H o r i z o n L a s e r V i s i o n C e n t e r

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H o r i z o n L a s e r V i s i o n C e n t e r

Technology

Quality

Education

Care

January 2015

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Hori zon Las er Vis ion Ce nt er is an e s tabli she d p remium r ef r activ e surge ry clin ic wit h facil ities in Sa sk atoon a nd R egina . We h av e a unique patie nt care sys t em t hat i n volv es t he op tome tris t, a nd t he par ticip ating opht ha lmol ogis t s. We provid e t he s af es t t echnol ogy at our cent er a nd t he high e s t qual ity of care t hroug h t his ca re s ys t em.

Our M issi on

Our mission is to provide the highest quality care to our refractive surgery patients.

We aim to achieve this mission by providing the latest and safest technology in a top quality facility, with the highest quality pre and post operative eye care.

Our Goal

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R efr activ e S urgery: Gene r al Informati on

We feel it is important that the patient be educated fully on all aspects of the surgical process so that they are properly

equipped for informed consent. At Horizon the patient has a consultation preoperatively to discuss procedure options (iLASIK, iLASIK Xtra, PRK, PRK Xtra or KAMRA Vision) and logistics.

Included in this book you will find all the tools you need to refer your patient to Horizon Laser Vision Center. The infor-mation includes protocol on referrals, follow-up, patient fees and reimbursement. It will also provide you with important information on patient selection and counseling.

We hope you find this book of use to you and your practice and we look forward to working with you. Feel free to contact us anytime if you have questions or if you have a situation with a patient where you are unsure of the next steps.

Toll-free phone number: 1-888-400-3937

www.horizonlaser.com

Regina:

Phone: 306.352.5277 Fax: 306.352.5202 regina@horizonlaser.com

Saskatoon:

Phone: 306.664.3937 Fax: 306.664.3927 saskatoon@horizonlaser.com Web-site Doctor’s Portal Log -In:

your office phone number (with da shes) Pa ssword: 123

Board of Directors:

Dr. Wa rren Toews Dr. Bob Neumann Dr. Ronan Conlon Dr. Rena tta Va rma Dr. Jim Kerr Dr. Bill Thatcher

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Our surgeons maintain private ophthalmology practices, and some maintain teaching appointments at the University of Saskatchewan

Our Surgeons

Dr. M. Ronan Conlon _{has been practicing Ophthalmology in Saskatoon since 1994.} His special interests in ophthalmology include cataract surgery, refractive and oculoplastic surgery. He completed his residency training in ophthalmology at the University of Western Ontario in 1991. Dr. Conlon has completed 3 years of fellowship training in ophthalmology; one year at Harvard University and two years at the University of Iowa Hospital and Clinic. Dr. Conlon first began performing PRK and LASIK surgery in 1995, and has been affiliated with HLVC since that time.

Dr. Conlon is a member of the Canadian Ophthalmology Society, the Canadian and American Society of Cataract and Refractive Surgery, the American Society of Cosmetic Surgery and the American Academy of Ophthalmology.

Dr. Jeffrey Judelson _{has been in practice in Regina since 1988. He} holds fellowships from the College of Surgeons of South Africa, the Royal Colleges of Surgeons of Edinburgh and Canada. The main focus of his practice is cataract, corneal and refractive surgery and he has been performing refractive surgery in Saskatchewan since 1994. Dr Judelson has run the corneal transplant program in Regina since 1989. He is a member of the Canadian Ophthalmology Society, America Society of Cataract and Refractive Surgeons and the Lions Eye Bank of Saskatchewan.

When not working Dr Judelson’s interests include reading, photography, computers and is a keen golfer and tennis player.

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Dr. Ravi Nrusimhadevara _{graduated as an Ophthalmologist and has been in practice since} 1999. He underwent a Fellowship in Diseases of Retina and Vitreous at the University of Toronto. He started practicing in Saskatoon in 2004 and has extensive surgical experience.

His special interests are diseases of retina, advanced cataract surgery, pupillary reconstructions, sutured and sutureless scleral fixation of intraocular lenses and refractive surgery.

