Refractive Surgery 2015 The Vegas Player`s Guide of Refractive
Transcription
Refractive Surgery 2015 The Vegas Player`s Guide of Refractive
Refractive Surgery 2015 The Vegas Player’s Guide of Refractive Surgery—Everyone Wins! Program Directors A John Kanellopoulos MD and Bonnie A Henderson MD The Annual Meeting of ISRS Sponsored by the International Society of Refractive Surgery (ISRS) Sand Expo/Venetian Las Vegas, Nevada Friday, Nov. 13, 2015 Presented by the American Academy of Ophthalmology Supported in part by an unrestricted educational grant from Clarity Medical Systems Refractive Surgery 2015 Planning Group A John Kanellopoulos MD Program Director Bonnie A Henderson MD Program Director Renato Ambrósio Jr MD Daniel S Durrie MD Ronald R Krueger MD Sonia H Yoo MD Former Program Directors 2014 Sonia H Yoo MD A John Kanellopoulos MD 2013 Michael C Knorz MD Sonia H Yoo MD 2012 David R Hardten MD Michael C Knorz MD 2011 Amar Agarwal MD David R Hardten MD 2010 Ronald R Krueger MD Amar Agarwal MD 2009 Gustavo E Tamayo MD Ronald R Krueger MD 2008 Steven C Schallhorn MD Gustavo E Tamayo MD 2007 Francesco Carones MD Steven C Schallhorn MD 2006 Steven E Wilson MD Francesco Carones MD 2005 2004 2003 2002 2001 2000 1999 1998 1995–1997 Jorge L Alió MD PhD Steven E Wilson MD John A Vukich MD Jorge L Alió MD PhD Terrence P O’Brien MD John A Vukich MD Daniel S Durrie MD Terrence P O’Brien MD Douglas D Koch MD Daniel S Durrie MD Richard L Lindstrom MD Douglas D Koch MD Marguerite B McDonald MD Richard L Lindstrom MD Peter J McDonnell MD Marguerite B McDonald MD Peter J McDonnell MD 2015 ISRS Executive Committee Ronald R Krueger MD, Chair Committee Members Richard L Abbott MD Amar Agarwal MD Jorge L Alió MD Renato Ambrósio Jr MD George Beiko MD John So-Min Chang MD Burkhard Dick MD Alaa M Eldanasoury MD A John Kanellopoulos MD Aylin Kılıç MD Richard L Lindstrom MD Marguerite B McDonald MD J Bradley Randleman MD William B Trattler MD George O Waring IV MD Subspecialty Day Advisory Committee William F Mieler MD Associate Secretary Donald L Budenz MD MPH Daniel S Durrie MD Francis S Mah MD R Michael Siatkowski MD Nicolas J Volpe MD Jonathan B Rubenstein MD Secretary for Annual Meeting Staff Melanie R Rafaty CMP, Director, Scientific Meetings Ann L’Estrange, Scientific Meetings Specialist Christa Fernandez, Presenter Coordinator Debra Rosencrance CMP CAE, Vice President, Meetings & Exhibits Patricia Heinicke Jr, Copyeditor Mark Ong, Designer Gina Comaduran, Cover Design ©2015 American Academy of Ophthalmology. All rights reserved. No portion may be reproduced without express written consent of the American Academy of Ophthalmology. ii 2015 Subspecialty Day | Refractive Surgery 2015 Refractive Surgery Subspecialty Day Planning Group On behalf of the American Academy of Ophthalmology and the International Society of Refractive Surgery, it is our pleasure to welcome you to Las Vegas and Refractive Surgery 2015: The Vegas Player’s Guide of Refractive Surgery—Everyone Wins!, the Annual Meeting of the International Society of Refractive Surgery. A John Kanellopoulos MD Bonnie A Henderson MD Alcon Laboratories, Inc.: C Allergan: C Avedro, Inc: C Carl Zeiss AG: C i-Optics: C ISP Surgical, LLC: C KeraMed, Inc.: C Abbott Medical Optics, Inc.: C Alcon Laboratories, Inc.: C Bausch + Lomb: C Clarvista: C Massachusetts Eye and Ear Infirmary: P Regeneron Pharmaceuticals, Inc.: C Stealth: C Program Director Program Director 2015 Subspecialty Day | Refractive Surgery 2015 Refractive Surgery Subspecialty Day Planning Group Renato Ambrósio Jr MD Ronald R Krueger MD Alcon Laboratories, Inc.: C Allergan: L Carl Zeiss, Inc.: L Mediphacos: L Oculus, Inc.: C Alcon Laboratories, Inc.: C Calhoun Vision, Inc.: O Clarity Medical, Inc.: C Cleveland Clinic Foundation: E LensAR Laser Systems: C,O Presbia: C Daniel S Durrie MD Abbott Medical Optics: S AcuFocus, Inc.: C,L,O,S Alcon Laboratories, Inc.: L,O,S Allergan: S Alphaeon: C,O Avedro: L,O,S Strathspey Crown, LLC: C,L,O Wavetec: C,O,P Sonia Yoo MD Abbott Medical Optics, Inc.: S Alcon Laboratories, Inc.: C Allergan, Inc.: S Avedro: S Bausch + Lomb Surgical: C Bioptigen: C Carl Zeiss Meditec: S SLACK Incorporated: L Transcend: C iii 2015 Subspecialty Day | Refractive Surgery Refractive Surgery 2015 Contents Refractive Surgery Subspecialty Day Planning Group ii CME vi 2015 Award Winners viii Faculty Listing xii Program Schedule xxiv Opening Keynote Lecture: Cornea Biomechanics and Its Application in Refractive Surgery 1 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2 Section II: Holding the Perfect Hand—Cornea- and Lens-Based Procedures 32 Section III: Fair Game—Refractive Surgery Interactive Doctor-Patient Consultations 45 Advocating for Patients 46 Section IV: The “Mojo Bag” of Videos on Lens and Cornea Refractive Surgery Complications 48 Section V: ESCRS Symposium—Secondary Procedures After Refractive Surgery 58 Section VI: The Journal of Refractive Surgery’s Hot, Hotter, Hottest—Late Breaking News 66 Troutman Prize: Antibacterial Efficacy of Accelerated Photoactivated Chromophore for Keratitis-Corneal Collagen Crosslinking 66 E-posters 83 Faculty Financial Disclosure 107 Presenter Index 117 v vi 2015 Subspecialty Day | Refractive Surgery CME Credit Academy’s CME Mission Statement The purpose of the American Academy of Ophthalmology’s Continuing Medical Education (CME) program is to present ophthalmologists with the highest quality lifelong learning opportunities that promote improvement and change in physician practices, performance, or competence, thus enabling such physicians to maintain or improve the competence and professional performance needed to provide the best possible eye care for their patients. 2015 Refractive Surgery Subspecialty Day Meeting Learning Objectives Upon completion of this activity, participants should be able to: • Evaluate the latest techniques and technologies in refractive surgery, specifically the latest and emerging techniques and technologies in cornea biomechanics, cornea imaging, IOL calculations, and ectasia detection • Identify the current status and future of femtosecond laser, excimer laser, inlay, intracorneal ring segment, and IOL refractive surgery • Compare the pros and cons of various lens- and cornealbased modalities, including presbyopic and toric IOLs • Describe the increasing importance that refractive surgery plays in the practice of every subspecialty in ophthalmology 2015 Refractive Surgery Subspecialty Day Meeting Target Audience The intended audience for this program is comprehensive ophthalmologists; refractive, cataract, and corneal surgeons; and allied health personnel who are performing or assisting in refractive surgery. 2015 Refractive Surgery Subspecialty Day Meeting CME Credit The American Academy of Ophthalmology is accredited by the Accreditation Council for Continuing Medical Education to provide CME for physicians. The American Academy of Ophthalmology designates this live activity for a maximum of 7 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ABO Self-Assessment Credit This activity meets the Self-Assessment CME requirements defined by the American Board of Ophthalmology (ABO). Please be advised that the ABO is not an accrediting body for purposes of any CME program. The ABO does not sponsor this or any outside activity, and the ABO does not endorse any particular CME activity. Complete information regarding the ABO SelfAssessment CME Maintenance of Certification requirements are available at http://abop.org/maintain-certification/part-2-lifelong -learning-self-assessment/cme/. NOTE: Credit designated as “self-assessment” is AMA PRA Category 1 Credit™ and is also preapproved by the ABO for the Maintenance of Certification (MOC) Part II CME requirements. Teaching at a Live Activity Teaching instruction courses or delivering a scientific paper or poster is not an AMA PRA Category 1 Credit™ activity and should not be included when calculating your total AMA PRA Category 1 Credits™. Presenters may claim AMA PRA Category 1 Credits™ through the American Medical Association. Please contact the AMA to obtain an application form at www.ama-assn.org. Scientific Integrity and Disclosure of Financial Interest The American Academy of Ophthalmology is committed to ensuring that all CME information is based on the application of research findings and the implementation of evidence-based medicine. It seeks to promote balance, objectivity, and absence of commercial bias in its content. All persons in a position to control the content of this activity must disclose any and all financial interest. The Academy has mechanisms in place to resolve all conflicts of interest prior to an educational activity being delivered to the learners. The Academy requires all presenters to disclose on their first slide whether they have any financial interests from the past 12 months. Presenters are required to verbally disclose any financial interests that specifically pertain to their presentation. Attendance Verification for CME Reporting Before processing your requests for CME credit, the Academy must verify your attendance at Subspecialty Day and/or AAO 2015. In order to be verified for CME or auditing purposes, you must either: • Register in advance, receive materials in the mail, and turn in the Final Program and/or Subspecialty Day Syllabus exchange voucher(s) onsite; • Register in advance and pick up your badge onsite if materials did not arrive before you traveled to the meeting; • Register onsite; or • Scan the barcode on your badge as you enter an AAO 2015 course or session room. CME Credit Reporting Level 2 and Academy Resource Center, Hall B – Booth 2632 Attendees whose attendance has been verified (see above) at AAO 2015 can claim their CME credit online during the meeting. Registrants will receive an email during the meeting with the link and instructions on how to claim credit. CME Credit 2015 Subspecialty Day | Refractive Surgery Onsite, you may report credits earned during Subspecialty Day and/or AAO 2015 at the CME Credit Reporting booth. Academy Members: The CME credit reporting receipt is not a CME transcript. CME transcripts that include AAO 2015 credits entered onsite will be available to Academy members on the Academy’s website beginning Dec. 10, 2015. NOTE: CME credits must be reported by Jan. 13, 2016. After AAO 2015, credits can be claimed at www.aao.org. The Academy transcript cannot list individual course attendance. It will list only the overall credits spent in educational activities at Subspecialty Day and/or AAO 2015. Nonmembers: The Academy will provide nonmembers with verification of credits earned and reported for a single Academysponsored CME activity, but it does not provide CME credit transcripts. To obtain a printed record of your credits, you must report your CME credits onsite at the CME Credit Reporting booths. vii Proof of Attendance The following types of attendance verification will be available during AAO 2015 and Subspecialty Day for those who need it for reimbursement or hospital privileges, or for nonmembers who need it to report CME credit: • CME credit reporting/proof-of-attendance letters • Onsite registration receipt • Instruction course and session verification Visit www.aao.org for detailed CME reporting information. viii 2015 Subspecialty Day | Refractive Surgery 2015 ISRS Award Winners José I Barraquer Lecture and Award Casebeer Award The José I Barraquer Lecture and Award honors a physician who has made significant contributions in the field of refractive surgery during his or her career. This individual exemplifies the character and scientific dedication of José I Barraquer MD—one of the founding fathers of refractive surgery. The Casebeer Award recognizes an individual for his or her outstanding contributions to refractive surgery through nontraditional research and development activities. Dr. Donnenfeld is clinical professor of ophthalmology at New York University and is a member of the Board of Overseers of Dartmouth Medical School. He is a founding partner of Ophthalmic Consultants of Long Island, one of the largest practices in the country. He received his undergraduate and medical degree from Dartmouth Medical School, where he was valedictorian of Eric D Donnenfeld MD his class. He completed his residency in ophthalmology at Manhattan Eye, Ear & Throat Hospital, where he was chief resident, and he was a fellow at Wills Eye Hospital in Philadelphia. In addition to his academic teaching, Dr. Donnenfeld has been an investigator for 60 FDA trials and a researcher for various industry groups. He performed his first excimer laser treatment in 1989 as a principle investigator for the FDA trials. He has authored 200 published, peer-reviewed articles and more than 30 book chapters, and he has given many invited lectures. He was editor-in-chief of Cataract and Refractive Surgery Today from 2009 to 2015 and is currently the editor-in-chief of EyeWorld, the publication of the American Society of Cataract and Refractive Surgery. He has been on the editorial board for numerous journals in the field of ophthalmology. Dr. Donnenfeld is the immediate past president of the American Society of Cataract and Refractive Surgeons, and he is a former president of the Nassau Surgical Society. He has served on the Board of Directors for both of these organizations, as well as others. He is the surgeon director of the Lions Eye Bank for Long Island. Dr. Donnenfeld has received four awards from the American Academy of Ophthalmology: the Honor Award, the Senior Honor Award, the Life Time Achievement Award, and the Secretariat Award. William Trattler attended Dartmouth College and then received his medical degree from the University of Miami School of Medicine. He completed his ophthalmology residency at the University of Pennsylvania, Scheie Eye Institute, and then spent an additional year on subspecialty training in cornea and refractive surgery at the University of Texas Southwestern Medical Center in Dallas. William B Trattler MD Dr. Trattler’s career in refractive surgery has been positively impacted by numerous mentors and thought leaders. Following training with Steven Orlin and Michael Sulewski at Scheie, he spent a year learning cornea and refractive surgery under Jim McCulley in Dallas. Early in his career, Dr. Trattler learned pearls for laser refractive surgery at lectures and courses held by Steven Slade, Buddy Culbertson, and Marguerite McDonald. Mentors who impacted his early career included Eric Donnenfeld, Perry Binder, Steve Schallhorn, Dick Lindstrom, Jim Salz, and Ron Krueger. More recently, Dr. Trattler has worked closely with the next generation of refractive cataract surgeons, including George Waring IV, Jennifer Loh, Rob Weinstock, Karolline Rocha, Kendall Donaldson, Ken Beckman, and Neda Shamie. Dr. Trattler has been invited to lecture at numerous conferences both in the United States and internationally, and he has helped stimulate discussions, sometimes controversial, with the goal of advancing the safety and visual outcomes of refractive surgery. The topics he has lectured on have included pearls for surface ablation to enhance previous LASIK (2002), risk factors for post-LASIK ectasia (2002), avoidance of Nevanac under the contact lens in surface ablation (2006), the importance of preoperative topography as a routine test prior to presbyopic IOLs (2007), the safety of LASIK in eyes with thin corneas and normal topography (2007), and the advantages of epi-on corneal crosslinking (2011). Dr. Trattler is board certified by the American Board of Ophthalmology and is the author of many articles and textbooks, including Clinical Microbiology Made Ridiculously Simple and Review of Ophthalmology. On a personal note, Dr. Trattler is fortunate to have three wonderful children: Ali, Jeremy, and Josh. He also has the pleasure of working in group practice at the Center for Excellence in Eye Care, in Miami, Florida, with his father, Henry Trattler, as well as Carlos Buznego and 13 other dynamic eye care professionals who have contributed greatly to his career. 2015 Subspecialty Day | Refractive Surgery 2015 ISRS Award Winners ix Founders’ Award Kritzinger Memorial Award The Founder’s Award recognizes the vision and spirit of the Society’s founders by honoring an ISRS member who has made extraordinary contributions to the growth and advancement of the Society and its mission. The Kritzinger Memorial Award recognizes an individual who embodies the clinical, educational, and investigative qualities of Dr. Michiel Kritzinger, who advanced the international practice of refractive surgery. Dr. Ronald R Krueger, medical director of Refractive Surgery at the Cleveland Clinic Cole Eye Institute in Ohio, is a renowned ophthalmologic surgeon with more than 30 years of experience in the field of refractive surgery, specifically in excimer and femtosecond laser research and wavefront optics. In 1982, Dr. Krueger graduated summa cum laude from Rutgers UniverRonald R Krueger MD sity with a BSEE in electrical engineering, followed by an MSE in bioengineering from the University of Washington in the following year. After receiving his medical training at the University of Medicine and Dentistry, New Jersey – New Jersey Medical School in 1987, he completed a residency in ophthalmology at Columbia Presbyterian Medical Center in New York City in 1991, followed by both a cornea fellowship at the Dean McGee Eye Institute at the University of Oklahoma and a refractive surgery fellowship at the Doheny Eye Institute of the University of Southern California in 1993. Dr. Krueger has performed over 20,000 refractive surgery procedures and has published more than 150 peer-reviewed manuscripts, as well as numerous abstracts, book chapters, and trade journal articles. He is credited with documenting the first physical description of the effects of the excimer laser on corneal tissue, in 1985, and coauthoring the first book on wavefront customized corneal ablation, in 2001. He also pioneered the development of femtosecond laser treatment of the crystalline lens and cataracts, leading to the cofounding of LensAR, Inc., in 2004, and publication of the first textbook on the subject, Textbook of Refractive Laser Assisted Cataract Surgery (ReLACS), in 2013. Dr. Krueger teaches as a professor of ophthalmology at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. He is currently serving the 2014-2015 term as president of the International Society of Refractive Surgery in partnership with the American Academy of Ophthalmology (ISRS/AAO). In addition, Dr. Krueger has served as the associate editor of the Journal of Refractive Surgery over the past 20 years and has lectured on refractive surgery in more than 40 countries. Dr. Krueger has received numerous awards, including the National Leadership Award, Castle Connolly America’s Top Doctors award in 2005 and 2010, the 2007 Kritzinger Memorial Award of the ISRS/AAO, and the 2008 Lans Distinguished Award of the ISRS/AAO. In 2013, his thesis, “Ultrashort-Pulse Lasers Treating the Crystalline Lens: Will They Cause Vision Threatening Cataract?,” was accepted for membership in the American Ophthalmological Society (AOS), the oldest and most prestigious in U.S. ophthalmology. Burkhard Dick was born in the small town of Brake in northern Germany. After graduating from the local high school, he served for two years as a medical officer with Germany’s NATO forces. He attended medical school at the University of Giessen, graduating in 1990. The city of Giessen had a strong American presence during the Cold War, and the year of Burkhard’s graduation Burkhard Dick MD brought German unification and changed Giessen’s relative location— transforming it from a bordertown at the edge of the Iron Curtain to a city at the country’s geographical center. There Burkhard Dick completed his residency in ophthalmology, becoming head physician at the University Eye Hospital in 1995 before moving to the Eye Hospital of the University of Mainz, which bears the name of that city’s greatest son, Johannes Gutenberg. Here he specialized in refractive and cataract surgery and in 1997 became head of the hospital’s Refractive Surgical Eye Care Center. Shortly after becoming a clinical professor in Mainz, the University of Bochum offered Burkhard Dick the position of head and director of its eye clinic and eye research center, which he accepted in 2006. Since then, the Bochum University Eye Clinic has become an internationally renowned institution with a constant output of highly ranked research papers and clinical studies, most of them published in the Journal of Cataract and Refractive Surgery and the Journal of Refractive Surgery. Burkhard Dick became one of the first ophthalmic surgeons in Europe to use a femtosecond laser in cataract surgery; to date almost 5000 eyes have been operated with that technology in Bochum. For his pioneering work, he has been awarded a number of honors, like the Choyce Medal of the British Ophthalmological Society, the Gold Medal Award of the Australian Society for Cataract and Refractive Surgery, the Waring Medal of the Journal of Refractive Surgery, and, most recently, the Visionary Award of the American-European Congress of Ophthalmic Surgery (AECOS). He is a regular lecturer at international meetings like those of the Academy, the European Society of Cataract & Refractive Surgeons, the Deutsche Ophthalmologische Gesellschaft, the Deutschen Ophthalmochirurgen (DOC), the Deutschsprachige Gesellschaft fur Intraokularlinsen-Implanation und Refraktive Chirurgie, and the American Society of Cataract and Refractive Surgery, and he has instructed fellows from 38 different countries in state-of-the-art cataract, refractive, glaucoma, and vitreoretinal surgery. x 2015 ISRS Award Winners 2015 Subspecialty Day | Refractive Surgery Lans Distinguished Lecturer Award Presidential Recognition Award The Lans Distinguished Lecturer Award honors Dr. Leedert J Lans. Given annually, the award is given to an individual who has made innovative contributions in the field of refractive surgery, especially in the correction of astigmatism. The Presidential Recognition Award is a special award that honors the recipient’s dedication and contributions to the field of refractive surgery and to the ISRS. Dr. José L Güell MD is a founding partner of Instituto Microcirugía Ocular of Barcelona and director of the Cornea and Refractive Surgery Department. He is past president of EuCornea and a past president of the European Society of Cataract and Refractive Surgeons. He is also associate professor of ophthalmology at the Universitat Autònoma of Barcelona and scientific coordinator and professor José L Güell MD PhD of the anterior segment activities at the European School for Advanced Studies in Ophthalmology (ESASO), USI, in Lugano. Presently, his main areas of interest and research are laser refractive surgery, phakic IOLs, cataract surgery, endothelial transplantation, and corneal surgery. He has lectured since 1991 nationally and internationally on these topics. He has given 700 presentations/talks in national and international meetings and has approximately 200 published articles / chapters in national and international journals. He has 19 international awards. Prof. Dr. Jorge Alió has been professor and chairman of ophthalmology since 1987, first at the University of Alicante and since 2002 at the University Miguel Hernandez de Elche, Alicante, Spain. Prof. Alió’s main research interests include lens, refractive, and corneal surgery; ocular inflammation; and preventative ophthalmology. He is the founder of Vissum Corporation, which Jorge L Alió MD PhD consists of a network of clinics throughout Spain, and the Jorge Alió Foundation for the Prevention of Blindness. He is the creator of the concept of microincisional cataract surgery (MICS) and has been a pioneer in the area of multifocal, accommodative, and toric IOLs and excimer laser refractive surgery and phakic IOLs, with over 40,000 surgeries performed during his professional life. He has been the author or coauthor of over 475 peerreviewed papers published in prestigious international scientific journals, 285 book chapters, 85 books (as editor or coeditor), over 340 collaborations in ophthalmic scientific journals, and over 2115 presentations and invited lectures in international meetings. Dr. Alió’s Hirsch factor (h-factor), which indicates the influence of his work on the publications of other researchers, is 50 (Scopus), and Dr. Alio is listed with a field rating of 19 among top authors worldwide in ophthalmology during the last 5 years by the Microsoft Academic Search. At present, he holds the LXIII chair of the Academia Ophthalmologica Internationalis and the XLIX chair of the European Academy of Ophthalmology and has received a total of 93 international and national awards. He is also creator and director of the first online course in refractive surgery from the Miguel Hernandez University, entitled “Scientific Methodology in Refractive, Cataract, and Cornea Surgery.” 2015 Subspecialty Day | Refractive Surgery Presidential Recognition Award The Presidential Recognition Award is a special award that honors the recipient’s dedication and contributions to the field of refractive surgery and to the ISRS. George O Waring IV MD FACS is an assistant professor of ophthalmology and the director of Refractive Surgery at Medical University of South Carolina, Storm Eye Institute, and he serves as the medical director at Magill Vision Center. Dr. Waring also serves as adjunct assistant professor of bioengineering at the College of Engineering and Science at Clemson University. He is a diplomate of George O Waring IV MD the American Board of Ophthalmology and has received numerous awards and distinctions for excellence in ophthalmology, including the American Academy of Ophthalmology’s Achievement Award and the Distinguished Lans Award from the International Society of Refractive Surgery. He has been recognized as one of the nation’s Top Doctors in Ophthalmology by Castle Connolly’s Guide to America’s Top Ophthalmologists, and as a Top Ophthalmologist and Leading Physician of the World by the International Association of Ophthalmologists. Dr. Waring is active in clinical research and is the cofounder of the Ocular Biomechanics and Diffusion Laboratory in the Department of Bioengineering at Clemson University. He has over 100 scientific publications, abstracts, and presentations to his credit, including 27 peer-reviewed manuscripts, over 50 invited lectures, and over half a dozen book chapters on cataract and refractive surgery. He has performed surgery, taught new surgical procedures, and delivered invited lectures on four continents. Dr. Waring is a founding member of the American and European College of Ophthalmic Surgeons and the Cornea, External Disease and Refractive Surgery Society and was selected as one of 10 founding members of the prestigious Vanguard Ophthalmology Society to recognize future leaders in ophthalmology. He is a fellow of the American Academy of Ophthalmology and the American College of Surgeons and is active in numerous other professional societies. He chairs and participates in multiple committees and courses for the American Academy of Ophthalmology and the International Society of Refractive Surgery. Dr. Waring serves on the editorial board for the Journal of Refractive Surgery and serves as senior editor for the American Academy of Ophthalmology’s Ophthalmic News and Education Subcommittee on Refractive Management. He is also on the editorial board for the Academy’s basic science series text on refractive surgery. He is chief medical editor of Millennial Eye and serves on the editorial board of Ocular Surgery News and Cataract and Refractive Surgery Today for both the United States and Europe. Dr. Waring also has served on over 15 scientific advisory panels, aiding in the development of new technologies. Dr. Waring completed a dual degree in economics and ecology at Emory University in Atlanta, Georgia, followed by his doctor of medicine degree at the Emory University School of Medicine. He served as administrative chief resident of ophthalmology at the State University of New York (SUNY). He completed his subspecialty fellowship training in cornea and refractive surgery under the world-renowned mentorship of Daniel S Durrie MD in Overland Park, Kansas. He is happily married to Karolinne Maia Rocha MD PhD, who is also his partner in cornea, cataract, and refractive surgery. 2015 ISRS Award Winners xi 24th Annual Richard C Troutman MD DSc (Hon) Prize The Troutman Prize recognizes the scientific merit of a young author publishing in the Journal of Refractive Surgery. This prize honors Richard C Troutman MD DSc (Hon). Dr. Olivier Richoz has been a resident in ophthalmology at the Geneva University Hospitals, Switzerland, where he completed his MD-PhD on the topic of corneal collagen crosslinking with respect to physiology and optimization of keratoconus treatment, as well as application to infectious keratitis and progressive myopia. He published articles on the oxygen dependency of collagen crosslinking and Olivier Richoz MD the effect of high fluency on the bacterial killing rate of collagen crosslinking. He is the coauthor of 23 peer-reviewed publications and 3 patents. He is the recipient of a fellowship grant from the Swiss National Fund and the Swiss Commission for Technology and Innovation. He is currently in a corneal-anterior segment fellowship at the Royal Victoria Hospital, UK. xii 2015 Subspecialty Day | Refractive Surgery Faculty Amar Agarwal MD Steve A Arshinoff MD Miltos O Balidis MD PhD DO Chennai, India Chairman and Managing Director Dr. Agarwal’s Group of Eye Hospitals North York, Ontario, Canada Clinical Instructor University of Toronto Assistant Clinical Professor, Adjunct McMaster University Thessaloniki, Greece Director of Cornea and Anterior Segment Ophthalmica Eye Institute PhD, Department of Ophthalmology Aristotle University Medical School No photo available Jorge L Alió MD PhD Alicante, Spain Professor of Ophthalmology Miguel Hernandez University Medical Director Vissum Corp. George Asimellis PhD Athens, Greece Researcher LaserVision.gr Eye Institute Allon Barsam MBBS FRCOphth London, United Kingdom Consultant, Cornea, Cataract, and Refractive Surgery L&D University Hospital UK and Focus Clinics, London No photo available Renato Ambrósio Jr MD Ehud I Assia MD Rio de Janeiro, RJ, Brazil Director of Cornea and Refractive Surgery Instituto de Olhos Renato Ambrósio VisareRIO Personal Refracta Laser Associate Professor Federal University of São Paulo Kfar Saba, Israel Director, Department of Ophthalmology Meir Medical Center, Kfar-Saba Medical Director Ein-Tal Eye Center, Tel-Aviv George Beiko MD St. Catharines, ON, Canada Assistant Professor McMaster University Lecturer, University of Toronto Faculty Listing 2015 Subspecialty Day | Refractive Surgery xiii Michael W Belin MD Alan N Carlson MD John So-Min Chang MD Marana, AZ Professor of Ophthalmology & Vision Science University of Arizona Health Sciences Durham, NC Professor of Ophthalmology Duke Eye Center Hong Kong, Hong Kong Clinical Associate Professor of Ophthalmology The Chinese University of Hong Kong Clinical Associate Professor of Ophthalmology The University of Hong Kong Roberto Bellucci MD Salo, Brescia, Italy Chief of Ophthalmology Hospital and University of Verona, Italy Professor of Anterior Segment Surgery University of Verona, Italy Francesco Carones MD Milan, Italy Medical Director Carones Ophthalmology Center Arturo S Chayet MD La Jolla, CA Medical Director Codet Vision Institute, Tijuana, Mexico No photo available David F Chang MD Carlos Buznego MD Miami, FL Vice President Center for Excellence in Eye Care Assistant Professor Florida International University College of Medicine Los Altos, CA Clinical Professor of Ophthalmology University of California, San Francisco Adjunct Clinical Professor Chinese University, Hong Kong Beatrice Cochener MD Brest, France Professor of Ophthalmology University of Brest - France MD PhD Faculty xiv Faculty Listing 2015 Subspecialty Day | Refractive Surgery No photo available Efekan Coskunseven MD Burkhard Dick MD Eric D Donnenfeld MD Istanbul, Turkey Bochum, NRW, Germany Professor of Ophthalmology and Chairman University of Bochum Chairman and Director Institute for Vision Science Garden City, NY Founding Partner Ophthalmic Consultants of Long Island and Connecticut Clinical Professor of Ophthalmology New York University Kendall E Donaldson MD Richard J Duffey MD Plantation, FL Associate Professor of Ophthalmology Bascom Palmer Eye Institute Mobile, AL Ophthalmologist Premier Medial Eye Group William W Culbertson MD Dublin, Ireland Medical Director Wellington Eye Clinic Consultant Ophthalmologist and Head of Department Beacon Hospital No photo available Arthur B Cummings MD Miami, FL Professor of Ophthalmology University of Miami David Donate MD William J Dupps MD PhD Lyon, France Bay Village, OH Staff in Ophthalmology, Biomedical Engineering & Transplant Cleveland Clinic Cole Eye Institute Adjunct Associate Professor Biomedical Engineering Case Western Reserve University Faculty Listing 2015 Subspecialty Day | Refractive Surgery Alaa M Eldanasoury MD Damien Gatinel MD Preeya K Gupta MD Jeddah, Saudi Arabia Consultant Ophthalmologist Magrabi Eye Hospital Paris, France Assistant Professor of Ophthalmology Head, Anterior Segment and Refractive Surgery Department Rothschild Ophthalmology Foundation Durham, NC Assistant Professor of Ophthalmology Duke University Eye Center No photo available Oliver Findl MD Vienna, Austria Professor and Chair of Ophthalmology Vienna Institute of Research in Ocular Surgery Hanusch Hospital, Vienna Consultant Ophthalmic Surgeon Moorfields Eye Hospital, London William J Fishkind MD FACS Tucson, AZ Clinical Professor of Ophthalmology University of Utah Clinical Professor of Ophthalmology University of Arizona Sadeer B Hannush MD Rome, Italy Medical Doctor Ophthalmologist Langhorne, PA Attending Surgeon Cornea Service, Wills Eye Hospital Department of Ophthalmology Jefferson Medical College José L Güell MD PhD David R Hardten MD Barcelona, Spain Associate Professor of Ophthalmology Universidad Autònoma de Barcelona Director of Cornea and Refractive Surgery Unit Instituto de Microcirugía Ocular de Barcelona Minnetonka, MN Adjunct Associate Professor of Ophthalmology University of Minnesota Director of Fellowships & Research Minnesota Eye Consultants Luca Gualdi MD xv xvi Faculty Listing 2015 Subspecialty Day | Refractive Surgery Bonnie A Henderson MD Osama I Ibrahim MD PhD Terry Kim MD Waltham, MA Partner, Ophthalmic Consultants of Boston Clinical Professor Tufts University School of Medicine Alexandria, Egypt Professor of Ophthalmology Chief of Cornea and Refractive Surgery Past President Alexandria University Durham, NC Professor of Ophthalmology Duke University School of Medicine Chief, Cornea and External Disease Service Director, Refractive Surgery Service Duke University Eye Center Jack T Holladay MD MSEE FACS A John Kanellopoulos MD Bellaire, TX Clinical Professor of Ophthalmology Baylor College of Medicine, Houston Athens, Greece Clinical Professor of Ophthalmology NYU Medical College Director, Laservision.gr Eye Institute, Athens Stephen D Klyce PhD Port Washington, NY Adjunct Professor of Ophthalmology Mount Sinai School of Medicine John A Hovanesian MD Laguna Hills, CA Clinical Instructor Jules Stein Eye Institute University of California, Los Angeles Private Practice Harvard Eye Associates Aylin Kılıç MD Douglas D Koch MD Istanbul, Turkey Medical Doctor Dunya Eye Hospital Istanbul Houston, TX Professor and The Allen, Mosbacher and Law Chair in Ophthalmology Cullen Eye Institute Baylor College of Medicine Faculty Listing 2015 Subspecialty Day | Refractive Surgery xvii No photo available Thomas Kohnen MD PhD FEBO Bryan S Lee MD JD Parag A Majmudar MD Frankfurt, Germany Professor and Chair, Department of Ophthalmology Goethe University Editor Journal of Cataract and Refractive Surgery Los Altos, CA Altos Eye Physicians South Barrington, IL Associate Professor of Ophthalmology Rush University Medical Center No photo available Joseph J Ma MD Ronald R Krueger MD North York, ON, Canada Assistant Professor University of Toronto Medical Director Veritas Eye Institute Robert K Maloney MD Scott M MacRae MD Boris Malyugin MD PhD Rochester, NY Professor of Ophthalmology Flaum Eye Institute University of Rochester Moscow, Russia Los Angeles, CA Director, Maloney Vision Institute Clinical Professor of Ophthalmology University of California, Los Angeles Cleveland, OH Medical Director Department of Refractive Surgery Cole Eye Institute – Cleveland Clinic Professor of Ophthalmology Cleveland Clinic Lerner College of Medicine Case Western Reserve University George D Kymionis MD PhD Heraklion, Greece Assistant Professor of Ophthalmology University of Crete No photo available Sonia Manning MD Dublin, Ireland xviii Faculty Listing 2015 Subspecialty Day | Refractive Surgery No photo available Stephanie Jones Marioneaux MD Michael Mrochen PhD Toshihiko Ohta MD Chesapeake, VA American Academy of Ophthalmology Assistant Professor of Ophthalmology Eastern Medical of Virginia Zurich, Switzerland Founder IROC Science Izunokuni, Shizuoka, Japan Professor Juntendo University Shizuoka Hospital Louis D Skip Nichamin MD Robert H Osher MD Avon, CO Private Ophthalmic Surgeon and Consultant Former Medical Director Laurel Eye Clinic, PA Cincinnati, OH Professor of Ophthalmology University of Cincinnati School of Medicine Medical Director Emeritus Cincinnati Eye Institute Marguerite B McDonald MD Lynbrook, NY Clinical Professor or Ophthalmology NYU Langone Medical Center Adjunct Clinical Professor of Ophthalmology Tulane University Health Sciences Center, New Orleans, LA No photo available Rudy Nuijts MD Peter J McDonnell MD Baltimore, MD William Holland Wilmer Professor of Ophthalmology and Director The Wilmer Eye Institute Johns Hopkins University Maastricht, Limburg, Netherlands Professor of Ophthalmology, MD, PhD University Eye Clinic Maastricht University Medical Center Richard B Packard MD London, England Director Arnott Eye Associates Faculty Listing 2015 Subspecialty Day | Refractive Surgery xix Ioannis G Pallikaris MD Roberto Pineda II MD Michael B Raizman MD Crete, Greece Professor in Ophthalmology University of Crete Director, Institute of Vision and Optics University of Crete Waltham, MA Associate Professor of Ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary Boston, MA Associate Professor of Ophthalmology Tufts University School of Medicine Director, Cornea and Cataract Service New England Eye Center Lisa Park MD Marianne O Price PhD J Bradley Randleman MD Leonia, NJ Indianapolis, IN Executive Director Cornea Research Foundation of America Atlanta, GA Professor of Ophthalmology Emory University Yaron S Rabinowitz MD Ronald Luke Rebenitsch MD Beverly Hills, CA Director of Ophthalmology Research Cedars Sinai Medical Center Clinical Professor of Ophthalmology David Geffen School of Medicine University of California, Los Angeles Oklahoma, OK Refractive Surgeon ClearSight Center No photo available Jay Stuart Pepose MD PhD Chesterfield, MO Professor of Clinical Ophthalmology Washington University School of Medicine Medical Director Pepose Vision Institute xx Faculty Listing 2015 Subspecialty Day | Refractive Surgery Dan Z Reinstein MD Steven I Rosenfeld MD FACS Ahmed N Sedky FRCOphth London, England Medical Director London Vision Clinic Adjunct Professor of Ophthalmology Columbia University Medical Center, New York Delray Beach, FL Voluntary Professor of Ophthalmology Bascom Palmer Eye Institute Chief of Corneal Service Delray Eye Associates Cairo, Egypt Chairman and Medical Director Eye Subspecialty Center Theo Seiler MD PhD Olivier Richoz MD Belfast, Ulster, United Kingdom Corneal Fellow Royal Victoria Hospital, UK MD-PhD Student Geneva University Hospitals Geneva, Switzerland Marcony R Santhiago MD Rio de Janeiro, RJ, Brazil Professor of Ophthalmology Staff Member, Refractive Surgery University of São Paulo Zurich, Switzerland Professor of Ophthalmology University of Zurich Chairman, IROC Zurich No photo available Neda Shamie MD Samir I Sayegh MD PhD Champaign, IL Karolinne M Rocha MD Mount Pleasant, SC MD, PhD Storm Eye Institute Medical University of South Carolina Beverly Hills, CA Associate Professor of Ophthalmology USC Eye Institute Keck School of Medicine University of Southern California Faculty Listing 2015 Subspecialty Day | Refractive Surgery xxi Michael E Snyder MD Karl G Stonecipher MD Alan Sugar MD Cincinnati, OH Faculty and Board of Directors Cincinnati Eye Institute Volunteer Faculty University of Cincinnati Greensboro, NC Medical Director TLC Greensboro Clinical Associate Professor of Ophthalmology University of North Carolina Ann Arbor, MI Professor of Ophthalmology and Visual Sciences Kellogg Eye Center University of Michigan Christopher E Starr MD Jonathan H Talamo MD New York, NY Associate Professor of Ophthalmology Director of Refractive Surgery Weill Cornell Medical College Michael D Straiko MD Portland, OR