract surgery makes

cataract removal a more predictable and potentially safer procedure by Creating more perfectly sized/shaped/centered capsulotomy Allowing for easier and more gentle break-up of the clouded lens

(phacoemulsification)

MK-00251 Rev A

Manual vs. Catalys Cataract Surgery –

1 month postop

Manual Surgery Catalys Surgery

MK-00251 Rev A

ENGAGE with Liquid Optics™ Interface

• Gentle dock for patient with minimal intraocular pressure (IOP) rise and minimal hemorrhaging

• No corneal distortion or induced folds

• Clear optical path for precise imaging and laser delivery

Liquid Optics Suction Ring Liquid Optics Docking

Liquid Optics Advantage: Optical and comfort gains Catalys OCT with Liquid

Optics

MK-00185 Rev B MK-00251 Rev A

VISUALIZE and CUSTOMIZE with

Integral Guidance™

• Integrated near-infrared video and 3D spectral domain OCT systems

visualize from anterior cornea through posterior lens

• Sophisticated algorithms customize treatment plan in 3D to anatomy of each patient

Catalys 3D spectral domain OCT

MK-00185 Rev B

Ocular surfaces mapped and treatment customized even when lens

is tilted

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More predictable outcomes More predictable and precise cuts

Better outcomes

Catalys Clinical Results:

Capsulotomy Shape

Manual Capsulorhexis

Catalys Capsulotomy

MK-00251 Rev A Images courtesy of OptiMedica Corp.

Catalys Unique Lens Fragmentation

Reduces Phaco Energy and

Manipulations

MK-00185 Rev B

Images courtesy of OptiMedica

MK-00251 Rev A E ff e ct iv e P h a co T im e (s e co n d s)

Standard Cataract Surgery Catalys

Effective Phaco Time (s) Femto (n=57) 0.16 ± 0.21 Standard (n=52) 4.07 ± 3.14 MK-00185 Rev B

Catalys Clinical Results:

Impact on Effective Phaco Time

Data courtesy of Prof. Burkhard Dick, MD, PhD. Ruhr University Eye Hospital. Bochum, Germany, Member of OptiMedica Medical Advisory Board.

96% reduction in effective phaco time compared to standard MK-00251 Rev A 0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00 100.00 0 100 200 300 400 500 600 700 IO P R is e ( m m H g ) Suction Vacuum (mmHg) Curved Lens porcine (n=6) Liquid Optics porcine (n=3) Liquid Optics cadaver (n=6)

Interface Configurations: IOP rise

pressure

Liquid Optics has >4x reduction in IOP rise at procedure suction pressure

MK-00185 Rev B Data courtesy of OptiMedica MK-00251 Rev A

Femto-Cataract Video

Patient Experience

• Clinical Workup

– No major changes to standard procedure – Things to note:

• How well patient dilates

• Is patient able to keep still during procedure

• Post-Surgery Follow-up

– Same regimen as existing practices – Things to note:

• Visual recovery may be faster because of reduced ultrasound energy

• Patient may notice slight hemorrhaging on the conjunctiva

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Case # 9

• 25 yo male

Surface Ablation

• PRK – Photorefractive keratotomy • LASEK – Alcohol assisted with epi-flap • Epi-LASIK – mechanical microkeratome • ASA – Advanced Surface Ablation -hybrid

Remove Epithelium

Removal of Epithelium

• Laser – transepithelial • Alcohol – 20% ETOH • Mechanical scrape • Brush – Amoil’s • Epi-keratome – Epi-LASIK

PRK Video

Case # 10

• 25 yo male

• OD -3.00 DS 20/20

• OS -2.00 -2.50 x 160 20/25-• Pachymetry 500 OD 465 OS • Abnormal Topography

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Early Keratoconus

Moderate Keratoconus

Severe Keratoconus

Femto-Intacs Goals

• Delay need for corneal transplant • Increase BCVA

• Improve ability to fit/wear CL’s • Increase UCVA

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Intacs

CXL – The Use of Corneal

Collagen Cross-linking

Clinical Studies

• 670 Peer-reviewed literature citations • 96% of eyes show topographic stability • Average flattening 1.7D of max-K • Flattening effect reduced max-K > 54D

• Formulation Composition • Method of Application

The Key “Ingredients”

• UVA Dose

• Continuous or Pulsed Illumination

• Consumption by Cross-linking Reactions • Supplemental Oxygen Delivery

Dresden Protocol

UVA dosage 3 mW/cm2 for 30 minutes

0.1% riboflavin

Minimal Corneal Thickness

• 400 microns when using 3.0 mW/cm2 • Stromal haze peaks at 1 month post-op and

decreases significantly between 3 and 12 months1

1. Greenstein SA, Fry KL, Bhatt J, Hersh PS Natural history of corneal haze after collagen crosslinking for keratoconus and corneal ectasia: Scheimpflug and biomicroscopic analysis. J Cataract Refract Surg. 2010 Dec;36(12):2105-14

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Intacs with Sequential CXL

• Effects of both treatments are synergistic

– Increased K flattening – Increased BCVA – Increased UCVA

• Kamburoglu G, Ertan A: Intacs Implantation with Sequential CXL Treatment in Postoperative LASIK Ectasia. J Refractive Surg. 2008:24:7:S726-S729

• Chan CC, Sharma M, Wachler BS: Effect of inferior-segment Intac with and without C3-R on keratoconus. J Cataract Refract Surg. 2007;33:75-80.

Demarcation Line at 1Month

10 minute soak with VibeX Rapid, 30mW/cm2,7.2J/cm2, Pulsed [2,1]

Credit: Dr. Miguel Rechichi

Transepithelial Cross-Linking with ParaCel

The corneal epithelium is left in place, and topical anaesthetic applied.

ParaCel is applied to completely

cover the cornea, and soaked for 4 minutes. VibeX Xtra is applied and soaked for an additional 6 minutes. Riboflavin is rinsed from the eye.

45mW/cm2 UVA is applied through the intact epithelium using pulsed Illumination

Advantages of Epi-ON CXL

• Faster visual recovery:

– Return to contact lenses in days

• Less pain

• Avoids risk of delays in epithelial healing • Reduced risk of infection

• Reduced development of corneal haze

William Trattler, MD

Keratoconus Treatment

• Early Keratoconus – progressive topography or

tomography minimal reduced BCVA

– CXL as soon as Dx confirmed

• Moderate Keratoconus –progressive topography or tomography moderate reduced BCVA

– Consider CXL / Intacs

• Advanced Keratoconus – pachymetry less than 400 microns