Dr. Ravi holds an academic appointment with the University of Saskatchewan as Clinical Assistant Professor in Ophthalmology and is actively involved in training residents and medical students. He has written chapters in textbooks, journal articles in medical literature and presented in various national and international meet-ings. He is a member of the Canadian Ophthalmological Society, American Academy of Ophthalmology, the American Society of Retinal Specialists, American Society of Cataract and Refractive Surgery. Apart from Ophthalmology Dr. Ravi has a strong interest in computer science, and solid-state electronics.

His other interests are Badminton, Tennis and Swimming. Dr. Ravi and his wife Vasudha have two young boys and he enjoys spending time with his family the most.

Dr. Renatta Varma _{graduated from medical school in 1998 with Great Distinction. She} complet-ed her residency in ophthalmology at the University of Saskatchewan in Saskatoon and holds a fellowship from the Royal College of Physicians of Canada. She then completed a subspecialty fellowship in vitreo-retinal surgery in New Orleans under Dr. Gholam Peyman, who holds the patent for LASIK surgery. She completed a second fellowship in vitreo-retinal surgery in Victoria, BC. She has been performing refractive surgery since 2005.

Dr. Varma is a member of the Canadian Ophthalmology Society, the American Academy of Ophthalmology, and the American Society of Cataract and Refractive Surgeons. She practices in Regina and has a special interest in retinal, cataract and refractive surgery.

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Referr al Protocol

Patients will require a recent full examination which should include a complete history including refractive history, complete medical history, a peripheral retinal examination (either dilated fundus examination or Optomap imag-ing), a thorough review of macula including when necessary macular OCT. Topography and pachymetry should be performed if possible. Dry eyes should be treated and controlled before assessment at Horizon. Referral forms should be completely filled out and sent to Horizon.

1. You are not REQUIRED to have a separate visit for a laser consult with the patients contact lenses off.

2. You are not REQUIRED to perform a cycloplegic refraction in all cases. Cycloplegic refraction is still required for all hyperopes but this can be performed at the time of the full examination. This can be done at Horizon if this is more convenient for the patient or the doctor.

The Horizon Optometrist will do the laser consult at Horizon after the patient has been out of contact lenses for the appropriate time. The surgeon will make the final determination of patient suitability.

The Horizon Optometrist will inform the referring doctor of the outcome of the assessment and recommended treatment. Horizon will notify the referring doctor if a candidate is rejected.

The HLVC consultation process is smoother for the patient and for referring doctors. This does not preclude you from doing any testing that you feel necessary for your screening and counselling of the patients, including the cycloplegic – use your clinical judgment to determine what is necessary to determine if a patient is a good candi-date.

Not e:

Please counsel your patients on both iLASIK and PRK procedures. The Horizon Optometrist will discuss treatment options with the patient and help the patient understand which procedure best suits their unique eye.

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P r e v i e w C o n s u l ta t i o n

Industry surveys have shown that the average time from when a patient first becomes curious about laser eye surgery until they become serious is about 22 months. Preview consultations can be done early in the decision-making process.

Preview consultations can be done to pre-screen patients and to find out if refractive surgery is an option, prior to the pa-tient being out of their contact lenses.

Testing will be done and the Horizon Optometrist will look it over to give an opinion if the patient is a candidate or not. If the patient is a candidate, they will be advised to book an eye exam with their optometrist for a full eye exam, if re-quired and pre-op. You will receive a note from HLVC to inform you of any testing results and opinions given by the HLVC Optometrist.

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Contact L en s Wear:

As contact lenses influence the corneal surface, great care should be taken to ensure the cornea is stable before surgery.

We recommend you inform your patient that prior to your patient’s refractive surgery assessment at Horizon they will need to discontinue their contact lens wear.  Soft lenses: discontinue x 2 weeks minimum  Toric lenses: discontinue x 4 weeks minimum  Rigid lenses: discontinue x 4-6 weeks minimum

Often the biggest inconvenience for patients is the discontinuation of their lenses. However, it cannot be stressed enough that it is imperative for a successful outcome.