Associate Director of Corneal Services Devers Eye Institute Waltham, MA Associate Professor of Ophthalmology, Part-time Harvard Medical School Roger F Steinert MD R Doyle Stulting MD PhD Audrey R Talley-Rostov MD Irvine, CA Irving H Leopold Professor Chair of Ophthalmology Gavin Herbert Eye Institute University of California, Irvine Atlanta, GA Director, Stulting Research Center Woolfson Eye Institute Professor Emeritus Emory University Seattle, WA Partner / Cornea, Cataract, and Refractive Surgeon Northwest Eye Surgeons Medical Advisory Board SightLife xxii Faculty Listing 2015 Subspecialty Day | Refractive Surgery Gustavo E Tamayo MD Minoru Tomita MD PhD Luis Felipe Vejarano MD Bogotá, DC, Colombia Director, Bogota Laser Refractive Institute Member, Executive Committee ISRS Tokyo, Japan Medical Director Minoru Tomita Eye Clinic Ginza Popayán, CA, Colombia Associate Professor University of Cauca William B Trattler MD Paolo Vinciguerra MD Miami, FL Director of Cornea Center For Excellence In Eye Care Milan, Italy Ophthalmology Department Istituto Clinico Humanitas Rozzano Abhay Raghukant Vasavada MBBS FRCS Avi Wallerstein MD No photo available Hungwon Tchah MD Seoul, Republic of Korea Professor, Ophthalmology Asan Medical Center University of Ulsan Vance Michael Thompson MD Sioux Falls, SD Assistant Professor of Ophthalmology University of South Dakota School of Medicine Ahmedabad, Gujarat, India Professor of Ophthalmology Raghudeep Eye Hospital Director, Iladevi Cataract & IOL Research Centre Montreal, QC, Canada Executive Vice President, Co-National Medical Director and Co-founder LASIK MD Assistant Professor of Ophthalmology McGill University Faculty Listing 2015 Subspecialty Day | Refractive Surgery xxiii George O Waring IV MD Robert J Weinstock MD Helen K Wu MD Mt. Pleasant, SC Assistant Professor of Ophthalmology Director of Refractive Surgery Storm Eye Institute Medical University of South Carolina Medical Director Magill Vision Center Largo, FL Director of Cataract and Refractive Surgery The Eye Institute of West Florida Chestnut Hill, MA Assistant Professor of Ophthalmology Tufts University School of Medicine Director of Refractive Surgery New England Eye Center Steven E Wilson MD Mitchell P Weikert MD Houston, TX Cleveland, OH Professor of Ophthalmology Staff Refractive and Corneal Surgeon The Cole Eye Institute The Cleveland Clinic Foundation Sonia H Yoo MD Miami, FL Professor of Ophthalmology Bascom Palmer Eye Institute Professor of Ophthalmology University of Miami Miller School of Medicine xxiv Program Schedule 2015 Subspecialty Day | Refractive Surgery Refractive Surgery 2015: The Vegas Player’s Guide of Refractive Surgery—Everyone Wins! The Annual Meeting of the International Society of Refractive Surgery Friday, Nov. 13, 2015 7:00 AM CONTINENTAL BREAKFAST, Hall D 8:00 AM Opening Remarks A John Kanellopoulos MD* Bonnie A Henderson MD* Opening Keynote 8:05 AM Cornea Biomechanics and Its Application in Refractive Surgery William J Dupps MD PhD* 1 Section I: Roll the Dice—New Diagnostics in Refractive Surgery Moderators: Douglas D Koch MD*, Sonia H Yoo MD* 8:15 AM New Corneal Imaging Devices: Clinical Examples and Applications Terry Kim MD* 2 8:22 AM Magnitude and Long-term Stability Associated With Changes After Crosslinking Parag A Majmudar MD* 3 8:29 AM Combining Refractive and Crosslinking Applications Avi Wallerstein MD 4 8:36 AM Diagnostics for Dry Eye Michael B Raizman MD* 7 8:43 AM Preop IOL Calculations and Challenging Cases Mitchell P Weikert MD* 8 8:50 AM Intraop IOL and Astigmatism Diagnostics Robert J Weinstock MD 11 8:57 AM How to Design a Universal IOL Calculator Samir I Sayegh MD PhD 12 9:01 AM Scheimpflug Analysis of Patients With Highly Asymmetric Keratoconus J Bradley Randleman MD 13 9:05 AM Ectasia Detection: Scheimpflug Tomography Is the Most Accurate Renato Ambrósio Jr MD* 14 9:10 AM Ectasia Detection: Placido and Other Reflection Topography Is the Most Accurate Jonathan H Talamo MD* 21 9:15 AM Ectasia Detection: Anterior Segment OCT Is the Most Accurate George Asimellis PhD 23 9:20 AM Panel Discussion Stephen D Klyce PhD* Marguerite B McDonald MD* Roberto Pineda II MD* Yaron S Rabinowitz MD Ahmed N Sedky MBBCH Steven E Wilson MD* 9:30 AM REFRESHMENT BREAK, Hall D 10:02 AM US Trends in Refractive Surgery: 2015 ISRS Surgery Richard J Duffey MD 10:07 AM Presentation of the 2015 ISRS Awards Ronald R Krueger MD* Section II: Holding the Perfect Hand—Cornea- and Lens-Based Procedures Moderators: Steve A Arshinoff MD, Jack T Holladay MD MSEE FACS* 10:17 AM Excimer Laser Presby Applications: Clinical Examples and Techniques Gustavo E Tamayo MD* 32 10:24 AM Customized Excimer Platforms Update Theo Seiler MD PhD 33 31 ISRS Awards * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 2015 Subspecialty Day | Refractive Surgery Program Schedule xxv 10:31 AM Update on Cornea Inlays for Presbyopia Jay Stuart Pepose MD PhD* 34 10:38 AM Intracorneal Ring Segments Review: New and Current Applications Jorge L Alió MD PhD* 35 10:45 AM Monofocal IOLs, Toric IOLs: New and Current Applications Alan N Carlson MD* 37 10:52 AM Overview on Trifocal, Multifocal, and Enhanced Depth of Focus IOLs Boris Malyugin MD PhD* 39 10:59 AM Phakic IOL Review: New and Current Applications Allon Barsam MBBS FRCOphth*40 11:06 AM Novel Lasers for Refractive Surgery Michael Mrochen PhD* 43 11:13 AM Review of Current and New Femtosecond Lasers and Their Applications in Refractive Surgery Burkhard Dick MD* 44 11:23 AM Panel Discussion Francesco Carones MD* Arthur B Cummings MD* David R Hardten MD* Peter J McDonnell MD* Alan Sugar MD* Section III: Fair Game—Refractive Surgery Interactive Doctor-Patient Consultations Moderators: Louis D Skip Nichamin MD*, Vance Michael Thompson MD* 11:33 AM “I do not want to wear any glasses after cataract surgery, Doctor!” Helen K Wu MD* Michael E Snyder MD* 45 Is Femto-Cataract Better Than Traditional? Karl G Stonecipher MD* Bryan S Lee MD JD* 45 “I have been a myope all my life. Should I aim for no glasses at far?” Audrey R Talley-Rostov MD* William C Culbertson MD 45 11:54 AM “I want to have laser vision correction for −6 D and I am 45 years old. What are my options, Doctor?” Thomas Kohnen MD PhD FEBO Miltos Balidis MD PhD DO* 45 12:01 PM “I had LASIK 5 years ago, and I still see haloes at night. Can you fix it, Doctor, or should I sue?” Carlos Buznego MD* Ronald Luke Rebenitsch MD* 45 12:08 PM “I want refractive surgery now! Why should I wait for my corneal surface to be improved, and who cares about dry eye?” Christopher E Starr MD* Neda Shamie MD 12:15 PM Advocating for Patients Stephanie Jones Marioneaux MD46 12:20 PM LUNCH—Hall D ISRS Member’s Lunch and Program—Venetian GH Section IV: The “Mojo Bag” of Videos on Lens and Cornea Refractive Surgery Complications Moderators: Amar Agarwal MD*, Ronald R Krueger MD* Virtual Moderator: Lisa Park MD 1:35 PM Suturing a Capsular Tension Ring Robert K Maloney MD* 48 1:40 PM Dislocated IOL Management With the Glued IOL Technique Eric D Donnenfeld MD* 49 1:45 PM Challenging Exchange of Refractive IOL David F Chang MD* 50 1:50 PM Mastering the Trocar Anterior Chamber Maintainer and Pre-Descemet Endothelial Keratoplasty With Glued IOL Amar Agarwal MD* 51 1:55 PM When Things Start Blowing, Try Beans George Beiko MD* 53 2:00 PM Placement of a Toric IOL in a Compromised Capsular Bag William B Trattler MD* 54 2:05 PM Corneal Inlay Complications George O Waring IV MD* 55 11:40 AM 11:47 AM * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 45 xxvi Program Schedule 2015 Subspecialty Day | Refractive Surgery 2:10 PM Small-Incision Lenticule Extraction (SMILE) Complications Ronald R Krueger MD* 56 2:15 PM Endothelial Keratoplasty and IOL Implantation Sadeer B Hannush MD 57 2:20 PM Panel Discussion Kendall E Donaldson MD Preeya K Gupta MD* Robert H Osher MD* Roger F Steinert MD* Michael D Straiko MD* REFRESHMENT BREAK and BREAK WITH THE EXPERTS, Hall D 2:30 – 3:10 PM Cataract and IOL Complications Ehud I Assia MD* Abhay Raghukant Vasavada MBBS FRCS* Collagen Crosslinking George D Kymionis MD PhD Paolo Vinciguerra MD* Corneal Inlays Ioannis G Pallikaris MD Minoru Tomita MD PhD* Elevation Corneal Tomography Hungwon Tchah MD Michael W Belin MD* Laser Refractive Lens Surgery William J Fishkind MD FACS* John A Hovanesian MD* Intracorneal Rings Efekan Coskunseven MD* Aylin Kılıç MD Laser Vision Correction Enhancements Steven I Rosenfeld MD FACS* R Doyle Stulting MD PhD* Phakic IOLs Arturo S Chayet MD Alaa M Eldanasoury MD* Planning IOL Powers John So-Min Chang MD* Bonnie A Henderson MD* Presbyopic IOL Pearls Beatrice Cochener MD* Scott M MacRae MD* Toric IOL Pearls Jose L Güell MD* Marianne O Price PhD* Section V: ESCRS Symposium—Secondary Procedures After Refractive Surgery Moderator: Roberto Bellucci MD* 3:10 PM Outcomes of Cataract Surgery in Post-Refractive Surgery Eyes Sonia Manning MD* 58 3:16 PM Residual Astigmatism After Toric IOL Implantation Rudy Nuijts MD* 59 3:22 PM Multifocal IOL Dissatisfaction: Causes and Solutions Oliver Findl MD* 60 3:28 PM Secondary Procedures in Eyes With Phakic IOLs José L Güell MD PhD* 61 3:34 PM Dealing With SMILE Inaccuracies David Donate MD* 62 3:40 PM Retreatments After Presbyopic LASIK Roberto Bellucci MD* 63 3:46 PM Discussion * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 2015 Subspecialty Day | Refractive Surgery Program Schedule xxvii Section VI: The Journal of Refractive Surgery’s Hot, Hotter, Hottest—Late Breaking News Moderators: J Bradley Randleman MD, Karolinne M Rocha MD* 3:55 PM Introduction of Troutman Prize J Bradley Randleman MD 4:00 PM Troutman Prize: Antibacterial Efficacy of Accelerated Photoactivated Chromophore for Keratitis-Corneal Collagen Crosslinking Olivier Richoz MD* 66 4:15 PM The Role of PTA in Screening Marcony R Santhiago MD* 68 4:20 PM Simultaneous Correction of Unilateral Rainbow Glare and Residual Astigmatism by Undersurface Flap Photoablation After Femtosecond Laser-Assisted LASIK Damien Gatinel MD* 70 4:25 PM Stromal Surface Topography-Guided Custom Ablation as a Repair Tool for Corneal Irregular Astigmatism Dan Z Reinstein MD* 73 4:30 PM Long-term Postoperative Results of T-Fixation Technique Used for Intrascleral Posterior Chamber IOL Fixation Toshihiko Ohta MD 75 4:35 PM Profocal Cornea Created by Transparent Hydrogel Corneal Inlay: Mechanism of Action and Clinical Implications Douglas D Koch MD* 76 4:40 PM Initial Clinical Experience With a New Laser Approach for Precise Capsulotomies Richard B Packard MD* 77 4:45 PM Micro-Electrostimulation of the Ciliary Body as a New Noninvasive Method for Presbyopia Treatment: Early Results Luca Gualdi MD 78 4:50 PM Sedky Approach for RelExSMILE Retreatment Ahmed N Sedky MBBCH 79 4:55 PM Diagnostic Intraoperative and Swept Source Postoperative OCT for the Prediction of Postoperative IOL Position During Femtosecond Refractive Laser-Assisted Cataract Surgery Joseph J Ma MD* 80 5:00 PM Refractive Lenticule Implantation for Unilateral Aphakia Osama I Ibrahim MD PhD* 81 5:05 PM PresbV (Presbyopia Vejarano) Tears Noninvasive Solution for Presbyopia Luis Felipe Vejarano MD 82 5:10 PM JRS QwikFacts J Bradley Randleman MD 5:15 PM Closing Remarks A John Kanellopoulos MD* Bonnie A Henderson MD* * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. Keynote Lecture 2015 Subspecialty Day | Refractive Surgery Cornea Biomechanics and Its Application in Refractive Surgery William J Dupps MD PhD NOTES 1 2 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2015 Subspecialty Day | Refractive Surgery New Corneal Imaging Devices: Clinical Examples and Applications Terry Kim MD I.Introduction A. Ophthalmic surgical microscopes provide top-down views of the surgical field. B. OCT provides direct depth information. C. Microscope integration of OCT allows for simultaneous surgery and imaging. II. Methods: Swept Source Microscope-Integrated (SS-MIOCT) Specifications A. Swept-source center: 1040 nm B. A-scan rate: 100 kHz C. A/B-scan ratio: 500 D. Volume rate: 2 Hz E. Resolution: 14x14x7.8 μm (x, y, z) F. Imaging range: 12x12x7.4 mm (x, y, z) III. Methods: Patient Recruitment A. Patients undergoing cataract and cornea procedures were enrolled from the Cornea Service clinics at the Duke Eye Center to have intraoperative imaging with SS-MIOCT. B. Informed consent was obtained from all study subjects prior to beginning any study activities. The study protocol was reviewed and approved by the Duke University Medical Center Institutional Review Board. IV. Methods: Operating Room Setup A. Surgeon at operating microscope B. Technician at MIOCT computer C. MIOCT data is read by the technician and conveyed to the surgeon or read directly by the surgeon. V. Methods: MIOCT Data VI. Clinical Examples A.Cataract 1. Wound testing a. Cataract: wound testing b. Cataract: wound testing (4D) c.Cases 2. Cataract: main incision B. Descemet-stripping automated endothelial keratoplasty (DSAEK) 1. Graft unfolding 2. Graft interface a. DSAEK: graft unfolding b. DSAEK: graft unfolding (4D) c. DSAEK: graft interface d. DSAEK: graft interface (4D) C. Deep anterior lamellar keratoplasty (DALK): needle depth (ex vivo/heads up display) 1. DALK: heads-up display (ex vivo) 2. DALK: heads-up display (ex vivo) VII. Clinical Applications Impact of microscope-integrated OCT on ophthalmology resident performance of anterior segment maneuvers in model eyes: Results A. 50% depth analysis B. 90% depth analysis C. Laceration repair D.Geometry E.Feedback VIII.Conclusion A. MIOCT feedback-enhanced performance of trainee surgeons in select depth-based anterior segment maneuvers had no effect on clear-cornea wound geometry as performed in this study. B. SS-MIOCT can be used to both monitor and guide anterior segment surgical maneuvers in real time and demonstrates promise as a training tool in surgical education of ophthalmology residents. Acknowledgments Duke Eye Center Anthony Kuo MD Neel Parischa Sandra Stinnett PhD Prithvi Mruthyunjaya MD Melissa Daluvoy MD Duke University BME Brenton Keller Linus Shen Cole Eye Institute (Cleveland Clinic) BJ Dupps MD PhD Justis Ehlers MD Kenny Tao PhD Sunil Srivastava MD 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery 3 Magnitude and Long-term Stability Associated With Changes After Crosslinking Parag A Majmudar MD I. History of Corneal Crosslinking A. 1970s: Siegel, formation of crosslinking aldehydes in collagen and elastin B. 1990s: Spoerl (1997), corneal application C. 2003: Wollensak, 22 eyes with keratoconus, 1-year results 1. K-max reduced at all follow-up periods 2. Average decrease in K-max: 1.45 D at 12 months D. Caporossi A, Mazzotta C, Baiocchi S. Age-related long-term functional results after riboflavin UV A corneal cross-linking. J Ophthalmol. 2011; 4;608041. E. Wittig-Silva C, Chan E, Islam FMA, Wu T, Whiting M, Snibson GR. A randomized, controlled trial of corneal collagen cross-linking in progressive keratoconus: three-year results. Ophthalmology 2014; 121(4):812-821. F. Vinciguerra R, Romano MR, Camesasca FI, et al. Corneal cross-linking as a treatment for keratoconus: four-year morphologic and clinical outcomes with respect to patient age. Ophthalmology 2013; 120:908-916. G. DeBernardo M, Capasso L, Lanzac M. Long-term results of corneal collagen crosslinking for progressive keratoconus. J Optom. 2015; 8(3):180-186. H. Marino GK, Toricelli AA, Giacomin N. Accelerated corneal collagen cross-linking for postoperative LASIK ectasia: two-year outcomes. J Refract Surg. 2015; 31(6):380-384. II. Debate About Techniques A. Dresden Protocol: Seiler, Wollensak, Spoerl, et al. B. Accelerated crosslinking: Avedro, etc. C.Epi-on 1.Iontophoresis 2.Noniontophoresis D. Lack of standardization and randomized trials makes it difficult to perform proper meta-analysis (China paper). III. Long-term Results A. Raiskup F. Corneal collagen crosslinking with riboflavin and ultraviolet-A light in progressive keratoconus: ten-year results. J Cataract Refract Surg. 2015; 41(1):41-46. B. Raiskupf-Wolf R, Hoyer A, Spoerl E, Pillunat L. Collagen crosslinking with riboflavin and ultraviolet-A light in keratoconus: long term results. J Cataract Refract Surg. 2008; 34:796-801. C. Caporossi A, Mazzotta C, Baiocchi S, Caporossi T. Long-term results of riboflavin ultraviolet A corneal collagen cross-linking for keratoconus in Italy: the Seina Eye Cross study. Am J Ophthalmol. 2010; 149:585-593. IV.Safety Other Readings 1. Koller T, Mrochen M, Seiler T. Complication and failure rates after corneal crosslinking. J Cataract Refract Surg. 2009; 35:1358-1362. 2. Sorkin N, Varssano D. Corneal collagen crosslinking: a systematic review. Ophthalmologica 2014; 232(1):10-27. 3. Chunyu T, Xiujun P, Zhengjun F, Xia Z, Feihu Z. Corneal collagen cross-linking in keratoconus: a systematic review and meta-analysis. Sci Rep. 2014; 4:5652. 4 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2015 Subspecialty Day | Refractive Surgery Combining Refractive and Crosslinking Applications Avi Wallerstein MD I. Collagen Crosslinking (CXL) A. Scientific background 1. Reaction of riboflavin + UV light 2. 3. Topography-guided surface ablation Purpose: Stiffen cornea, increase biomechanical stability, halt ectatic progression, improve corneal curvature B.Methods 1. Standard procedure: 30 minutes riboflavin soak + 30 min UV irradiance b. Outcomes: One-year results show improvement of visual acuity and refractive error. a. Shorter UV treatment time + higher intensity UV exposure b. Results equivalent to standard procedure? i. Partial correction of cylinder and corneal HOAs ii. Improved irregularity/regularization of cornea iii. Redistribute biomechanical forces 2. Accelerated procedure a.Mechanism b.Outcomes i. Sequential vs. simultaneous (a) Simultaneous procedure more beneficial than sequential: Less haze, better UDVA, CDVA (b) Greater reduction in MRSE, keratometry (c)Convenience II. Why Combine Refractive Applications With CXL A. Ectatic corneal disorders 1. KC, POE, PMD 2. Reduction of corneal curvature 3. Improve corneal irregularity 4. Improve refractive error 5. Improve visual rehabilitation 6. Improve quality of life B. Adjunct in primary LASIK 1. Lock-in/stabilize refractive treatment 2. Minimize myopic/hyperopic regression 3. Reduce incidence of POE A. Excimer laser combined with CXL iii. Montreal protocol: One-year results show improvements in corneal curvature, visual acuity, and refractive error. 1.Mechanism a. Flattens cone b. Improves VA and corneal topography c. Improves biomechanical stability 1.PTK (a) Three-year results show continued improvements in corneal curvature, visual acuity, and refractive error. B. ICRS combined with CXL III. Ectatic Corneal Disorders ii. Athens protocol – simultaneous procedure 2.Outcomes a. Mechanism: Differentially ablates peak of cone using epithelium to mask. a. Differences in number of segments, location, tunnel creation, and timing of procedures b.Outcomes b. Up to 2-year results show improvements in corneal curvature, visual acuity, and refractive error. c. Intacs + CXL: Variable results – improvement? d. Keraring, Ferrara ring + CXL: effective results Cretan protocol – transepithelial PTK i. Better outcomes than mechanical PTK ii. Up to 5-year results show improvement in corneal curvature, visual acuity, and refractive error. 2.PRK a.Mechanism i. Attempt to improve refractive error ii. Does not account for irregular astigmatism C. P-IOLs combined with CXL 1. Toric, posterior chamber P-IOL or iris claw P-IOL a. Mechanism: Correcting high refractive error Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2015 Subspecialty Day | Refractive Surgery 5 Table 1. Long-Term Outcomes of Excimer Ablation, ICRS, or P-IOL and CXL for Ectatic Eyes Variable 5-Year CRETAN Protocol 1-Year MONTREAL Protocol 3-Year ATHENS Protocol 2-Year CXL + ICRS 3-Year CXL + P-IOL N 13 103 1981 & 2312 20 17 K-max (D) ↓ 2.5 ↓ 2.1 ↓ 2.8 & ↓ 4.4 ↓ 4.3 ↓ 0.2 K-min (D) ↓ 2.1 n/a n/a & ↓ 3.3 ↓ 1.7 ↓0.3 UDVA (logMAR) ↓ 0.31 ↓ 0.37 ↓ 0.41 & ↓ 0.56 ↓ 0.33 ↓ 0.83 CDVA (logMAR) ↓ 0.08 ↓ 0.6 ↓ 0.25 & ↓ 0.1 ↓ 0.16 NC MRSE (D) ↓ 1.05 NC ↓ 2.5 & n/a ↓ 1.89 ↓ 6.77 Cylinder (D) ↓ 0.48 ↓ 2.39 n/a ↓ 0.79 ↓ 2.92 Pachymetry (um) ↓9 ↓ 76 ↓ 70 & ↓ 81 ↓1 ↑5 Publication Kymionis et al, 2014 2015 (unpublished) Kanellopoulos et al, 20091/Kanellopoulos & Asimellis, 20142 Renesto et al, 2012 Guell et al, 2012 Abbreviations: K-max indicates maximum keratometry; K-min, minimum keratometry; UDVA, uncorrected distance visual acuity; CDVA, corrected distance visual acuity; MRSE, manifest refraction spherical equivalent; CRETAN protocol, transepithelial PTK+CXL; MONTREAL protocol, simultaneous topography-guided PRK+CXL (proprietary algorithm); ATHENS protocol, simultaneous topography-guided PRK+CXL; ICRS, intrastromal corneal ring segments; P-IOL, phakic IOL; n/a, not available; NC, no change b. Used after CXL stabilization 2. Outcomes: Three-year results show improvements in corneal curvature, visual acuity, and refractive error. D. Excimer surface ablation, ICRS, and/or P-IOL combined with CXL 1. PRK and ICRS, PRK and P-IOL, ICRS and P-IOL, PTK and ICRS reported 2. Three-year results show improvements in corneal curvature, visual acuity, and refractive error. IV. Adjunct With Primary LASIK A. Primary LASIK combined with CXL (LASIK Xtra) 1.Technique a. Laser ablation b. Riboflavin under flap c. Flap repositioned d. UV light on flap surface 2.Outcomes a. Contralateral/comparative and bilateral studies of myopic and hyperopic LASIK + CXL i. 3.5-year outcomes show no difference in refractive outcome vs LASIK. ii. Equivalent safety iii. Less regression? b. Risk: Continued flattening over time V. Complications With CXL Combined With Excimer A. Most due to wound healing after epithelium removal for CXL B. Corneal haze – most common C. Infectious keratitis: Case reports of polymicrobial, fungal, Acanthamoeba, and herpetic keratitis VI. Future Directions A. Randomized clinical trials are still lacking. B. Longer-term follow-up with larger sample sizes for combined procedures for accuracy, efficacy, safety, and stability References 1. Alió JL, Toffaha BT, Piñero DP, Klonowski P, Javaloy J. Crosslinking in progressive keratoconus using an epithelial debridement or intrastromal pocket technique after previous corneal ring segment implantation. J Refract Surg. 2011; 27:737-743. 2. Aslanides IM, Mukherjee AN. Adjuvant corneal crosslinking to prevent hyperopic LASIK regression. Clin Ophthalmol. 2013; 7:637-641. 3. Celik HU, Alagoz N, Yildirim Y, et al. Accelerated corneal crosslinking concurrent with laser in situ keratomileusis. J Cataract Refract Surg. 2012; 38:1424-1431. 4. Coskunseven E, Jankov M, Hafezi F, Atun S, Arslan E, Kymionis GD. Effect of treatment sequence in combined intrastromal corneal rings and corneal collagen cross-linking for keratoconus. J Cataract Refract Surg. 2009; 35:2084-2091. 5. Coskunseven E, Kymionis GD, Grentzelos MA, et al. INTACS followed by KeraRing intrastromal corneal ring segment implantation for keratoconus. J Refract Surg. 2010; 26:371-374. 6. Güell JL, Morral M, Malecaze F, Gris O, Elies D, Manero F. Collagen crosslinking and toric iris-claw phakic intraocular lens for myopic astigmatism in progressive mild to moderate keratoconus. J Cataract Refract Surg. 2012; 38:475-484. 7. Kanellopoulos AJ. Comparison of sequential vs same-day simultaneous collagen cross-linking and topography-guided PRK for treatment of keratoconus. J Refract Surg. 2009; 25:S812-S818. 6 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 8. Kanellopoulos AJ. Long-term safety and efficacy follow-up of prophylactic higher fluence collagen cross-linking in high myopic laserassisted in situ keratomileusis. Clin Ophthalmol. 2012; 6:11251130. 9. Kanellopoulos AJ, Asimellis G. Epithelial remodeling after remtosecond laser-assisted high myopic LASIK: Comparison of standalone with LASIK combined with prophylactic high-fluence crosslinking. Cornea 2014; 33:463-469. 10. Kanellopoulos AJ, Asimellis G. Keratoconus management: longterm stability of topography-guided normalization combined with high-fluence CXL stabilization (the Athens protocol). J Refract Surg. 2014; 30:88-93. 11. Kanellopoulos AJ, Asimellis G, Karabatsas C. Comparison of prophylactic higher fluence corneal cross-linking to control, in myopic LASIK, one year results. Clin Ophthalmol. 2014; 8:2373-2381. 12. Kanellopoulos AJ, Binder PS. Management of corneal ectasia after LASIK with combined, same-day, topography-guided partial transepithelial PRK and collagen cross-linking: the Athens protocol. J Refract Surg. 2011; 27:323-331. 13. Kanellopoulos AJ, Kahn J. Topography-guided hyperopic LASIK with and without high irradiance collagen cross-linking: initial comparative clinical findings in a contralateral eye study of 34 consecutive patients. J Refract Surg. 2012; 28:S837-S840. 14. Kymionis GD. Corneal collagen cross linking-PLUS. Open Ophthalmol J. 2011; 5:10. 15. Kymionis GD, Grentzelos MA, Kankariya VP, Pallikaris IG. Combined transepithelial phototherapeutic keratectomy and corneal collagen crosslinking for ectatic disorders: Cretan protocol. J Cataract Refract Surg. 2013; 39:1939. 16. Kymionis GD, Grentzelos MA, Kounis GA, Diakonis VF, Limnopoulou AN, Panagopoulou SI. Combined transepithelial phototherapeutic keratectomy and corneal collagen cross-linking for progressive keratoconus. Ophthalmology 2012; 119:1777-1784. 2015 Subspecialty Day | Refractive Surgery 17. Kymionis GD, Grentzelos MA, Liakopoulos DA, et al. Long-term follow-up of corneal collagen cross-linking for keratoconus—the Cretan Study. Cornea 2014; 33:1071-1079. 18. Kymionis GD, Karavitaki AE, Kounis GA, Portaliou DM, Yoo SH, Pallikaris IG. Management of pellucid marginal corneal degeneration with simultaneous customized photorefractive keratectomy and collagen crosslinking. J Cataract Refract Surg. 2009; 35:12981301. 19. Kymionis GD, Kontadakis GA, Kounis GA, et al. Simultaneous topography-guided PRK followed by corneal collagen cross-linking for keratoconus. J Refract Surg. 2009; 25:S807-S811. 20. Kymionis GD, Portaliou DM, Diakonis VF, et al. Management of post laser in situ keratomileusis ectasia with simultaneous topography guided photorefractive keratectomy and collagen cross-linking. Open Ophthalmol J. 2011; 5:11-13. 21. Kymionis GD, Siganos CS, Tsiklis NS, et al. Long-term follow-up of Intacs in keratoconus. Am J Ophthalmol. 2007; 143:236-244. 22. Kymionis GD, Tsiklis NS, Pallikaris AI, et al. Long-term follow-up of Intacs for post-LASIK corneal ectasia. Ophthalmology 2006; 113:1909-1917. 23. Randleman JB, Khandelwal SS, Hafezi F. Corneal cross-linking. Surv Ophthalmol. In press. 24. Renesto Ada C, Melo LA Jr, Sartori Mde F, Campos M. Sequential topical riboflavin with or without ultraviolet a radiation with delayed intracorneal ring segment insertion for keratoconus. Am J Ophthalmol. 2012; 153:982-993. 25. Tomita M, Yoshida Y, Yamamoto Y, Mita M, Waring IV G. In vivo confocal laser microscopy of morphologic changes after simultaneous LASIK and accelerated collagen crosslinking for myopia: One-year results. J Cataract Refract Surg. 2014; 40:981-990. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery Diagnostics for Dry Eye Dry Eye and Refractive Surgery Michael B Raizman MD I.Principles A. Dry eye is a significant cause of morbidity after corneal refractive surgery. B. Many patients with dry eye should be excluded from surgery. C. Many patients with dry eye can be good candidates for surgery with appropriate screening and therapy. D. Dry eye alters the refractive error of the eye and can lead to undesirable refractive results. (True for noncorneal refractive surgery as well, including lens implant surgery.) E. Dry eye slows healing and increases the risk of complications in the immediate postoperative recovery period. F. Screening is critical. IV. Discussion With the Patient A. Is dryness only with contact lens wear? B. Times of day and times of year C. Response to prior therapy D. Dry eye questionnaires: Ocular Surface Disease Index (OSDI) E. Schirmer testing A. Systemic and topical medications that dry the eyes B. Environmental insults C. Contact lens wear D. Exposure from lid function abnormalities E.Blepharitis III. Other Risk Factors A.Age B.Menopause C. Systemic conditions D. Previous surgery, injury 1. With anesthesia 2. Without anesthesia F. Tear break-up time G. Tear meniscus at slit lamp H. Conjunctival staining II. Potentially Reversible Risk Factors I. Corneal staining 1.Fluorescein 2. Lissamine green 3. Rose bengal J. Tear osmolarity K. MMP-9 level in tears L. OCT of tear film and tear meniscus M. Tear film reflectivity and regularity N. Corneal topography O.Videokeratoscopy P. Interferometry (tear lipid layer analysis) Q.Aberrometry R. Noncontact confocal microscopy 7 8 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2015 Subspecialty Day | Refractive Surgery Preop IOL Calculations and Challenging Cases Mitchell P Weikert MD I.Goals A. Accurate biometry 1. Axial length (AL) b. Holladay 2 c. Barrett Universal II d.Olsen a. Critical for accurate IOL calculations b. 1-mm error in AL ~ 2-3 D error in IOL power ~ 1.3-2.0 D refractive error e. Haigis, Holladay 2, and Barrett Universal II formulas are also based on vergence formula. c. Optical biometry preferred over ultrasoundbased measurements f. Haigis ELP calculation has no dependence upon K. g. Olsen formula uses ray tracing. d. Intereye asymmetry typically < 0.1-0.2 mm e. However, asymmetry may be > 0.3 mm in 24% (increases with increasing axial length). f. If asymmetry > 0.2 mm, explain (eg, scleral buckle) and/or repeat measurements. 3. Primarily dictated by axial length a. Also critical for accurate IOL calculations b. 1-mm error in K ~ 0.9 D error in IOL power ~ 0.6 D refractive error c. Formulas developed with manual keratometry (anterior surface measurements only) d. Automated keratometry more commonly used e. Corneal topography/tomography recommended in all cases ii. Quantitative analysis after corneal alteration f. Serves 2 roles in most formulas: calculation of IOL power and effective lens position (ELP) a. Holladay 1 b.SRK/T c.Hoffer-Q d. All based on vergence formula (Binkhorst formula) e. Calculation of ELP varies, but all depend upon AL and K. 2. Fourth-generation formulas a.Haigis i. Holladay 1 (optimized) ii. SRK/T (optimized) iii. Barrett Universal II c. Short eyes (AL < 22 mm) i.Olsen ii.Hoffer-Q iii.Haigis 1. Potential sources of prediction error (% error attributable to them)1 a. ELP (36%) b. Postoperative refraction (27%) c. Axial length (17%) d. Keratometry (11%) e. Pupil size (8%) 1. Third-generation formulas C. Calculation error minimization B. Optimal formula choice i. Holladay 1 b. Long eyes (AL ≥ 26 mm) i. Qualitative analysis of astigmatism (location, regularity) 3. Other variables: preoperative anterior chamber depth (ACD), lens thickness, retinal thickness a. Normal eyes (22 mm ≤ AL < 26 mm) 2. Keratometry (K) 2. What can we control? a. Quality of measurements b. Quality of postoperative refraction 3. What can’t we control? a. ELP calculation (except via formula choice) and limits of current models b. Limits of measurement accuracy (K accuracy < AL accuracy) 4. Recognize limits and counsel patients accordingly. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery 9 Table 1. Comparison of Holladay 1, SRK/T, and Haigis Formulas With Adjusted AL to Olsen and Barrett Universal II (n = 226 eyes)3 Formula Mean RPE (D) ± SD Postop SE ± 0.5 D (% eyes) Postop Hyperopia (%) Holladay 1 optimized AL -0.07 ± 0.47 73.9 46 SRK/T optimized AL -0.01 ± 0.51 73.5 50 Haigis optimized AL -0.14 ± 0.47 72.6 35 Olsen +0.23 ± 0.48 68.6 71 Barrett Universal II +0.16 ± 0.46 74.3 64 II. Challenging Cases 3. Comparison of formulas that use the ΔMR achieved with LASIK/PRK (n = 28 eyes):7 Optimal single formula A. Long eyes 1. Prone to hyperopic errors 2. Wang-Koch AL adjustment2 a. Holladay 1: ALadj = (0.8289 * AL) + 4.2663 b. SRK/T: ALadj = (0.8544 * AL) + 3.7222 c. Haigis: ALadj = (0.9286 * AL) + 1.5620 B. Short eyes 1. Prone to myopic errors 2. Comparison #1: Formulas for eyes < 22 mm (n = 163 eyes)4 a. Haigis vs. Hoffer-Q vs. SRK/T vs. Holladay 1 b. Haigis performed best: MAE = 0.50, eyes ±0.5 D = 61%, eyes ±1.0 D = 88% a. Haigis vs. Hoffer-Q vs. SRK/T vs. Holladay 1 b. Haigis performed best: MAE = 0.43, eyes ±0.5 D = 72%, eyes ±1.0 D = 93% a. Modified Masket: median RPE = 0.32 D, eyes ±0.5 D = 64%, eyes ±1.0 D = 93% b. Barrett True-K: median RPE = 0.33 D, Eyes ±0.5 D = 68%, eyes ±1.0 D = 89% D.Astigmatism 1. Posterior cornea8 3. Comparison #2: Formulas for eyes < 22 mm (n = 69 eyes)5 a. Anterior corneal steep meridian transitions from vertical to horizontal with age (ie, patients transition from with-the-rule [WTR] to against-the-rule [ATR] astigmatism). b. Posterior corneal steep meridian remains vertical with age for the vast majority of patients (equivalent to ATR astigmatism since the posterior cornea has negative power). c. Astigmatism magnitudes based entirely on the anterior corneal surface may overestimate astigmatism in WTR eyes and underestimate in ATR eyes. 2. Astigmatism assessment is best accomplished by factoring in measurements obtained with a combination of automated keratometry, corneal topography, and corneal tomography. 3.Recommendations 4. Olsen formula (ELP based on preoperative ACD and lens thickness) C. Post-corneal refractive surgery 1. ASCRS Post-Refractive IOL Calculator updates (post-myopic LASIK/PRK) a. Removal of formulas based on pre-LASIK/ PRK Ks and ΔMR achieved with LASIK/PRK (poor performance)5 b. Addition of OCT and Barrett True-K formulas 2. Comparison of formulas that use no pre-LASIK/ PRK data (n = 104 eyes)6 a. Optimal single formula—OCT: median RPE = 0.35 D, eyes ±0.5 D = 68%, eyes ±1.0 D = 92% b. Optimal formula combination—Avg OCT/ Barrett True-K/Haigis: median RPE = 0.31 D, eyes ±0.5 D = 65%, eyes ±1.0 D = 95% a. Account for posterior corneal ATR astigmatism – 0.5 D in WTR corneas, 0.3 D in ATR corneas b. Account for ATR shift with age (approx. 0.37 D per decade): OK to flip axis to WTR a small amount c. Factor in your surgically induced astigmatism (SIA) d. Account for lens effectivity: greater IOL toric effect in short eyes (with higher IOL power) and less in long eyes (with lower IOL power). e. Measure posterior corneal astigmatism and intraoperative aberrometry, when possible. 10 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 4. Tools available to maximize toric IOL selection and alignment a.Planners i. Baylor Nomogram ii. Barrett Toric Calculator (ASCRS.org) iii. Holladay Toric Planner iv. Manufacturer toric calculators i. Intraoperative aberrometry (ORA and Holos) ii.Verion iii. True Vision iv.Calisto E. First eye surprise (time permitting)9: Apply half the prediction error of the first eye to the calculations and IOL selection for the second eye. b. Intraoperative measurement and alignment F. Keratoconus (time permitting) 1. Prone to hyperopic errors 2. Most likely etiologies a. Poor assessment of posterior corneal contribution to total corneal power b. Poor estimate of ELP III.Conclusions A. Patient expectations are extremely high. B. Even the simplest IOL calculation cases are not always simple. C. Meticulous attention to detail should be present in all steps of biometry and IOL selection. D. Include a quick discussion of the limitations of biometry and IOL calculations in your consent. 2015 Subspecialty Day | Refractive Surgery References 1. Norrby S. Sources of error in intraocular lens power calculation. J Cataract Refract Surg. 2008; 43:368-376. 2. Wang L, et al. Optimizing intraocular lens power calculations in eyes with axial lengths above 25.0 mm. J Cataract Refract Surg. 2011; 37:2018-2027. 3. Day AC, et al. Accuracy of intraocular lens power calculations in eyes with axial length < 22.0 mm. Clin Exp Ophthalmol. 2012; 40:855-862. 4. Eom Y, et al. Comparison of Hoffer Q and Haigis formulae for intraocular lens power calculation according to the anterior chamber depth in short eyes. Am J Ophthalmol. 2014; 157:818-824. 5. In-house data. 6. In-house data. 7. Koch DD, et al. Contribution of posterior corneal astigmatism to total corneal astigmatism. J Cataract Refract Surg. 2012; 38:20802087. 8. Gorodezky L, et al. Influence of the prediction error of the first eye undergoing cataract surgery on the refractive outcome of the fellow eye. Clin Ophthalmol. 2014; 8:2177-2181. 9. Weikert MP, et al. Evaluation of methods to improve the accuracy of IOL calculations in long eyes. Presented at the Annual Meeting of the American Society of Cataract and Refractive Surgery; 2014. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery 11 Intraoperative IOL and Astigmatism Diagnostics Robert J Weinstock MD Intraoperative diagnostics that are available today fall into two categories. The first are those that measure the eye during surgery, and the second are those that provide visual guidance during surgery. Intraoperative Aberrometry ORA (Alcon), Holos (Clarity) Intraoperative aberrometry uses wavefront technology on equipment attached to the microscope during surgery. These systems can be used in the aphakic eye during surgery, after cortex removal, in order to provide another measurement for IOL selection. It is important that the cornea is adequately lubricated and the eye is normotensive at the time the measurements are taken. Combining the measurements taken with preoperative corneal measurements already within the system, a table with IOL powers and estimated postoperative refractions is generated. These systems can also be used to take pseudophakic refractions at the end of the case, helping to aid in the decision if proper IOL power was selected. In toric IOL cases, aberrometry can aid in axis rotation. In cases with limbal relaxing incision (LRI) placement, it can also be used after lens insertion to titrate the manual or laser created incisions. Image Guidance Systems Verion (Alcon), Callisto (Zeiss), TrueVision (TrueVision 3D Surgical), Spectrus (Bausch + Lomb) Image guidance systems can be very useful for intraoperative guidance during cataract surgery cases. These devices can allow for image overlays in real time, either through the oculars of the microscope or on a separate 3-D screen. They can be useful for corneal incision placement, LRI placement, and toric IOL axis placement. Some systems allow for integration of preoperative images, allowing for reduction of cyclotorsion error during the procedure. These systems make it much faster, easier, and more precise to place LRIs and toric IOLs. 12 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2015 Subspecialty Day | Refractive Surgery How to Design a Universal IOL Calculator Samir I Sayegh MD PhD Purpose To present the design principles of a universal IOL calculator capable of simultaneously handling spherical, toric, and postrefractive surgery cases. Methods IOL power calculation methods (eg, SRK/T, Hoffer Q, etc.) are coupled to toric IOL and post-refractive computational methods, LRI nomograms and associated to a comprehensive database including both spherical and toric IOLs produced by a majority of lens manufacturers. Results A smooth fusion of computational tools allows for the efficiency of integrated IOL calculations and the benefit of optimal solutions where the traditional sequential sphere-then-cylinder approach may yield suboptimal ones, in particular for toric IOLs. Conclusion Solid design principles allow for the emergence of a new generation of universal IOL calculators. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery Scheimpflug Analysis of Patients With Highly Asymmetric Keratoconus J Bradley Randleman MD, Song Woo Kim MD, Heather M Weissman MD Purpose To evaluate Scheimpflug measurements in distinguishing highly asymmetric keratoconus from normal corneas. Methods Comparative analysis of Pentacam HR analysis of the forme fruste eye of 20 patients and 100 eyes from 50 normal controls, including keratoconus indices (IHD) and thickness measurements: central corneal thickness (CCT), superior-inferior difference (SI), superonasal-inferotemporal difference (SN-IT), ARTMax, and the BAD-D score. Results Thickness indices performed poorly at distinguishing the groups. ROC area under the curve values were CCT, 0.28; S-I, 0.67; SN-IT, 0.63; IHD, 0.63; and BAD-D score, 0.86. Conclusion Highly asymmetric keratoconus eyes were thinner than normal corneas but otherwise difficult to distinguish using Scheimpflug imaging. The combined ARTMax and BAD-D metric failed to identify 40% of forme fruste eyes. 13 14 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2015 Subspecialty Day | Refractive Surgery Ectasia Detection: Scheimpflug Tomography Is the Most Accurate Renato Ambrósio Jr MD I.Introduction A. Progressive “iatrogenic” keratectasia occurs due to a biomechanical failure of the corneal stroma to support the unremitting stresses caused by IOP, extraocular muscle actions, eyelid blinking, and other forces such as eye rubbing,1,2 causing thinning and protrusion of the cornea.3,4 II. Defining Ectasia Susceptibility: What Are We Screening For? A. Identifying cases at high risk of or susceptibility to biomechanical failure after laser vision correction (LVC) represents a major challenge for refractive surgeons.9 B. Screening is defined as the application of a diagnostic test to detect cases with mild to moderate disease or with high susceptibility or predisposition for developing disease.6 It is typically applied to prevent suffering and morbidity, when treatment decisions can best alter the natural course for the patient. C. Placido disc-based corneal topography is sensitive enough to detect abnormal front curvature patterns of ectatic disease in patients with relatively normal distance corrected visual acuity and unremarkable biomicroscopy.4,6,10 Corneal topography and central corneal thickness (CCT) have a recognized role in screening refractive candidates.10 D. The Ectasia Risk Scoring System (ERSS), developed by Randleman and coworkers, found abnormal topography as the most important risk factor for ectasia development.5 ERSS also considers the level of refractive correction, residual stromal bed (RSB), and patient’s age along with corneal topography and CCT. E. There is significant interobserver variability in subjective classifications of corneal topography maps.11 Also, changing from an absolute to a normative scale increased the scores on the classifications by the same examiner, with significant intraobserver variability.11 F. Objective quantitative indices, such as the classic Rabinowitz inferior-superior dioptric asymmetry value (I-S) and the keratoconus percentage index (KISA), and qualitative pattern of asymmetric bowtie with skewed radial axes (AB/SRAX), should be considered.4 B. Risk factors for ectasia are related to 3 factors: 1. Preoperative structural abnormalities such as keratoconus (clinical or subclinical),4,5 including cases with higher susceptibility of the cornea due to weak innate biomechanical properties,6 2. Severe biomechanical impact from surgery,5,7 and 3. Severe trauma after surgery, such as vigorous eye rubbing in response to allergic conjunctivitis, to cause (possibly unilaterally) post-LASIK keratectasia without other known predisposing risk factors.2 C. Since the first report from Prof. Seiler,8 the hypothesis that post-LASIK ectasia occurred due to the structural impact from the procedure on a cornea with altered biomechanical properties was pondered. D. Thereby, understanding current diagnostic technology for characterizing the cornea preoperatively is a fundamental pillar for assessing ectasia risk prior to refractive surgery. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery G. However, a major fundamental concept is that normal topography does not exclude mild or early ectatic corneal disease.6,9,12-15 There is a fundamental need to recognize subclinical cases with normal topography, such as those from patients with keratoconus in the fellow eye (see Figure 1). J. Analysis of the preoperative status of cases of ectasia after LASIK without identifiable risk factors (see Clinical Example 2 below) are considered the ideal population to train and test clinical tests for screening ectasia risk.20,21 These cases, when a thick flap or excessive tissue ablation are excluded, represent the closest to the ideal population for the studies involving screening for ectasia risk. In fact, the analysis of the preoperative data from these cases has provided the most important advances in the field.5,6,21,22 Many of the reported cases, however, had limited preoperative data on front surface curvature and CCT, which restricts their study potential.6 K. A major concept is that any cornea can undergo ectasia progression if there is enough disturbance from surgery and/or by other environmental factors, such as ocular trauma and eye rubbing.2,6 L. The goal, therefore, is not solely to detect or screen for mild or subclinical keratoconus but to lengthily assess an individual’s susceptibility to ectasia progression, which also depends on the biomechanical impact from the LVC procedure.6,12 Figure 1. Scheimpflug (A and B) and Placido-disk based (Oculus Keratograph 5; C and D) curvature maps from a female patient, 50 years old, presenting with very asymmetric keratoconus. O.D. has mild keratoconus, while O.S. has a normal curvature map. Note the similarity of the generated maps from these different technologies. Uncorrected distance visual acuity was 20/200 in both eyes; MRx was -0.75 = -2.25 x 81°, giving 20/25 in O.D. and -2.00 = 0.50 x 115°, giving 20/20 in O.S. (see Figure 2). H. While these cases have been considered to demonstrate enhanced accuracy of corneal tomography,9,12,14-18 they do not represent the ideal study population for assessing high susceptibility to or predisposition for ectasia progression. This is because some of these patients may truly have unilateral ectatic disease14-16 due to unilateral stimuli such as chronic eye rubbing.2 I. These cases have been referred to as forme fruste keratoconus (FFKC), which may not be an ideal term. FFKC was originally described by Prof. Marc Amsler (1891-1961) based on reflection Placidodisk photography, prior to the development of computerized corneal imaging technologies. FFKC was used to describe an abortive form of the disease that may progress or may not.4,14,19 Only longitudinal follow-up studies are able to elucidate such cases. 15 III. Defining Advanced Corneal Analysis Beyond Curvature A. “Corneal tomography” provides a 3-D reconstruction of the corneal shape, enabling the calculation of elevation maps of the front and back surfaces of the cornea, along with pachymetric mapping.12,14 B. Epithelial thickness mapping by “segmental tomography” using OCT23 and very-high frequency ultrasound24 may provide additional information for ectasia risk detection. C. Scheimpflug imaging 1. The Scheimpflug principle is a geometric rule commonly used in photography that was first described in 1901 by Jules Carpentier, who was cited and credited in the original patent by Theodor Scheimpflug in 1904.14 In this technique, three imaginary planes—the film plane, the lens plane, and the plane of sharp focus—are disposed in a nonparallel manner to extend the depth of focus. 2. The Orbscan slit scanning, or parallelepiped corneal tomography, system uses the projection of 40 slits (12.50-mm high and 0.30-mm wide) at a Scheimpflug angle of 45 degrees.14 However, there are advantages of a rotating Scheimpflug system, the method used by the more modern systems.25,26 3. Scheimpflug rotating tomography is the method that provides most clinically useful information for screening ectasia risk.13,14 16 Section I: Roll the Dice—New Diagnostics in Refractive Surgery IV. Interpretation of Clinical Data A. Corneal elevation maps dependent on the reference surface26 B. The method of depicting the elevation is the subtraction of the measured surface (either front or back) and a reference shape, which is calculated to have the highest coincident points to a determined area of the cornea that was analyzed. C. Best-fit sphere (BFS) to the 8-mm zone has been recommended, as it provides adequate data points without the need to use extrapolated data for the majority of cases.13,14 D. The map patterns, the elevation values at the thinnest point and at maximum elevation within central 4-5 mm zone, are the most important characteristics for clinical interpretation.13,14 Different reference shapes, such as the best-fit toric and aspheric ellipsoid (BFTA or BFTE), may be used.18 E. Using the Pentacam, the cut-off criteria for the posterior elevation value at the thinnest point was 12 µm using the BFS and 8 µm using the BFTE, with respective sensitivity of 96.28% and 95.04% and specificity of 98.79% and 99.09% for detecting keratoconus.14 Using the Galilei Analyzer (Ziemer Ophthalmic Systems AG; Port, Switzerland), the cut-off values for maximum posterior elevation within the central 5-mm diameter obtained by BFTA were 16 μm and 13 μm for keratoconus and mild (forme fruste) keratoconus, respectively, with sensitivities of 99% and 82%.18 F. The concept of an enhanced elevation has been introduced and implemented on the Pentacam.13,14 After calculating the standard BFS for the 8-mm corneal zone, a second “enhanced” best-fit sphere for the same zone excluding the 3.5-mm diameter zone centered at the thinnest point is calculated. The difference map from the standard and enhanced BFS will exaggerate any differences (protrusions) within the excluded zone. More than 5 μm of difference for the front elevation and 12 μm difference for the back elevation are considered suspicious.9,13,14 Changes in posterior corneal elevation have been studied to document long-term stability after LASIK, so that using the same BFS for the preoperative corneal information, less than 7 µm on the maximal difference in the central 4.0-mm zone was found on stable LASIK cases.27 G. Corneal thickness maps enable the characterization of the thinnest point value and its location, along with thickness distribution.9,13,14 H. The thinnest point (TP) is a more accurate para meter than central thickness for screening ectatic corneal diseases,9,13,14,19 as well as for calculating the PTA and RSB.6,9 2015 Subspecialty Day | Refractive Surgery I. In the Pentacam, thickness distribution is described as the average of thickness values in concentric annular circles with increasing diameters centered on the TP. These values are presented in the corneal thickness spatial profile (CTSP) and the percentage of thickness increase (PTI) graphs, which also contain reference data (mean and 95% confidence intervals) from a normal population.9,13,14 In addition, a pachymetric progression index (PPI) is calculated for every 1 degree of meridians of the cornea, starting from the thinnest point outward. This calculation considers the increase in thickness and comparing to the TP at each point of the cornea, referencing to a normal population. The Ambrósio relational thickness (ART) values are calculated as the ratios of the TP and the average of the PPI at all meridians (ART-Ave) and the meridian with maximal PPI (ART-Max).9,14 The cut-off criteria for ART-Ave for clinical and mild (FFKC) keratoconus were, respectively, 474 μm and 521 μm, with sensitivity and specificity of 99.59% and 98.19% for keratoconus and 91.49% and 93.05% for FFKC. For ART-Max, 386 μm and 416 μm were the cutoffs, which had, respectively, sensitivity and specificity of 99.17% and 97.28% for keratoconus and 85.11% and 93.05% for subclinical disease.14 V. The Belin/Ambrósio Enhanced Ectasia Display A. The Pentacam Belin/Ambrósio Enhanced Ectasia Display (BAD) is a comprehensive display that combines the standard and enhanced BFS elevation maps of the front and back surfaces, and the thickness distribution data. Different tomographic parameters are presented as the standard deviation from normality towards disease (d values): anterior and posterior elevation at the thinnest point (8 mm BFS), change in anterior and posterior elevation of the standard and enhanced BFS, thinnest value and location, PPI, ART and maximal curvature (K-max). The BAD-D final parameter is calculated based on a regression analysis to maximize accuracy for detecting ectatic disease.9,13,14 B. BAD-D higher than 2.11 was a criteria with sensitivity and specificity of 99.59% and 100% for diagnosing keratoconus, while for detecting mild or subclinical disease the criteria of higher than 1.22 provided 93.62% sensitivity and 94.56% specificity.14 Interestingly, in a retrospective nonrandomized study involving preoperative LASIK data from an international pool comprised of 23 post-LASIK ectasia cases and from 266 stable-LASIK with over 1 year of follow-up, the criteria of BAD-D higher than 1.29 provided 87% sensitivity and 92.1% specificity.22 Even though the BAD-D was the most accurate parameter in predicting ectasia risk, these data support the need to integrate other variables. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery 17 Figure 2. Belin/Ambrósio Enhanced Ectasia Display (BAD) from the left eye with FFKC (same case as Figure 1). VI. Enhanced Screening for Ectasia Susceptibility A. An enhanced screening approach for the prevention of keratectasia should consider preoperative corneal data to estimate ectasia susceptibility and procedure-related parameters. While it may be a challenging and complex task for the clinician to combine the data from different sources, artificial intelligence techniques such as neural network (NN), decision tree (DT), and regression analysis have been used to facilitate clinical decisions. 6,12,17,19,22 B. In a retrospective case-control study, 177 normal eyes were compared to 148 eyes with clinical keratoconus and to 47 eyes with normal topography from 47 patients with clinical keratoconus in the fellow eye using the Galilei. Fifty-five parameters were analyzed so that a machine learning algorithm was created using a DT approach. Two machine learning algorithms were created using automated decision tree classifier. The one for the discrimination between normals and keratoconus had 100% sensitivity and 99.5% specificity. The one developed for discriminating between normals and mild (subclinical) keratoconus had 93.6% sensitivity and 97.2% specificity.17 However, it is fundamental to validate such approaches in a new set of cases. In another study, a combination of corneal topography (inferior-superior [I-S] value) and minimum pachymetry from OCT was statistically the most significant in separating the ectatic from normal eyes.19 18 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2015 Subspecialty Day | Refractive Surgery Figure 3. Curvature maps from the postop and the preop femto-assisted LASIK of a female patient (32 years old, MRx: -5.75 -0.50 x 95º [20/20]), along with subtraction maps. C. Example Case 2 D. The Ectasia Susceptibility Score (ESS-I) was created based on the preoperative clinical and corneal tomography data from 23 cases that developed ectasia after LASIK and from 266 stable-LASIK with over 1 year of follow-up.22 The regression formula combining BAD-D, age, and RSB was calculated. The cut-off of 0.068 (6.8% of relative risk) provided 100% sensitivity and 94% specificity, with better area under the receiver operating characteristic (ROC) curve (AUC = 0.989; 95% CI, 0.969 to 0.998) than all parameters, including the BAD-D (AUC = 0.931; CI, 0.895 to 0.957; De Long, P > .001).22 Thereby, the ESS-I enables the calculation of the relative risk of developing ectasia accordingly to the BAD-D, age, and RSB. The logarithmic function leads to a binary outcome from 0 to 1, which represents the relative risk for ectasia. For example, a patient who is 21 years old and with BAD-D of 0.9 would be at high risk of ectasia (24%) with 350 µm of RSB. But a patient who is 21 years old, with BAD-D of 0.2 and RSB of 350 µm, would be at low risk (3%). Also, a patient who is 42 years old and with BAD-D of 0.9 would have low ectasia risk (1%) with RSB of 350.22 E. Validation studies and further improvement for the conception of the Enhanced Ectasia Susceptibility Score (EESS) are currently being performed, including a larger set of 60 cases of ectasia with preoperative corneal tomography data (Ramos et al. Poster. ESCRS 2014). VII. Conclusion and Future Remarks A. Currently, Scheimpflug corneal tomography provides the most advanced and accurate method for screening ectasia risk prior to LVC. B. Long-term stability after LVC is determined by a combination of the preoperative corneal biomechanical structure and the alteration caused by the surgery, along with postoperative stress load to the cornea. C. Young age and low preoperative thickness are surrogates for corneal biomechanical properties, presenting as important risk factors for keratectasia. However, the advent of corneal biomechanical parameters may exclude these factors in artificial intelligence techniques, such as regression analysis. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery 19 Figure 4. Preoperative Belin/Ambrósio Enhanced Ectasia Display (BAD) from the left eye (same case as Figure 3). D. Considering that keratectasia occurs due to a combination of preoperative predisposition or susceptibility of the patient’s cornea and the impact from surgery on corneal structure, future screening approaches for detecting ectasia risk should consider a combination of patient-related data and procedure-related parameters. Simulation analysis and artificial intelligence strategies will play a significant role. References 1. Dupps WJ Jr, Wilson SE. Biomechanics and wound healing in the cornea. Exp Eye Res. 2006; 83(4):709-720. 2. Padmanabhan P, Aiswaryah R, Abinaya Priya V. Post-LASIK keratectasia triggered by eye rubbing and treated with topographyguided ablation and collagen cross-linking: a case report. Cornea 2012; 31(5):575-580. 3. Binder PS. Ectasia after laser in situ keratomileusis. J Cataract Refract Surg. 2003; 29(12):2419-2429. 6. Ambrosio R Jr, Randleman JB. Screening for ectasia risk: what are we screening for and how should we screen for it? J Refract Surg. 2013; 29(4):230-232. 7. Santhiago MR, Smadja D, Gomes BF, et al. Association between the percent tissue altered and post-laser in situ keratomileusis ectasia in eyes with normal preoperative topography. Am J Ophthalmol. 2014; 158(1):87-95 e81. 8. Seiler T, Quurke AW. Iatrogenic keratectasia after LASIK in a case of forme fruste keratoconus. J Cataract Refract Surg. 1998; 24(7):1007-1009. 9. Ambrosio R Jr, Nogueira LP, Caldas DL, et al. Evaluation of corneal shape and biomechanics before LASIK. Int Ophthalmol Clin. 2011; 51(2):11-38. 10. Ambrosio R Jr, Klyce SD, Wilson SE. Corneal topographic and pachymetric screening of keratorefractive patients. J Refract Surg. 2003; 19(1):24-29. 11. Ramos IC, Correa R, Guerra FP, et al. Variability of subjective classifications of corneal topography maps from LASIK candidates. J Refract Surg. 2013; 29(11):770-775. 4. Binder PS, Lindstrom RL, Stulting RD, et al. Keratoconus and corneal ectasia after LASIK. J Refract Surg. 2005; 21(6):749-752. 12. Saad A, Gatinel D. Topographic and tomographic properties of forme fruste keratoconus corneas. Invest Ophthalmol Vis Sci. 2010; 51(11):5546-5555. 5. Randleman JB, Trattler WB, Stulting RD. Validation of the Ectasia Risk Score System for preoperative laser in situ keratomileusis screening. Am J Ophthalmol. 2008; 145(5):813-818. 13. Belin MW, Ambrosio R. Scheimpflug imaging for keratoconus and ectatic disease. Indian J Ophthalmol. 2013; 61(8):401-406. 20 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2015 Subspecialty Day | Refractive Surgery 14. Ambrosio R Jr, Valbon BF, Faria-Correia F, Ramos I, Luz A. Scheimpflug imaging for laser refractive surgery. Curr Opin Ophthalmol. 2013; 24(4):310-320. 21. Buhren J, Schaffeler T, Kohnen T. Preoperative topographic characteristics of eyes that developed postoperative LASIK keratectasia. J Refract Surg. 2013; 29(8):540-549. 15. Ruisenor Vazquez PR, Galletti JD, Minguez N, et al. Pentacam Scheimpflug tomography findings in topographically normal patients and subclinical keratoconus cases. Am J Ophthalmol. 2014; 158(1):32-40 e32. 22. Ambrósio R Jr, Ramos I, Lopes B, et al. Assessing ectasia susceptibility prior to LASIK: the role of age and residual stromal bed (RSB) in conjunction to Belin-Ambrósio deviation index (BAD-D). Revista Brasileira de Oftalmologia. 2014; 73:75-80. 16. Bae GH, Kim JR, Kim CH, Lim DH, Chung ES, Chung TY. Corneal topographic and tomographic analysis of fellow eyes in unilateral keratoconus patients using Pentacam. Am J Ophthalmol. 2014; 157(1):103-109 e101. 23. Li Y, Tan O, Brass R, Weiss JL, Huang D. Corneal epithelial thickness mapping by Fourier-domain optical coherence tomography in normal and keratoconic eyes. Ophthalmology 2012; 119(12):24252433. 17. Smadja D, Touboul D, Cohen A, et al. Detection of subclinical keratoconus using an automated decision tree classification. Am J Ophthalmol. 2013; 156(2):237-246 e231. 24. Reinstein DZ, Archer TJ, Gobbe M. Stability of LASIK in topographically suspect keratoconus confirmed non-keratoconic by Artemis VHF digital ultrasound epithelial thickness mapping: 1-year follow-up. J Refract Surg. 2009; 25(7):569-577. 18. Smadja D, Santhiago MR, Mello GR, Krueger RR, Colin J, Touboul D. Influence of the reference surface shape for discriminating between normal corneas, subclinical keratoconus, and keratoconus. J Refract Surg. 2013; 29(4):274-281. 19. Rabinowitz YS, Li X, Canedo AL, Ambrosio R Jr, Bykhovskaya Y. Optical coherence tomography combined with videokeratography to differentiate mild keratoconus subtypes. J Refract Surg. 2014; 30(2):80-87. 20. Ambrosio R Jr, Dawson DG, Salomao M, Guerra FP, Caiado AL, Belin MW. Corneal ectasia after LASIK despite low preoperative risk: tomographic and biomechanical findings in the unoperated, stable, fellow eye. J Refract Surg. 2010; 26(11):906-911. 25. Ambrosio R Jr, Belin MW. Imaging of the cornea: topography vs tomography. J Refract Surg. 2010; 26(11):847-849. 26. Belin MW, Khachikian SS. An introduction to understanding elevation-based topography: how elevation data are displayed—a review. Clin Experiment Ophthalmol. 2009; 37(1):14-29. 27. Ciolino JB, Khachikian SS, Cortese MJ, Belin MW. Long-term stability of the posterior cornea after laser in situ keratomileusis. J Cataract Refract Surg. 2007; 33(8):1366-1370. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery 21 Ectasia Detection: Placido and Other Reflection Topography Is the Most Accurate Jonathan H Talamo MD I. A more appropriate title for this talk would be “Placido and Other Reflection Topography Is an Essential Adjunct to Accurate Ectasia Detection.” II.Advantages A. Longest track record B. Widest availability C. Highly reproducible D. Reflection data directly measure corneal power; other technologies do this as derivative of elevation data (Scheimpflug, OCT). E. Copious literature: Sentinel diagnostic features are universally well recognized. 1. Easy to assess image quality (influence of tear film, ocular surface pathology) Figure 1. Case example from my practice: 20-year-old white male with visual acuity loss O.S. over 2 years prior. Topo shows clear-cut inferior corneal steepening. 2. Qualitative pattern recognition well known to all levels of providers (ODs, ophthalmologists of all levels of training) a. Inferior steepening b. Non-orthogonal (“skewed bowtie”) astigmatism c. “Crab-claw” bowtie astigmatism (pellucid marginal degeneration) 3. Quantitative indices well established: Rabinowitz/McDonnell1, Maeda/Klyce, Rabinowitz/ Rasheed’s KISA%.2 F. Contrary to popular belief, there are cases of early ectasia diagnosed by Placido-based topography that are missed or at least much less obvious using Scheimpflug-generated tomographic indices.3 I opine that this is rare, but having dual modalities helps to clinch a diagnosis, as demonstrated in Figures 1-3. Figure 2. Pattern analysis of corneal power distribution shows suspicion of KC. 22 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2015 Subspecialty Day | Refractive Surgery Figure 3. Scheimpflug indices are equivocal: elevation and thickness pattern distribution appears normal or at least much less obvious than power distribution maps with topography, with relative elevation and secondarily derived K-max upper limit of normal (shaded boxes). III.Disadvantages References A. No elevation data 1. Rabinowitz YS. Keratoconus. Surv Ophthalmol. 1998; 42:297-319. B. No pachymetry data C. Abnormalities of both of these metrics may allow detection of early ectasia in some instances despite the absence of Placido / reflection-based abnormalities. 2. Rabinowitz YS, Rasheed K. KISA% index: a quantitative videokeratography algorithm embodying minimal topographic criteria for diagnosing keratoconus. J Cataract Refract Surg. 1999; 25:13271335. 3. Ruiseñor Vázquez PR, Galletti JD, Minguez N, et al. Pentacam Scheimpflug tomography findings in topographically normal patients and subclinical keratoconus cases. Am J Ophthalmol. 2014; 158(1):32-40. 4. Matalia H, Swarup R. Imaging modalities in keratoconus. Indian J Ophthalmol. 2013; 61(8):394-400. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery Ectasia Detection: Anterior-Segment OCT Is the Most Accurate George Asimellis PhD There is an increasing awareness pertaining to epithelial thickness characteristics in keratoconus (KCN). Specifically, overall corneal epithelial thickness, as well as epithelial thickness topographic variability, may serve as diagnostic elements, in synergy with other topographic and Scheimpflug tomographic screening indicators such as irregular corneal thickness and anterior surface topographic variability. In addition, the corneal epithelial layer thickness distribution can be very useful in clinical as well as in basic research. We have introduced and reported a potentially novel epithelial clinical indicator for biomechanical corneal instability in keratoconus, as a criterion demonstrating increased overall corneal epithelial thickness. We have thus proposed this simple clinical parameter as an early keratectasia diagnostic marker. Figure 1. Outline I. Corneal Mapping With Anterior Segment OCT (ASOCT): Presentation of Principles and Examples OCT-derived corneal thickness asymmetry indices: clinical reference study of normal eyes. Kanellopoulos AJ, Chiridou M, Asimellis G. J Cataract Refract Surg. 2014; 40(10):1603-1609. A. Corneal thickness asymmetry and focal thinning parameters, measured by detailed pachymetry provided by AS-OCT, have been proposed for the keratoconus and ectasia screening. B. In healthy population studies employing Scheimpflug or high-frequency ultrasonography (HFU), a 23.2-μm apical pachymetry difference is reported to represent less than 5% of the population. C. Clinical investigation of corneal asymmetry and focal thinning in 561 normal eyes with current ASOCT. D. Inferior and inferior-nasal thinning is on the average of 25 μm (95% CI, 1.2); Min-Med index is on the average -21 μm (95% CI, 0.50); Min-Max is on the average of -60 μm (95% CI, 1.4). E. No statistically significant differences between corneal asymmetry exist between gender groups. The corneal asymmetry is increased in older patient groups. Figure 2. 23 24 Section I: Roll the Dice—New Diagnostics in Refractive Surgery II. Epithelial Mapping With AS-OCT: Presentation of Principles and Examples OCT-derived comparison of corneal thickness distribution and asymmetry differences between normal and keratoconic eyes. A Kanellopoulos, G Asimellis. Cornea 2014; 33(12):1274-1281. A. Investigation of distributions of OCT-derived corneal asymmetry and focal thinning parameters in a large pool of keratoconic patients B. Correlation of the OCT indices with Scheimpflugimaging derived keratoconus severity classification and anterior-surface irregularity indices C. The OCT-derived corneal asymmetry and focal thinning indices correlate remarkably with established Scheimpflug imaging-derived anterior-surface irregularity indices for keratoconus and keratoconus severity. Figure 4. Figure 3. 2015 Subspecialty Day | Refractive Surgery 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery III. Normal vs. Ectatic Corneas as Imaged by Corneal and Epithelial Mapping With AS-OCT: Presentation of Clinical Examples In vivo 3-dimensional epithelial imaging of corneal epithelium in normal eyes by anterior segment OCT: a clinical reference study. Kanellopoulos AJ, Asimellis G. Cornea 2013; 32(11):1493-1498. A. Corneal epithelial thickness distribution and topographic thickness variability were clinically investigated with AS-OCT in 373 cases of normal, healthy eyes. B. The epithelial thickness has a near-uniform distribution of approximately 53 μm, ranging between 45 and 60 μm. Epithelial thickness is slightly increased inferiorly. C. Average topographic variability, expressed by the standard deviation of 17 points, of the order of 2 μm. D. Average epithelial thickness range (minimum– maximum) of -8 μm. Figure 5. Figure 6. 25 26 Section I: Roll the Dice—New Diagnostics in Refractive Surgery IV. Correlation between overall epithelial thickness in normal corneas, ectatic and ectatic previously treated with CXL corneas: can overall epithelial thickness become a very early ectasia prognostic factor? Kanellopoulos AJ, Aslanides IM, Asimellis G. Clin Ophthalmol. 2012; 6:789-800. A. Compensatory nature of epithelial distribution in response to anterior stromal surface irregularities B. The epithelium is thinner over the steeper “conic” section in a keratoconic eye and thicker over the flatter areas. C. Overall increase in epithelial thickness, particularly in younger keratoconic patients D. This “reactive” epithelial hypertrophy may precede any of the standard topographic or tomographic cornea findings. 2015 Subspecialty Day | Refractive Surgery V. Anterior segment optical coherence tomographyassisted topographic corneal epithelial thickness distribution imaging of a keratoconus patient. Kanellopoulos AJ, Asimellis G. Case Rep Ophthalmol. 2013; 4(1):74-8. A. Three-dimensional imaging of epithelial thickness had been performed only with HFU system. B. The epithelium is thinner over the steeper “conic” section in a keratoconic eye and thicker over the flatter areas. C. First peer-review published paper on the subject of imaging of keratoconic eye employing the RtVue100 System D. AS-OCT epithelial imaging is easier to use than HFUBM, and increased predictability may be offered by AS-OCT. Figure 7. Figure 8. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery VI. Epithelial Remodeling Following LASIK Longitudinal postoperative LASIK epithelial thickness profile changes in correlation with degree of myopia correction. Kanellopoulos AJ, Asimellis G. J Refract Surg. 2014; 30(3):166-171. A. Epithelial thickness changes have been reported in studies of microkeratome-assisted myopic excimer laser refractive correction. B. The noted central epithelial thickness increase has been associated with refractive regression. C. Epithelial thickness remodeling following LASIK has indicated a slight (average +3 μm) increase in epithelial thickness. D. The increase was not lenticular, but more emphasized in the mid-periphery of 5 mm. E. The noted increase showed a positive correlation to the amount of attempted myopic correction: the larger the myopic correction, and thus, the stromal flattening, the larger the noted epithelial thickness increase. Figure 9. 27 28 Section I: Roll the Dice—New Diagnostics in Refractive Surgery VII. Comparison of Epithelial Remodeling Following LASIK With Concurrent Prophylactic Crosslinking Epithelial remodeling after femtosecond laser-assisted high myopic LASIK: comparison of stand-alone with LASIK combined with prophylactic high-fluence crosslinking. Kanellopoulos AJ, Asimellis G. Cornea 2014; 33(5):463-469. A. Investigation of matched groups of myopic ablation, between a “standard” LASIK treatment and a LASIK treatment with concurrent prophylactic in situ crosslinking, has indicated that there is no further noted increase in epithelial remodeling when the crosslinking is applied. B. These clinical differences observed, despite the possible attribution to the epithelial compensatory response, may not be fully justified with this theory. C. A possible explanation is the reduced epithelial hyperactivity attributed to a biomechanically strengthened cornea due to CXL. Figure 10. 2015 Subspecialty Day | Refractive Surgery 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery VIII. Epithelial Remodeling Following Partial PRK and Crosslinking in Keratoconic Eyes. Epithelial remodeling after partial topography-guided normalization and high-fluence short-duration crosslinking (Athens Protocol): Results up to 1 year. Kanellopoulos AJ, Asimellis G. J Cataract Refract Surg. 2014; 40(10):1597-1602. A. Postoperative epithelial remodeling following partial anterior surface normalization with excimer laser and high-fluence crosslinking, investigated with HFU, results in reduced overall epithelial thickness and topographic variability. B. Novel clinical investigation of large pool of keratoconic eyes subjected to the Athens Protocol procedure, in comparison to untreated keratoconic eyes and a control group of healthy eyes, using clinical, Fourier-domain AS-OCT providing in vivo, 3-dimensional epithelial thickness maps C. Detailed follow-up of the treated eyes up to 1 year confirms previous HFU findings of the overall thinner, as well as smoother, epithelial thickness profile in comparison to untreated keratoconic eyes. IX. OCT corneal epithelial topographic asymmetry as a sensitive diagnostic tool for early and advancing keratoconus. Kanellopoulos AJ, Asimellis G. Clin Ophthalmol. 2014; 8:2277-2287. A. Investigation of distributions of OCT-derived epithelial thickness parameters in a large pool of keratoconic (160) and control (160) patients B. High predictability of measurement in keratoconus patients C. Verification of increased overall epithelial thickness in keratoconic eyes, in comparison to normal, particularly in relation to lower stages of keratoconus D. Increased topographic thickness variability and range has been identified to be in correlation with severity of keratoconus. E. The OCT-derived epithelial topographic thickness variability and epithelial thickness range correlate remarkably with established Scheimpflug imagingderived anterior-surface irregularity indices for keratoconus. Figure 12. Figure 13. Figure 11. 29 30 Section I: Roll the Dice—New Diagnostics in Refractive Surgery 2015 Subspecialty Day | Refractive Surgery Figure 14. Figure 15. X.Summary Clinical in vivo epithelial mapping by AS-OCT is currently in practice and introduces a simple and effective clinical tool for corneal epithelium mapping. The data are very easily obtained, and epithelial thickness parameters are automatically calculated by the system software report. The ease of use and the reliable and predictable measurement as indicated by the low intraindividual repeatability, which was only slightly elevated in the keratoconic group, suggest that epithelial imaging by AS-OCT holds promise for wider clinical application, such as screening of young adults for early keratoconus and, in a much wider perspective, potential candidates for laser cornea refractive surgery. One may wonder what the clinical potential of epithelial thickness measurements might be, and what this technology could accomplish that other imaging technologies in widespread use might not? One reason lies in the fact that the irregular epithelial thickness distribution can “compensate” for underlying irregular stromal distribution and thus may mask topographic and tomographic results, particularly in early-stage keratoconus investigation. We believe, therefore, that epithelial thickness imaging may be extremely helpful in keratoconus investigation by revealing the accentuated stromal irregularities that may not be detected by traditional corneal topography. 2015 Subspecialty Day | Refractive Surgery Section I: Roll the Dice—New Diagnostics in Refractive Surgery US Trends in Refractive Surgery: 2015 ISRS Surgery Richard J Duffey MD NOTES 31 32 Section II: Cornea- and Lens-Based Procedures 2015 Subspecialty Day | Refractive Surgery Excimer Laser Presby Applications: Clinical Examples and Techniques Gustavo Tamayo MD, Claudia Castell MD, Pilar Vargas MD For the surgical correction of presbyopia in the precataract patient, few options are available. Clear lens extraction with IOLs in this group is chosen in only 5% to 9% of the cases in the United States, due to the potential problems associated with a permanent intraocular surgery. A corneal method for correction of presbyopia is then a viable option for “young presbyopes” (patients between 40 years and 55 years of age). Only 2 extraocular surgeries are in use today: corneal inlays and excimer laser surgery. All other extraocular surgeries, such as scleral bands or conductive keratoplasty, are disappearing from the ophthalmology world. Clearly, for excimer surgery there is a space in the surgical correction of presbyopia. Today, we understand much more the role of corneal aberrations in the increase of depth of focus and therefore improvement of presbyopia. Two types of corneal aberrations are in play: spherical aberration and coma. We know today that combination of a positive spherical aberration with a negative spherical aberration increases the depth of focus, just as two negative spherical aberrations. The spherical aberrations combination is shared by other methods of presbyopia correction, such as multifocal IOLs and corneal inlays. Presbyopia excimer laser ablation (PresbyLASIK) utilizes two methods: creating a central zone for near vision (central PresbyLASIK) or leaving the center for distance and creating the zone for near at the periphery of the cornea (peripheral PresbyLASIK). The difference between the two methods is the spherical aberration produced: Central ablation creates a negative spherical aberration in the center of the cornea (Z40) and a positive spherical aberration in the periphery (Z60). Peripheral ablation creates a central positive spherical aberration (Z40) and a negative spherical aberration (Z60). In both cases, the presence of these two aberrations increases the depth of focus and improves the near vision, making the patient less dependent on glasses. Our own results with peripheral PresbyLASIK are as follows: 121 eyes from 66 patients have been followed up for close to 5 years. Mean age is 51 years, with a range between 41 and 67 years. Preoperative sphere is 0.180 ± 2.2 D (-5.0 to +5.0 D). Preoperative cylinder is -0.736 ± 0.97 (-6.5 to 0.0 D). 57.9% of the patients were hyperopic, 31.4% were myopic, and 10.7% were emmetropic. 86.8% were treated in a LASIK format, either with femtosecond or with microkeratome. There was a 9.9% retreatment rate at 1 to 3 months (enhancement surgery). Ninety-four percent of the eyes were 20/30 or better uncorrected for distance and 95% of the eyes were 20/25 or better for near. 100% of the eyes reached 20/25 or better BCVA for distance and near, and no loss of lines of BCVA were detected. When analyzed by refractive defect, myopes behave better with this type of surgery than hyperopes for distance and near. In general, 92% of the patients do not wear glasses under any condition, and all of them will recommend the surgery to a friend. However, 3.2% of the patients do not drive at night due to visual symptoms. The advantages of PresbyLASIK are (1) It is a completely extraocular surgery with no sight-threatening complications. (2) LASIK is a well-known surgery for ophthalmologists and therefore easy and accessible to many of them. The change is the laser software; techniques are similar to any other excimer surgery. (3) Complications of this surgery are very low and easily managed in the postoperative period. Technical improvements predict fewer complications. (4) Excimer laser ablation corrects all types of refractive defects with the precision characteristic of this surgery. This is done at the time of the surgery together with the presbyopia correction. In astigmatism, as is well known, there is no more precise method. (5) Of great importance is the fact that this surgery is completely reversible with a wavefront (CustomVue) ablation. This is a huge difference with intraocular surgery. Of course some disadvantages are present: (1) It is a temporary solution (5 years as a mean), although can be repeated. (2) There is some concern about the presence of a future cataract, but new elevation topography softwares and formula calculations make this problem small at the time of cataract surgery in an already treated eye. (3) Visual symptoms are just as with multifocal lenses; however, they are less severe and usually not permanent. (4) Decrease of contrast sensitivity vision has been reported, as with other types of surgery. This is a temporary problem and studies have shown contrast vision returns to normal limits between 3 and 6 months. In summary: Excimer laser ablation is another viable option for correction of presbyopia, particularly suited for “young presbyopes.” Its advantages surpass the disadvantages and offer a solution to a very big group of patients, willing to improve their quality of life without glasses. 2015 Subspecialty Day | Refractive Surgery Section II: Cornea- and Lens-Based Procedures Customized Excimer Platforms Update Theo Seiler MD PhD The refractive success rate of current LASIK operations for myopia is between 90% and 95%, very close to the precision of refraction itself. Customized wavefront-guided and wavefrontoptimized are approximately equivalent in simple myopia cases. In aberrated eyes the surgeon needs to decide between wavefront-guided and topography-guided customized treatment. Examples as well as success rates dependent on indication will be presented. 33 34 Section II: Cornea- and Lens-Based Procedures 2015 Subspecialty Day | Refractive Surgery Update on Corneal Inlays for Presbyopia Jay S Pepose MD PhD I. History of Corneal Inlays—1949 to the Present C. Flexivue Microlens A. Barraquer: Homoplastic frozen, flint glass, Plexiglas, PMMA 1. Transparent, hydrogel-based, concave-convex disc B. Acrylic, polyethylene 2. Refractive index: 1.4583 C. Dohlman et al: Hydrogels 3. Optically clear copolymer made of hydroxyethyl methacrylate and methyl methacrylate with ultraviolet blocker 4. 3-mm diameter and 15-20 micron thickness, depending on additional power 5. Central 1.8-mm diameter plano; annular peripheral zone has add power ranging from +1.25 to 3.0 D in 0.25-D steps. 6. A central 0.15-mm hole facilitates transfer of oxygen and nutrients. 7. Intracorneal pocket, 280-micron depth II. Demographics of Presbyopia A. Approximately 2 billion presbyopes worldwide B. Greatest number in Europe and eastern Asia C. Approximately 80 million presbyopes between 45 and 60 in the United States III. Four Types of Corneal Inlays A. Kamra (AcuFocus; Irvine, CA) B. Raindrop (Revision Optics; Lake Forest, CA) C. Flexivue Microlens (Presbia Coöperatief U.A.; Irvine, CA) D. Icolens (Neoptics AG; Hünenberg, Switzerland) IV. Design Features V. Mechanism of Action A.Kamra 1. Small aperture (1.6 mm), 3.8-mm diameter, 5 microns thick 2. Polyvinylidine fluoride 3. 3800 microperforations in pseudorandom pattern for transfer of oxygen and nutrients A.Kamra 1. Small aperture optics 2. Small aperture blocks peripheral unfocused light, narrowing blur circle on retina. B.Raindrop 1. Corneal reshaping 2. Alters eye’s refractive power by changing radius of curvature of cornea in region overlying inlay 4. 180- to 200-micron pocket B.Raindrop D. Icolens: Hydrogel microlens 1. Positive meniscus-shaped, diameter of 2 mm, and a central thickness of 32 microns 2.Hydrogel 3. 150- to 160-micron flap C. Flexivue Microlens 1. Refractive optics 2. Corneal multifocality is achieved by changing the refractive power of the cornea. 3. Plano central zone surrounded by rings of increasing add power for intermediate and near D.Icolens 1. Refractive optics 2. Central zone for distance vision and peripheral zone for near Section II: Cornea- and Lens-Based Procedures 2015 Subspecialty Day | Refractive Surgery 35 Intracorneal Rings Segments Review: New and Current Applications Jorge L Alió MD PhD and Alfredo Vega-Estrada MD PhD Intracorneal ring segments (ICRS) implantation is a surgical procedure used as a treatment alternative in patients with keratoconus.1 Small devices made of a synthetic material are inserted deep within the corneal stroma in order to reshape corneal tissue and thus improve the patient’s visual function and tolerance to contact lenses.1 ICRS are one of the so-called corneoplastic techniques that allow surgeons to reshape the cornea for therapeutic and refractive purposes. The use of this technique is relatively recent, as it was introduced in 2000 by Colin et al.2 Intracorneal segments were initially designed for merely refractive purposes for patients not affected with keratoconus; however, this technique is now primarily used to remodel corneal shape in eyes with corneal ectasia.1-5 This reshaping may result in direct improvement by enhancing patients’ visual acuity or in indirect improvement by facilitating contact lens fitting. Types of Intracorneal Segments Nowadays the most commercially available ICRS are the Kera ring (Mediphacos, Ophthalmic Professionals; see Figure 1) and Ferrara rings (AJL Ophthalmic; see Figure 2). These ring segments are made of polymethyl methacrylate (PMMA). Triangular in shape, they are manufactured with different arc lengths and a variable optical zone, ranging between 5 and 7 mm. This allows for treatment to be customized depending on the needs in each case. Segments with shorter arc lengths are intended to reduce astigmatism, while longer arc lengths are effective in reducing keratometry. On the other hand, the MyoRing (Dioptex GmbH; see Figure 3), which is a 360° full ring, has a greater capacity to flatten and reduce the spherical equivalent than segments but does not usually significantly reduce astigmatism, and therefore its use is limited to cases in which patients have a high spherical error and low astigmatism. Figure 2. Ferrara ring. Figure 3. Myoring. Surgical Procedure for ICRS Implantation Figure 1. Keraring. ICRS are implanted by dissecting tunnels in the corneal stroma in one of two ways: either manually or using a femtosecond laser. With the manual technique, the surgeon performs the stromal tunnel creation by using two semicircular dissectors that are rotated in a clockwise and anticlockwise movement to form the channels in the middle of the corneal tissue. The femtosecond laser produces a more precise and controlled stromal dissection than manual dissection. However, when analyzing visual and refractive outcomes, most studies agreed that both techniques showed similar results when treating keratoconus patients.6 For 36 Section II: Cornea- and Lens-Based Procedures ICRS implantation, several nomograms have been proposed as a guide to decide the number, arc length, thickness, and position of the segments in the cornea. The main limitations of these nomograms are that most of them are based on anecdotal clinical data or on variables that are very subjective in keratoconic patients, such as spherocylindrical refraction and topographic pattern of the cone. The main nomograms that are used in clinical practice are those developed by the main manufacturers of ICRS. Results and Indications Several authors have demonstrated the efficacy of this surgical technique in reducing the spherical equivalent and keratometric readings in patients with corneal ecstatic disorders.1-6 In addition, investigations that have analyzed the changes in corneal aberrations have found a reduction in these variables after ICRS implantation, mainly in the coma and coma-like Zernike coefficients.1,7 In spite of the good results reported by most authors regarding the improvement in visual acuity, recently our research team conducted an investigation in which it was observed that the efficacy of ICRS was in relation to the visual limitation of the patients.1 In that study, the outcomes of the surgical procedure were analyzed taking into account a grading system based on the visual acuity of the patients and not the morphology of the cornea. It was found that those patients who benefit the most from the surgical procedure are those with a severe visual impairment before the surgery; on the other hand, those cases with good visual acuity before the procedure are at risk of losing visual acuity lines after ICRS implantation. Another issue that has always been a topic of interest regarding this surgical procedure is the long-term stability of ICRS implantation. Our research group conducted a study in which it was observed that long-term stability of ICRS implantation depends on the progression pattern of keratoconus at the moment of the surgical technique.8 We found that in those cases with the stable form of the disease, ICRS implantation remains without significant changes after a long period of follow-up. However, cases that showed clinical signs of progression at the moment of the intervention presented a significant regression after a long time.9 Based on the different outcomes published in the scientific literature, we should take some preoperative considerations and indications into account in order to increase the likelihood of attaining the best possible postoperative outcomes for the patient: 1. Spectacle corrected visual acuity < 0.9 2. No clinical signs of progression / patients with visual, refractive, and topographic stability, confirmed in the previous 12 months 3. Corneal pachymetry in tunnel area > 300 µm, with these being minimum thicknesses depending on the thickness of each ICRS 4. Absence of corneal leukoma 2015 Subspecialty Day | Refractive Surgery Conclusions ICRS are an effective therapeutic approach in the treatment of keratoconus, able to improve the visual function and the quality of life of patients with keratoconus. However, predictability of the outcomes is still an issue with ICRS. Many factors, and especially the role of biomechanics, influence the results, and future studies are being developed in order to increase the efficacy of this surgical technique in treating corneal ecstatic disorders. References 1. Vega-Estrada A, Alió JL, Brenner LF, et al. Outcomes analysis of intracorneal ring segments for the treatment of keratoconus based on visual, refractive and aberrometric impairment. Am J Ophthalmol. 2013; 155(3):575-584. 2. Colin J, Cochener B, Savary G, Malet F. Correcting keratoconus with intracorneal rings. J Cataract Refract Surg. 2000; 26(8):11171122. 3. Coskunseven E, Kymionis GD, Tsiklis NS, et al. One-year results of intrastromal corneal ring segment implantation (KeraRing) using femtosecond laser in patients with keratoconus. Am J Ophthalmol. 2008; 145(5):775-779. 4. Ertan A, Kamburoglu G. Intacs implantation using femtosecond laser for management of keratoconus: comparison of 306 cases in different stages. J Cataract Refract Surg. 2008; 34(9):1521-1526. 5. Shabayek MH, Alió JL. Intrastromal corneal ring segment implantation by femtosecond laser for keratoconus correction. Ophthalmology 2007; 114(9):1643-1652. 6. Piñero DP, Alio JL. Intracorneal ring segments in ectatic corneal disease—a review. Clin Experiment Ophthalmol. 2010; 38(2):154167. 7. Shabayek MH, Alió JL. Intrastromal corneal ring segment implantation by femtosecond laser for keratoconus correction. Ophthalmology 2007; 114: 1643-1652. 8. Vega-Estrada A, Alio JL, Brenner LF, Burguera-Gimenez N. Outcomes of intracorneal ring segments for the treatment of keratoconus: five years follow up analysis. J Cataract Refract Surg. 2013; 39(8):1234-1240. 9. Vega-Estrada A, Alió JL, Plaza-Puche A. Keratoconus progression following intrastromal corneal ring segments in young patients: five-year follow-up. J Cataract Refract Surg. 2015; 41(6):11451152. Section II: Cornea- and Lens-Based Procedures 2015 Subspecialty Day | Refractive Surgery 37 Monofocal IOLs, Toric IOLs: New and Current Applications Alan N Carlson MD I. Present Toric IOL Options III. Alcon AcrySof Toric IOL 2015 Figure 1. Figure 3. II. Alcon AcrySof Toric IOL 2005 IV. Online Toric IOL Calculators A. AcrySof: www.acrysoftoriccalculator.com/ B. Abbott Medical Optics: https://www.amoeasy.com/ toric C. B+L/Trulign Toric Calculator: https://trulign .toriccalculator.com D. ASCRS/Barrett Toric Calculator: http://www.ascrs .org/barrett-toric-calculator Figure 2. V. Dr. Warren Hill’s “Top 4” Sources for Error A. Preop measurement errors B. Incorrect marking of reference points on the cornea C. Incorrect placement of the IOL D. Failure to take into account the impact of surgically induced astigmatism 38 Section II: Cornea- and Lens-Based Procedures VI. D. Koch: Taking Into Account the Posterior Corneal Contribution to Total Corneal Astigmatism 2015 Subspecialty Day | Refractive Surgery IX. Are Monofocal IOLs Obsolete? A. NanoFlex IOL 1.Predictable 2.Centration 3.Clarity 4.Reflections 5.Dysphotopsia 6.YAG 7. Night vision 1. No “glint” 2.Time X. Indications for a Monofocal IOL A. Matches patient’s expectations B. History of successful monovision C. “…as long as my insurance covers it.” D. Macular degeneration VIII. Toric IOL: When is it not the best option? E. Advanced glaucoma A. Insufficient astigmatism F. Diabetic retinopathy B. Patient decision G. IOL support, previous trauma, etc. C.Economics H. Let’s face it, they work! D. Femtosecond laser correction E. Irregular astigmatism (keratoconus) F. Unable to resolve data with confidence G. IOL support and stability Figure 4. VII. Berdahl & Hardten Toric IOL Calculator B. Lack of glistenings The Toric Results Analyzer: http://astigmatismfix.com/ XI.Pearl Asking “Would you be ok wearing reading glasses after surgery?” is all right, but try instead asking, “What would you consider the ideal outcome after cataract surgery?” This opens the door for the discussion: femto, LipiFlow, and premium IOLs. 2015 Subspecialty Day | Refractive Surgery Section II: Cornea- and Lens-Based Procedures Overview on Trifocal, Multifocal, and Enhanced Depth of Focus IOLs Boris Malyugin MD PhD NOTES 39 40 Section II: Cornea- and Lens-Based Procedures 2015 Subspecialty Day | Refractive Surgery Phakic IOL Review: New and Current Applications Allon Barsam MBBS FRCOphth, Amelia Davidson MBChB, Felicity Allen MBChB Introduction Keratorefractive surgeries, such as PRK or LASIK, have limitations when used for correction of high refractive errors.1 Corneal thickness limits aggressive tissue ablation when performing LASIK for high myopia. Alternative intraocular refractive procedures are gaining ground, as they can safely treat a broader range of ametropia.2,3 Refractive lens exchange can be performed to correct high refractive errors; however, this results in loss of accommodation and carries an increased risk of retinal detachment, particularly in young myopic patients. Phakic intraocular lens (P-IOL) implantation preserves accommodation and utilizes surgical techniques already familiar to the cataract and refractive surgeon. P-IOLs are associated with a lower risk of retinal detachment than clear lens exchange; however, their use may be inappropriate in eyes with shorter anterior chamber dimensions.4 The implantation of a P-IOL is a reversible procedure; it has been associated with a more favorable uncorrected visual acuity and an improved predictability and stability of refraction when compared to LASIK in those with moderate to high myopia.5,6 Three types of P-IOLs exist: anterior-chamber P-IOL—angle fixated and iris fixated—and posterior chamber P-IOLs. The purpose of this talk is to discuss current applications of P-IOLs and then introduce some of the newer models for presbyopia. Implantable Collamer Lens (ICL) The Staar Visian ICL is currently the only posterior chamber P-IOL approved by the FDA for correction of myopia.7 It is made from a copolymer of hydroxyethyl methacrylate and porcine collagen, and final design modifications encompass increased vaulting over the anterior lens capsule.8 The newest models include V3 (for hyperopia), V4, V4b, and V4c (for myopia and astigmatism). The ICL is indicated for patients aged 21-45 with an anterior chamber depth of more than 3.0 mm who demonstrate refractive stability for 1 year before implantation. The ICL can correct myopia from -3 to -15 D and reduce myopia from -15 to -20 D with -2.5 D of astigmatism at the spectacle plane. Three-year clinical outcomes data show excellent UCVA (> 6/6 in 41% of eyes and 6/12 in 81% of eyes),9 refractive predictability, and contrast sensitivity under mesopic illumination without glare.10 Additionally, the ICL confers significant visionrelated quality-of-life advantages (symptoms, appearance, satisfaction with visual correction) compared to wavefront-guided LASIK for myopia (P < .5).11 Reported complications include glare (9.7% of patients worse at 3 years) and halos (11.4% of patients worse at 3 years). Reported rates of visually significant anterior subcapsular cataract resulting in P-IOL explantation were 0.61% in model V4 and 0% in models V4b and V4c.12 Toric ICL The toric version of the ICL has expanded the pool of potential candidates for P-IOL implantation, including those with keratoconus. Short-term results are very encouraging—at 3 years 82% of patients are within 0.5 D of targeted correction13—but it is yet to be approved by the FDA. The axis of the Visian V4 ICL is aligned with the 180-degree meridian, with only a minor adjustment of no more than 22 degrees rotation, clockwise or counterclockwise, required to correct the astigmatism. A recent study demonstrated high rotational stability with no significant rotation or axis misalignment.14 Other applications of the Visian ICL include reduction of myopia and astigmatism in patients with keratoconus in combination with collagen corneal crosslinking.15 V4c ICL The V4c is a newer ICL model with an artificial port integrated in the center of the lens optic. This development eliminates the need to perform a preoperative peripheral laser iridotomy, simplifying the surgical procedure and reducing complications associated with ablating the iris. Additionally, older ICLs were hampered with reports of raised IOP postoperatively, usually due to residual viscoelastic blocking the iridotomy site, and late-onset cataract, resulting from physical contact between the ICL and the crystalline lens. The V4c may reduce the threat of both of these complications.12 Verisyse (Artisan/Artiflex) Artisan The Artisan (Verisyse) lens is an anterior chamber iris claw-fixated P-IOL. Its myopic correction parameters are slightly wider than the ICL, ranging from -5 D to -20 D with 2.5 D of astigmatism at the spectacle plane. A toric Artisan model is available in Europe. Patients who had myopic/toric Artisan in one eye and LASIK in the other reported no significant difference in satisfaction, but patients had a significantly higher preference for the Artisan due to better reported quality of vision.16,10 Complications in the literature include a higher incidence of glare and halos (18.2%) and cataract (5.2%) than the Visian ICL but less endothelial cell loss and no influence on IOP.4 The Artisan/Verisyse toric P-IOL for myopia and hyperopia with astigmatism has respectable short-term outcomes; with 95% of patients gaining ≥ 1 line BSCVA at 6 months with no serious complications and high patient satisfaction.17 By nature, this toric lens has high rotational stability as it is firmly fixed to the iris stroma. Artiflex The Artiflex (Veriflex) anterior chamber P-IOL consists of a flexible convex-concave 6.0-mm silicone optic. It is inserted via a small self-sealing incision, facilitating rapid return of visual acu- 2015 Subspecialty Day | Refractive Surgery ity. As a paradox, the tiny incision requires a more demanding surgical technique, and moving the instruments around the eye can cause damage to local structures. The flexible lens is more susceptible to mechanical factors and therefore a flat iris, in addition to a sufficient anterior chamber depth, is an essential selection criterion. There are limited data for paired comparison studies between P-IOLs, but of the studies available one found Artisan and Artiflex to have similar complication rates.18 AcrySof Cachet The AcrySof Cachet is an acrylic angle-supported P-IOL. It requires a small incision and does not require a peripheral iridectomy. There are good 3-year outcomes. However, there is no toric model available, and it is not yet FDA approved. Concerns about potential long-term risks to anterior segment structures after implantation of angle-supported P-IOLs have been partially put aside by several studies demonstrating that the AcrySof Cachet demonstrates excellent intraocular stability after pupil dilation, with no shortening of distance between the P-IOL and the central corneal endothelium.19 A study comparing the abberometric performance of the Visian ICL and the AcrySof Cachet reported no significant differences in induction of higher-order aberrations and similar reduction in spherical aberrations, indicating that both are effective phakic implants to correct high refractive errors.20 Presbyopic P-IOLs A novel posterior chamber P-IOL has recently been marketed (IPCL, Care Group India) that may provide correction for presbyopia in addition to myopia and astigmatism. The IPCL is made from reinforced hybrid acrylic and has 6 points of contact with the ciliary sulcus, instead of the usual 4, to increase stability. It has 2 positioning holes in the haptics to facilitate implantation and 4 holes in the optical zone margin to regulate aqueous flow. A diffractive optical zone of 3.5 mm allows gliding of the iris over the lens and aims to reduce halos. The main target group for this lens is patients aged 40-55 who have not yet developed cataract, in whom this technology provides a reversible presbyopia solution. The lens comes with intermediate/near additions between +1.50 and +3.50 in 0.50-D increments. The interaction between this diffractive optic and the patient’s natural lens is described by the manufacturers as “panfocality.” A small study evaluated the safety parameters and visual results of the lens by implanting 3 patients with a monofocal IPCL in one eye and a standard Vision ICL in the contralateral eye.21 There were no intraoperative complications, and provisional results showed no differences in BCVA and no complaints relating to higher-order aberrations. More research, experience, and long-term patient outcomes are required to assess the safety and efficacy of this lens. References and Selected Readings 1. Sugar A, Rapuano CJ, Culbertson WW, et al; Ophthalmic Technology Assessment Committee 2000-2001, Refractive Surgery Panel. Laser in situ keratomileusis for myopia and astigmatism: safety and efficacy: a report by the American Academy of Ophthalmology. Ophthalmology 2002; 109:175-87. Section II: Cornea- and Lens-Based Procedures 41 2. Schallhorn S, T. D. Randomised prospective comparison of Visian toric implantable collamer lens and conventional photorefractive keratectomy for moderate to high myopic astigmatism. J Refract Surg. 2007; 23:853- 867. 3. Sanders DR. Matched population comparison of the Visian implantable collamer lens and standard LASIK for myopia of -3.00 to -7.88 diopters. J Refract Surg. 2007; 23:537-553. 4. Huang D, Schallhorn SC, Sugar A, et al. Phakic intraocular lens implantation for the correction of myopia : a report by the American Academy of Ophthalmology. Ophthalmology 2009; 116(11):2244-2258. 5. Sanders DR, Vukich JA. Comparison of implantable contact lens and laser assisted in situ keratomileusis for moderate to high myopia. Cornea 2003; 22(4):324-331. 6. Barsam A, Allan B. Meta-analysis of randomized controlled trials comparing excimer laser and phakic intraocular lenses for myopia between 6.0 and 20.0 diopters. Cornea 2012; 31(4):454-461. 7. FDA, U. F. (September, 2015 25). Devices@FDA. -, -, U.S.A. 8. Chang JS, Meau AY. Visian collamer phakic intraocular lens in high myopic Asian eyes. J Refract Surg., 2007; 23:17-25. 9. FDA; ICL in Treatment of Myopia (ITM) Study Group. United States Food and Drug Administration clinical trial of the implantable collamer lens (ICL) for moderate to high myopia: three-year follow-up. Ophthalmology 2004; 111:1683-1692. 10. Barsam A, Allan BD. Excimer laser refractive surgery versus phakic intraocular lenses for the correction of moderate to high myopia. Cochrane Database Syst Rev. 2010; 12(5):CD007679. 11. Kobashi H, Kamiya K, et al. Long-term quality of life after posterior chamber phakic intraocular lens implantation and after wavefront-guided laser in situ keratomileusis for myopia . J Cataract Refract Surg. 2014; 40:2019-2024 . 12. Alfonso JF, Lisa C, Fernandez-Vega CL, et al. Clinical outcomes after implantation of a posterior chamber collagen copolymer phakic intraocular lens with a central hole for myopic correction. J Cataract Refract Surg. 2013; 39(6):915-921. 13. Alfonso JF, Lisa C, Fernandez-Vega CL. Prevalence of cataract after collagen copolymer phakic intraocular lens implantation for myopia, hyperopia, and astigmatism. J Cataract Refract Surg. 2015; 41:800-805. 14. Lisa C, Fernandez-Vega CL. Rotational stability of the V4b implantable collamer lens. J Emmetropia. 2015; 1:7-12. 15. Antonios R, Dirani A, et al. Safety and visual outcome of Visian toric ICL implantation after corneal collagen cross-linking in keratoconus: up to 2 years of follow-up. J Ophthalmol. 2015; 2015:514834. 16. el Danasoury MA, El Maghraby A, Gamali TO. Comparison of iris-fixed Artisan lens implantation with excimer laser in situ keratomileusis in correcting myopia between -9.00 and -19.50 diopters: a randomized study. Ophthalmology 2002; 109(5):955-964. 17. Dick HB, Alió J, et al. Toric phakic intraocular lens: European multicenter study. Ophthalmology 2003; 110:150-162. 18. Coullet J, Guell JL, et al. Iris-supported phakic lenses (rigid vs foldable version) for treating moderately high myopia: randomized paired eye comparison. Am J Ophthalmol. 2006; 142:909-916. 19. Alio JL, Piñero DP, et al. Intraocular stability of an angle-supported phakic intraocular lens with changes in pupil diameter. J Cataract Refract Surg. 2010; 36:1517-1522. 42 Section II: Cornea- and Lens-Based Procedures 20. Hosny MH, Shalaby AM. Visian implantable contact lens versus AcrySof Cachet phakic intraocular lenses: comparison of aberrometric profiles. Clin Ophthalmol. 2013; 1477-1486. 21. Salva Ladaria L. Phakic lens offers new option for presbyopic correction. Ocular Surgery News: Europe Edition, Sept. 1, 2015: 32-37. 22. Baïkoff G, Matach G, et al. Correction of presbyopia with refractive multifocal phakic intraocular lenses. J Cataract Refract Surg. 2004; 30(7):1454-1460. 23. el Danasoury MA, El Maghraby A, Gamali TO. Comparison of iris-fixed Artisan lens implantation with excimer laser in situ keratomileusis in correcting myopia between -9.00 and -19.50 diopters: a randomized study. Ophthalmology 2002; 9(5):955-956. 24. Mertens EL, A. T. New phakic implants surgeons share their experiences with the Visian ICL V4c and the AcrySof Cachet. Cataract and Refractive Surgery Today (CRST), 2012; 26-30. 2015 Subspecialty Day | Refractive Surgery 25. Krommes G. Evaluation of our first 100 implanted Visian ICL V4c lenses (implantable collamer lens, Staar surgical) in patients with myopia and astigmatic myopia concerning predictability, safety and visual acuity. ESCRS London. 2014. 26. Kamiya K, Shimizu K, et al. Three-year follow-up of posterior chamber toric phakic intraocular lens implantation for moderate to high myopic astigmatism. PLoS One 2013; 8(2). 27. Menezo JL, Peris-Martinez C, Cisneros AL, Martinez-Costa R. Posterior chamber phakic intraocular lenses to correct high myopia: a comparative study between Staar and Adatomed models. Refract Surg. 2001; 17:32- 42. 28. Bhikoo R, Rayner S, Gray T. Toric implantable collamer lens for patients with moderate to severe myopic astigmatism: 12-month follow-up. Clin Experiment Ophthalmol. 2010; 38(5):467-474. 2015 Subspecialty Day | Refractive Surgery Section II: Cornea- and Lens-Based Procedures Novel Lasers for Refractive Surgery Michael Mrochen PhD NOTES 43 44 Section II: Cornea- and Lens-Based Procedures 2015 Subspecialty Day | Refractive Surgery Review of Current and New Femtosecond Lasers and Their Applications in Refractive Surgery Burkhard Dick MD The introduction of the femtosecond laser in refractive surgery has made LASIK the most popular form of corneal refractive surgery, more precise and more tailored to the patient’s individual needs while also reducing surgery time—sometimes making the intervention less time consuming than the procedure with a microkeratome. One of the main advantages of the femtosecond laser is the reproducibility and accuracy of the flap. The thickness of a flap created by femtosecond laser is generally closer to the intended target thickness than after using the microkeratome, as Chen et al have demonstrated with the IntraLase platform. They reported a mean deviation from intended flap thickness of 6.5 ± 5.2 µm for the laser, versus 16.8 ± 10.5 µm for the microkeratome.1 The flap integrity also seems to be equal or superior to that of a mechanically created flap. Several different platforms have been employed over the last couple of years: the iFS platform (AMO), the Technolas 520F (Bausch + Lomb), the WaveLight FS200 (Alcon), the LDV Z6 (Ziemer) and the VisuMax (Zeiss). The flap cutting time for all these platforms is 8 to 20 seconds. So far only the VisuMax offers the ability to perform the ReLex (SMILE: small-incision lenticule extraction) procedure. The laser systems differ in the variety of applications aside LASIK-like tunnels for ring segments, lamellar or penetrating keratoplasty, pockets for the Kamra inlay (eg, arcuate cuts). Moreover, there are differences in pulse duration, pulse repetition, scan pattern, patient interface, and vacuum suction control. The safety standard of LASIK performed by femtosecond laser is high. Zhang et al, for instance, could demonstrate that there is no higher rate of vision loss—overall a very uncommon occurrence—than after microkeratome LASIK. Furthermore, in eyes that had femtosecond LASIK, the postoperative total aberrations (mean difference -0.03 μm; 95% CI, -0.05 to -0.01; P = .002) and spherical aberrations (mean difference -0.02 μm; 95% CI, -0.03 to -0.01; P < .00001) were significantly lower.2 In a large study published by Tanna, Schallhorn and Ettinger, 1000 eyes with low myopia that had LASIK flaps created with a femtosecond laser were compared with 1000 eyes that had flaps created with a mechanical microkeratome. The percentage of eyes that achieved a postoperative UCVA of 20/20 or better was significantly higher in the femtosecond laser group than in the mechanical keratome group. Also a lower percentage of eyes in the femtosecond laser group lost 2 or more lines of BSCVA at 1 week and 1 month postoperatively.3 These superb results are reflected in the patients’ experience with the femtosecond laser. Of more than 300 U.S. Navy aviators who underwent femtosecond-assisted wavefront-guided LASIK, no fewer than 99.6% answered when interviewed 3 months after the procedure that they would recommend this kind of treatment to other people with refractive errors.4 The femtosecond laser platforms currently in clinical use have proved to be highly effective and safe—in refractive surgery and in cataract surgery as well. Surgeons who have witnessed the rise of this technology will have no doubt that further evolutions and refinements are on the horizon; or, as a former president who lived not too far away from this year’s meetingplace used to say, “Our best days are still ahead.” References 1. Chen S, Feng Y, Stojanovic A, et al. IntraLase femtosecond laser vs mechanical microkeratomes in LASIK for myopia: a systematic review and meta-analysis. J Refract Surg. 2012; 28(1):15-24. 2. Zhang ZH, Jin HY, Suo Y, et al. Femtosecond laser versus mechanical microkeratome laser in situ keratomileusis for myopia: metaanalysis of randomized controlled trials. J Cataract Refract Surg. 2011; 37(12):2151-2159. 3. Tanna M, Schallhorn SC, Hettinger KA. Femtosecond laser versus mechanical microkeratome: a retrospective comparison of visual outcomes at 3 months. J Refract Surg. 2009; 25(7 suppl):S668-671. 4. Tanzer DJ, Brunstetter T, Zeber R, et al. Laser in situ keratomileusis in United States naval aviators. J Cataract Refract Surg. 2013; 39(7):1047-1058. 2015 Subspecialty Day | Refractive Surgery Section III: Interactive Doctor-Patient Consultations 45 Section III: Fair Game—Refractive Surgery Interactive Doctor-Patient Consultations NOTES 46 Advocating for Patients 2015 Subspecialty Day | Refractive Surgery 2015 Advocating for Patients Stephanie J Marioneaux MD Ophthalmology’s goal in protecting quality patient eye care remains a key priority for the Academy. All ophthalmologists should consider their contributions to the following three funds as (a) part of their costs of doing business and (b) their individual responsibility in advocating for patients and their profession: • Surgical Scope Fund (SSF) • OPHTHPAC® Fund • State Eye PAC Your ophthalmologist colleagues serving on Academy committees—the Surgical Scope Fund Committee and the Secretariat for State Affairs and OPHTHPAC Committee—are committing many hours on your behalf. The Secretariat for State Affairs is collaborating closely with state ophthalmology society leaders to protect Surgery by Surgeons at the state level. Meanwhile, the OPHTHPAC Committee is hard at work identifying congressional advocates in each state to maintain close relationships with federal legislators in order to advance ophthalmology and patient causes. Both groups’ ultimate goals are to ensure robust funds for both the SSF and the OPHTHPAC Fund so that they are able to (a) protect quality patient eye care, (b) protect ophthalmology practices from payment cuts, (c) reduce burdensome regulations, and (d) advance the profession by promoting funding for vision research and expanded inclusion of ophthalmology in public and private programs. These committed ophthalmologists serving on your behalf have a simple message to convey: “We also need you”! • We need you to contribute to each of these three funds. • We need you to establish relationships with state and federal legislators. • We need you to help us protect quality patient eye care and the profession. Surgical Scope Fund The Surgical Scope Fund (SSF) provides grants to state ophthalmology societies to support their legislative, regulatory, and public education efforts to derail optometric surgery proposals that pose a threat to patient safety, quality of surgical care, and surgical standards. Since its inception, the Surgery by Surgeons campaign—in partnership with state ophthalmology societies and with support from the SSF—has helped 32 state/territorial ophthalmology societies reject optometric surgery proposals. As of July 1, 2015, the Secretariat for State Affairs, in collaboration with the California Academy of Eye Physicians and Surgeons (CAEPS) and the California Medical Society, continues to battle an onerous optometric surgery scope of practice bill (SB 622) in the Golden State. The Secretariat has reached out to all ophthalmology subspecialty society partners to help in this effort, and several have stepped up to the plate. In addition, ophthalmology leaders at California academic institutions have played a critical role by voicing their concerns about the California surgery bill and the impact it would have on quality eye care for patients. A June 24 op-ed in the San Francisco Examiner aptly focused on these leaders’ concerns with its headline “Quality surgical eye care ensured through training.” CAEPS has benefitted from contributions to the SSF, having received significant support from the fund. Other state ophthalmology societies have also benefitted from SSF distributions in 2015 and were able to successfully implement patient safety advocacy campaigns to defeat attempts by optometry to expand its scope of practice to include surgery. The Texas Ophthalmological Association was successful in its patient advocacy and public education efforts to defeat three different optometric-backed surgical scope expansion bills in the Texas state legislature. In addition, the Academy supported the Alaska Society of Eye Physicians and Surgeons in opposing optometric surgery scope legislation that posed a threat to patient surgical care. If enacted, the optometric surgery bill would have authorized optometrists in Alaska to perform surgery with lasers, scalpels, and needles, and to perform other surgical procedures. The legislation would also have allowed optometrists to perform all injections except intravitreal and to prescribe any controlled substances. Thanks to an effective Surgery by Surgeons advocacy campaign, with support from the SSF, this legislation died in committee. The Alaska state legislature adjourned for the year on April 27. The Academy relies not only on the financial contributions to the SSF from individual ophthalmologists and their business practices, but also on the contributions made by ophthalmic state, subspecialty, and specialized interest societies. The American Society of Cataract & Refractive Surgery (ASCRS) contributed to the Surgical Scope Fund in 2014, and the Academy counts on its contributions in 2015. OPHTHPAC® Fund OPHTHPAC is a crucial part of the Academy’s strategy to protect and advance ophthalmology’s interests in key areas, including physician payments from Medicare as well as protecting ophthalmology from federal scope of practice threats. Established in 1985, OPHTHPAC is one of the oldest, largest, and most successful political action committees in the physician community and is very successful in representing your profession to the U.S. Congress. As one election cycle ends, a new one starts. OPHTHPAC is always under financial pressure to support our incumbent friends as well as to make new friends with candidates. These relationships allow us to have a seat at the table and legislators willing to work on issues important to us and our patients. Among the significant achievements of OPHTHPAC are the following: • Repealed the flawed Sustainable Growth Rate (SGR) formula • Blocked the unbundling of the Medicare global surgery fee period • Removed a provision in fraud and abuse legislation that targeted eyelid surgery • Protected your ability to perform ancillary services in your office Advocating for Patients 2015 Subspecialty Day | Refractive Surgery 47 Surgical Scope Fund OPHTHPAC® Fund State Eye PAC To derail optometric surgical scope of practice initiatives that threaten patient eye safety and quality of surgical care Ophthalmology’s interests at the federal level Support for candidates for State House and Senate Support for candidates for U.S. Congress Political grassroots activities, lobbyists and media Campaign contributions, legislative education Campaign contributions, legislative education No funds may be used for candidates or PACs. Contributions: Unlimited Contributions: Limited to $5,000 Contribution limits vary based on state regulations. Contributions above $200 are on the public record. Contributions are on the public record depending upon state statutes. Individual, practice, and organization Contributions are 100% confidential. • Working to reduce the burdens from Medicare’s existing quality improvement programs such as the Electronic Health Record Meaningful Use program • Working in collaboration with subspecialty societies to preserve access to compounded and repackaged drugs such as bevacizumab Leaders of the ASCRS are part of the American Academy of Ophthalmology’s Ophthalmic Advocacy Leadership Group (OALG), which has met every January for the past eight years in the Washington D.C. area to provide critical input and to discuss and collaborate on the Academy’s advocacy agenda. The topics discussed at the 2015 OALG meeting included collaborative efforts on the IRIS Registry and quality reporting under Medicare. As a 2015 Congressional Advocacy Day (CAD) partner, the ASCRS ensured a strong presence of refractive specialists to support ophthalmology’s priorities as nearly 400 Eye M.D.s had scheduled CAD visits to members of Congress in conjunction with the Academy’s 2015 Mid-Year Forum in Washington, D.C. The ASCRS remains a crucial partner with the Academy in its ongoing federal and state advocacy initiatives. State Eye PAC It is also important for all ophthalmologists to support our respective State Eye PACs because state ophthalmology societies cannot count on the Academy’s SSF alone. The presence of a strong State Eye PAC providing financial support for campaign contributions and legislative education to elect ophthalmologyfriendly candidates to the state legislature is also critical. The Secretariat for State Affairs strategizes with state ophthalmology societies on target goals for State Eye PAC levels. ACTION REQUESTED: ADVOCATE FOR YOUR PATIENTS!! Academy Surgical Scope Fund contributions are used to support the infrastructure necessary in state legislative / regulatory battles and for public education. PAC contributions are necessary at the state and federal level to help elect officials who will support the interests of our patients. Contributions to each of these three funds are necessary and should be considered the costs of doing business. SSF contributions are completely confidential and may be made with corporate checks or credit cards, unlike PAC contributions, which must be made by individuals and which are subject to reporting requirements. Please respond to your Academy colleagues who are volunteering their time on your behalf to serve on the OPHTHPAC* and Surgical Scope Fund** Committees, as well as your state ophthalmology society leaders, when they call on you and your subspecialty society to contribute. Advocate for your patients now! *OPHTHPAC Committee Donald J Cinotti MD (NJ) – Chair Janet A Betchkal MD (FL) William S Clifford MD (KS) Robert A Copeland Jr MD (Washington DC) Anna Luisa Di Lorenzo MD (MI) Sidney K Gicheru MD (TX) Michael L Gilbert MD (WA) Gary S Hirshfield MD (NY) Jeff S Maltzman MD (AZ) Thomas J McPhee MD (AZ) Lisa Nijm MD JD (IL) Andrew J Packer MD (CT) Diana R Shiba MD (CA) Woodford S Van Meter MD (KY) John (“Jack”) A Wells III MD (SC) Ex Officio Members Daniel J Briceland MD (AZ) Michael X Repka MD (MD) Russell Van Gelder MD PhD (WA) George A Williams MD (MI) **Surgical Scope Fund Committee Thomas A Graul MD (NE) – Chair Arezo Amirikia MD (MI) Matthew F Appenzeller MD (NC) Ronald A Braswell MD (MS) John P Holds MD (MO) Cecily A Lesko MD FACS (NJ) William (“Chip”) W Richardson II MD (KY) David E Vollman MD MBA (MO) Ex Officio Members Daniel J Briceland MD (AZ) Kurt F Heitman MD (SC) 48 Section IV: The “Mojo Bag” of Videos 2015 Subspecialty Day | Refractive Surgery Suturing a Capsular Tension Ring on Complications Robert K Maloney MD A 65-year-old male tripped in 2004, and his right eye struck the corner of a bookcase, causing a ruptured globe. A primary repair was done, leaving exposed uvea under the conjunctiva posterior to the limbus. The patient underwent successful cataract surgery in 2010 with insertion of a capsule tension ring. He presented to me in 2014 with inferotemporal dislocation of the lens-capsular bag complex. The case illustrates the challenges in trans-scleral suturing of a dislocated IOL. 2015 Subspecialty Day | Refractive Surgery Section IV: The “Mojo Bag” of Videos 49 Dislocated IOL Management With the Glued IOL Technique Eric Donnenfeld MD The management of the IOL in aphakia or in the presence of a dislocated posterior chamber IOL is often one of the most challenging decisions for the anterior segment surgeon. The surgical options have been an anterior chamber IOL or suturing the IOL to the iris or trans-sclerally. A new technique, the glued posterior chamber IOL (PC-IOL), offers a new option for these challenging cases. Glued intrascleral haptic fixation of an IOL as a technique for PC-IOL fixation in eyes with absent or insufficient capsule support was first described in 2007 by Amar Agarwal. The name does not fully describe the technique, and a more complete representation is a sutureless, fibrin-glue assisted PC-IOL implantation with intrascleral tunnel fixation. The scleral tuck and intrascleral haptic fixation of a PC-IOL were first described by Gabor Pavilidis; Maggi subsequently evolved the technique and its application has been extended to managing a decentered IOL or a Soemmerring ring and also as part of combined surgeries. The technique involves several steps, which should be followed to ensure success: 1. Perform a conjunctival peritomy and limbus-based scleral flap 180 degrees apart. Generally these incisions are made at 3 and 9 o’clock. For larger eyes where there may not be sufficient IOL length to fixate the lens, the flaps can be created at 12 and 6 o’clock. 