Patient Se le ction:

At Horizon we feel it is the eye care professional who is best able to judge who is a suitable candidate for laser surgery. It is our mandate to direct all patients towards their own eye doctors for the pre-operative exam and post-operative care. Here are a few guidelines for patient selection:

 Patients should be over 18 years of age  Intelligent and motivated

 Stable refraction for at least one year with less than 0.50 diopter change

 Uncorrected acuity that is sufficiently reduced to ensure the risk/benefit ratio is desirable

 Have an understanding of the capabilities and limitations of the procedures

 Realistic goals and expectations  Educated about presbyopia

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Cornea l Pach yme try:

Pachymetry or corneal thickness measurement is a determining factor in whether your patient has iLASIK or PRK. A sufficient amount of corneal tissue must remain untouched during the iLASIK procedure and therefore an adequate amount of tissue must be present initially.

Pachymetry is always performed by the clinic prior to surgery. If you have access to a pachymeter, it is often helpful in higher myopes to determine their suitability for iLASIK.

Pentacam an d Topogr a ph y Im ages :

Horizon Laser Vision Center is equipped with Pentacam technology. These images are captured on all patients.

The advantage of the pentacam is that it not only captures pachymetry on the entire surface, but it is also able to image the posterior corneal surface which is not possible with regular topography.

The pentacam has kerataconus screening software which is useful to exclude form fruste- or early keratoconus.

Topography maps may be done by Horizon at the time of surgeon consultation, to help with diagnosis of asymmetrical steepening.

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K readings

_{are very important as it tells us the shape of the patient’s eye. To calculate whether or not}

the eye would be too flat after surgery:

Ex: OD: 46.00/47.25 x 090 OD –7.00/-1.00 x 070

1. The treatment would be for 8 diopters (-7.00 +(-1.00) = -8.00)

2. 8 diopters multiplied by 0.7 = 5.6

3. The average of the K-reading is 46.63

4. Take 46.63 subtract 5.6 = 41.03

This K reading is acceptable after surgery. The cut off for too flat is 35.00

Corneal Thickness:

Custom Treatment is 18-22 Microns/Diopter

1. Patient’s lowest pach reading = 546

2. Subtract approximate flap=

120 3. Subtract treatment=

40

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Corneal Thickness (Microns) Correction Factor (mmHg) 405 7 425 6 445 5 465 4 485 3 505 2 525 1 545 0 565 -1 585 -2 605 -3 625 -4 645 -5 665 -6 685 -7 705 -8

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Contr ain dica tions: OCULAR

 Significant ocular patholog y  Severe dry eyes

 Recur rent iritis/uveitis  Corneal anesthesia

 History of herpes simplex keratitis  Glaucoma

 Marginal corneal dystrophies  Endothelial dystrophies

 Significant cataract development  Monocular patients

 Unstable refraction SYSTEMIC

 Active collagen vascular disease  Long ter m insulin diabetes  Immune compromised patients  Thyroid eye disease

 Pregnancy and lactation

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T r e a t m e n t R a n g e s i L A S I K

SURGEON MYOPIA HYPEROPIA CYLINDER PAST K’S

R. Conlon -10.00 +3.00 -5.00 300 microns 35.00 and 50.00

R. Varma -10.00 +2.00 -5.00 300 microns 35.00 and 49.00

J. Judelson -10.00 +2.50 -5.00 300 microns 35.00 and 48.00

R. Nrusimhadevara -10.00 +2.00 -5.00 300 microns 36.00 and 49.00

T r e a t m e n t R a n g e s P R K

SURGEON MYOPIA HYPEROPIA CYLINDER PAST K’S

R. Conlon -8.00 +3.00 -4.00 400 microns 35.00 and 50.00

R. Varma -9.00 No -3.00 400 microns 35.00 and 49.00

J. Judelson -8.00 No -3.00 400 microns 35.00 and 48.00

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The iDesign technology uses light waves to identify and measure imperfections in the eye 25 times more accurately than standard methods used for glasses and contact lenses. The Wavefront map is a visual representation of how the patient’s entire optical system processes light. iDesign technology uses a high-definition sensor capturing over 1200 data points to more precisely measure your unique vision imperfections in each eye and deliver a truly personalized treatment.