2. Insert a chamber maintainer. 3. Enter the posterior chamber under both scleral flaps. I generally use an MVR blade. 4. Perform a pars plana vitrectomy to reduce the risk of vitreous traction. 5. Insert a 3-piece PC-IOL at the limbus or free an existing dislocated PC-IOL. Decentered IOLs that are 3-piece can be reaffixed with the glued IOL technique rather than suturing them or explanting them and putting in an ACIOL. Prolapse the IOL into the anterior chamber and remove lens remnants. 6. Employ the “handshake” technique, in which the IOL haptic is bimanually transferred from one microforceps in the anterior segment to another microforceps inserted through the pars plana under the scleral flap, with direct visualization in the pupillary plane until the tip of the haptic is grasped to facilitate easy externalization. The intraoperative externalization of the IOL haptics is the key step in glued IOL surgery. Inappropriate handling of the haptics can lead to disfigurement, which can be a kink or a breakage that requires an IOL exchange. It is crucial to grab the haptic with the microforceps from the tip and not from anywhere else down the entire length of the haptic. 7. Insert the externalized prolene haptic, which is under the scleral flap, into a scleral tunnel. 8. Employ fibrin glue to seal the scleral flaps and conjunctival peritomy. The major advantage of the glued IOL technique is the stability and centration of the IOL. There is no pseudophacodonesis and no IOL tilt as compared to other suturing techniques. Longterm follow-up will confirm the efficacy of this procedure. 50 Section IV: The “Mojo Bag” of Videos 2015 Subspecialty Day | Refractive Surgery Challenging Exchange of Refractive IOL David F Chang MD This video shows a case of a severe Crystalens Z-syndrome that was not improved with YAG posterior capsulotomy combined with YAG relaxing incisions of the anterior capsulorrhexis. The patient has severe astigmatism and decreased BCVA, with an intolerable anisometropia. An IOL exchange is attempted. 2015 Subspecialty Day | Refractive Surgery Section IV: The “Mojo Bag” of Videos 51 Mastering the Trocar Anterior Chamber Maintainer and Pre-Descemet Endothelial Keratoplasty With Glued IOL Amar Agarwal MD Self-sealing wounds are the most desirable and are the hallmark of any intraocular surgery. Controlled access to the intraocular segment structures without running risk of hypotony is the prime concern of all surgeons. Anterior chamber (AC) maintainer and trocar cannula are the most common methods employed for infusion by anterior segment and posterior segment surgeons, respectively. Taking into consideration the advantages of a trocar system, we employed a method of introducing the trocar cannula for the maintenance of the AC, the advantages of which anterior segment surgeons too would avail themselves with equal ease and élan. We designate this procedure as the trocar anterior chamber maintainer (TACM). Surgical Procedure Before cannula insertion, conjunctiva is displaced with a cotton tip to keep the conjunctival puncture away from the sclera-limbal wound. The cannula (on a trocar) is inserted into the limbus approximately 1 mm away (see Figure 1), usually at a 45° angle (depending on gauge) and parallel to the limbus. The trocar is then turned directly toward the center of the globe so that it enters the AC in front of the iris tissue. It is advanced until the hub of the cannula is flush with the sclera. The trocar is then removed, leaving the cannula in place. This maneuver allows a longer scleral wound and carries a lower risk of wound leakage. The infusion line is attached to the stent of the cannula, and the infusion is turned on. At the end of the surgical procedure, the surgeon just withdraws the TACM, and, as the wound is selfsealing, no leakage is observed. Pre-Descemet Endothelial Keratoplasty and Glued IOL Pre-Descemet endothelial keratoplasty (PDEK)1 is the latest iteration in the congregation of various procedures for endothelial keratoplasty that evolved following a detailed description of the pre-Descemet layer (PDL, or Dua’s layer) by Harminder Dua.2 This technique allows the separation and usage of PDL, which is an additional 10-micron layer to the conventional Descemet membrane (DM)-endothelium graft.2 The key to the success of donor graft creation lies in the formation of a type 1 bubble, which is a central, well-circumscribed, dome-shaped bubble and typically spreads from center to periphery in the donor lenticule.2 Glued IOL3 is a well-established form of intrascleral haptic fixation for secondary IOL procedures. The combination of PDEK with glued IOL serves the purpose of handling corneal endothelial dysfunction and secondary IOL fixation simultaneously. Figure 1. Trocar AC maintainer. (A) 23-gauge trocar cannula system. (B) Trocar needle being inserted obliquely in the sclera about 1 mm away from the limbus. (C) The direction of the trocar needle is turned perpendicular toward the globe. (D) The trocar is inserted in the eye so that it enters the eye in front of the iris. (E) The trocar is removed and the cannula is fixed in place. The cannula is positioned in place and it snugly fits the limbal area. The infusion line is attached to the cannula and the TACM is in place. (F) The cannula is removed and no active leakage is observed. The anterior chamber is well maintained. 52 Section IV: The “Mojo Bag” of Videos When air is slowly injected with a 30-gauge needle attached to a 5-ml syringe inserted from the limbus into superficial, midperipheral stroma, it can form either a type 1 or type 2 big bubble (BB). Type 1 big bubble is a PDEK graft. It is a well-circumscribed, central, dome-shaped elevation measuring 7 to 8.5 mm in diameter. It always starts in the center and enlarges centrifugally, retaining a circular configuration. Type 2 big bubble is a DMEK graft. It is larger—up to 10.5 mm—and extends from the periphery. The bursting pressure of the PDEK graft is higher than that of DMEK graft thus prepared. The type 2 bubble collapses on attempting to peel the Descemet membrane off, whereas it can be peeled off a type 1 bubble without the bubble collapsing, proving the inclusion of the pre-Descemet layer in the PDEK graft. Sometimes, a combination of type 1 and type 2 bubble may be obtained. The pre-Descemet layer provides additional splintage and makes the graft more robust and resistant to tears. Creation of the type 1 big bubble is very similar to the Anwar big bubble created for DALK, except that air is injected from the endothelial side. Once a type 1 bubble is obtained, further expansion may also be achieved with viscoelastic. Harvesting the PDEK graft is easy and can be done in donor corneas of any age. After achieving a type 1 big bubble, the donor graft is trephined along the margins of the bubble. The bubble is pierced at the extreme periphery, and trypan blue is injected into the bubble to stain the graft. The PDEK graft is then cut around the trephine mark with a pair of Vannas scissors and placed in the tissue culture medium. The final size of the graft after cutting may be slightly larger than the trephine. The graft is loaded into an injector when ready for insertion. Glued IOL technique consists of making 2 partial scleral thickness flaps approximately 2.5x2.5 mm in size and 180 degrees opposite to each other. The epithelium of the recipient eye is often debrided due to epithelium decompensation, which hinders the intraoperative view to a great extent. An AC maintainer is introduced in the lower quadrant and a sclerotomy wound is created with a 20-gauge needle approximately 1 mm away from limbus, beneath the scleral flaps, and the entire glued IOL surgery is performed until the tucking of the haptics in the scleral pockets.3 The AC maintainer helps to maintain the AC throughout the surgery and the use of viscoelastic is deterred, as it is important not to leave residual viscoelastic in the AC as it is thought to potentially hamper good adhesion between the donor corneal disc and the recipient corneal stroma. 2015 Subspecialty Day | Refractive Surgery Cases with decompensated corneas (see Figures 2 and 3) due to endothelial disorders requiring secondary IOL implantation or an IOL exchange are potential candidates for undergoing PDEK with glued IOL surgery. The main advantage of combining PDEK and glued IOL surgery is that patients undergo a single surgery, attend fewer appointments, and deal with a specific set of postoperative medications. Alternatively, both surgeries can be performed sequentially, wherein glued IOL is performed as an initial procedure followed by PDEK in a second stage. Figure 2. Pre- and postop images of a case of pseudophakic bullous keratopathy followed by PDEK with glued IOL and pupilloplasty using a 9-month-old donor. Entire surgery was done in 1 step. Figure 3. Pre- and postop image of a case of pseudophakic bullous keratopathy followed by EK with glued IOL using a young donor. This was done in 2 steps. First glued IOL was done, then 2 months later the EK was done. References 1. Agarwal A, Dua HS, Narang P, et al. Pre- Descemet’s endothelial keratoplasty (PDEK). Br J Ophthalmol. 2014; 98(9):1181-1185. 2. Dua HS, Faraj LA, Said DG, et al. A novel pre-Descemet’s layer (Dua’s layer). Ophthalmology 2013; 120:1778-1185. 3. Agarwal A, Kumar DA, Jacob S, et al. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008; 34:14331438. Section IV: The “Mojo Bag” of Videos 2015 Subspecialty Day | Refractive Surgery When Things Start Blowing, Try Beans George Beiko MD NOTES 53 54 Section IV: The “Mojo Bag” of Videos 2015 Subspecialty Day | Refractive Surgery Placement of a Toric IOL in a Compromised Capsular Bag William Trattler MD This video presents a challenging case in which the surgeon is faced with an important decision. A 72-year-old patient with 2.5 D of astigmatism is scheduled for cataract surgery with a toric IOL with the goal of good uncorrected distance vision postoperatively. The patient undergoes femtosecond laser cataract surgery, and during the nuclear removal, an anterior capsular tear occurs. Following careful cortical removal, the capsular bag is inflated with viscoelastic. The decision point is whether or not to place a toric IOL in a compromised capsular bag. While placement of the IOL at the intended axis is possible without extending the capsular tear, there is an increased risk for the IOL to shift out of position, or even dislocate out of the capsular bag. Figure 1. Section IV: The “Mojo Bag” of Videos 2015 Subspecialty Day | Refractive Surgery Corneal Inlay Complications George O Waring IV MD NOTES 55 56 Section IV: The “Mojo Bag” of Videos 2015 Subspecialty Day | Refractive Surgery Small-Incision Lenticule Extraction (SMILE) Complications Ronald R Krueger MD Small incision lenticular extraction (SMILE) is rapidly growing in popularity as the next generation of laser vision corrective surgery. The perceived benefit of improved preservation of biomechanical tissue strength, less potential dry eyes, smaller external incision size, and less dependence on environmental variables makes SMILE an increasingly attractive procedure. Despite the perceived benefits, SMILE involves a greater level of surgical skill, and there are potential complications that may be unfamiliar to refractive surgeons. The risk and management of these complications must be understood for the new refractive surgeon to be fully equipped in optimally selecting and performing SMILE. This video will demonstrate a compilation of recorded complications, experienced by variety of surgeons, and briefly highlight how they were best managed. These will include suction loss, obstructive OBL (opaque bubble layer), incomplete lenticular dissection, and torn lenticule during extraction. By viewing the video, the surgeon will gain a proper perspective on the possible complications to be expected when performing SMILE. 2015 Subspecialty Day | Refractive Surgery Section IV: The “Mojo Bag” of Videos Endothelial Keratoplasty and IOL Implantation Sadeer B Hannush MD Introduction Pseudophakic corneal edema is a well-known short- and longterm complication of cataract extraction with IOL implantation. The common pathway to corneal edema involves corneal endothelial cell loss to a level below what is required to maintain corneal clarity. This complication is more frequently associated with anterior chamber IOLs (AC-IOLs). Cystoid macular edema may develop as a comorbid condition. An 83-year-old gentleman is referred 6 months post-cataract extraction with AC-IOL implantation complaining of decreased visual acuity (VA). He is noted to have a VA of 20/400, IOP of 18 on a prostamide pressure-lowering agent, corneal edema (pachymetry = 754 microns), a retained nuclear fragment in the anterior chamber, an AC-IOL with iris tuck, and cystoid macular edema (foveal thickness = 403 microns). Video 23-gauge transconjunctival sclerotomies are created to perform a generous pars plana anterior vitrectomy. The nuclear fragment is emulsified. The AC-IOL is dissected from its iris/angle attachments and delivered out of the eye. A 3-piece acrylic optic IOL is intrasclerally fixated. Endothelial keratoplasty is performed. 57 58 Section V: ESCRS Symposium 2015 Subspecialty Day | Refractive Surgery Cataract Surgery Outcomes in Corneal Refractive Surgery Eyes EUREQUO Steering Group: Sonia Manning MD, Peter Barry MD, Ype Henry**, Paul Rosen MD**, Ulf Stenevi MD**, Mats Lundström MD** I.Introduction A. Is the number of corneal refractive surgery patients, undergoing cataract surgery, increasing? B. Is previous corneal refractive surgery likely to affect the visual outcome of cataract surgery? IV.Discussion II.Methods A. Database study (EUREQUO) B. All reported cataract extractions from 18 European countries and Australia (2008-2013) III.Results A. Preoperative data B. Visual outcome C. Worse postoperative CDVA D. 6/6 threshold for cataract surgery in Europe 1. 2.8% of cataract surgery patients in total 2. 8.5% in the corneal refractive surgery group vs. 2.8% in the non-corneal refractive surgery group (P < 0.001) 1. Low tolerance for visual symptoms 2. To reverse lenticular myopic shift 3. Myopes develop cataract sooner. 4. Laser cataractogenic? C. Age, gender, previous corneal refractive surgery, pre- and post-CDVA, % 6/12 or better pre- and postoperatively, % 6/6 or better pre- and postoperatively. A.Age B. Worse BCVA 1. Corneal refractive surgery: iatrogenic positive spherical aberration 2. Cataract surgery: iatrogenic positive spherical aberration (depending on IOL) 3. ? Enough net positive spherical aberration to degrade spectacle-corrected VA? V.Conclusion A. Cataract surgery in corneal refractive surgery eyes is increasing. B. Patients with previous corneal refractive surgery undergo cataract surgery younger and they are at higher risk of worse visual outcome. ** The co-authors have not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. Section V: ESCRS Symposium 2015 Subspecialty Day | Refractive Surgery 59 Residual Astigmatism After Toric IOL Implantation Rudy M M A Nuijts MD and N Visser** Approximately 20% to 30% of patients who undergo cataract surgery have corneal astigmatism of 1.25 D or more, and approximately 10% of patients have 2.00 D or more of corneal astigmatism.1 Not correcting the astigmatism component at the time of cataract surgery will fail to achieve spectacle independency in these patients. Toric IOLs have been shown to be a safe and effective treatment option for correcting astigmatism.2 In a recent randomized clinical trial comparing spectacle independency for distance vision following bilateral toric IOL implantation, compared to bilateral spherical IOL implantation, spectacle independency was achieved in 84% of patients with bilateral toric IOLs compared to 31% of patients with control IOLs.3 We found an uncorrected distance visual acuity of 20/25 or better in 70% of patients in the toric group and 31% in the control group. Regarding refractive astigmatism, the correction index of 1.20 and magnitude of error of +0.38 D demonstrated a general overcorrection of astigmatism. The surgically induced corneal astigmatism of a superior 2.2-mm incision was about -0.1 D, and the mean toric IOL misalignment was approximately 4 degrees. Sources of residual astigmatism after toric IOL implantation may be the effect of the spherical power and anterior chamber depth (ACD) in toric IOL calculations,4 the effect of posterior corneal astigmatism,5 the effect of a large pupil size and toric misalignment and rotation. Toric IOL outcomes may be optimized by incorporating IOL sphere power and estimated lens position in the IOL calculation. The IOL spherical power and estimated lens position (ACD plus pachymetry) determine the effective cylinder power of a toric IOL at the corneal plane. As shown by Koch, the posterior cornea surface also affects corneal astigmatism. The posterior corneal surface acts as a minus lens and is generally steep vertically. It therefore creates a plus power along the horizontal meridian and induces againstthe-rule corneal astigmatism.5 This effect may be accounted for in toric IOL calculations by decreasing corneal astigmatism by 0.5 D in patients with with-the-rule astigmatism and increasing corneal astigmatism by 0.3 D in patients with against-the-rule astigmatism. Also a relatively large pupil diameter and the subsequent influence of the prolate or aspherical shape of the cornea may contribute to the overcorrection of astigmatism.6 The normal aspherical shape of the cornea implies that the center of the cornea is steeper than the periphery. Various methods may be used to measure corneal astigmatism, including automated keratometry, manual keratometry, and corneal topography. However, these methods determine corneal astigmatism based on a central 2.0- to 3.0-mm zone of the cornea. This may be an effective measure of corneal astigmatism in the majority of patients, but it may be inadequate in younger patients with larger pupil diameters. We recommend measuring the pupil diameter in relatively young patients before implanting a toric IOL. If the photopic pupil diameter is larger than 4 mm, we recommend using corneal astigmatism values for a larger zone of the cornea. Crucial to the efficacy of toric IOLs is the position of the IOL with regard to the intended alignment axis, since the amount of misalignment contributes to residual astigmatism. Misalignment may be caused by two factors: inaccurate alignment of the toric IOL during surgery or postoperative rotation following surgery. For acrylic toric IOLs, the postoperative rotation has been shown to be less than 1 degree.7 The accuracy of toric IOL alignment during surgery has been reported to result in a mean error of approximately 5 degrees.8 Combined aberrometry and corneal topography may be used to determine the postoperative toric IOL alignment axis. In addition, aberrometry may be used to determine the source of residual refractive astigmatism following toric IOL implantation. In conclusion, unexplained residual refractive astigmatism following toric IOL implantation may be the result of multiple factors: the effect of the spherical power and ACD on toric IOL calculations, the effect of posterior corneal astigmatism, the effect of a large pupil size and toric IOL misalignment or rotation. The first two issues may be compensated for by improving toric IOL calculations. In addition, we recommend performing pupillometry in relatively young patients who wish to undergo cataract surgery with toric IOL implantation. If the photopic pupil diameter is larger than 4 mm, we recommend incorporating corneal astigmatism values for a larger zone of the cornea into the toric IOL calculation. Implementation of eye-tracking technology may further improve the accuracy of toric IOL alignment.7 References 1. Ferrer-Blasco T, Montes-Mico R, Peixoto-de-Matos SC, et al. Prevalence of corneal astigmatism before cataract surgery. J Cataract Refract Surg. 2009; 35(1):70-75. 2. Visser N, Bauer NJ, Nuijts RM. Toric intraocular lenses: historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes, and complications. J Cataract Refract Surg. 2013; 39(4):624-637. 3. Visser N, Beckers HJ, Bauer NJ, et al. Toric vs aspherical control intraocular lenses in patients with cataract and corneal astigmatism: a randomized clinical trial. JAMA Ophthalmol. 2014; 132(12):1462-1468. 4. Goggin M, Moore S, Esterman A. Outcome of toric intraocular lens implantation after adjusting for anterior chamber depth and intraocular lens sphere equivalent power effects. Arch Ophthalmol. 2011; 129(8):998-1003. 5. Koch DD, Ali SF, Weikert MP, et al. Contribution of posterior corneal astigmatism to total corneal astigmatism. J Cataract Refract Surg. 2012; 38:2080-2087. 6. Visser N, Bauer NJ, Nuijts RM. Residual astigmatism following toric intraocular lens implantation related to pupil size. J Refract Surg. 2012; 28(10):729-732. 7. Visser N, Berendschot TT, Bauer NJ, et al. Accuracy of toric intraocular lens implantation in cataract and refractive surgery. J Cataract Refract Surg. 2011; 37(8):1394-1402. ** The co-author has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 60 Section V: ESCRS Symposium 2015 Subspecialty Day | Refractive Surgery Multifocal IOL Dissatisfaction: Causes and Solutions Oliver Findl MD NOTES 2015 Subspecialty Day | Refractive Surgery Section V: ESCRS Symposium Secondary Procedures in Eyes With Phakic IOLs Jose L Güell MD During these last few years, phakic IOLs have established their role in managing refractive errors, especially in high ametropia and in those eyes who have corneal surgery nonindicated. We are well aware of their limitations and long-term safely results. As with any other refractive procedure, reinterventions to adjust final refraction, either because of an initial under- or overcorrection or because of certain instability with time, are relatively common. On the other hand, other reinterventions such as explantation with or without crystalline lens surgery, endothelial transplantation, or retinal surgery may also take place. We will present our experience with the different situations where a reintervention is needed after phakic IOL implantation, including refractive adjustments, explantations for different reasons, and secondary surgeries. 61 62 Section V: ESCRS Symposium 2015 Subspecialty Day | Refractive Surgery Dealing With SMILE Inaccuracies David Donate MD Introduction A New Technique: SubCap-LE Small lenticule extraction (SMILE) is considered safe, predictable, and effective in treating myopia and myopic astigmatism. Nevertheless, the presence of residual refractive errors may require further enhancements. Successful enhancement of femtosecond lenticule extraction has also been reported. To our knowledge, this is the first detailed description of a retreatment performed with modified SMILE technique after a primary SMILE surgery. It is called “sub-cap-lenticule-extraction” (SubCap-LE). The aim of this new technique is to leave the cap of the primary SMILE procedure untouched to conserve the benefits associated with SMILE. It has no new superior lenticule cut to avoid the risk of a multiple dissection plane. The interface of the primary SMILE procedure became the superior plane of the new lenticule; and the laser cut, the inferior plane and the side cut of the new lenticule. The surgeon stopped the treatment after the laser cut the new lenticule and the side cut. The new lenticule was removed through the original corneal incision. The Alternatives for Retreatment After SMILE The possibility of retreatment after refractive surgery is significant and depends on several factors, such as preoperative ametropia, topographical and biomechanical characteristics, individual healing, and patient complaints. PRK is considered the simplest procedure to correct a residual refraction after SMILE, but pain, slow recovery, and postoperative haze are the major concern. A new strategy called “Circle” has been developed with the aim of transforming the original cap into a flap. It is also possible to perform a secondary SMILE procedure after a primary SMILE procedure. This has the advantage of retaining SMILE’s main benefits, such as absence of pain and dryness and maintenance of biomechanical properties of the cornea. However, the challenge is to avoid any interference between the new lenticule and the existing interface. As D. Reinstein described, LASIK is still the best solution for an enhancement after a primary SMILE procedure. Conclusion SubCap-LE enhancement after primary SMILE procedure to eliminate residual refractive myopic error is feasible and has demonstrated its efficacy and safety in our case. More cases are needed and further studies should be performed to determine a precise surgical profile for SMILE enhancements. Figure 1. The SubCap-LE. From Donate D, Thaëron R. Preliminary evidence of successful enhancement after a primary SMILE procedure with the sub-cap-lenticule-extraction technique. J Refract Surg. In press. Section V: ESCRS Symposium 2015 Subspecialty Day | Refractive Surgery 63 Retreatments After Presbyopic LASIK Roberto Bellucci MD presbyLASIK, retreatments have been performed for a variety of reasons: I. Presbyopic LASIK A. For more than 15 years refractive surgeons have been trying to correct for presbyopia through an excimer laser corneal approach. Over the latest years 3 procedures have gained clinical acceptance: 1. Micromonovision (Zeiss AG; Oberkochen, Germany) The building of a plus add of about +1.5 D in the nondominant eye, while the dominant eye is corrected to emmetropia. It can be titrated to meet individual needs. 2. PresbyMAX (Schwind AG; Kleinostheim, Germany) A bilateral procedure that builds a small plus add in the central cornea, gradually fading pericentrally to emmetropia. Currently there are 3 versions, including micromonovision to improve near vision. 3. Supracor (Technolas PV; Munich, Germany) A bilateral procedure that builds a 1.5-mm small plus add in the central cornea, immediately fading pericentrally to emmetropia. Currently there are 2 versions: “regular,” adding about +2.0 D, and “mild,” adding about +1.5 D. B. Good results have been reported with each technique, claiming up to 90% success rate.1-6 However, patient satisfaction varied across studies, and every author reported about retreatments. Early retreatments are not recommended because the complex corneal profile that is aimed for by PresbyMAX and Supracor require some time to stabilize. Therefore a 6-month waiting period is recommended before considering retreatment. After 1. Insufficient distant vision: Far vision enhancement 2. Insufficient near vision: Near vision enhancement 3. Inability to accept the new visual condition: Treatment reversal As many retreatments are performed only in 1 eye, the number of retreated patients is of outmost importance in evaluating the actual success rate of these procedures. II. Retreatments After Micromonovision Retreatments after micromonovision were published by Reinstein et al.1-3 They employed a microkeratome to cut the flap, 130- to 160-µm depth, and the MEL 80 excimer laser (Zeiss) to perform the ablation. The overall success and retreatment rates were similar in the first series and improved slightly in the last series of nearly emmetropic patients. Noticeably, the percentage of retreatments to improve distance vision decreased over time, probably because of small protocol adjustments. Employing a slightly different technique and the Allegretto excimer laser (WaveLight; Erlangen, Germany), Alacorn et al had a similar retreatment rate of 12%.4 It appears that some retreatments must be taken into account with the micromonovision technique, despite the latest improvements in patient selection and counseling. However, retreatments yielded satisfactory results with this technique, increasing patient satisfaction and independence from spectacles. Table 1. Micromonovision Reinstein 20091 Reinstein 20112 Reinstein 20123 Alacorn 20114 Original refraction Hyperopia Myopia Emmetropia All Patients (N) 111 136 148 25 UDVA 0.00 or better (%) 94 82 98 90 UNVA J2 or better (%) 81 91 96 90 Success % (patients) 74 76 81 88 Retreat % (patients) 26 24 19 12 Far retreat (eyes) % 17 20 9 12 Near retreat (eyes) % 26 18 14 0 64 Section V: ESCRS Symposium 2015 Subspecialty Day | Refractive Surgery opic patients and in 2013 for myopic patients. Therefore the experience with this type of treatment is lower, and the available research is reported in Table 3. The 4 reported data sets can be divided into 2 groups. Ryan7 and Bellucci8 report rather high retreatment rates, mainly due to distant vision problems. The patients were originally low hyperopes, so this may be related to the persistence of the low myopia induced by the treatment in the first weeks after surgery. To overcome this problem and to increase patient satisfaction, a micromonovision approach has been subsequently adopted, aiming at inducing -0.5 D of myopia in the nondominant eye. The early results of this algorithm have been reported by Bellucci9 and Saib,10 indicating better outcome as compared with the previous protocol. The number of retreatments dropped, with higher patient satisfaction. It should be noted that they employed a femtosecond laser to cut the flap. III. Retreatments After PresbyMAX There are 2 recent papers reporting retreatments after the PresbyMAX technique. They differ both for the number of involved patients and for the employed technique. Baudu et al employed the original protocol implementing the same refraction in both eyes,5 while Luger et al tried to improve near vision by targeting low myopia in both eyes: -0.1 D in the dominant eye and -0.9 D in the nondominant eye.6 Another difference is the flap cut system, which was CarriazoPendular Microkeratome in the Baudu series and IntraLase 100µ in the Luger series. According to published results, the need for retreatment increased with micromonovision, because 37% of patients reported their distance vision as insufficient, as compared with 19% of total retreatments in the Baudu series. As expected, no treatment was required to improve near vision in the Luger study. Interestingly, 3% of the Baudu patients received a second presbyopic treatment, apparently with no centration problems. One patient in each series received a reversal of the presbyopic treatment, again with apparent satisfactory results. Table 2. PresbyMAX (Schwind) Baudu 20135 Luger 20156 Treatment Regular Micromonovision Original refraction All All Patients (N) 358 32 UDVA 0.00 or better (%) 44 93 UNVA J2 or better (%) 94 90 Success % (patients) 81 63 Retreat % (patients) 19 37 Far retreatments (%) 13 37 Near retreatments (%) 6 0 IV. Retreatments After Supracor The Supracor algorithm to treat presbyopia at the time of LASIK surgery received approval in 2011 for hyper- V. Discussion and Conclusion From this analysis and from personal experience we can draw some conclusions about the success and the retreatment rate after presbyopic LASIK. Regardless of the procedure adopted, the balance between far and near vision is a difficult one to obtain in every patient, and probably some individual adjustment of the proposed ablation profile is required to increase patient satisfaction. As a rule, the improvement of near vision obtained by increasing myopia in the nondominant eye led to better results, but retreatments to improve distant vision increased as well. The introduction of even low myopia (-0.1 D) in the dominant eye was associated with the highest retreatment rate so far. Recent technology employing femtosecond laser to cut the flap and centration through iris recognition is probably of help in improving patient satisfaction and reducing the retreatment rate. The outcome of retreatments has been described as successful in all the examined studies. Only 1 patient had to be retreated twice to meet his expectations. In addition, the feasibility of presbyLASIK reversal has been demonstrated for both PresbyMAX and Supracor algorithms, thus encouraging patients and doctors to implement this precise, demanding, and yet exciting procedure. Table 3. Supracor (Technolas PV) Ryan 20137 Bellucci 20148 Bellucci 20159 Saib 201510 Treatment Regular Regular Micromonovision Micromonovision Original refraction Hyperopia Hyperopia All All Patients (N) 23 22 15 37 UDVA 0.00 or better 48 54 83 64 UNVA J2 or better 74 89 93 86 Success (%) 78 75 93 86 Retreat (%) 22 25 7 14 Far retreatments (%) 22 20 7 11 Near retreatments (%) 4 5 0 3 2015 Subspecialty Day | Refractive Surgery Section V: ESCRS Symposium 65 References 1. Reinstein DZ, Couch DG, Archer TJ. LASIK for hyperopic astigmatism and presbyopia using micro-monovision with the Carl Zeiss Meditec MEL80 platform. J Refract Surg. 2009; 25(1):37-58. 2. Reinstein DZ, Archer TJ, Gobbe M. LASIK for myopic astigmatism and presbyopia using non-linear aspheric micro-monovision with the Carl Zeiss Meditec MEL 80 platform. J Refract Surg. 2011; 27(1):23-37. 3. Reinstein DZ, Carp GI, Archer TJ, Gobbe M. LASIK for presbyopia correction in emmetropic patients using aspheric ablation profiles and a micro-monovision protocol with the Carl Zeiss Meditec MEL 80 and VisuMax. J Refract Surg. 2012; 28(8):531-541. 4. Alarcón A, Anera RG, Villa C, Jiménez del Barco L, Gutierrez R. Visual quality after monovision correction by laser in situ keratomileusis in presbyopic patients. J Cataract Refract Surg. 2011; 37(9):1629-1635. 5. Baudu P, Penin F, Arba Mosquera S. Uncorrected binocular performance after biaspheric ablation profile for presbyopic corneal treatment using Amaris with the PresbyMAX module. Am J Ophthalmol. 2013; 155(4):636-647, 647.e1. 6. Luger MH, McAlinden C, Buckhurst PJ, Wolffsohn JS, Verma S, Mosquera SA. Presbyopic LASIK using hybrid bi-aspheric micromonovision ablation profile for presbyopic corneal treatments. Am J Ophthalmol. 2015; 160(3):493-505. 7. Ryan A, O’Keefe M. Corneal approach to hyperopic presbyopia treatment: six-month outcomes of a new multifocal excimer laser in situ keratomileusis procedure. J Cataract Refract Surg. 2013; 39(8):1226-1233. 8. Bellucci R. One-year results with a new presbylasik algorithm. Proceedings of the Romanian Ophthalmological Society; Bucharest; 2014. 9. Bellucci R. LASIK correction of presbyopia/ Correzione laser della presbyopia [in Italian]. MIDO, Milan, 2015. 10. Saib N, Abrieu-Lacaille M, Berguiga M, Rambaud C, FroussartMaille F, Rigal-Sastourne JC. Central presbyLASIK for hyperopia and presbyopia using micro-monovision with the Technolas 217P platform and Supracor algorithm. J Refract Surg. 2015; 31(8):540546. 11. Luger MH, Ewering T, Arba-Mosquera S. Nonwavefront-guided presby reversal treatment targeting a monofocal cornea after biaspheric ablation profile in a patient intolerant to multifocality. J Refract Surg. 2014; 30(3):214-216. 12. Ang RE, Reyes RM, Solis ML. Reversal of a presbyopic LASIK treatment. Clin Ophthalmol. 2015; 9:115-119. 66 Troutman Prize 2015 Subspecialty Day | Refractive Surgery Antibacterial Efficacy of Accelerated Photoactivated Chromophore for Keratitis: Corneal Collagen Crosslinking PACK-CXL Olivier Richoz MD and Farhad Hafezi MD PhD I. Infectious keratitis is a major cause of global blindness. V.Investigation A. The incidence varies between 27 and 200 in 100,000 contact lens wearers per year.1,2 B. In the United States, a central register reports 60,000 new cases per year.3 C. In India, the estimated number of corneal ulcers is 2 million per year.4 We investigated antimicrobial killing efficacy of accelerated PACK-CXL. II. Treatment of bacterial and fungal keratitis is challenging. A. Fluoroquinolone- and azole-resistant pathogens have been reported.5,6 B. Antibiotic and antifungal treatment is difficult and expensive. C. Infectious keratitis may be therapy resistant. III. Photoactivated Riboflavin (PACK-CXL) for Treatment of Keratitis A. In 2008, a proof of concept study showed photoactivated riboflavin to be beneficial in cases of therapy-resistant infectious keratitis.7 B. PACK-CXL is the object of many clinical and laboratory studies.8-15 IV.Issues A. Most PACK-CXL has used time-consuming settings of conventional CXL for keratoconus: 3 mW/cm2 for 30 minutes. B. The therapeutically increased biomechanical stiffness produced by CXL is time limited; when high intensities are used, stiffness is significantly reduced.16 A. Materials and methods 1. The killing rate of PACK-CXL at increased irradiance was tested on Staphyloccocus aureus strain SA564 and Pseudomonas aeruginosa strain PA01 (see Table 1). 2. Bacterial suspensions of fresh cultures grown on Mueller-Hinton agar at a titer of 0.5 McFarland diluted 1:10 in NaCl 0.9% were preincubated 30 minutes with 0.1% riboflavin. 3. Pig stromal corneal lamellas of 150-μm thickness and 10-mm diameter were created. 4. 10 μL of each bacterial suspension was applied onto a corneal lamella. 5. PACK-CXL of 5.4 J/cm2 was performed at 365 μm on individual corneal lamellae at either 5 minutes at 18 mW/cm2 (low irradiance) or 2.5 minutes at 36 mW/cm2 (high irradiance). 6. Control corneal lamellae received no CXL treatment. 7. After CXL, lamellae were placed in an Eppendorf tube in 1 ml of 0.9% NaCl for 30 minutes, and then 10 μL were plated on Mueller-Hinton agar. 8. Colony forming units were counted after 24 hours of aerobic incubation at 37° C. B.Results 1. Significant differences (P < .001) were observed between control and cross-linked corneal lamellae. 2. No significant difference in colony count reduction was found between the high and low irradiation-treated lamellae. C. However, the bacterial killing effect of high-irradiance PACK-CXL was unknown. Table 1. Bacteria Control 5 min at 18 mW/cm2 2.5 min at 36 mW/cm2 Staphylococcus aureus (SA564) 100% 93.2% ± 8.3% 92.9% ± 5.0% Pseudomonas aeruginosa (PA01) 100% 92.5% ± 5.5% 94.4% ± 2.9% 2015 Subspecialty Day | Refractive Surgery VI.Discussion A. Several mechanisms may be responsible for the antimicrobial effect of photoactivated riboflavin. 1. Riboflavin does intercalate and irreversibly bind to nucleic acids.17 2. Photoactivated riboflavin creates reactive oxygen species.18 B. The efficiency of one or both mechanisms seems to remain relatively elevated at high irradiance. VII.Conclusions A. High-fluency CXL is less effective for therapeutically increasing corneal biomechanics for keratoconus treatment. B. High-fluency CXL (PACK-CXL) shows high antimicrobial killing efficacy. C. PACK-CXL may be a promising treatment for microbial keratitis treatment. References 1. Cheng KH, Leung SL, Hoekman HW, et al. Incidence of contactlens-associated microbial keratitis and its related morbidity. Lancet. 1999; 354(9174):181-185. 2. Stapleton F, Keay L, Edwards K, et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology 2008; 115(10):1655-1662. 3. Jeng BH, Gritz DC, Kumar AB, et al. Epidemiology of ulcerative keratitis in Northern California. Arch Ophthalmol. 2010; 128(8):1022-1028. 4. Whitcher JP, Srinivasan M. Corneal ulceration in the developing world—a silent epidemic. Br J Ophthalmol. 1997; 81(8):622-623. 5. Goldstein MH, Kowalski RP, Gordon YJ. Emerging fluoroquinolone resistance in bacterial keratitis: a 5-year review. Ophthalmology 1999; 106(7):1313-1318. 6. Edelstein SL, Akduman L, Durham BH, Fothergill AW, Hsu HY. Resistant Fusarium keratitis progressing to endophthalmitis. Eye Contact Lens. 2012; 38(5):331-335. Troutman Prize 67 7. Iseli HP, Thiel MA, Hafezi F, Kampmeier J, Seiler T. Ultraviolet A/ riboflavin corneal cross-linking for infectious keratitis associated with corneal melts. Cornea 2008; 27(5):590-594. 