ActiveTrak 3D Tracker follows the fine motions of the eye instantaneously and automatically, in all three dimensions, continually re-positioning the laser to ensure accuracy.

Iris Registration (IR) is an enhancement that works by recognizing the unique pattern of each eye and precisely aligning the laser so that the surgery is even more accurate.

The VSS Refractive™ technology produces variable beam sizes from as small as 0.65 mm up to 6.5 mm, while VRR™ varies the la-ser's repetition rate from 6 Hz to 20 Hz. By continually changing the size and placement of the laser beam, the STAR S4 IR™ Ex-cimer Laser rapidly delivers the precise ablation pattern required, significantly reducing ablation time. This capability minimizes ther-mal effects on the cornea and allows you to perform the procedure as quickly as possible.

Our Laser Eye Surgery Technology The Visx Star S4 Excimer Laser System is a computer-assisted, surgeon-controlled device that includes iDesign, ActiveTrak, Iris Registration, VSS Refractive and VRR technologies..

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The Intralase Method is a 100% blade-free approach to creating the thin flap of tissue that the surgeon folds back in order to perform the iLASIK procedure. It can only be performed using the IntraLase laser.

Traditionally, surgeons used a microkeratome for flap creation. Regular LASIK is safe but if complications occur, the microkeratome is frequently the cause. Our blade-free iLASIK approach removes this possible source of complication. With the IntraLase Method, tiny pulses of laser light, a quadrillionth of a second each, pass harmlessly through the out-er portion of the cornea and form a uniform layout-er of microscopic bubbles just beneath the surface of the eye. The ex-act dimensions of this layer of bubbles are determined by the surgeon based on each individual eye. The flap creation takes about 10 seconds.

With the iLASIK procedure, patients experience fewer flap-related complications and fewer induced higher order aber-rations that contribute to visual disturbances, such as glare and halos. It is the most advanced treatment available.

iLASIK is the approved procedure for NASA astronauts and pilots.

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iLASIK or PRK

iLASIK and PRK both use the excimer laser to reshape the front surface of the cornea. For iLASIK, a flap is created, which preserves the corneal surface. For PRK, the front surface (epithelium) of the cornea must be removed, prior to the reshaping. As a result, the surface of the eyes treated with iLASIK heals faster than those treated with PRK. Most patients achieve reasonable vision the day following the surgery. Furthermore, patients experience less discomfort with iLASIK post-operatively than with custom PRK.

While a patient’s prescription MAY make them a candidate for either procedure …. it is important to let the assessing doctor and the patient make the decision together based on a number of factors including risk vs benefit, expectation, k-readings and pachymetry.

KAMRA VISION

The outpatient procedure consists of implanting the corneal inlay under a LASIK-type flap in the eye’s outer layer. The procedure lasts less than 20 minutes and patients can resume most activities the next day. Implanting of the KAMRA inlay can be done alone or in a two-step procedure following iLASIK. Or PRK

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iL AS IK XTRA /PRK XTRA

XTRA is a 3-minute procedure used in conjunction with a standard LASIK or PRK surgery to add biomechanical strength to the cornea through accelerated corneal cross-linking. In standard LASIK surgery, the creation of the flap affects the biomechanics of the cornea. A change in biomechanics may cause the refractive effect to regress and possi-bly necessitate an enhancement procedure. Adding biomechanical strength through cross-linking has been shown to halt refractive regression in conditions associated with weakened corneas.

The indications/protocols for CXL and “XTRA” continue to evolve and surgeons are advised to keep up with the current literature on the subject, and provide appropriate counselling to patients prior to treatment.

Indications for XTRA

Young patients for iLasik (under 30 years of age).

Patients with severe ocular allergies, due to the risk of heavy rubbing.

Completely normal corneas, with no one sign of keratoconus, but family history.