8. Galperin G, Berra M, Tau J, Boscaro G, Zarate J, Berra A. Treatment of fungal keratitis from Fusarium infection by corneal crosslinking. Cornea 2012; 31(2):176-180. 9. Hellander-Edman A, Makdoumi K, Mortensen J, Ekesten B. Corneal cross-linking in 9 horses with ulcerative keratitis. BMC Vet Res. 2013; 9:128. 10. Li Z, Jhanji V, Tao X, Yu H, Chen W, Mu G. Riboflavin / ultraviolet light-mediated crosslinking for fungal keratitis. Br J Ophthalmol. 2013; 97(5):669-671. 11. Makdoumi K, Mortensen J, Crafoord S. Infectious keratitis treated with corneal crosslinking. Cornea 2010; 29(12):1353-1358. 12. Makdoumi K, Mortensen J, Sorkhabi O, Malmvall BE, Crafoord S. UVA-riboflavin photochemical therapy of bacterial keratitis: a pilot study. Graefes Arch Clin Exp Ophthalmol. 2012; 250(1):95-102. 13. Martins SA, Combs JC, Noguera G, et al. Antimicrobial efficacy of riboflavin/UVA combination (365 nm) in vitro for bacterial and fungal isolates: a potential new treatment for infectious keratitis. Invest Ophthalmol Vis Sci. 2008; 49(8):3402-3408. 14. Moren H, Malmsjo M, Mortensen J, Ohrstrom A. Riboflavin and ultraviolet A collagen crosslinking of the cornea for the treatment of keratitis. Cornea 2010; 29(1):102-104. 15. Pot SA, Gallhöfer NS, Matheis FL, Voelter-Ratson K, Hafezi F, Spiess BM. Corneal collagen cross-linking as treatment for infectious and noninfectious corneal melting in cats and dogs: results of a prospective, nonrandomized, controlled trial. Vet Ophthalmol. 2014; 17(4):250-260. 16. Hammer A, Richoz O, Arba Mosquera S, Tabibian D, Hoogewoud F, Hafezi F. Corneal biomechanical properties at different corneal cross-linking (CXL) irradiances. Invest Ophthalmol Vis Sci. 2014; 55(5):2881-2884. 17. Naseem I, Ahmad M,Hadi SM. Effect of alkylated and intercalated DNA on the generation of superoxide anion by riboflavin. Biosci Rep. 1988; 8:485-492. 18. Kumari MV, Yoneda T, Hiramatsu M. Scavenging activity of “beta catechin” on reactive oxygen species generated by photosensitization of riboflavin. Biochem Mol Biol Int. 1996; 38:1163-1170. 68 Section VI: The Journal of Refractive Surgery’s Late Breaking News 2015 Subspecialty Day | Refractive Surgery The Role of PTA in Screening Marcony R Santhiago MD What Is PTA? Role of PTA in Eyes With Suspicious Topography There is an integrated relationship between preoperative corneal thickness, ablation depth, and flap thickness in determining the relative amount of biomechanical change that has occurred after a LASIK procedure. We have proposed and investigated a new metric, the percent of anterior tissue depth altered, or percent tissue altered (PTA), that describes this interaction during excimer laser refractive surgery, which for LASIK can be described as: Previous studies have shown that abnormal corneal topographic patterns are the most significant risk factor for postoperative ectasia.8,9 Our study specifically conducted on eyes with suspicious topography revealed that there remains a significant correlation between PTA values and ectasia risk after LASIK, even in eyes with suspicious corneal topography. Less tissue alteration, or a lower PTA value, was necessary to induce ectasia in eyes with more remarkable signs of topographic abnormality, and PTA provided better discriminative capabilities than RSB for all study populations. It should also be clear that these results do not indicate that is safe to perform LASIK in eyes with suspicious topographic patterns simply by respecting a low PTA limit. These findings merely demonstrate that lower PTA values are associated with increased corneal stability and therefore reduced ectasia risk even in eyes with suspicious preoperative topography. PTA = (FT + AD)/CCT1-5 where PTA = percent tissue altered, FT = flap thickness, AD = ablation depth, and preoperative CCT = central corneal thickness. Potential Use in Practice While most patients who have developed ectasia after LASIK have, in retrospect, had identifiable risk factors, particularly irregular topographic patterns, that placed them at higher risk for this complication, ectasia cases in patients with normal preoperative topography still present a conundrum. Our studies provided evidence that a high value of PTA, especially greater than 40%, is a relevant factor in the development of post-LASIK ectasia in eyes with normal preoperative Placido disk-based topography, and that therefore PTA should be taken into account as a screening parameter for refractive surgery candidates. This metric more accurately represents the risk of ectasia than the individual components that comprise it.1-3 Since the cohesive tensile strength is not uniform throughout the central corneal stroma, and the anterior 40% of the corneal stroma has significantly greater cohesive tensile strength, removing this relevant part of the stroma may induce corneal weakening in increasing proportion as the threshold of 40% is reached and crossed.6,7 As compared to specific residual stromal bed (RSB) or CCT values, PTA likely provides a more individualized measure of biomechanical alteration because it considers the relationship between thickness, tissue altered through ablation and flap creation, and ultimate residual stromal bed thickness. Association Between PTA and Ectasia in Eyes With Normal Topography Our studies1 revealed that in eyes with normal preoperative topography, PTA had higher prevalence, higher odds ratio, and higher predictive capabilities for ectasia risk than moderate to high ERSS (Ectasia Risk Score System) values, RSB, CCT, high myopia, ablation depth, and age. PTA ≥ 40 was a more robust indicator of risk than other variables in patients with normal preoperative topography, being even more sensitive than the absolute cut-off value of the RSB (300 μm) itself, which influenced the risk of ectasia the most. Relative Contribution of Flap Thickness and Ablation Depth to PTA Despite representing a more individualized metric than CCT or RSB, PTA still has equally weighted components, flap thickness (FT) and ablation depth (AD), that may not have equal importance. Since these variables affect the central cornea similarly but have significant differences in their relative alteration of peripheral corneal fibers, they may have different effects on ultimate biomechanical integrity based on anatomic differences in the anterior corneal stromal fiber interconnections. We also conducted a specific study3 to investigate the relative contribution of FT and AD to the PTA after LASIK, and to evaluate the importance of these differences in further differentiating between eyes that do and do not develop ectasia with normal preoperative topography. We found that LASIK flap had greater impact than ablation depth; however, thicker flaps alone were insufficient to create ectasia unless coupled with greater ablation depths and thus high PTA values. PTA was a more significant factor than the variables that comprise it. References 1. Santhiago MR, Smadja D, Gomes BF, et al. Association between the percent tissue altered and post-laser in situ keratomileusis ectasia in eyes with normal preoperative topography. Am J Ophthalmol. 2014; 158:87-95. 2. Santhiago MR, Smadja D, Wilson SE, Krueger RR, Monteiro ML, Randleman JB. Role of percent tissue altered on ectasia after LASIK in eyes with suspicious topography. J Refract Surg. 2015; 31:258265. 3. Santhiago MR, Smadja D, Wilson SE, Randleman JB. Relative contribution of flap thickness and ablation depth to the percent tissue altered (PTA) in post-LASIK ectasia. J Cataract Refract Surg. In press. 2015 Subspecialty Day | Refractive Surgery Section VI: The Journal of Refractive Surgery’s Late Breaking News 4. Santhiago MR, Wilson SE, Hallahan KM, et al. Changes in custom biomechanical variables after femtosecond laser in situ keratomileusis and photorefractive keratectomy for myopia. J Cataract Refract Surg. 2014; 40:918-928. 5. Santhiago MR, Kara-Junior N, Waring GO 4th. Microkeratome versus femtosecond flaps: accuracy and complications. Curr Opin Ophthalmol. 2014; 25:270-274. 6. Randleman JB, Dawson DG, Grossniklaus HE, et al. Depth-dependent cohesive tensile strength in human donor corneas: implications for refractive surgery. J Refract Surg. 2008; 24:85-89. 7. Reinstein DZ, Archer TJ, Randleman JB. Mathematical model to compare the relative tensile strength of the cornea after PRK, LASIK, and small incision lenticule extraction. J Refract Surg. 2013; 29:454-460. 8. Randleman JB, Russell B, Ward MA, et al. Risk factors and prognosis for corneal ectasia after LASIK. Ophthalmology 2003; 110:267275. 9. Randleman JB, Woodward M, Lynn MJ, Stulting RD. Risk assessment for ectasia after corneal refractive surgery. Ophthalmology 2008; 115:37-50. 69 70 Section VI: The Journal of Refractive Surgery’s Late Breaking News 2015 Subspecialty Day | Refractive Surgery Simultaneous Correction of Unilateral Rainbow Glare and Residual Astigmatism by Undersurface Flap Photoablation After Femtosecond-Assisted LASIK Damien Gatinel MD, Alain Saad MD, Emmanuel Guilbert MD, Hélène Rouger OD** Abstract Case Report Purpose: To report and document a case of successful rainbow glare correction using undersurface ablation of the LASIK flap. Methods: A 33-year-old female was treated bilaterally for myopia with femto-laser assisted LASIK using the FS200 femtosecond laser. Postoperatively, she complained of rainbow glare in her right eye (O.D.) and presented some residual myopic astigmatism. Six months after the initial LASIK procedure, the O.D. flap was lifted and a toric excimer correction was delivered on its stromal side. Results: Visual symptoms related to the rainbow glare disappeared immediately after the completion of the procedure and did not reoccur. Uncorrected visual acuity improved by 2 lines. Conclusions: Rainbow glare following femto LASIK can be successfully corrected by undersurface ablation of the flap. A 33-year-old Asian female was referred to our clinic for compound myopic astigmatism correction. Her preoperative BCVA was 20/20 in both eyes, with a refractive correction of -3.50 (-1.25x180°) O.D., and -3(-1.75x5°) O.S. An FS200 femtosecond laser (Alcon Laboratories, Inc.; Fort Worth, TX) was used to create superiorly hinged elliptical 9.3 mm x 7.8 mm flaps, followed by excimer laser ablation using the EX500 excimer laser (Alcon Laboratories, Inc., Fort Worth, TX). The FS200 laser settings were identical in both eyes, with a planned interface depth of 130 microns. The bed spots and line separation was 8 microns, and the energy was 0.82 μJ. The O.D. cornea image taken by the FS200 laser camera immediately after the completion of the laser flap creation revealed a subtle raster pattern created by the cavitation bubbles. This was not observed on the OS cornea (see Figure 1). One day postoperatively, uncorrected distance visual acuity (UDVA) was 20/25 O.D. and 20/20 O.S. In the early postoperative period, the patient complained about colored radiating haloes extending laterally and vertically around bright light sources, which were seen with the right eye only. Each radiating band contained a typical rainbow-spectrum color pattern, extending from violet to blue to red at its outermost extent. In addition, the patient reported slight blurring of her vision O.D. At 1 month postoperatively, UCVA was 20/25 O.D., and BCVA was 20/20 with a plano (-1x180°) lens. Rainbow glare is a rare optical side effect of femtosecond LASIK that was first described in 2008 by Krueger et al.1 Patients affected by this describe seeing a spectrum of colored bands proceeding in rainbow-like fashion. The cause of the rainbow glare is thought to be the diffraction of light from the grating pattern created on the back surface of the LASIK flap after femtosecond laser use. We report the first case of successful rainbow glare surgical correction using undersurface ablation of the flap for LASIK retreatment of low residual astigmatism. Figure 1. Energy and spot parameters used for the right eye flap creation with the FS200 femtosecond laser. The snapshots of the right taken right after the completion of the interface creation is evocative of a raster shot pattern. ** The co-author has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 2015 Subspecialty Day | Refractive Surgery Section VI: The Journal of Refractive Surgery’s Late Breaking News 71 Figure 2. Six months postoperative axial curvature map, showing withthe-rule corneal toricity (OPD SCAN III). O.S. and O.D. anterior axial curvature maps showed a central flattened zone without significant irregularities. On the right eye, simulated keratometry showed 1 D of with-the-rule astigmatism (see Figure 2). Confocal microscopy of the right and left corneas were obtained using the HRT II confocal microscope equipped with the Rostock corneal module (RCM). On the right cornea, multiples rows of hyper-reflective spots appeared at about 125 microns below the anterior corneal surface (see Figure 3). Six months later, it was decided to attempt to correct the persistent residual astigmatism and rainbow glare symptoms by performing undersurface ablation of the LASIK flap (see Figure 4). A gentian violet pen was used to mark the center of the pupil on the cornea and create lateral marks to improve flap repositioning. A flap rhexis was followed by elevation and turn back of the flap. The patient was asked to look downward and the EX500 excimer laser delivered a 6.50-mm optical zone toric ablation plano (-1x180°) on the stromal portion of the flap. Immediately after the procedure, a white flash light was shone at 50 cm from the patient’s right eye. The rainbow glare pattern was no longer perceptible. At Day one and Day 30 controls, UCVA was 20/20 O.D., and the rainbow glare pattern perception did not reoccur. Confocal microscopy examination performed 1 week after undersurface ablation showed no evidence of the prior multiple spot patterns. Discussion Even with the latest advances in femtosecond laser technology, rainbow glare remains a possible optical side effect related to diffraction of light from the grating pattern created on the back surface of the LASIK flap after femtosecond laser use.1,2 Using in vivo confocal microscopy, we have reported the presence of similar hyper-reflective spots after LASIK in rainbow glare symptomatic eye in which flaps were also created with the FS200 femtosecond laser.3 It was presumed, but not confirmed, that these irregularities were located on the posterior side of the flap. In the present case, the disappearance of visual symptoms and hyper-reflective shot pattern in the right eye after undersurface flap ablation reinforces the hypothesis that the uniform array of periodically aligned photodisruption defects are located at the posterior surface of the LASIK flap. Figure 3. Observation of hyper-reflective zones in an equidistant arrangement, measuring only a few microns at the Month 6 examination of the patient’s right eye. This aspect is evocative of the tissular response of the femtosecond laser impacts at the posterior side of the flap: the spacing of the impacts is about 8 microns (HRT II image; magnification, 400×400 μm.) Maldonado first reported in 2002 that undersurface ablation of the flap for LASIK retreatment of low residual myopic and astigmatic refractive errors seemed safe and effective.4 Other reports have confirmed that this method was effective for retreatments5,6 or when combined with LASIK in eyes with high myopia and thin corneas.7,8 Our observation is the first report of successful undersurface ablation of rainbow glare occurring after femto-LASIK and suggests that this technique may be an effective method to suppress the symptoms related to rainbow glare. In conclusion, we report the first case of successful undersurface ablation of rainbow glare occurring after femto-LASIK. Further cases are necessary to confirm these findings. Consequently, further investigation is necessary to evaluate its clinical impact and effect on the visual function, and to better understand the factors contributing to it. 72 Section VI: The Journal of Refractive Surgery’s Late Breaking News Figure 4. Steps in undersurface of the flap retreatment: (A) The right eye was draped in a sterile fashion; care was taken to keep the lashes out of the surgical field. The peripheral cornea and the corneal center of the entrance pupil were marked with a blunt tip stained with a gentian violet solution. (B) While the patient as asked to look downward, the hinged anterior corneal flap was temporarily elevated and reclined on a flat domed spatula using a Merocel sponge. (C) The eye tracker of the EX500 excimer laser was deactivated, and the photoablation was delivered on 2015 Subspecialty Day | Refractive Surgery the stromal bed, manually centered on the entrance pupil center mark. (D) The laser-treated corneal flap was replaced on the cornea, and the interface irrigated with BSS before the flap was painted back into position with a wet Merocel sponge. (E) After the completion of the procedure, the patient was asked to describe her visual perception by looking at a bright white light source. The typical rainbow glare pattern, which was present before the surgery, had disappeared immediately after. References 1. Krueger RR, Thornton IL, Xu M, Bor Z, van den Berg TJ. Rainbow glare as an optical side effect of IntraLASIK. Ophthalmology 2008; 115(7):1187-1195. 6. Taneri S, Azar DT. Ablation on the undersurface of a LASIK flap: instrument and method for continuous eye tracking. Ophthalmologe 2007; 104(2):132-136. 2. Bamba S, Rocha KM, Ramos-Esteban JC, Krueger RR. Incidence of rainbow glare after laser in situ keratomileusis flap creation with a 60 kHz femtosecond laser. J Cataract Refract Surg. 2009; 35(6):1082-1086. 7. Joo MJ, Kim YN, Hong HC, Ryu DK, Kim JH. Simultaneous laser in situ keratomileusis on the stromal bed and undersurface of the flap in eyes with high myopia and thin corneas. J Cataract Refract Surg. 2005; 31(10):1921-1927. 3. Gatinel D, Saad A, Guilbert E, Rouger H. Unilateral rainbow glare after uncomplicated femto-LASIK using the FS-200 femtosecond laser. J Refract Surg. 2013; 29(7):498-501. 8. Li LW, Mei WQ, Jun FX. Combined flap undersurface and bed LASIK for high myopia. J Refract Surg. 2005; 21(5 suppl):S606-609. 4. Maldonado MJ. Undersurface ablation of the flap for laser in situ keratomileusis retreatment. Ophthalmology 2002; 109(8):14531464. 5. Fernández-Vigo J, Macarro A, Fernández Sabugal J. [Undersurface ablation of the corneal flap for LASIK enhancement]. Arch Soc Esp Oftalmol. 2007; 82(11):697-703. 2015 Subspecialty Day | Refractive Surgery Section VI: The Journal of Refractive Surgery’s Late Breaking News 73 Stromal Surface Topography-Guided Custom Ablation as a Repair Tool for Corneal Irregular Astigmatism Dan Z Reinstein MD As described by Alfred Vogt in 1921,1 it is known that the corneal epithelium has the ability to alter its thickness profile to compensate for changes in stromal surface curvature in order to try and re-establish a smooth, symmetrical optical surface. Such compensatory epithelial thickness changes have since been described after myopic excimer laser ablation,2-4 hyperopic excimer laser ablation,5 radial keratotomy,6 orthokeratology,7 keratoconus,8 ectasia,9 and in cases of irregular astigmatism.10,11 This is summarized by the Law of Epithelial Compensation for corneal irregular astigmatism: “If a patient presents with stable refraction and (corneal) irregular astigmatism, by definition the epithelium has reached its maximum compensatory function,” with the corollary that corneal “irregular astigmatism has irregular epithelium.” In cases of irregular astigmatism, the compensatory mechanism of the epithelium has a significant effect, as epithelial thickness changes mask the true curvature of the irregular stromal surface.10,12,13 Due to this epithelial masking, topography and wavefront measurements cannot provide a diagnosis for the exact anatomy of the pathology that needs correcting (ie, the irregular stromal surface). This is due to the fact that internal corneal refractive interfaces (such as the epithelial–stromal interface) to date are still not being measured and incorporated independently into the diagnostic assessment. As a result, topography-guided treatment may lead to a suboptimal treatment,10-13 as it can correct only for the proportion of the stromal irregularity that is not masked by the epithelium. On the other hand, transepithelial phototherapeutic keratectomy (PTK) can correct only for the proportion of the stromal irregularity that has been compensated for by epithelium (ie, that is masked by the epithelium). Therefore, both procedures might be needed to fully regularize the stromal surface. Chen et al14 described the combination of transepithelial PTK ablation with a corneal topography-guided ablation to theoretically fully correct corneal irregularities, based on the assumption that the stromal irregularity consists of the sum of the corneal surface irregularity plus the epithelial remodelling. However, a disadvantage of this technique lies in the postoperative refractive inaccuracy that results from the lack of information regarding the refractive effect of the epithelial remodelling.10 In addition, this technique could potentially result in unnecessarily excessive stromal tissue being removed in corneas that are often already pachymetrically compromised due to multiple procedures. Therefore, the ideal solution would be for the therapeutic profile applied to the eye to be based on the shape of the stromal surface itself to perform a stromal surface topography-guided ablation. The stromal surface shape can be calculated by subtracting the epithelial thickness data from the corneal front surface elevation, which is a method that we first employed in a single clinical case in 2000. A 29-year-old woman presented at Lasik Vision in June 1998, complaining of night vision difficulties and starburst following previous complicated LASIK surgery in her left eye. She had been treated in 1996 with bilateral LASIK for moderate to high myopia (approximately -6 D) with a nasal hinge using the Moria LSK-1 (Antony, France) with the 130-µm head microkeratome and the Nidek EC5000 excimer laser (Hiroishi, Japan); the planned opti- cal zone was 6 mm. On presentation, her manifest refraction in the left eye was +1.75/-0.25x65 with a best-corrected distance visual acuity (CDVA) of 20/25. Slitlamp examination revealed a short nasal flap. Topography and front and back surface elevations were obtained with Orbscan II (Bausch + Lomb; Salt Lake City, Utah). The axial map demonstrated a highly asymmetrical topography with increased flattening on the nasal cornea. The simulated keratometry was 41.4 D @ 169° and 40.4 D @ 79°. The anterior best-fit-sphere elevation map also revealed a high asymmetry across the pupil with a depression nasally where the cornea was the flattest and an elevation temporally. Stromal surface shape was calculated by subtracting the VHF digital ultrasound-derived epithelial thickness data from the Orbscan-derived corneal front surface elevation data. The stromal surface elevation data was used to produce a stromal surface topography ablation profile using the TopoLink software (Version 2.9992TL; Bausch + Lomb Surgical Technolas; Munich, Germany). The final ablation profile map demonstrated a crescent of deep tissue removal nasally, with a maximum ablation of 107 µm where there had been no ablation during the primary procedure because of the short flap. Postoperatively, the epithelial thickness map demonstrated that the epithelial thickness range (max-min) had been reduced from 56 µm to 30 µm, indicating that the stromal surface had been made more regular. Similarly, the axial curvature and anterior elevation maps showed a significant change nasally, resulting in a reduction of the asymmetry. The patient reported a subjective significant improvement in quality of vision and night vision symptoms. This case demonstrates the validity of the method of generating a custom ablation profile defined by the stromal surface topography, as calculated by subtracting the epithelial thickness profile from the front surface elevation. By incorporating the epithelial thickness data into the ablation planning software, a transepithelial PTK ablation would not be required and the custom ablation could be performed under a flap. A stromal topographyguided procedure therefore offers the same advantage as LASIK over PRK, including preservation of the corneal epithelium and a quicker healing response. The ability to map the stromal surface directly would also offer the advantage of being able to regularize the stromal surface in a single treatment, as opposed to what is usually a 2-step procedure with transepithelial PTK. References 1. Vogt A. Textbook and Atlas of Slit Lamp Microscopy of the Living Eye. Bonn: Wayenborgh Editions; 1981. 2. Gauthier CA, Holden BA, Epstein D, Tengroth B, Fagerholm P, Hamberg-Nystrom H. Role of epithelial hyperplasia in regression following photorefractive keratectomy. Br J Ophthalmol. 1996; 80:545-548. 3. Reinstein DZ, Srivannaboon S, Gobbe M, et al. Epithelial thickness profile changes induced by myopic LASIK as measured by Artemis very high-frequency digital ultrasound. J Refract Surg. 2009; 25:444-450. 74 Section VI: The Journal of Refractive Surgery’s Late Breaking News 4. Reinstein DZ, Archer TJ, Gobbe M. Change in epithelial thickness profile 24 hours and longitudinally for 1 year after myopic LASIK: three-dimensional display with Artemis very high-frequency digital ultrasound. J Refract Surg. 2012; 28:195-201. 5. Reinstein DZ, Archer TJ, Gobbe M, Silverman RH, Coleman DJ. Epithelial thickness after hyperopic LASIK: three-dimensional display with Artemis very high-frequency digital ultrasound. J Refract Surg. 2010; 26:555-564. 6. Reinstein DZ, Archer TJ, Gobbe M. Epithelial thickness up to 26 years after radial keratotomy: three-dimensional display with Artemis very high-frequency digital ultrasound. J Refract Surg. 2011; 27:618-624. 7. Reinstein DZ, Gobbe M, Archer TJ, Couch D, Bloom B. Epithelial, stromal, and corneal pachymetry changes during orthokeratology. Optom Vis Sci. 2009; 86:E1006-1014. 8. Reinstein DZ, Archer TJ, Gobbe M, Silverman RH, Coleman DJ. Epithelial, stromal and corneal thickness in the keratoconic cornea: three-dimensional display with Artemis very high-frequency digital ultrasound. J Refract Surg. 2010; 26:259-271. 9. Reinstein DZ, Gobbe M, Archer TJ, Couch D. Epithelial thickness profile as a method to evaluate the effectiveness of collagen cross-linking treatment after corneal ectasia. J Refract Surg. 2011; 27:356-363. 2015 Subspecialty Day | Refractive Surgery 10. Reinstein DZ, Archer TJ, Gobbe M. Refractive and topographic errors in topography-guided ablation produced by epithelial compensation predicted by three-dimensional Artemis very high-frequency digital ultrasound stromal and epithelial thickness mapping. J Refract Surg. 2012; 28:657-663. 11. Reinstein DZ, Archer TJ, Gobbe M. Improved effectiveness of trans-epithelial phototherapeutic keratectomy versus topographyguided ablation degraded by epithelial compensation on irregular stromal surfaces [plus video]. J Refract Surg. 2013; 29:526-533. 12. Reinstein DZ, Archer T. Combined Artemis very high-frequency digital ultrasound-assisted transepithelial phototherapeutic keratectomy and wavefront-guided treatment following multiple corneal refractive procedures. J Cataract Refract Surg. 2006; 32:18701876. 13. Reinstein DZ, Silverman RH, Sutton HF, Coleman DJ. Very highfrequency ultrasound corneal analysis identifies anatomic correlates of optical complications of lamellar refractive surgery: anatomic diagnosis in lamellar surgery. Ophthalmology 1999; 106:474-482. 14. Chen X, Stojanovic A, Zhou W, Utheim TP, Stojanovic F, Wang Q. Transepithelial, topography-guided ablation in the treatment of visual disturbances in LASIK flap or interface complications. J Refract Surg. 2012; 28:120-126. 2015 Subspecialty Day | Refractive Surgery Section VI: The Journal of Refractive Surgery’s Late Breaking News Long-term Postoperative Results of T-Fixation Technique Used for Intrascleral Posterior Chamber IOL Fixation Toshihiko Ohta MD Purpose To evaluate 2-year postoperative outcomes of T-fixation technique used for intrascleral haptic fixation of posterior chamber IOL. Methods Eyes operated with T-fixation technique from January 2012 to April 2013 were included. All patients were evaluated for preoperative status, postoperative status, and complications. Results A total of 71 eyes of 65 patients were analyzed. The median follow-up was 32.7 months. Transient raised IOP was observed in 3 eyes, vitreous hemorrhage was observed in 2 eyes, and optic capture was observed in 2 eyes. There was no decline in corrected visual acuity except 1 eye with an epiretinal membrane. Conclusion Results obtained 2 years after T-fixation technique showed good visual outcomes with minimal complications. 75 76 Section VI: The Journal of Refractive Surgery’s Late Breaking News 2015 Subspecialty Day | Refractive Surgery Profocal Cornea Created by Transparent Hydrogel Corneal Inlay: Mechanism of Action and Clinical Implications Douglas D Koch MD, Enrique Barragan MD, Arturo Chayet MD Purpose To demonstrate how a profocal cornea provides a functional range of vision. Methods In 188 presbyopes implanted with a Raindrop Near Vision Inlay in their nondominant eye, we measured visual outcomes and patient satisfaction. Using ray-trace (Zemax), we calculated the range of good near VA as a function of spectacle defocus. Results Mean uncorrected near VA (logMAR) improved from 0.51 preop to 0.06 (P < .001) at 3 months postop. Uncorrected intermediate VA improved by 2.5 lines (P < .001). Overall satisfaction improved as well (P < .001). Zemax simulations demonstrated corneal power changes consistent with the clinical outcomes. Conclusion Raindrop Inlay creates smooth steepening in the central cornea (profocal cornea), which generates a gradient of power and provides full range of vision and patient satisfaction. 2015 Subspecialty Day | Refractive Surgery Section VI: The Journal of Refractive Surgery’s Late Breaking News 77 Initial Clinical Experience With a New Laser Approach for Precise Capsulotomies Richard B Packard MD, Pavel Stodulka MD Purpose To undertake initial clinical evaluation of a new laser developed for capsulotomy during cataract surgery and attached to the operating microscope. Methods Twenty patients underwent laser capsulotomy with this new thermal laser as part of their cataract surgery. They were evaluated intraoperatively and at 1 week, 1 month, and 3 months postoperatively. Results All capsulotomies were complete and precise. No untoward complications occurred. Postoperative results of capsular changes and IOL position will be presented. Conclusion This new thermal laser demonstrated that using capsular staining as part of the normal workflow of cataract surgery followed by laser use enabled precise, consistent, and complete capsulotomy formation. 78 Section VI: The Journal of Refractive Surgery’s Late Breaking News 2015 Subspecialty Day | Refractive Surgery Micro-Electrostimulation of the Ciliary Body as a New Noninvasive Method for Presbyopia Treatment: Early Results Luca Gualdi MD Purpose Electrostimulation of the ciliary body as a new method for presbyopia treatment: early results. Methods Generator connected 3.5 mm to the limbus by a cable and 4 electrodes in a 20-mm polycarbonate scleral contact lens. An 8-min., 1-200 Hz treatment was performed in 20 eyes (age range: 41-50). Pre- and postop uncorrected near VA (UNVA) and AA with subjective (push-up/blurring) and objective tests, ultrasound biomicroscopy (Sonomed), and AR-1A (Nidek) with accommodation module were analyzed. Results All eyes gained UNVA (avg. +1.25 D). The treatment was able to increase the strength and the function of the ciliary body, partially reactivating the amplitude of accommodation loss due to the early presbyopia. Conclusion Ciliary body electrostimulation is a promising technique to delay accommodation loss, improving presbyopic symptoms. Further follow-up will confirm the stability of the results. 2015 Subspecialty Day | Refractive Surgery Section VI: The Journal of Refractive Surgery’s Late Breaking News Sedky Approach for RelExSMILE Retreatment Ahmed N Sedky FRCOphth Purpose To assist the efficiency of this technique for retreatment after RelExSMILE—how it is unique and easy to overcome one of the still unsolved concerns of this technique. Methods After doing over 600 eyes, we concluded that the RelExSMILE is a unique technique because it preserved the anterior corneal layers with a strong Bowman membrane and it showed less than 1% of retreatment. But we also concluded that all retreatment techniques available (PRK, flap, and a new lenticule formation) are not practical. Results Our new technique for retreatment aims to preserve the Bowman membrane and is easy to perform, using the original cap and original incision. Conclusion Our technique showed easy, predictable results. 79 80 Section VI: The Journal of Refractive Surgery’s Late Breaking News 2015 Subspecialty Day | Refractive Surgery Diagnostic Intraoperative and Swept Source Postoperative OCT for the Prediction of Postoperative IOL Position During Femtosecond Refractive Laser-Assisted Cataract Surgery Joseph J Ma MD, Alice Zhu** Purpose To predict postoperative lens position (pELP) with a 3-D OCT algorithm (A3D) to improve outcomes. Methods Retrospective review of refractive laser-assisted cataract surgery (ReLACS) patients. A3D was compared to predictions with multivariate preop biometry (t1-ELP, t2-ELP) and pELP. pELP: masked, manually validated Scheimpflug imaging (SI) and swept source (SS) OCT at > 1 month postop. Results Average pELP: 4.99 mm (SD: 0.30), average A3D: 5.02 mm (SD 0.32) (r = 0.68; P < .01). Average t1-ELP: 5.71 (SD: 0.40) (r = 0.53; P < .01). Average pachymetry, anterior chamber depth, lens thickness correlation coefficients were r = 0.872, r = 0.910, and r = 0.942, respectively, vs. reflectometry, P < .01, SI:SS, r = 0.82 (P < .01). Conclusion A3D is superior to theoretically calculated multivariate estimates of pELP. Further refinements in this algorithm can potentially result in more accurate postoperative refractive outcomes. ** The co-author has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 2015 Subspecialty Day | Refractive Surgery Section VI: The Journal of Refractive Surgery’s Late Breaking News Refractive Lenticule Implantation (Relimp) for Unilateral Aphakia Osama I Ibrahim MD PhD, Moones Fathi Abdalla MD, Ibrahim Osama Sayed-Ahmed MBBCH Purpose To evaluate the visual and refractive outcomes, as well as the reproducibility, of small incision lenticule implantation in unilateral aphakia in which secondary IOL is not possible to perform. Methods SMILE was performed to correct the astigmatic element, then a fresh lenticule from a myopic donor was implanted instead. Results Four eyes of 4 patients underwent SMILE followed by donor lenticule implantation procedure. Mean follow-up was 4 months (range: 2-6 months). The mean UCVA (Snellen decimal) changed from 0.05 preoperatively (range: 0.01-0.1) to 0.3 postoperatively (range: 0.1-0.5). The mean BCVA changed from 0.3 preoperatively (range: 0.1-0.5) to 0.3 at last follow-up postoperatively (range: 0.1-0.6). There was no loss of lines of UCVA or BCVA in any of our patients postoperatively. 81 82 Section VI: The Journal of Refractive Surgery’s Late Breaking News 2015 Subspecialty Day | Refractive Surgery PRESBV (Presbyopia Vejarano) TEARS Noninvasive Solution for Presbyopia Luis Felipe Vejarano MD Purpose To evaluate the predictability, efficacy, reliability, and safety of this innovative noninvasive treatment for ameliorating presbyopia. Methods Prospective study of results in pseudo and accommodation refraction / change UCVA / BCVA for far and near pupil size Km and others, using 1 drop in both eyes. Results Twenty patients who received PresbV Tears—9 emmetropes, 5 post-LASIK, and 6 post-presbV LASIK—with average age of 49.65 years (range: 41-57), were measured previously, half an hour later, 1, 2, 3, 4, and 5 hours later, and 1 week and 1 month after. Globally improved 1 line far and 3 near, min photopic and scotopic changes in pupil size, mild myopic shift, decreased IOP 2 mm, and Km get steep typically, showing the accommodation stimulus. Conclusion This is a promising noninvasive and adjuvant solution for presbyopic patients, with no risks or secondary effects. 