Thin corneas with complete normal preoperative evaluation (Risk of ectasia has been ruled out).

High myopes (large resections) Hyperopes

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Recommended Pre-op Testing AT OPTOMETRIST OFFICE: Patient History Ocular Medical Vision Assessment

UCVA (distance and near) BCVA Dry MRx Cycloplegic Rx Eye Dominance TBUT Cover Test Lensometry

AT HORIZON LASER VISION CENTER: Ocular Assessment:

AcuTarget TM

OCT

Slit Lamp Exam Pupil Size

Topography Tonometry

Corneal Diameter (WTW) Dry Eye Assessment Pachymetry

Posterior Segment Review

Ocular Surface Assessment _{– a dry eye test should be performed on all patients for selection. Moderate to} more severe Dry Eye should be treated before a patient has KAMRA inlay. Continued dry eye even with treatment is contraindicated for KAMRA.

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Fol low -up ca re:

After Surgery, all instructions and medications will be given to the patient before they leave Horizon. They will also receive a written copy of these instructions. The patient will follow these instructions until seen at your office at ONE WEEK POSTOP. If you have any questions, please call HLVC for guidance.

The patient will be seen by the HLVC post-op doctor following surgery; iLASIK patients are seen on day 1 and PRK patients may be seen on day 1 to 5, depending on surgeon preference. If the patient has any inflammation/ delayed healing, the time could be extended.

The patient will then be seen at your office at 1WEEK, 1 MONTH, 3 MONTHS, 6 MONTHS AND 12 MONTHS postop. These visits are vital to the patient’s success and happiness as well as to Horizon statistics. It is imperative that these visits be kept.

At each of these visits a POSTOPERATIVE ASSESSMENT form must be completed and faxed to Horizon. These forms will be provided to your office with patient-specific information entered at the time the surgery is performed. This will save you or your staff from having to fill in the basic information.

Please fill in the Post-op form as completely as possible, to give the Horizon doctors as much information as possible when they is reviewing the findings. They will respond and fax the form back to your office.

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POST-OP PROTOCOL

All lubricating eye drops are provided by Horizon Laser Vision Center for one month following surgery.

Medicated eye drops are provided as long as the patient remains on the drops—as prescribed by the surgeon.

Sunglasses and eye shields are provided to the patient on the day of surgery and are to be used as outlined by

the surgeon.

For LASIK patients, driving is not recommended for 48 hours following surgery. PRK patients will need to

refrain from driving for at least one week. The patient should be cautioned that they should not drive until

they are comfortable to do so, even if this differs than the recommended time.

The optometrist is to send in a note to the patient’s license issuer to remove the glasses restriction. Horizon

does not send these letters.

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Medications for iLASIK

 Vigamox or Zymar QID for one week and discontinue at the optometrist’s one week visit.  Maxidex QID for one week and discontinue at the optometrist’s one week visit.

 Artificial tears often

Retreatments for iLASIK are not considered until the 3 month mark. Shifting can occur until the 2-3 month time frame.

Not e:

Please consult surgeon if any significant deviations from expected results occur OR if there is any significant rise in intraocular pressure. Modifying medications effectively can significantly modulate the effect of PRK but less so in iLASIK.

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Medicati ons for PRK,

ple ase fol low s pecif ic su rgeon’s rec ommendati ons:

Nor mal Regime Following Surgery: * Vigamox or Zymar 1 drop QID * Flarex 1 drop QID

* Voltaren PRN

* Artificial tears often * Bandage contact lens Day 3-4 Post-op:

* The patient should be assessed and if epithelium is well -healed, bandage lens removed. * Vigamox or Zymar 1 drop QID

* Flarex 1 drop QID * Artificial tears often One Week Post-op:

* Assess epithelial healing

* Complete postop assessment for m and fax to Horizon * Follow Surgeon’s recommendations for tapering Flarex.

You may wish to see the patient more often than usual. Feel free to do this in order to establish where the patient is refractively. This is often difficult to do during the early visits.

Retreatments for PRK are not considered until the 6 MONTH mark. Stability is the most impor tant factor in retreatment. Patients must be completely off steroids before considered stable.

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Medications for KAMRA

VIGAMOX (antibiotic)

Day of Surgery, following surgery: Suppertime and Bedtime. Day One: 1 drop 4 x per day for 1 week, then stop.

PRED FORTE: WEEK ONE:

Starting Day One: 4 times per day for 1 week, then stop. LOTEMAX

Weeks 2 to 4: 4 times per day 2nd_{Month: 2 times per day}

3rd_{Month: 1 time per day, then stop unless otherwise directed by your optometrist.}

HYLO Drops and HYLO Gel (non-preservative tears) Use at least once every waking hour for the first week Continue to use as needed over the next 3 months

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Recommended Schedule of Visits and Procedures following KAMRA

1 Day 1 Wk 1 Mo 3 Mo 6 Mo 12 Mo

Ocular Surface Assessment ( eg Schirmer’s Test and TBUT) _x _x

Uncorrected VA - Distance at 6m/20ft

 Intermediate at 80cm/32in.

 Near at 40cm/16in. Safety VA x x x x x

Manifest Refraction (mid-point) x x x x x

Distance-Corrected VA - Distance at 6m/20ft

 Intermediate at 80cm/32 in.

 Near at 40cm/16in. x x x x

Distance-Corrected VA - (With Add):

 Near at 40cm/16 in. x x x x

Slit Lamp Examination w/fluorescein x x x x x x

Computerized Corneal Topography x x x x x

Pachymetry x x x

Intraocular Pressure x x x x x

Cycloplegic Refraction x

Dilated Fundus Exam x

SLIT LAMP EXAMINATION: Inspect inlay and cornea closely for:

Areas of irregularity or damage Stromal inflammation (DLK) Epithelial ingrowth

Stromal haze

Side-cut misalignment or epithelial defects Striae:

Use retro-illumination/red reflex to assess presence of striae

Most important to assess for striae within the central aperture of the inlay Dilation may be required if suspicious

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PRICING:

 iLASIK or PRK $2,295/Eye = $4,590.00 OU  Xtra, if necessary, is no additional cost.

 KAMRA (no LASIK needed) $4800.  KAMRA following LASIK $3250.

 For LASIK or PRK cases, the OD fee is $300/ eye; surgeon’s fee is $325/eye.

 KAMRA cases, the surgeon fee is $500 and OD fee is $300.

Patient financing is available through Medicard 1-888-689-9876

www. medicard.com RETREATMENTS:

 Within two years of procedure, there is no charge for retreatment

 Two to five years after procedure, the patient will pay $500/eye. ($250 for the OD and $250 for the surgeon)

 Five years or more after the procedure, the patient will be responsible for paying new treatment fees, whatever that might be at the time.

 Retreatment rate is less than 5%

DISCOUNT POLICY

CLASSIFICATION NO CHARGE INCLUDES:

1.) Optometrist, their Spouse and all their immediate dependent (< 25 years) children

All fees will come from HLVC General Revenue

2.) HLVC Full Time staff, their spouse and all their immediate dependent (< 25 years) children , as well as HLVC Part Time Staff.

All fees will come from HLVC General Revenue.

CLASSIFICATION PARTIAL CHARGE INCLUDES:

1.) Optometrist and Surgeon office staff

Each office staff member is responsible for paying a Facility Fee of $1000.00

It is suggested that the staff member have a minimum of ONE year commitment to the referring office before this benefit be extended to the staff member

2.) Optometrist and Surgeon Office Staff Spouses and dependent Children

Each office staff member’s spouse and their immediate dependent (<25 years) children will be responsible for paying 50% of the Facility fee. The surgeon and optometrist fee is paid for by the patient.

3.) Healthcare practitioners

Each healthcare practitioner will receive a maximum 25% discount.

This fee will be allocated as follows with the surgeon and optometrist receiving their Full Fee. The balance will be used to pay the Clinic its Facility Fee.

4.) Horizon Part Time Staff ’s spouse and immediate dependent children.

Responsible to pay 50% of the total cost

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