2015 Subspecialty Day | Refractive Surgery Refractive Surgery E-posters 83 Refractive Surgery E-posters Friday, Nov. 13 7:00 AM – 5:30 PM, Level 2 View E-posters at the terminals on Level 2, or through the Mobile Meeting Guide, www.aao.org/mobile Diagnostics/Biomechanics/Ectasia/CXL RP30045306 Analysis of Corneal Biomechanical Properties After Femtosecond-LASIK Using a Noncontact Tonometer With a Dynamic Ultrahigh-Speed Scheimpflug Camera Ryan N Mercer BS 91 RP30045307 Comparison of Corneal Biomechanical Parameters in Keratoconus and Normal Eyes Using a Noncontact Tonometer With a Dynamic UltrahighSpeed Scheimpflug Camera Karolinne M Rocha MD* 91 RP30045309 Bilateral Central Toxic Keratopathy After LASIK: A Case Report and Review of the Literature Ahmed A Abdelmaksoud FRCS 91 RP30045311 Evolution Profiles of Different Corneal Parameters in Progressive Keratoconus David Smadja MD* 91 RP30045317 Outcomes of Femtosecond Flap LASIK Enhancement After Primary PRK Regression Mohammed A Taha MBBS 92 RP30045348 Comparison of Corneal Epithelial Thickness Measurements by OCT and VHF Digital Ultrasound Dan Z Reinstein MD* 92 RP30045352 Asphericity After Transepithelial Photorefractive Keratectomy Using 2 Lasers David T Lin MD 92 RP30045354 Comparison of IOP Evaluation Before and After Myopic PRK With 4 Different Devices Michele Lanza MD 92 RP30045355 A Novel Vacuum-Mediated System to Deliver Riboflavin to the Cornea Edward E Manche MD* 92 RP30045358 Sequential Corneal Collagen Crosslinking and Topography-Guided PRK in Keratoconus Treatment Alexander V Doga MD PhD 93 RP30045360 More Selective Crosslink Carla Santos Medeiros MD 93 RP30045365 Vitreoretinal Alterations Following Microkeratome-Assisted LASIK: Spectral Domain OCT Analysis Akihiro Yasuda MD 93 RP30045368 Early Outcome of Combined Small-Incision Lenticular Extraction (SMILE) and Corneal Collagen Crosslinking Lap Ki Ng MBBS 93 RP30045369 Visual, Refractive, and Aberrometric Outcomes After 3 Years of LASIK for the Correction of High Myopia Felipe Soria MD 93 RP30045395 Accommodative Response With a New Accommodative IOL Jorge L AliÓ MD PhD* 94 RP30045396 Three Years’ Follow-up After Hyperopic LASIK Using a 500-Hz Excimer Laser System Ahmed A Abdou MD PhD 94 RP30045397 Visual Performance of a New Trifocal Toric Diffractive IOL Felipe A Soria MD 94 RP30045398 Long-term Corneal Topography Stability After PresbyLASIK Treatment Ahmed A Abdou MD PhD 94 RP30045399 Documentation of Stromal Strengthening in Myopic LASIK With Adjunct Corneal Crosslinking: An Ex Vivo Comparison Study A John Kanellopoulos MD* 94 RP30045400 Intrastromal Corneal Ring Segment Implantation for Ectasia After Refractive Surgery Marisa Novaes Falleiro Chaves de Figueiredo Rassi 95 RP30045403 Ex Vivo Comparison of Biomechanical Changes in High Myopic LASIK vs. Small-Incision Lenticule Extraction (SMILE) Ioanna Kontari MD 95 * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 84 Refractive Surgery E-posters 2015 Subspecialty Day | Refractive Surgery RP30045405 Small-Incision Lenticular Extraction (SMILE) vs. LASIK Treating High Myopic Patients Jorge L AliÓ MD PhD* 95 RP30045406 Transepithelial and Stromal Pulsed-Light Accelerated Corneal Crosslinking for Patients With Progressive Keratoconus Andrew Olivo MD 95 RP30045410 Pupil Shape, Size, and Centroid Changes Associated With Clear-Cornea Cataract Surgery Ioanna Kontari MD 95 RP30045411 OCT and Scheimpflug Tomography Ectasia Diagnostics: Corneal Epithelium, Total Thickness and Refractive Symmetry Mapping A John Kanellopoulos MD* 96 RP30045412 Refractive Power Changes in Ectasia Management With the Athens Protocol: Topo-Guided PTK and Corneal Crosslinking Gregory J Pamel MD 96 RP30045420 Anterior Segment OCT to Assess Predictability of Femtosecond LaserAssisted Intrastromal Corneal Ring Segment Depth Michele Angely Pacheco MD 96 RP30045421 Evaluation of Topography-Guided Photorefractive Keratectomy for Irregular Astigmatism Following Penetrating Keratoplasty (PK) 1 Year Result Simon P Holland MD* 96 RP30045422 Comparison of Early Results of Topo-Guided Photorefractive Keratectomy With 2 Lasers Simon P Holland MD* 96 RP30045423 Evaluation of Transepithelial Photorefractive Keratectomy After Modification of Laser Beam Profile David T Lin MD 97 RP30045424 Prevalence of Color Vision Deficiency in Saudi Males Aspiring to Join Saudi Military Nasir Nisar MBBS 97 RP30045427 Effects of Small-Incision Lenticule Extraction (SMILE) on Corneal Endothelial Cells Arturo J Ramirez-Miranda MD 97 RP30045428 IOL Power Calculations Following Myopic LASIK: A Systematic Review With Meta-analysis Qi Yu MD 97 RP30045429 Quality of Life After Refractive Surgery: Small-Incision Lenticule Extraction and Implantable Collamer Lens Juan Carlos Serna MD 97 RP30045435 Utility of Intraoperative Refractive Aberrometry During Resident Cataract Surgery Natasha V Nayak MD 97 RP30045438 Epithelial-on Corneal Crosslinking in Thin Corneas William B Trattler MD* 98 RP30045444 Posterior Corneal Changes After Intracorneal Ring Segment Implantation in Eyes With Keratoconus Orkun Muftuoglu MD 98 RP30045445 Correlation of Anterior and Posterior Corneal Shape in Clinical Keratoconus Arturo J Ramirez-Miranda MD* 98 JRS Hot, Hotter, and Hottest: Late Breaking News RP30045312 The Visual and Refractive Outcomes and Aberrometric Changes of Aspheric Wavefront-Guided vs. Aspheric Laser-Assisted Subepithelial Keratectomy With TENEOTM 317 P for Myopia Correction: Prospective 6-Month Study Seyed Javad Hashemian MD 98 RP30045318 Review of Postoperative Care Following Refractive Surgery in the U.S. Military Marshall Hill MD 98 RP30045319 New Technique for Astigmatism: Beveled, Full-Thickness Astigmatic Keratotomy Sujoung Mun MD* 99 RP30045320 Evaluation of a Bitoric, Trifocal Multifocal IOL Florian T A Kretz MD* 99 RP30045321 Evaluation of 2 Multifocal IOLs With a Lower Near Addition Florian T A Kretz MD* 99 RP30045322 Small-Incision Lenticule Extraction (SMILE) Combined With Astigmatic Keratotomy to Treat High-Level and Mixed Astigmatism Sujoung Moon MD* 99 * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 2015 Subspecialty Day | Refractive Surgery Refractive Surgery E-posters 85 RP30045329 Higher-Order Aberration Changes After Customized Femtolaser-Assisted LASIK vs. Laser-Assisted Subepithelial Keratectomy for the Correction of High Myopia and Astigmatism Seyed Javad Hashemian MD RP30045334 Evaluation of In Vitro Glistening Formation in Different Hydrophobic Acrylic IOLs Ramin Khoramnia MD* 100 RP30045335 Evaluation of Reading Performance With the Salzburg Reading Desk of an Extended Depth of Focus IOL Ramin Khoramnia MD* 100 RP30045336 Risk Factors for Poor Epithelial Flap Quality in Laser Epithelial Keratomileusis Ali Fadlallah Yahya MD 100 RP30045337 Integrity of Intrastromal Arcuate Keratotomies Performed by Femtosecond Laser Maheen Haque MD 100 RP30045338 A Tissue-Sparing Technique for Phototherapeutic Keratectomy With Mitomycin C for Intractable Corneal Haze After Surface Refractive Procedure Ali Fadlallah Yahya MD 100 RP30045339 Long-term Risk Factors for Dry Eyes and Visual Aberrations After Corneal Refractive Surgery Samir A Melki MD PhD* 101 RP30045342 Clinical Impact After Implantation of Nonrefractive Presbyopic Corneal Inlay: U.S. Investigational Device Exemption Clinical Trial Update Gregory D Parkhurst MD* 101 RP30045347 Small-Incision Lenticule Extraction (SMILE) Hyperopia: Comparison of Optical Zone Centration and Diameter and Higher-Order Aberrations Between LASIK and SMILE Dan Z Reinstein MD* 101 RP30045350 Nonrefractive Corneal Inlay for the Treatment of Presbyopia: U.S. FDA Clinical Trial Update Roger F Steinert MD* 101 RP30045351 Comparing 2 Different Presbyopia-Correcting Treatments: Nonrefractive Hydrogel Corneal Inlay and Monovision LASIK Cornelis Verdoorn MD* 101 RP30045353 Satisfaction Following Combined Small-Aperture Corneal Inlay (Kamra) Implantation and LASIK for Presbyopia Correction in an Irish Population Estera Igras FRCOphth MD MRCOphth 102 RP30045356 Toric IOL Alignment: Computerized, Image-Based System vs. Slitlamp Marking System Paolo Vinciguerra MD* 102 RP30045359 Long-term Results of Combined Small-Aperture Corneal Inlay (Kamra) Implantation and LASIK for Presbyopia Correction Estera Igras FRCOphth MD MRCOphth 102 RP30045372 A 3-Dimensional “Super Surface” Combining IOL Formulas to Create a “Super Formula” to Optimize IOL Calculations John G Ladas MD 102 RP30045373 Femtosecond-Assisted LASIK With and Without Mitomycin C Performed to Correct Hyperopia: A 15-Month Follow-up Montserrat Garcia-Gonzalez MD 102 RP30045374 Comparison of Optical Quality in Monofocal, Bifocal, and Trifocal IOLs of the Same Manufacturer Tamer Tandogan MD* 103 RP30045376 Visual Outcomes and Patient Satisfaction Following Implantation of the Tecnis Symfony IOL David W Teenan MBChB 103 RP30045377 Initial Results of Cornea Inlay Use for Presbyopia in a Single Center Following FDA Approval Phillip Hoopes Jr MD* 103 RP30045383 Preliminary Outcomes in Phaco Refractive Surgery With Multifocal Lens in a Post-LASIK Hispanic Population Jose A Nava Garcia MD 103 RP30045384 The Effect of Angle Kappa on Clinical Outcomes With Pupil-Centered Wavefront-Guided LASIK to Correct Hyperopia Steven C Schallhorn MD* 103 RP30045385 Outcomes of a Large Population of Wavefront-Guided LASIK Using a Recently Approved Aberrometer Steven C Schallhorn MD* 103 RP30045387 Treatment of Hyperopic Presbyopes With Laser Vision Correction Combined With Corneal Inlay Implantation Jeffrey J Machat MD* 104 * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 99 86 Refractive Surgery E-posters 2015 Subspecialty Day | Refractive Surgery RP30045388 Treatment of Myopic Presbyopes With Laser Vision Correction Combined With Corneal Inlay Implantation Jeffrey J Machat MD* 104 RP30045389 The Changes of Keratometric Values After Raindrop Corneal Inlay With LASIK in Hyperopic Presbyopia Choun-ki Joo MD 104 RP30045390 Bilateral Implantation of a Polyfocal Bioanalogic IOL: One-Year Outcomes Robert Edward T Ang MD* 104 RP30045392 Safety and Efficacy of Myopic LASIK Performed on Thin Corneas Jorge E Valdez-Garcia MD 104 RP30045402 Digitized Objective Excimer Laser Ablation Centration Evaluation: A Novel Postoperative Assessment Technique George Asimellis PhD 104 RP30045407 Comparison of Wound Integrity Between Clear Corneal Incisions Created Using a Keratome or a Femtosecond Laser Harvey S Uy MD* 105 RP30045408 Novel Objective Assessment of Cyclorotation Compensation in Topo-Guided Excimer Ablation in Highly Irregular Corneas George Asimellis PhD 105 RP30045409 Eighteen-Month Follow-up Results of Single-Step Transepithelial Photorefractive Keratectomy in Myopia: Qualitative and Quantitative Visual Outcomes Soheil Adib Moghaddam MD 105 RP30045413 Monovision LASIK as a Treatment for Presbyopia Alejandro Tamez MD 105 RP30045419 Visual, Refractive, and Clinical Outcomes of Small-Incision Lenticule Extraction (SMILE) vs. Implantable Collamer Lens for High Myopia Jesus Cabral-Macias MD 105 RP30045425 Visual Performance Following Bilateral LASIK and Monocular Corneal Inlay Implantation Wayne Crewe-Brown MD* 106 RP30045431 Bioptics: Toric Implantable Collamer Lens Following Intracorneal Ring Segments in Keratoconus Patients Tamer O Gamaly FRCS MD 106 RP30045436 Comorbidity of Dry Eye Syndrome in Patients Undergoing Allergy Skin Testing Mujtaba A Qazi MD* 106 RP30045440 Outcomes of Femtolaser-Assisted LASIK With Breakthrough Gas Bubble in Anterior Chamber During Flap Creation Nagesh Bn MBBS MD 106 RP30045443 Laser Bridge Astigmatic Keratotomy Novel Incision Architecture: Comparison and Validation of Patient-Specific Computational Modeling Anita Nevyas-Wallace MD* 106 * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. 2015 Subspecialty Day | Refractive Surgery 87 E-poster Presenting Authors Ahmed A Abdelmaksoud FRCS Montserrat Garcia-Gonzalez MD John G Ladas MD Preston, United Kingdom Madrid, Spain Ophthalmologist Vissum Santa Hortensia Silver Spring, MD Ahmed A Abdou MD PhD Alicante, Spain MD, PhD, Lecturer of Ophthalmology AUH, Egypt Postdoctorate Clinical Research Fellow Vissum Corporation Soheil Adib Moghaddam MD Shahrak-E Gharb, Tehran, Islamic Republic of Iran General Physician Tehran University of Medical Sciences Jorge L Alió MD PhD Alicante, Spain Professor of Ophthalmology Miguel Hernandez University Medical Director Vissum Corporation Chicago, IL Napoli, Italy Assistant Professor in Ophthalmology Seconda Università di Napoli Seyed Javad Hashemian MD David T Lin MD Tehran, Islamic Republic of Iran Rassoul Akram Hospital Tehran University of Medical Sciences Negah Eye Center Rasoul Akram Hospital Vancouver, BC, Canada Clinical Assistant Professor University of British Columbia Pacific Laser Eye Centre Marshall Hill Toronto, ON, Canada Medical Director Crystal Clear Vision Canada, Inc. Maheen Haque MD Kaysville, UT Simon P Holland MD Vancouver, BC, Canada Clinical Professor of Ophthalmology University of British Columbia Robert Edward T Ang MD Phillip Hoopes Jr MD Makati City, Philippines Senior Consultant Asian Eye Institute Draper, UT George Asimellis PhD Athens, Greece Researcher LaserVision.gr Eye Institute Nagesh Bn MBBS MD New Delhi, India Jesus Cabral-Macias, MD Mexico City, DF Mexico Wayne Crewe-Brown MD London, United Kingdom Alexander V Doga MD PhD Moscow, Russian Federation Ali Fadlallah Yahya MD Beirut, Lebanon Tamer O Gamaly FRCS MD Al Ain, United Arab Emirates Chief, Cornea and Refractive Surgery Unit Magrabi Eye & Ear Center Michele Lanza MD Estera Igras MD Dublin, Ireland Choun-ki Joo MD Seoul, Republic of Korea Professor of Ophthalmology The Catholic University of Korea A John Kanellopoulos MD Jeffrey J Machat MD Edward E Manche MD Palo Alto, CA Professor of Ophthalmology Byers Eye Institute Stanford University School of Medicine Carla Santos Medeiros MD Rio de Janeiro, RJ, Brazil Samir A Melki MD PhD Brookline, MA Assistant Professor (part time) Harvard Medical School Attending Physician Massachusetts Eye and Ear Infirmary Athens, Greece Clinical Professor of Ophthalmology NYU Medical College Director Laservision.gr Eye Institute, Athens Orkun Muftuoglu MD Ramin Khoramnia MD San Pedro Garza Garcia, NL, Mexico Heidelberg, Germany Ioanna Kontari MD Athens, Greece Ophthalmologist Laservision.gr Florian T A Kretz MD Ahaus, Germany Senior Researcher, Consultant International Vision Correction Research Centre and David J Apple Laboratory for Ocular Pathology University of Heidelberg Istanbul, Turkey Associate Professor of Ophthalmology Ankara University School of Medicine Jose A Nava-Garcia MD Natasha V Nayak MD New York, NY Anita Nevyas-Wallace MD Bala Cynwyd, PA Director of Refractive Surgery Nevyas Eye Associates Lap Ki Ng MBBS Hong Kong, Hong Kong Nasir Nisar MBBS Riyadh, Saudi Arabia 88 E-poster Presenting Authors 2015 Subspecialty Day | Refractive Surgery Andrew Olivo Steven C Schallhorn MD David W Teenan MBChB Huixquilucan, Mexico Fellow, Cornea and Refractive Surgery Conde de Valenciana San Diego, CA Professor of Ophthalmology University of San Francisco Ayr, Scotland, United Kingdom Consultant Ophthalmologist Optical Express Michele Angely Pacheco MD Juan Carlos Serna MD William B Trattler MD Ciudad de Mexico, DF, Mexico Miami, FL Director of Cornea Center For Excellence In Eye Care New York, NY Mexico City, DF, Mexico Chief Resident Instituto de Oftalmología, Conde de Valenciana Gregory D Parkhurst MD David Smadja MD San Antonio, TX Chief of Ophthalmology Fort Hood, Texas Tel Aviv, Israel Ophthalmologist Bordeaux Hospital University Researcher Associate Nanotechnology Center Bar-Ilan University Quezon City, MM, Philippines Clinical Associate Professor of Ophthalmology University of the Philippines, Manila Consultant, Uy Eye Clinic St. Luke’s Medical Center, Quezon City Gregory J Pamel MD Mujtaba A Qazi MD Chesterfield, MO Director, Clinical Studies Pepose Vision Institute Arturo J Ramirez-Miranda MD Mexico City, DF, Mexico Assistant Professor of Ophthalmology Instituto de Oftalmología, Conde de Valenciana IAP Universidad Nacional Autónoma de México Marisa Novaes Falleiro Chaves de Figueiredo Rassi MD Goiania, Brazil Dan Z Reinstein MD London, England Medical Director London Vision Clinic Adjunct Professor of Ophthalmology Columbia University Medical Center New York, NY Karolinne M Rocha MD Mount Pleasant, SC Storm Eye Institute Medical University of South Carolina Felipe A Soria MD Alicante, Spain Ophthalmologist Vissum Corporation Alicante Roger F Steinert MD Irvine, CA Irving H Leopold Professor and Chair of Ophthalmology Gavin Herbert Eye Institute University of California, Irvine Harvey S Uy MD Jorge E Valdez-Garcia MD San Pedro Garza Garcia, NL, Mexico Dean, Escuela de Medicina Tecnológico de Monterrey Cornelis Verdoorn MD Vught, Netherlands Paolo Vinciguerra MD Milan, Italy Ophthalmology Department Istituto Clinico Humanitas Rozzano Mohammed A Taha MBBS Akihiro Yasuda MD Montreal, QC, Canada Tokyo, Japan Alejandro Tamez MD Qi Yu MD San Pedro Garza Garcia, NL, Mexico Shanghai, Shanghai, China Tamer Tandogan MD Heidelberg, Germany Ophthalmologist University of Heidelberg 2015 Subspecialty Day | Refractive Surgery E-poster Presenting Author Financial Disclosures Ahmed A Abdelmaksoud FRCS Alexander V Doga MD PhD Ramin Khoramnia MD None Not submitted by press date Ahmed A Abdou MD PhD Ali Fadlallah Yahya MD None None Soheil Adib Moghaddam MD Tamer O Gamaly FRCS MD None None Jorge L Alió MD PhD Montserrat Garcia-Gonzalez MD Abbott Medical Optics: S Akkolens: C,S Bausch + Lomb Surgical: C,S Carl Zeiss Meditec: S CSO: C Dompe: S Hanita Lenses: C Jaypee Bros: P Mediphacos: C Novagali: S Oculentis: C,S Presbia: C Santen, Inc.: C Schwind eye-tech-solutions: L,S Stark, Inc.: C Springer Verlag: P Tekia, Inc.: P Thea: S Topcom: C Vissum Corp.: E,O None Abbott Medical Optics, Inc.: S Alcon Laboratories, Inc.: S Bausch + Lomb: S Bayer Healthcare Pharmaceuticals: S Carl Zeiss Meditec: S Contamac: S Hoya: S HumanOptics: S Kowa: S LensAr: S Mediphakos: S Novartis Pharmaceuticals Corp.: S Occulentis: S,L Powervision: S Rayner Intraocular Lenses Ltd.: L,S Robert Edward T Ang MD Research Foundation Royal VIctoria Eye and Ear Hospital: S AcuFocus, Inc.: C,L,S Allergan, Inc.: L,S Bausch + Lomb Surgical: C,L,S Santen, Inc.: L Staar Surgical: L George Asimellis PhD None Nagesh Bn MBBS MD None Jesus Cabral-Macias MD Maheen Haque MD None Seyed Javad Hashemian MD None Marshall Hill None Simon P Holland MD Alcon Laboratories, Inc.: C Allergan: C Clarion: C Phillip Hoopes Jr MD Abbott Medical Optics, Inc.: C AcuFocus, Inc.: O Estera Igras MD Choun-ki Joo MD None A John Kanellopoulos MD Alcon Laboratories, Inc.: C Allergan: C Avedro, Inc.: C Carl Zeiss AG: C i-Optics: C ISP Surgical, LLC: C KeraMed, Inc.: C None Wayne Crewe-Brown MD AcuFocus, Inc.: C,O Presby Corp.: C Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures Ioanna Kontari MD None Florian T A Kretz MD Abbott Medical Optics: L,S Alcon Laboratories, Inc.: L,S Alimera Sciences, Inc.: L,S,C Allergan: L,S Bausch + Lomb: S Bayer Healthcare Pharmaceuticals: L Carl Zeiss Meditec: L,S Geuder AG: L,S Glaukos Corp.: S Heidelberg Engineering: S HOYA: L KOWA: L Mediphacos: S Novartis Pharmaceuticals Corp.: L,S Oculentis: L,S Ophtec: S Powervision: S Rayner Interocular Lenses Ltd.: L,S John G Ladas MD None Michele Lanza MD None David T Lin MD PRN Physician Recommended Nutriceuticals: C SCHWIND ey-tech-solutions: C 89 90 E-poster Presenting Author Financial Disclosures 2015 Subspecialty Day | Refractive Surgery Jeffrey J Machat MD Mujtaba A Qazi MD Tamer Tandogan MD AcuFocus, Inc.: C Bausch + Lomb: C Schwind eye-tech-solutions: C Zimmer: C Bausch + Lomb Surgical: C,L Ivantis, Inc.: C Arcscan, Inc., Morrison, Colorado: O,P Carl Zeiss Meditec: C Alcon Laboratories, Inc.: S Bausch + Lomb: S Bayer Healthcare Pharmaceuticals: L Carl Zeiss Meditec: S Contamac: S Hoya: L,S HumanOptics: S Kowa: S LensAr: S Mediphakos: S Oculentis: S PowerVision: S Rayner Intraocular Lenses Ltd: S Edward E Manche MD Arturo J Ramirez-Miranda MD Carl Zeiss Meditec: C,L,S Best Doctors, Inc.: C Calhoun Vision, Inc.: O Guidepoint: C Krypton Vision, Inc.: C,O Oculeve, Inc.: C Refresh Innovations, Inc.: C,O Seros Medical, LLC: C,O,P Veralas, Inc.: C,O Marisa Novaes Falleiro Chaves de Figueiredo Rassi MD Carla Santos Medeiros MD Karolinne M Rocha MD David W Teenan MBChB Abbott Medical Optics, Inc.: C Alcon Laboratories, Inc.: C Allergan: C None None Samir A Melki MD PhD Qualsight: C None Dan Z Reinstein MD Steven C Schallhorn MD None Abbott Medical Optics: C AcuFocus, Inc.: C Allergan: C Innovega: C Optical Express: C Zeiss: C Natasha V Nayak MD Juan Carlos Serna MD None None Anita Nevyas-Wallace MD David Smadja MD Bausch + Lomb: C Eye IC, Inc.: O Master, Inc.: P Varitronics, Inc.: C,O Abbott Medical Optics, Inc.: L Alcon Laboratories, Inc.: C Ziemer, Inc.: C Lap Ki Ng MBBS None Orkun Muftuoglu MD None Jose A Nava-Garcia MD None Nasir Nisar MBBS Felipe A Soria MD Roger F Steinert MD William B Trattler MD Abbott Medical Optics: C,L,S Allergan, Inc.: C,L,S Bausch + Lomb: S CXLO: C,O CXLUSA: C LensAR: C Oculus, Inc.: L Rapid Pathogen Screenings: S Tear Science: C Vmax Vision: C Harvey S Uy MD Alcon Laboratories, Inc.: S Allergan: L Beaver-Visitec International, Inc.: S LensAR: L,S Novartis Pharmaceuticals Corp.: C,L Santen, Inc.: L Jorge E Valdez-Garcia MD None None Abbott Medical Optics: C,S Avedro: C,O LensGen: O ReVision Optics: C Rhein Medical, Inc.: P Michele Angely Pacheco MD Mohammed A Taha MBBS None None Nidek, Inc.: C Oculus, Inc.: C Schwind eye-tech-solutions: C Gregory J Pamel MD Alejandro Tamez MD Akihiro Yasuda MD None None None None Andrew Olivo Cornelis Verdoorn MD Revision Optics: C Paolo Vinciguerra MD Gregory D Parkhurst MD Qi Yu MD Alcon Laboratories, Inc.: L Oasis Medical, Inc.: C ReVision Optics: C,L Staar Surgical: C,L None Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures 2015 Subspecialty Day | Refractive Surgery 91 E-poster Abstracts Diagnostics/Biomechanics/Ectasia/ CXL Analysis of Corneal Biomechanical Properties After Femtosecond-LASIK Using a Noncontact Tonometer With a Dynamic Ultrahigh-Speed Scheimpflug Camera Abstract #: RP30045306 Senior Author: Ryan N Mercer BS** Coauthors: Richard A Hemings BA**, George O Waring IV MD, Karolinne M Rocha MD Purpose: To evaluate changes in corneal biomechanical properties after femtosecond-LASIK using a dynamic ultrahigh-speed Scheimpflug camera and noncontact tonometer (Corvis ST; Oculus, Inc.). Methods: Corvis ST was used to evaluate 39 eyes before and after femtosecond LASIK (WaveLight EX 500; FS 200). Manifest refraction, Scheimpflug imaging, corneal topo graphy, and central corneal thickness were assessed in all eyes. Results: The parameter delta arc length describes the change of arc length during deformation. The mean preoperative delta arc value (HC dArclength) at highest concavity was -0.13205 ± 0.02385 mm. The mean postoperative delta-arc value was -0.08608 ± 0.037208 mm at 1 month postoperatively (P = .026). Conclusion: Delta arc length is a sensitive indicator in detecting corneal biomechanical changes after femtosecond LASIK. Comparison of Corneal Biomechanical Parameters in Keratoconus and Normal Eyes Using a Noncontact Tonometer With a Dynamic Ultrahigh-Speed Scheimpflug Camera Abstract #: RP30045307 Senior Author: Karolinne M Rocha MD Coauthors: Ryan N Mercer BS**, Richard A Hemings BA**, George O Waring IV MD Purpose: To evaluate differences in corneal biomechanical properties in keratoconus and normal eyes using a noncontact tonometer with a dynamic ultrahigh-speed Scheimpflug camera (Corvis ST). Methods: Forty eyes with keratoconus and 40 normal eyes underwent Corvis ST examination. Manifest refraction, Belin-Ambrosio (D and ART-Max), topographic keratoconus classification (TKC), and central corneal thickness were assessed. Results: Maximum concave power (MCP) and deformation amplitude ratio (DAR) parameters were statistically significantly different between the groups (P < .05). The AUROC analysis of maximum concave power and deformation amplitude ratio were, respectively, 0.782 and 0.797. Conclusions: MCP and DAR may be considered as reliable corneal biomechanical parameters to distinguish between keratoconic and normal eyes. Bilateral Central Toxic Keratopathy After LASIK: A Case Report and Review of the Literature Abstract #: RP30045309 Senior Author: Ahmed A Abdelmaksoud FRCS Coauthors: Nigel Terk Howe Khoo BS, Osama I Ibrahim MD PhD Purpose: To report a case of bilateral central toxic keratopathy 1 week after myopic LASIK that responded to steroid treatment. Methods: Case report. Results: Treatment included topical steroids, along with the routine postoperative treatment regimen of broad spectrum antibiotics and lubricants. After 1 month, the case started to improve and the steroids were tapered. Final vision of 6/6 after 6 months. Conclusion: CTK is a rare potential complication of LASIK surgery with only very few patients reported so far. Pathophysiology and treatment yet to be identified. Evolution Profiles of Different Corneal Parameters in Progressive Keratoconus Abstract #: RP30045311 Senior Author: David Smadja MD Coauthors: Joy Tellouck MD, Marcony R Santhiago MD, Glauco H Reggiani Mello MD, David Touboul MD Purpose: To analyze the evolution profiles of several corneal topographic and tomographic parameters in progressive keratoconus. Methods: 124 eyes of 62 patients were prospectively enrolled and imaged every 3 months during at least 1 year. Fiftysix corneal parameters were measured at each visit, and the percentage of progression (PP) between each visit was calculated for each parameter. Results: At 1 year, 12% of eyes (15/124) were progressing. Posterior steepest keratometry and vertical coma had a significantly higher PP (P < .01, Student test) and modifications that occurred significantly earlier than in anterior keratometry. Conclusion: Posterior keratometry and vertical coma were modified earlier than the anterior keratometry in progressive keratoconus and may be relevant warning signs of progression. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 92 E-poster Abstracts Outcomes of Femtosecond Flap LASIK Enhancement After Primary PRK Regression Abstract #: RP30045317 Senior Author: Mohammed A Taha MBBS Coauthors: Eser Adiguzel PhD, Mark J Cohen MD, Avi Wallerstein MD Purpose: To determine the outcomes of femto flap LASIK enhancements after primary PRK regression. Methods: Retrospective chart review of eyes having enhancements after initial PRK. Standard outcomes analysis and quality of vision (QoV) questionnaire were administered. Results: Eight eyes. Average time to enhancements: 86 ± 96 months (7-249 months). Average pre-enhancement pachymetry: 461 ± 44 μm. Average flap thickness: 105 ± 14 μm. Average follow-up time: 13 ± 2 months. Postenhancement sphere: -0.13 ± 0.35 D; cylinder: -0.28 ± 0.28 D. Fifty percent, 88%, and 100% were within ±0.25, ±0.50, and ±0.75 D. Cumulative uncorrected distance visual acuity (VA) 20/20 and 20/25 in 75% and 100%; preop corrected distance VA in 83% and 100%; efficacy index: 1.0 ± 0.1. Corrected distance VA loss: 0% lost ≥ 1 lines, 17% gained 1 line; safety index: 1.0 ± 0.1. One hundred percent indicated QoV better than preop. Conclusion: Femtosecond flap LASIK enhancement for PRK regression demonstrates excellent accuracy, efficacy, safety, and satisfaction. Comparison of Corneal Epithelial Thickness Measurements by OCT and VHF Digital Ultrasound Abstract #: RP30045348 Senior Author: Dan Z Reinstein MD Coauthors: Timothy E Yap**, Timothy J Archer MS, Marine Gobbe PhD, Ronald H Silverman PhD Purpose: To compare epithelial thickness measurements using OCT and VHF digital ultrasound (VHF-DU). Methods: Retrospective study of 211 virgin corneas and 191 post-laser refractive surgery (LRS) corneas with epithelial thickness measurements by RTVue OCT and Artemis VHF-DU. Mean differences and 95% limits of agreement (LoA) were calculated and compared for 17 zones. Results: In virgin epithelium, mean central thickness was 53.4 ± 3.2 μm with OCT and 54.1 ± 3.0 μm with VHF-DU; a mean difference of -0.7 μm (95% LoA of ±3.94 μm). In post-LRS epithelium, mean central thickness was 57.9 ± 6.1 μm with OCT and 60.5 ± 6.5 μm with VHF-DU; a mean difference of -2.5 μm (95% LoA of ±5.3 μm). Conclusions: OCT measured epithelium was thinner than VHF-DU. In contrast to VHF-DU, OCT includes tear film, so the true difference is probably about 4 μm more. Asphericity After Transepithelial Photorefractive Keratectomy Using 2 Lasers 2015 Subspecialty Day | Refractive Surgery 0.069, with manifest refraction of -3.53 ± 1.48 D SA and -3.38 ± 1.58 D WA. Postoperative Q of -0.064 ± 0.346 SA, +0.207 ± 0.255 with WA. Pre- to postoperative change of +0.049 ± 0.365 and +0.228 ± 0.253 respectively, not statistically significant. Conclusion: Less positive asphericity appeared to result from treatment with Schwind Amaris than Allegretto WaveLight after TE PRK, with potentially better uncorrected near visual acuity with SA. Comparison of IOP Evaluation Before and After Myopic PRK With 4 Different Devices Abstract #: RP30045354 Senior Author: Michele Lanza MD Coauthors: Carlo Irregolare MD**, Luigi Mele MD**, Sandro Sbordone, Mario Bifani MD** Purpose: To study IOP before and after myopic PRK with Goldmann applanation tonometry (GAT), Dynamic Contour Tonometry (DCT), Ocular Response Analyzer (ORA), and Corvis. Methods: A complete eye visit, corneal tomography, and IOP evaluation with GAT, DCT, ORA, and Corvis were performed in 36 eyes of 36 patients before myopic PRK and at 6 months follow-up. Analysis of IOP differences before and after surgery were run for all devices. Results: Every tonometer showed significant (P < .05) IOP underestimation after surgery; IOP difference observed with Corvis (-0.50 ± 0.55 mmHg) could be considered clinically irrelevant. Conclusions: Even if these results have to be confirmed in further studies, these data suggest that Corvis could be a reliable device in IOP measurement after myopic PRK. A Novel Vacuum-Mediated System to Deliver Riboflavin to the Cornea Abstract #: RP30045355 Senior Author: Edward E Manche MD Coauthor: David Myung** Purpose: To describe a novel vacuum-based device to deliver riboflavin to the cornea through an intact epithelium. Methods: The delivery system is a handheld unit and a vacuum pump that induces negative pressure. Riboflavin 0.1% was used on live rabbit eyes. Corneal buttons were analyzed to determine the total riboflavin concentration. Results: The concentration of riboflavin in explanted corneal buttons was measured by mass spectrometry. Corneal riboflavin concentrations increased as a function of time, ranging between 90 and 1200 ng/mL. The maximum riboflavin concentration achieved was found to be greater than 6-fold higher than the epithelium-on study control. Conclusions: This novel vacuum-based system delivers therapeutic doses of riboflavin to the cornea through an intact epithelium. Abstract #: RP30045352 Senior Author: David T Lin MD Coauthors: Simon P Holland MD, Karolien M Termote MD Purpose: We aimed to evaluate pre- and postoperative asphericity using 2 lasers. Methods: Retrospective case series, TE PRK, -1 to -6 D. Thirty with Schwind Amaris 1050 (SA) HO aberration treatment on and 30 with WaveLight Allegretto 400 (WA) WO evaluated at 3 months. Pre- and postoperative Q factor using Sirius imaging at zone size 6.0 mm. Results: Eyes treated with SA, preop mean Q value of -0.113 ± 0.132 and AW of -0.033 ± ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. E-poster Abstracts 2015 Subspecialty Day | Refractive Surgery Sequential Corneal Collagen Crosslinking and Topography-Guided PRK in Keratoconus Treatment 93 may induce vitreous change to diminish posterior vitreocortical pocket. Abstract #: RP30045358 Senior Author: Alexander V Doga MD PhD** Coauthors: Ekaterina Branchevskaya, Svetlana Izmaylova MD PhD** Purpose: To evaluate the efficacy of sequential corneal collagen crosslinking (CXL) and topography-guided PRK in keratoconus management. Methods: Consecutive patients with progressive keratoconus received CXL procedure. Topography-guided PRK was performed 12 months after CXL. Outcome measurements included uncorrected and corrected distance visual acuity (UDVA and CDVA), topography, Scheimpflug tomography, and ocular aberrations (PSF, Strehl ratio). Results: Study included 38 eyes of 32 patients; preop UDVA and CDVA (logMAR) were 1.04 ± 0.23 and 0.64 ± 0.16 and improved at last follow-up 12 months after PRK to 0.42 ± 0.25 and 0.20 ± 0.12. No patients lost lines of CDVA. Conclusion: Sequential CXL and topography-guided PRK was effective for improving visual functions in select patients. More Selective Crosslink Abstract #: RP30045360 Senior Author: Carla Santos Medeiros MD Coauthor: Marcony R Santhiago MD Purpose: To provide an overview of the safety, efficacy, and different techniques and applications of the accelerated corneal collagen crosslinking (A-CXL). Methods: Sixty-nine eyes with keratoconus in progression underwent A-CXL using ultravioletA irradiation intensity of 9 mW/cm2, during 10 minutes. Data relating to visual acuity, as well as topography and corneal pachymetry, were extracted and analyzed. Results: The mean age was 22.60 ± 9.02. There was a slight improvement in visual acuity, but without statistical significance. All corneal parameters were stable after 12 months in all patients, as were pachymetric values. No complications were observed. Conclusion: Accelerated corneal CXL is effective in stabilizing all cornea parameters after 12 months of follow-up in mild moderate keratoconusaffected corneas. Vitreoretinal Alterations Following MicrokeratomeAssisted LASIK: Spectral Domain OCT Analysis Abstract #: RP30045365 Senior Author: Akihiro Yasuda MD Coauthors: Junko Koshimizu MD**, Kentaro Tsuzuki MD**, Kishiko Okoshi MD Purpose: To evaluate impact of microkeratome-assisted LASIK on posterior segments. Methods: Posterior segments of 10 eyes of 5 consecutive patients were measured with spectral domain OCT. Results: Posterior vitreocortical pocket had a mean horizontal area of 2.19 ± 0.59 mm2 at baseline and decreased to 1.75 ± 0.35 mm2 at 1 day, 1.51 ± 0.41 mm2 at 1 week, and 1.38 ± 0.33 mm2 at 1 month (P < .05), and a mean vertical area of 2.17 ± 0.52 mm2 decreased to 1.53 ± 0.53 mm2, 1.62 ± 0.41 mm2, and 1.38 ± 0.32 mm2, respectively (P < .05). No eye developed posterior vitreous detachment postoperatively. Central retinal thickness and subfoveal choroidal thickness showed no change from baseline. Conclusion: Microkeratome-assisted LASIK has no impact on retinal and choroidal thickness; however, it Early Outcome of Combined Small-Incision Lenticular Extraction (SMILE) and Corneal Collagen Crosslinking Abstract #: RP30045368 Senior Author: Lap Ki Ng MBBS Coauthors: Tommy Chung Yan Chan FRCS(ED) MBBS**, George P M Cheng MD, Victor Chi Pang Woo MBBS, Jimmy Shiu Ming Lai FCOphthHK FRCOphth FRCS(ED) MBBS MD Purpose: To report the early outcome of combined SMILE and corneal collagen crosslinking (SMILE Xtra). Methods: The safety and efficacy parameters were reported and compared between 23 SMILE Xtra eyes and 22 control eyes (SMILE only). Results: The average age was 28.4 ± 5.9 and 27.3 ± 5.7 in SMILE Xtra and controls, respectively. At 3 months, no eyes lost more than 1 line in corrected distance visual acuity. The safety index was 0.952 ± 0.073 and 1.001 ± 0.033 in SMILE Xtra and controls, respectively (P = .007). All eyes were within 0.50 D of target refraction, and the efficacy index was 0.894 ± 0.102 in SMILE Xtra compared with 0.968 ± 0.048 in controls (P = .013). Conclusion: SMILE Xtra had good safety profile and good predictability at 3 months follow-up, but the safety and efficacy indices were significantly lower than in control eyes receiving SMILE only. Visual, Refractive, and Aberrometric Outcomes After 3 Years of LASIK for the Correction of High Myopia Abstract #: RP30045369 Senior Author: Felipe A Soria MD Coauthors: Alfredo Vega-Estrada MD, Jorge L Alió MD PhD, Pablo Sanz MS OD Purpose: To evaluate long-term outcomes of LASIK for high myopia using a 500-Hz repetition rate excimer laser. Methods: Retrospective study of 70 eyes that were evaluated during 3 years. Visual, refractive, and corneal aberrometric changes were analyzed. Results: Significant improvement in uncorrected vision 3 years after surgery (P < .01). Significant reduction of spherical equivalent, from preoperative -7.79 ± 1.38 D to 3 years postoperative -0.29 ± 0.54 D (P < .01). Significant induction of primary spherical aberration and coma was also found (P < .01) at 3 years with levels of -0.41 ± 0.52 µm and 0.53 ± 0.31 µm, respectively. Conclusion: LASIK for high myopia using fast repetition excimer laser is an effective procedure, with stable results after long follow-up period. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 94 E-poster Abstracts Accommodative Response With a New Accommodative IOL 2015 Subspecialty Day | Refractive Surgery able to provide a complete visual rehabilitation in eyes with preexisting corneal astigmatism. Abstract #: RP30045395 Senior Author: Jorge L Alió MD PhD Coauthors: Alexey Simonov PhD, Ana Belen Plaza, Alexander Angelov Angelov MD**, Yavor Petrov Angelov MS**, Michiel Rombach Purpose: The aim of this study is to report the accommodative response with a new accommodative intraocular lens (A-IOL), the Lumina. Methods: Two groups of patients were differentiated: Group A, 59 eyes with the Lumina A-IOL, and Group B, 23 eyes with the monofocal AcrySof SA60AT IOL. Defocus curve and accommodation with the WAM-5500 Autorefractometer were measured. Results: Statistically significant differences were observed between groups for defocus levels between -4.50 and -0.50 D (P < .01), with better values for Group A. Statistically significant differences were observed for the WAM accommodative stimuli of -2.00, -2.50, and -3.00 D (P < .01), with higher values for the A-IOL. Conclusion: This A-IOL showed an accommodative response and a depth of focus higher than the monofocal group. Three Years’ Follow-up After Hyperopic LASIK Using a 500-Hz Excimer Laser System Abstract #: RP30045396 Senior Author: Ahmed A Abdou MD PhD Coauthors: Ana Belen Plaza, Pilar Yebana**, Samuel Arba Mosquera, Jorge L Alió MD PhD Purpose: Visual outcomes after correction of hyperopia in the long term with the sixth-generation excimer laser. Methods: This study comprised 86 eyes that underwent LASIK to correct hyperopia with a postoperative follow-up of 3 years. LASIK procedures were performed using the sixth-generation Amaris excimer laser. Results: Seventy-six percent of eyes had an UCVA of 20/20 or better; 70% of eyes had a spherical equivalent within ±0.50 D. There was regression of 0.47 D between 3 and 36 months postoperatively. A flattening of 0.16 D was observed between 3 and 36 months after surgery in the mean keratometry. Conclusion: Treatment of hyperopia using sixth-generation Amaris excimer laser provides very good results in terms of stability, efficacy, safety, and predictability after 3 years. Long-term Corneal Topography Stability After PresbyLASIK Treatment Abstract #: RP30045398 Senior Author: Ahmed A Abdou MD PhD Coauthors: Esperanza Sala OD, Ana Belen Plaza, Jorge L Alió MD PhD Purpose: To evaluate the visual outcomes and cornea stability of patients after presbyLASIK treatment for the correction of presbyopia. Methods: Eighty-two eyes of 41 patients treated with PresbyMAX software. Main outcome measures were distance, near, and intermediate visual acuity, refractive outcomes, and topography analysis. Results: Postoperatively, significant improvements in uncorrected distance and near visual acuity were found (P < .01). Statistically significant differences were not found (P ≥ .06) in corneal aberrations and optical zone diameter over the time. Conclusion: PresbyLASIK treatments provided stable visual and topographic outcomes over the time. Documentation of Stromal Strengthening in Myopic LASIK With Adjunct Corneal Crosslinking: An Ex Vivo Comparison Study Abstract #: RP30045399 Senior Author: A John Kanellopoulos MD Coauthor: George Asimellis PhD Purpose: To evaluate ex vivo biomechanical differences between standard myopic LASIK and LASIK with high-fluence crosslinking (LASIK+CXL). Methods: Human donor corneas were subjected to myopic LASIK (-6.00 D). Group A (n = 4), controls (no CXL); Group B (n = 4), LASIK+CXL. Transverse biaxial resistance (stress and Young modulus) and enzymatic (collagenase A) digestion resistance tests. Results: Stroma stress was 128 ± 11 kPa in Group A vs. 293 ± 20 kPa in Group B (Δ = +129%, P < .05). Enzymatic degradation time was 157.5 ± 15.0 min. in Group A and 186.25 ± 7.5 min. in Group B (Δ = +18%, P = .014). For the flaps, both biomechanical and enzymatic degradation tests had no significant differences. Conclusion: LASIK+CXL appears to provide significant increase in stroma rigidity and enzymatic digestion resistance. Visual Performance of a New Trifocal Toric Diffractive IOL Abstract #: RP30045397 Senior Author: Felipe A Soria MD Coauthors: Peter Mojzis MD PhD**, Katarina Majerova**, Ana Belen Plaza, Lucia Hrckova, Jorge L Alió MD PhD Purpose: To assess the visual performance after phacoemulsification with implantation trifocal toric lens (AT LISAtri 939MP). Methods: Thirty eyes with corneal astigmatism greater than +1.25 D were enrolled in this study. All patients underwent phacoemulsification surgery with implantation of intraocular trifocal lens with toric component. Results: Statistically significant improvement was found in uncorrected distance, near, and intermediate visual acuity (P < .01). Significant decrease in refractive cylinder was measured (P < .01). Rotations of 0° in 40% of eyes, between 1° and 3° in 53% of eyes, and between 4° and 5° in 7.0% of eyes were measured. Conclusion: Trifocal toric IOLs are ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. E-poster Abstracts 2015 Subspecialty Day | Refractive Surgery Intrastromal Corneal Ring Segment Implantation for Ectasia After Refractive Surgery Abstract #: RP30045400 Senior Author: Marisa Novaes Falleiro Chaves de Figueiredo Rassi MD Coauthors: Larissa Souza Stival Sr**, Belquiz A Nassaralla MD PhD, Frederico Bicalho**, Joao J Nassaralla MD PhD Purpose: To evaluate the clinical outcomes of intrastromal corneal ring segment (ICRS) implantation to correct ectasia in eyes with prior refractive surgery. Methods: Forty-one eyes of 25 patients (13 men, 12 women; mean age, 28.66 years) with ectasia after refractive surgery (PRK or LASIK) were included in a nonrandomized, observational case series. Main outcome measures included UCVA, BCVA, refraction, keratometry, and topography. Patients were divided into 2 groups: Group A, PRK; Group B, LASIK. Results: The mean preoperative manifest astigmatism decreased from -1.88 to -0.84 D in Group A (P = .096) and -3.18 to -1.77 D in Group B (P = .000). The mean keratometric astigmatism decreased from -2.58 to -1.66 D in Group A (P = .010) and -4.80 to -2.78 D in Group B (P = .000) Conclusion: ICRS implantation is a useful treatment option for ectasia following refractive surgery. Ex Vivo Comparison of Biomechanical Changes in High Myopic LASIK vs. Small-Incision Lenticule Extraction (SMILE) Abstract #: RP30045403 Senior Author: Ioanna Kontari MD Coauthors: A John Kanellopoulos MD, George Asimellis PhD Purpose: To comparatively evaluate corneal biomechanical changes in high myopic LASIK vs. SMILE. Methods: Twenty human donor corneas (n = 4 in each group). Group A, SMILE -3.00 D; Group B, SMILE -8.00 D; Group C, LASIK -3.00 D; Group D, LASIK -8.00 D; Group E, control. Ex vivo tests: transverse biaxial-resistance tensile strength (10% strain) and enzymatic digestion (time to dissolution). Results: High myopia: Shear modulus 3.7 ± 2.1 MPa, Group C; 2.9 ± 2.2 MPa, Group D. Enzymatic digestion: time to dissolution, 155 ± 17 min., Group C; 129 ± 37 min., Group D. Low myopia, non-statistically significant differences. Control: Shear modulus 5.7 ± 1.9 MPa; time to dissolution, 240 ± 35 min. Conclusion: SMILE and LASIK appear to result in comparable biomechanical reduction for low myopia; high myopia LASIK affects biomechanics more. Small-Incision Lenticular Extraction (SMILE) vs. LASIK Treating High Myopic Patients 95 Transepithelial and Stromal Pulsed-Light Accelerated Corneal Crosslinking for Patients With Progressive Keratoconus Abstract #: RP30045406 Senior Author: Andrew Olivo MD Coauthors: Jaime Larrea Sr MD**, Alexandra Abdala Figuerola MD, Erick Hernandez-Bogantes MD, Arturo J RamirezMiranda MD, Alejandro Navas MD, Enrique O Graue Hernandez MD Purpose: To evaluate pulsed-light accelerated crosslinking (paCXL) in keratoconus (KC). Methods: Prospective study of 60 eyes. Pa-CXL using transepithelial (30 eyes) or stromal (30 eyes). Uncorrected and corrected distance visual acuity (UDVA and CDVA) and corneal topography were measured. STATA 8.0 and t test were used. Results: Sixteen eyes had severe KC, 23 had moderate KC, and 21 had mild KC. Before pa-CXL mean UDVA was 0.87 ± 0.49 logMAR, and after pa-CXL UDVA was 0.85 ± 0.39 at 7.44 ± 2.28 months follow-up. Preop keratometry (K-max) was 54.19 ± 5.77 D, and after pa-CXL K-max was 54.43 ± 6.80 D. Pachymetry varied from 440.86 ± 46.90 µm to 435.80 ± 43.46 µm. No statistical differences were found in UDVA (P = .67), K-max (P = .39), or Km (P = .27). Statistical differences in CDVA (P = .01) and pachymetry (P = .001). Conclusion: Transepithelial and stromal pa-CXL were safe and effective; CDVA was better (P = .01) in stromal pa-CXL. Pupil Shape, Size, and Centroid Changes Associated With Clear-Cornea Cataract Surgery Abstract #: RP30045410 Senior Author: Ioanna Kontari MD Coauthors: A John Kanellopoulos MD, George Asimellis PhD Purpose: To investigate pupil size and shape changes following clear cornea cataract surgery (CCCS). Methods: Eighty-six consecutive eyes—patient age, 70.6 ± 10.3 years—underwent digital analysis of Scheimpflug imaging (pupil-edge marking) and auxiliary infrared imaging in a Placido topography screening device subjected to CCCS. Changes in horizontal (XØ) and vertical (YØ) pupil diameter, eccentricity (EE), and mesopic/photopic centroid shift were evaluated. Results: XØ was reduced by -0.27 ± 0.22 mm (-9.7%), and YØ by -0.32 ± 0.24 mm (-11%) (both P < .05). Eccentricity was reduced by -0.10 ± 0.11 (-39.56%) (P < .001). Temporal centroid shift was reduced. Conclusion: CCCS appears to significantly affect pupil size, eccentricity, and centration, changes that appear more significant with increasing patient age. These data may aid in operative planning and IOL design. Abstract #: RP30045405 Senior Author: Jorge L Alió MD PhD Coauthors: Mohamed Elbahrawy MBBCH MS**, Delores Ortiz PhD**, Dan Z Reinstein MD, Timothy J Archer MS Purpose: Refractive, visual and tensile outcomes in SMILE and LASIK in high myopic patients. Methods: Retrospective series of cases: (A) SMILE: 96 eyes, mean SE of -7.71 D. LASIK in (B) 48 Amaris eyes, mean SE of -7.85 D and (C) MEL 80144 eyes, mean SE -7.87 D. Results: Uncorrected distance visual acuity 20/20 or more: 76%, 81%, and 78% in Groups A, B, and C, respectively. No loss of any lines: 93%, 98%, and 98% in Groups A, B, and C. 0.50 D of target: 78%, 75%, and 64% in A, B, and C. Conclusion: LASIK showed slightly higher efficacy and safety. SMILE had the highest accuracy. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 96 E-poster Abstracts 2015 Subspecialty Day | Refractive Surgery OCT and Scheimpflug Tomography Ectasia Diagnostics: Corneal Epithelium, Total Thickness and Refractive Symmetry Mapping since AS-OCT provides evidence of stromal compaction after femto-assisted ICRS implant. Abstract #: RP30045411 Evaluation of Topography-Guided Photorefractive Keratectomy for Irregular Astigmatism Following Penetrating Keratoplasty (PK): 1 Year Result Senior Author: A John Kanellopoulos MD Purpose: To generate more sensitive and specific corneal ectasia criteria. Methods: 1260 keratoconus eyes were evaluated with the above principles that also correlated to the standard AmslerKrumeich (A-K) criteria. Results: Increased corneal epithelial thickness and variability and overall corneal thickness variability and asymmetry, along with increase of the index of height decentration and/or increase of the index of surface variance, appeared far more sensitive and specific than the A-K criteria (P < .001). Range and variability correlated with all the parameters studied correlated with the keratoconus severity. Conclusion: Novel cornea imaging metrics may increase the accuracy of keratoconus diagnosis and monitoring of its possible progression. Refractive Power Changes in Ectasia Management With the Athens Protocol: Topo-Guided PTK and Corneal Crosslinking Abstract #: RP30045412 Senior Author: Gregory J Pamel MD Coauthors: A John Kanellopoulos MD, George Asimellis PhD Purpose: Refractive power changes (RPC) of the anterior and posterior cornea in Athens Protocol long-term follow-up. Methods: 267 cases had RPC evaluation over 3 years with Scheimpflug tomography. Results: Strong correlation of RPC between anterior and posterior surface was established: Mean anterior flattening was as follows: K1, -3.09 ± 2.67 D, and K2, -4.19 ± 2.96 D; mean posterior RPC for K1 (flat) was +0.12 ± 0.61 D, and for K2 (steep), -0.02 ± 0.55 D. Index of height decentration improvement (mean): 0.145 ± 0.85 to 0.42 ± 28. Index of surface variance improvement (mean): 78 ± 35 to 34 ± 14. Mean corrected distance visual acuity improvement went from 0.4 (20/50) ± 0.25 to 0.8 (20/25) ± 0.27. Conclusion: Long-term stability, marked anterior RPC normalization, and effective visual rehabilitation may account the Athens Protocol as a valid alternative for ectasia management. Anterior Segment OCT to Assess Predictability of Femtosecond Laser-Assisted Intrastromal Corneal Ring Segment Depth Abstract #: RP30045420 Abstract #: RP30045421 Senior Author: Simon P Holland MD Coauthors: David T Lin MD, Choon Hwai Johnson Tan MBBS, Karolien M Termote MD Purpose: To evaluate efficacy and safety of topography-guided photorefractive keratectomy (TG PRK) for irregular astigmatism following penetrating keratoplasty (PK). Methods: Fiftythree eyes with post-PK astigmatism underwent transepithelial TG PRK with the Allegretto WaveLight (AW) laser and were evaluated for symptoms, UCVA, and BSCVA over 12 months. Results: Forty-five eyes completed 12 months of follow-up: 31% had UCVA ≤ 20/40, while none had it preoperatively. Fifty-one percent had BSCVA improved, 31% gained ≥ 2 lines, and 4% lost ≥ 2 lines. Refractive cylinder reduced from a mean of 3.6 D to 1.4 D; mean spherical equivalent from -3.13 ± 2.18 D to -1.38 ± 1.97 D. Retreatment rate: 10%. Conclusion: One-year results of TG PRK for post-PK astigmatism showed satisfactory efficacy and safety. Almost one-third gained 2 or more lines of BSCVA and achieved a UVA of 20/40. Comparison of Early Results of Topo-Guided Photorefractive Keratectomy With 2 Lasers Abstract #: RP30045422 Senior Author: Simon P Holland MD Coauthors: David T Lin MD, Karolien M Termote MD Purpose: Evaluation of topography-guided photorefractive keratectomy with collagen cross-linking (TG PRK/CXL) for keratoconus (KC) with two lasers. Methods: TG PRK/CXL with Allegretto Wavelight (AW) and Schwind Amaris (SA) in KC evaluated at 6 months for UVA, BSCVA, efficacy, and safety. Results: 183 AW and 52 SA eyes met follow-up criteria. 54% AW and 57% SA achieved 20/40 or better UCVA. 51% AW and 44% SA had BSCVA improved while 31% AW and 28% SA had ≥2 lines improvement with 7% AW and 14% SA loss of 2 lines. Conclusion: Almost half of the cases of both lasers had UCVA ≥20/40 and improved BCVA at 6 months. Early results of both WA and SA TG PRK with CXL for keratoconus show similar efficacy and safety. Senior Author: Michele Angely Pacheco MD Coauthors: Arturo J Ramirez-Miranda MD, Alejandro Navas MD, Leticia Elizabeth Pacheco, Enrique O Graue Hernandez MD Purpose: To evaluate the predictability of intrastromal corneal ring segment (ICRS) depth using anterior segment OCT (ASOCT). Methods: Transversal study of 33 eyes that underwent intrastromal femtosecond-assisted ICRS with the VisuMax. Postoperatively, AS-OCT distances from the anterior corneal surface to the anterior surface of the ring, ring depth, and incision depth were evaluated and compared with the attempted depth. Results: Distance from the ring apex to the anterior corneal surface was shorter (283 μm) than the target femtosecond depth (471 μm), probably due to stromal compaction (P < .05). Conclusion: In order to assess segment depth, incision depth may be considered ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. E-poster Abstracts 2015 Subspecialty Day | Refractive Surgery 97 Evaluation of Transepithelial Photorefractive Keratectomy After Modification of Laser Beam Profile IOL Power Calculations Following Myopic LASIK: A Systematic Review With Meta-analysis Abstract #: RP30045423 Senior Author: Qi Yu MD Coauthors: Weijun Wang MD**, Xun Xu MD Purpose: To evaluate and compare published methods of IOL power calculation after LASIK by systematic review with metaanalysis. Methods: We searched the peer-reviewed literature in PubMed, Embase, Biosis, and the Cochrane Library to identify relevant studies on cataract surgery following LASIK that assessed the IOL prediction error. Results: The Feiz-Mannis and the corneal bypass methods show the highest accuracy while all needed parameters are collected. The Haigis-L and the Shammas formulas have the advantage of not requiring laser surgery historical information. Conclusion: Inputting the most data obtained, comparing the calculations of multiple formulas, and having a discussion with each patient to inform consent dedicated to post-refractive surgery will allow for a satisfied patient. Senior Author: David T Lin MD Coauthors: Simon P Holland MD, Karolien M Termote MD Purpose: To determine if rate of recovery of uncorrected vision (UCVA) after transepithelial PRK (TE PRK) with existing Schwind Amaris SA laser beam profile (SPOA) could be improved with modification (SPNA). Methods: Forty-two eyes underwent TE PRK with SPOA, 433 eyes with SPNA, and 368 pre- and postoperative assessments of UCVA, BSCVA, manifest refraction (MR), and predictability were analyzed at 2 weeks and 1 and 3 months. Range of -1.00 to -6.00 D. Results: At 2 weeks, 25% of SPOA eyes had UCVA ≥ 20/25 compared to 42% of SPNA eyes (P < .05). At 3 months, 90% of SPOA eyes had UCVA ≥ 20/25 compared to 94% of SPNA eyes (P < .05). Conclusion: Modification of the Schwind (SA) beam profile significantly improved recovery of UCVA following TE PRK, allowing earlier return of functional vision. Prevalence of Color Vision Deficiency in Saudi Males Aspiring to Join Saudi Military Abstract #: RP30045424 Abstract #: RP30045428 Quality of Life After Refractive Surgery: SmallIncision Lenticule Extraction (SMILE) and Implantable Collamer Lens Abstract #: RP30045429 Senior Author: Nasir Nisar MBBS Purpose: Color vision deficiency is a decreased ability to see color. It interferes in learning or performing jobs. The aim is to find out the prevalence in Saudi males. Methods: Males were tested with Ishihara color vision test at any of the 3 main government hospitals in Saudi Arabia. The hospitals are SFH, PSMH, and KAAMC. We screened males every working day, from January 2014 to January 2015, for a period of 12 months (1 year). At the end, we collected and compiled our results. Then we calculated the prevalence. Results: Total sample size of 9620 males in the age group of 18-25 was screened. In total, 17.5% of males (1430) from the total sample were tested as positive. The calculated statistical prevalence is P < .001, and hence, it is significant. Conclusion: We conclude from the results that the prevalence is significant. Senior Author: Juan Carlos Serna MD Coauthors: Jesus Cabral-Macias MD, Guillermo Garcia De La Rosa MD, Alejandro Navas MD, Arturo J Ramirez-Miranda MD, Aida Jimenez, Enrique O Graue Hernandez MD Purpose: To compare the quality of life in patients after two types of refractive surgeries. Methods: The Quality of life Impact of Refractive Correction (QIRC) questionnaire was applied to individuals who had undergone SMILE or implantable collamer lens (ICL) V4 in both eyes. The main outcome was the comparison of the overall QIRC score. Results: Thirteen patients with SMILE and 10 patients with ICLV4 were included. The median score of the patients with SMILE (51.58, 95% CI, from 47.49 to 55.68) was not different from the median score of the ICLV4 group (52.59, 95% CI, from 44.85 to 60.33) (P = .053) after adjustment by spherical equivalent and baseline logMAR. Conclusion: SMILE patients had QIRC scores similar to those of ICL patients. Effects of Small-Incision Lenticule Extraction (SMILE) on Corneal Endothelial Cells Utility of Intraoperative Refractive Aberrometry During Resident Cataract Surgery Abstract #: RP30045427 Abstract #: RP30045435 Senior Author: Arturo J Ramirez-Miranda MD Coauthors: Flor Daniela Guzman, Alejandro Navas MD, Enrique O Graue Hernandez MD Purpose: To investigate the corneal endothelial changes after the SMILE procedure. Methods: Prospective study; a total of 30 eyes of 15 patients with myopia ranging from -3.25 to -10.00 D and astigmatism up to -3.50 D were treated by SMILE. Endothelial cell density (ECD) and the coefficient of variation (CV) were measured preoperatively and at 1 day and 3 months postoperatively. Results: No eyes developed corneal edema or other complications. There were no significant changes in the ECD or CV at any visit point (P > .05). Endothelial cell changes in terms of ECD or CV were not correlated with the amount of myopia of astigmatism. Conclusion: SMILE showed improvement in visual acuity and no adverse effects to corneal endothelial cells were found. Senior Author: Natasha V Nayak MD Coauthor: Anita Gupta MD Purpose: To assess the utility of intraoperative refractive aberrometry with Optiwave Refraction Analysis (ORA) for IOL power calculation in resident cataract surgery. Methods: Retrospective review. Results: Conventional method (CM; preoperative biometry) and intraoperative ORA were used for IOL power calculation in 18 patients (19 eyes; 42% male; mean age, 63.5 years; 6 toric IOL; 3 post-refractive surgery; 3 femtosecond laser). Seven of 19 cases had agreement between ORA and CM, 5 of which were adjusted by 0.5 D. In 12 cases of ORA and CM disagreement: 7 chose ORA, 4 chose CM, 1 chose a power between the 2 methods. Mean BCVA at postoperative Month 1 was 20/29. Fifty-six percent and 94% of eyes were within 0.5 D and 1.0 D of targeted postoperative refraction, respectively. Conclusion: ORA plays an important role in resident cataract surgery. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 98 E-poster Abstracts Epithelial-on Corneal Crosslinking in Thin Corneas Abstract #: RP30045438 Senior Author: William B Trattler MD Coauthors: Michelle Abou-Jaoude MD, Carl S Wilkins BA, Roy Scott Rubinfeld MD, Gabriela Perez** Purpose: To evaluate epithelial-on corneal crosslinking (CXL) in patients with keratoconus or post-LASIK ectasia with thin corneas. Methods: Keratoconus or post-LASIK ectasia patients with a preop corneal thickness less than 400 microns underwent epithelial-on CXL, with UV light exposure time of 30 minutes. UCVA, BCVA, and K-max were evaluated at 6, 12, and 24 months postop. Results: 141 eyes were evaluated. The average age was 37.1 years. At 6, 12, and 24 months after CXL, 37.2%, 44.3%, and 65.4% had improved UCVA. Improvement in BCVA at 6, 12, and 24 months postop was 37.2%, 41.4%, and 48.0%. Patients demonstrated an average reduction in K-max of -1.35 D, -1.19 D, and -1.75 D at 6, 12, and 24 months postop. Conclusions: In patients with keratoconus or post-LASIK ectasia with thin corneas, epithelial-on CXL is safe and effective. Posterior Corneal Changes After Intracorneal Ring Segment Implantation in Eyes With Keratoconus Abstract #: RP30045444 Senior Author: Orkun Muftuoglu MD Coauthor: Rukiye Aydin Purpose: To evaluate the relationship between anterior and posterior corneal changes after intracorneal ring segment (ICRS) implantation in eyes with keratoconus. Methods: 102 eyes of 68 patients with keratoconus that underwent ICRS implantation using femtosecond laser were included. All eyes were evaluated before and 6 months after surgery using Placido-Scheimpflug tomographer and anterior segment OCT. Results: The mean K decreased from 47.2 ± 2.6 D to 43.9 ± 1.8 D, and the mean posterior K increased from -7.5 ± 1.6 D to -6.3 ± 1.9 D. The mean total coma and spherical aberration (SA) decreases were more prominent in anterior (coma, 0.32 ± 0.15; SA, 0.09 ± 0.08 μm) than posterior cornea (coma, 0.18 ± 0.09; SA, 0.07 ± 0.06 μm). Conclusion: Antero-posterior compensation changes after ICRS. Correlation of Anterior and Posterior Corneal Shape in Clinical Keratoconus Abstract #: RP30045445 Senior Author: Arturo J Ramirez-Miranda MD Coauthors: Jaime Larrea Sr MD, Alejandro Navas MD, Enrique O Graue Hernandez MD Purpose: To evaluate the corneal volume, pachymetry, and correlation of anterior and posterior corneal shape in subclinical and clinical keratoconus. Methods: Eyes were placed into 3 groups: keratoconus grade I, grade II, subclinical, and a control group. All eyes underwent corneal curvature evaluation by Scheimpflug imaging (Sirius). The posterior-anterior corneal power ratio was also calculated. Results: 172 eyes (92 patients) were evaluated. Astigmatism and keratometry of both surfaces were significantly higher in the 3 groups (P ≤ .05). Posterior astigmatism was significantly higher in the subclinical group. A correlation in astigmatism between the anterior and posterior surface was found in all groups. Conclusion: The correlation between both surfaces was low, and the correlation between anterior and posterior astigmatism was maintained. 2015 Subspecialty Day | Refractive Surgery JRS Hot, Hotter, and Hottest: Late Breaking News The Visual and Refractive Outcomes and Aberrometric Changes of Aspheric WavefrontGuided vs. Aspheric Laser-Assisted Subepithelial Keratectomy With TENEOTM 317 P for Myopia Correction: Prospective 6-Month Study Abstract #: RP30045312 Senior Author: Seyed Javad Hashemian MD Purpose: To evaluate the visual and refractive outcomes and aberrometric changes of aspheric wavefront-guided (AWG) vs. aspheric laser-assisted subepithelial keratectomy (LASEK) for myopia correction. Methods: Sixty-six eyes treated by TENEO 317 P Excimer Laser (Bausch + Lomb). Forty-five eyes were treated with AWG and 21 eyes with aspheric LASEK (AG). Uncorrected and distance corrected visual acuity (UCVA and DCVA), aberrometric changes, and complications were evaluated over 6 months. Results: The mean SE was -3.69 D in AWG and -3.57 D in AG, improving to 0.06 and 0.14 D, respectively. At 6 months logMAR UCVA and CDVA in both groups were 0.00; the higher-order aberrations (HOAs) at 6-mm pupil were 0.350 µ in AWG and 0.270 µ in AG, increasing to 0.464 µ and 0.431 µ, respectively (P = .00). Z3-1 and Z40 increased significantly. Conclusion: Both AWG and the aspheric ablation profile of the TENEO are safe and effective, with little change in HOAs in myopic patients treated with LASEK. Review of Postoperative Care Following Refractive Surgery in the U.S. Military Abstract #: RP30045318 Senior Author: Marshall Hill MD Purpose: To evaluate guidelines for postoperative care of service members following refractive surgery. Methods: Eighteen military refractive centers that perform over 20,000 procedures annually were surveyed regarding postoperative care guidelines. Results: Time off work after surgery was 2-7 days (µ = 5.06). The length of time before returning the field duty was 7-90 days (µ = 34.56). Time before being allowed to deploy was 14-120 days (µ = 66.83). Time before being allowed to exercise was 1-30 days (µ = 10.87). The use of antibiotic drops and steroid treatment were similar among facilities. Conclusion: Postrefractive care and guidelines vary throughout each facility. Further research is needed to determine appropriate recommendations for returning to duty after surgery. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. E-poster Abstracts 2015 Subspecialty Day | Refractive Surgery New Technique for Astigmatism: Beveled, FullThickness Astigmatic Keratotomy Abstract #: RP30045319 Senior Author: Sujoung Mun MD Coauthors: Buki Kim, Daegyu Lee**, Youngtaek Chung** Purpose: To evaluate beveled, full-thickness astigmatic keratotomy (BF-AK). Methods: This study included 185 eyes of 112 patients treated with BF-AK. Treated eyes were divided into 3 groups: BF-AK after ICL implantation (Group A), BF-AK after cataract surgery (Group B), and BF-AK alone (Group C). Results: At 6 months, astigmatism was significantly reduced: 68.9 ± 18.24% in total, 69.24 ± 20.76% in Group A, 67.84 ± 17.56% in Group B, and 67.82 ± 13.97% in Group C. The proportion of eyes with astigmatism 1.0 or less was 88.65% in total, 91.49% in Group A, 87.5% in Group B, and 70.0% in Group C. Postoperative complications were not observed. Conclusion: BF-AK is effective and safe for correcting astigmatism alone as well as correcting astigmatism after ICL implantation or cataract surgery. Evaluation of a Bitoric, Trifocal Multifocal IOL Abstract #: RP30045320 Senior Author: Florian T A Kretz MD Coauthors: Detlev R H Breyer MD, Matthias Gerl MD**, Ralf H Gerl MD**, Hakan Kaymak MD, Matthias Mueller PhD, Gerd U Auffarth MD Purpose: To evaluate the functional outcome after implantation of a bitoric, trifocal multifocal IOL (MIOL), the AT LISA 939MP (Carl Zeiss Meditech; Germany). Methods: Examinations included uncorrected distance, intermediate, and near visual acuities (UDVA, UIVA, UNVA), corrected distance VA, and distance-corrected intermediate and near VA (DCIVA and DCNVA; logMAR). Additionally a Salzburg Reading Desk (SRD) evaluation (uncorrected and distance corrected) was performed. Results: Median binocular UDVA, UIVA, and UNVA were 0.02, 0.04, and 0.10 compared to a CDVA, DCIVA, and DCNVA of 0.04, -0.10, and -0.10 (logMAR). The SRD evaluation showed a binocular, objective UNVA (39.4 cm) of 0.11, similar to a subjective UNVA (38.9 cm). Conclusion: The bitoric, trifocal MIOL offers a high amount of spectacle independence for daily tasks. Small postsurgical refractive errors can be balanced by the wide range of focus of this type of lens. Evaluation of 2 Multifocal IOLs With a Lower Near Addition Abstract #: RP30045321 Senior Author: Florian T A Kretz MD Coauthors: Detlev R H Breyer, MD, Hakan Kaymak MD**, Ralf H Gerl MD, Matthias Gerl MD, Matthias Mueller PhD**, Gerd U Auffarth MD Purpose: Clinical evaluation of 2 diffractive, pupil independent, multifocal IOLs (MIOL) with a different near addition (Tecnis ZKB00 and ZLB00, AMO; USA). Methods: The ZKB00 and the ZLB00 with a near addition of +2.75 D and +3.25 D were evaluated. Follow-up examinations included monocular and binocular uncorrected distance and near visual acuity (VA), corrected distance and near VA, distance-corrected near VA, and individual reading distance and speed (Salzburg Reading Desk). Results: Three months postop, the median UDVA and UNVA were 0.1 and 0.15 with a binocular UNVA of 0.05 (logMAR). 99 The patients were very satisfied with their outcome. Conclusion: Both MIOLs with a lower near addition provide good functional results with a high percentage of spectacle independence and patient satisfaction. Small-Incision Lenticule Extraction (SMILE) Combined With Astigmatic Keratotomy to Treat High-Level and Mixed Astigmatism Abstract #: RP30045322 Senior Author: Sujoung Moon MD Coauthors: Buki Kim, Daegyu Lee, Youngtaek Chung Purpose: To explore the clinical effects of combined astigmatic keratotomy and SMILE for patients who are inoperable using SMILE alone. Methods: We included 13 eyes of 9 patients with high-level or mixed astigmatism who underwent astigmatic keratotomy followed by SMILE to correct residual refractive error. Results: Six months after SMILE, the SE was reduced from -4.83 ± 3.26 to -0.17 ± 0.38 D (P < .001), and astigmatism was reduced from 5.12 ± 0.96 to 0.21 ± 0.22 D (P < .001). The uncorrected and corrected distance visual acuities (UDVA and CDVA) improved from 1.07 ± 0.62 to 0.02 ± 0.13 (P < .001) and from 0.08 ± 0.14 to -0.01 ± 0.14 (P = .002), respectively. The CDVA improved by 1 or 2 Snellen lines in 8 cases (61.5%), and there was no loss in CDVA. Conclusions: This combined procedure was effective and safe in the treatment of high-level or mixed astigmatism. Higher-Order Aberration Changes After Customized Femtolaser-Assisted LASIK vs. Laser-Assisted Subepithelial Keratectomy for the Correction of High Myopia and Astigmatism Abstract #: RP30045329 Senior Author: Seyed Javad Hashemian MD Purpose: To compare the higher-order aberration (HOA) changes after wavefront-guided femtolaser LASIK (WFG FLASIK) with those of WFG LASEK in the treatment of high myopia. Methods: 114 eyes with spherical component > -6.0 D and cylinder < -3.0 D were assigned to 2 groups: 47 eyes were treated with FLASIK and 67 eyes with LASEK. Total RMS and HOA value changes were measured using Zywave (B+L) preoperatively and 6 months postoperatively. Results: Preoperatively the MRSE was -7.12 in the FLASIK group and -6.97 D in the LASEK group. At 6 months it was -0.27 and -0.05 D, respectively. UCVA, DCVA, and total RMS values were nearly the same. Mean HOA values were 0.36 µm in both groups, increasing to 0.61 µ and 0.71 µ, respectively. Z3-1 and Z40 increased significantly in the LASEK group. Conclusion: Both techniques were safe and effectively treated eyes with high myopia, although HOA values increased significantly more in the LASEK group. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 100 E-poster Abstracts 2015 Subspecialty Day | Refractive Surgery Evaluation of In Vitro Glistening Formation in Different Hydrophobic Acrylic IOLs Integrity of Intrastromal Arcuate Keratotomies Performed by Femtosecond Laser Abstract #: RP30045334 Abstract #: RP30045337 Senior Author: Ramin Khoramnia MD Coauthors: Tamer Tandogan MD, Chul Young Choi**, Tanja M Rabsilber MD, Gerd U Auffarth MD Purpose: To compare the glistening formation in different hydrophobic acrylic IOLs. Methods: Glistenings were created as aqueous-filled microvacuoles in 5 IOLs per model—AU6KA (Kowa; Japan), Envista (Bausch + Lomb; USA), AcrySof MA60AC (Alcon; USA), and I-Sert PC-60AD (Hoya; Japan)—using an accelerated laboratory method. Results: The range of the glistening density for the IOLs was as follows (in microvacuoles per square millimeter [MVs/mm2]): AU6KA, 1-4; Envista, 1-2; AcrySof MA60AC, 507-804; and I-Sert PC-60AD, 684-2699. Conclusion: The amount of glistenings differed significantly. While 2 IOL models, AU6KA and Envista, showed a glistening grade of only 0 according to Miyata et al, the other 2 models, MA60AC and PC-60AD, showed a glistening grade of 3. Senior Author: Maheen Haque MD Coauthors: Ali Fadlallah Yahya MD, Samir Jabbour MD, Mona Harissi-Dagher MD, Samir A Melki MD PhD Purpose: To evaluate the integrity of intrastromal arcuate keratotomies (ISAK) performed by femtosecond laser cataract surgery (FSLCS). Methods: Twenty-eight consecutive eyes that underwent an OCT-guided FSLCS (Catalys, Abbott Medical Optics) with ISAK were evaluated. Videotaped femtosecond surgeries were reviewed for presence of bubble seepage as an indicator of a microperforation. Results: Of 37 incisions, 56.7% showed evidence of an anterior microperforation. No posterior or full perforation was noted. No evidence of infection was noted postoperatively. Perforation status was not found to affect BCVA or mean spherical equivalent. Length of incisions did not seem to increase the risk of perforation. Conclusion: We noted a high incidence of anterior microperforations in ISAK performed by FSLCS. Evaluation of Reading Performance With the Salzburg Reading Desk of an Extended Depth of Focus IOL Abstract #: RP30045335 Senior Author: Ramin Khoramnia MD Coauthors: Mary Attia MBBCH, Tamer Tandogan MD, Gerd U Auffarth MD Purpose: To evaluate visual and reading performance of a new extended depth of focus IOL. Methods: In this ongoing prospective study, 20 eyes of 10 patients have so far received the Tecnis Symfony IOL (Abbott Medical Optics). Among other parameters, the reading acuity was calculated by the Salzburg Reading Desk (SRD) with consideration of reading distance, speed, and print size. Results: Median visual acuity (VA) results were as follows: uncorrected distance VA, 0.06 logMAR (range: 0.44 to -0.14 logMAR); uncorrected near VA, 0.20 logMAR (range: 0.46 to 0.00 logMAR); uncorrected intermediate VA, 0.00 logMAR (range: 0.14 to -0.18 logMAR). The SRD measured an uncorrected reading acuity of 0.09 logMAR (range: 0.28 to 0.00 logMAR). Conclusion: The IOL provides promising results at far and intermediate distances but also at near distance. Risk Factors for Poor Epithelial Flap Quality in Laser Epithelial Keratomileusis A Tissue-Sparing Technique for Phototherapeutic Keratectomy With Mitomycin C for Intractable Corneal Haze After Surface Refractive Procedure Abstract #: RP30045338 Senior Author: Ali Fadlallah Yahya MD Coauthors: Stephanie Hopp BS MS, Daniel Cherfan MBBS, Samir A Melki MD PhD Purpose: To evaluate the use of a modified phototherapeutic keratectomy (PTK) technique with mitomycin C (MMC) combined with surgical scraping as a treatment modality in patients with haze after corneal surface refractive surgery. Method: Six eyes of 6 patients were treated with PTK with MMC for clinically significant haze following surface corneal refractive procedures. Result: Mean follow-up period after PTK and MMC was 13 months. Mean BCVA prior to the PTK ranged between 20/200 and 20/30. After treatment, 2 patients had a BCVA of 20/20, and 6 had a BCVA > 20/30. The technique allowed 56.9% less tissue ablation than in previously published reports. Conclusion: A modified PTK technique seems safe and effective in improving visual acuity in patients with haze after surface refractive procedures. It allows less tissue removal compared to previously published methods. Abstract #: RP30045336 Senior Author: Ali Fadlallah Yahya MD Coauthors: Joanna Galindo MS, Samir A Melki MD PhD Purpose: To evaluate risk factors leading to poor epithelial flap quality in laser epithelial keratomileusis (LASEK). Methods: Logistic regression was performed to determine if epithelium preservation was correlated with age, sex, sphere, cylinder, keratometry, and corneal thickness. Results: A total of 1009 eyes were reviewed. Successful mobilization of the loosened epithelium flap was found in 72.35%. Epithelial preservation was significantly correlated only with age (P = .048). Older patients (age 50 and above) were more likely to experience flap removal due to poor flap quality. Conclusion: Our data show that older age is a significant factor adversely affecting epithelial flap integrity in LASEK. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. E-poster Abstracts 2015 Subspecialty Day | Refractive Surgery Long-term Risk Factors for Dry Eyes and Visual Aberrations After Corneal Refractive Surgery Abstract #: RP30045339 Senior Author: Samir A Melki MD PhD Coauthors: Samuel G Hilbert BA MS**, Ali Fadlallah Yahya MD Purpose: To examine risk factors for dry eyes and visual aberrations 1 year after corneal refractive surgeries. Methods: 319 participants completed a novel online questionnaire to assess dry eye and visual aberration symptoms. Results: Mean follow-up was 2.5 ± 1.2 years. Preoperative risk factors associated with postoperative dryness were presence of dry eyes and greater flap thickness. Risk factors associated with postoperative visual aberrations were higher cylindrical manifest refraction, higher flat K, and greater flap thickness. Conclusion: Dry eyes and visual aberrations remain common complications 1 year after corneal refractive procedures. Preoperative risk factor assessment can identify patients at risk. Clinical Impact After Implantation of Nonrefractive Presbyopic Corneal Inlay: U.S. Investigational Device Exemption Clinical Trial Update Abstract #: RP30045342 Senior Author: Gregory D Parkhurst MD Coauthors: Roger F Steinert MD, Douglas D Koch MD Purpose: To evaluate the change in safety parameters from baseline to 12 months postop. Post-explant visual recovery will also be evaluated in complicated cases. Methods: Raindrop Near Vision Inlay subjects (n = 373) will be evaluated preop to 12 months on the following safety parameters: IOP, endothelial cell count (ECC), and corrected distance visual acuity (CDVA). Results: At 12 months (n = 340), mean change in IOP from baseline was < 0.5 mmHg, mean change in ECC from baseline after the 1-month visit was ≤ -0.1 kcells/mm2, and ≤ 2% of subjects experienced a CDVA loss of ≥ 2 lines at each visit. In explant cases, all subjects returned to 20/25 CDVA for near and distance. Conclusion: The clinical impact after Raindrop Inlay implantation appears to be minimal, and if a subject had the inlay removed, most returned to near baseline values. Small-Incision Lenticule Extraction (SMILE) Hyperopia: Comparison of Optical Zone Centration and Diameter and Higher-Order Aberrations Between LASIK and SMILE 101 centration was equal for SMILE and LASIK. SA change was similar for 6.3-mm SMILE and 7-mm LASIK. OZ diameter was larger for 6.3-mm SMILE than 7-mm LASIK. Nonrefractive Corneal Inlay for the Treatment of Presbyopia: U.S. FDA Clinical Trial Update Abstract #: RP30045350 Senior Author: Roger F Steinert MD Coauthor: Douglas D Koch MD Purpose: To evaluate visual outcomes and satisfaction in emmetropic presbyopes implanted with the Raindrop Near Vision Inlay. Methods: Multicenter, nonrandomized, prospective investigational device exemption study in the United States. Visual acuities (VA), ocular symptoms, satisfaction, and safety were assessed at various visits to 1 year. Results: At 1 year (n = 340), almost all patients binocularly achieved ≥ 20/25 (100% uncorrected distance VA, 95% uncorrected near VA). Monocularly in the inlay eye, uncorrected near VA improved 5.1 lines, uncorrected intermediate VA, 2.5 lines, and uncorrected distance VA decreased 1.2 lines. Overall satisfaction was high, at 93%, and complications were low, at 3.2% explant rate. Conclusion: The Raindrop Inlay provided patients with good functional acuity, with 95% of patients seeing ≥ 20/25 at all distances with high satisfaction (93%). Comparing 2 Different Presbyopia-Correcting Treatments: Nonrefractive Hydrogel Corneal Inlay and Monovision LASIK Abstract #: RP30045351 Senior Author: Cornelis Verdoorn MD Purpose: To compare 2 different presbyopia-correcting treatments: Raindrop Near Vision Inlay (R) and monovision LASIK (M). Methods: Previously treated patients (R, n = 16; M, n = 15) from a single commercial site were prospectively evaluated on visual acuity (VA), stereopsis, and spectacle independence. Results: With binocular vision, the Raindrop performed better than monovision LASIK (uncorrected distance VA > 1.0: R, 100% vs. M, 98%; uncorrected near VA > 1.0: R, 79% vs. M, 53%). Stereopsis results were also better for Raindrop (R, 98 secs vs. M, 286 secs). Eighty-six percent of both groups were spectacle free. Conclusion: The Raindrop provided better binocular vision and stereopsis when compared to monovision LASIK. Abstract #: RP30045347 Senior Author: Dan Z Reinstein MD Coauthors: Kishore Raj Pradhan MD, Glenn Ian Carp MBBCH, Timothy J Archer MS, Marine Gobbe PhD, Raynan Khan BS Purpose: To evaluate results of hyperopic SMILE. Methods: Prospective study of hyperopic SMILE (n = 30), sphere ≤ +7 D, cyl ≤ 6 D, corrected distance visual acuity ≥ 20/40. Optical zone (OZ) was 6.3 mm and 2-mm transition. OZ centration (Atlas tangential), diameter, and spherical aberration (SA) were analyzed. MEL80 LASIK matched groups were generated for 6.5-mm and 7-mm OZ. Results: Mean SEQ was +5.15 D. For SMILE, 7-mm LASIK, and 6.5-mm LASIK, respectively, mean SA change was -0.49 μm, -0.47 μm, and -0.79 μm; mean OZ offset was 0.30 mm, 0.34 mm, and 0.29 mm; mean OZ diameter was 5.55 mm, 4.93 mm, and 4.65 mm. Conclusion: OZ ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 102 E-poster Abstracts Satisfaction Following Combined Small-Aperture Corneal Inlay (Kamra) Implantation and LASIK for Presbyopia Correction in an Irish Population Abstract #: RP30045353 Senior Author: Estera Igras MD Coauthors: Paul D O’Brien MBBCH BA, William J Power MD Purpose: To measure patient satisfaction following LASIK and a small-aperture corneal inlay insertion. Methods: A cross-sectional survey. Results: In total, 97/146 patients (66%) returned the questionnaire. The most common reason for selecting the procedure was the inconvenience of wearing spectacles (87/97, 90%). The majority (72/95, 76%) heard about the procedure online or through personal recommendation. Most patients reported improvement in distance vision tasks (55/96, 57%), intermediate tasks (73/96, 76%), and near vision tasks (78/96, 81%). Daily activities were significantly better in bright than in dim light (P < .001). In all, 85/97 (88%) scored 8-10/10 for overall satisfaction, while 81/96 (84%) would recommend the procedure to another. Conclusion: The combined procedure was well tolerated, with most expressing satisfaction with their vision. Toric IOL Alignment: Computerized, Image-Based System vs. Slitlamp Marking System Abstract #: RP30045356 Senior Author: Paolo Vinciguerra MD Coauthors: Fabrizio I Camesasca MD, Riccardo Vinciguerra MD, Silvia Trazza Purpose: To compare results in cataract astigmatic eyes receiving a toric IOL aligned with a slitlamp marking system (SLMS) vs. a computerized, ocular image-based system (COIBS). Methods: We assessed toric IOL alignment comparing 42 SLMS eyes (Group 1) with 30 COIBS eyes (Group 2). COIBS preoperatively detects scleral, limbal, pupil, and iris features, intraoperatively injecting alignment axis image in the microscope view. Results: Mean subjective astigmatism changed from -2.15 ± 1.73 D to -0.63 ± 0.66 D for Group 1, and from -2.48 ± 1.16 D to -0.40 ± 0.28 D for Group 2 (P < .05). Axis difference between IOL alignment and objective intraocular astigmatism was 12.86° ± 13.63° for Group 1 vs. 7.50° ± 3.63° for Group 2 (P < .01). Conclusion: COIBS provided more effective toric IOL alignment and astigmatism reduction. Long-term Results of Combined Small-Aperture Corneal Inlay (Kamra) Implantation and LASIK for Presbyopia Correction 2015 Subspecialty Day | Refractive Surgery (BCDVA) unchanged for 84% at 18-24 months. No patient lost ≥ 1 line of BCDVA. Two inlays were explanted due to suboptimal adaptation. Conclusion: Overall, this is a safe, effective, and reversible procedure for presbyopia treatment. A 3-Dimensional “Super Surface” Combining IOL Formulas to Create a “Super Formula” to Optimize IOL Calculations Abstract #: RP30045372 Senior Author: John G Ladas MD Coauthors: Aazim A Siddiqui, Uday Devgan MD, Albert S Jun MD Purpose: To develop a method for displaying IOL formulas in 3 dimensions and create a “super surface” based on current formulas, resulting in an IOL “super formula.” Further, to develop a methodology to refine optimization. Methods: A graphical environment was used to create 3-D surfaces of IOL formulas. A 3-D super surface was generated that incorporated the most ideal portions from various IOL formulas based on current literature. Results: Individual formulas diverge from the super surface by more than 0.5 D in 16%-58% of the cases. Conclusion: We have developed a novel method to characterize IOL formulas that will broaden the conceptual understanding of IOL calculations, improve patient outcomes and optimization, and stimulate further research in the field of IOL calculations. Femtosecond-Assisted LASIK With and Without Mitomycin C Performed to Correct Hyperopia: A 15-Month Follow-up Abstract #: RP30045373 Senior Author: Montserrat Garcia-Gonzalez MD Coauthors: Isabel Rodriguez-Perez MHSA, Mariluz Iglesias Iglesias, Miguel A Teus MD, Javier Paz Moreno-Arrones MD Purpose: To compare the 15-month visual and refractive results of femtoLASIK with and without mitomycin C (MMC) to correct hyperopia. Methods: 152 consecutive eyes were divided into 2 groups: applying 0.02% MMC for 5 seconds and without MMC. We compared the refractive results 15 months postoperatively. Results: No significant differences were found in the postoperative uncorrected distance visual acuity, corrected distance visual acuity, or residual refraction. Retreatment rate was significantly lower in the MMC group (6.58% vs. 10.53%; P = .01). Conclusion: Hyperopic femtoLASIK provides good refractive outcomes in a 15-month follow-up. The use of MMC seems to reduce the incidence of retreatments. Abstract #: RP30045359 Senior Author: Estera Igras MD Coauthors: Paul D O’Brien MBBCH BA, William J Power MD Purpose: To evaluate the long-term efficacy and safety of combined LASIK procedure and Kamra implantation for the correction of presbyopia and refractive errors. Methods: Case-note review. Results: 146 patients were available; median age, 56 years. Median preoperative MRSE was +1.37 D (±0.87). The majority, 116 (79%), were hypermetropic. Preoperative uncorrected near visual acuity (UCNVA) improved from N24 to N5 by Day 1, remaining stable throughout follow-up. At 18 months 97% achieved UCNVA ≥ N6, with median uncorrected distance VA (UCDVA; implanted eye) improving from 6/12 to 6/7.5. Binocular UCDVA was 6/6 in 88%, with best corrected distance VA ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. E-poster Abstracts 2015 Subspecialty Day | Refractive Surgery Comparison of Optical Quality in Monofocal, Bifocal, and Trifocal IOLs of the Same Manufacturer Abstract #: RP30045374 Senior Author: Tamer Tandogan MD Coauthors: Ramin Khoramnia MD, Hyeck-Soo Son**, Florian T A Kretz MD, Gerd U Auffarth MD Purpose: To compare optical quality in 3 different IOL designs. Methods: In a laboratory study, optical bench analyses were performed with the OptiSpheric IOL Pro (Trioptics; Germany). We compared the modulation transfer function (MTF), MTF area (MTFA) measurements, and through focus scans (TFS) of 3 different IOL models based on the same platform: CT Asphina 409M (monofocal), AT Lisa 809M (bifocal), and AT Lisa Tri 839M (trifocal) from Carl Zeiss Meditech (Germany). Results: Mean MTF values (50 lp/mm far focus) were 0.804 for the monofocal, 0.448 for the bifocal, and 0.387 for the trifocal IOL. Conclusion: The monofocal IOL showed the best image quality for a single focal point, the bifocal IOL at near and the trifocal IOL at intermediate distance, which was confirmed in USAF target analysis. 103 Preliminary Outcomes in Phaco Refractive Surgery With Multifocal Lens in a Post-LASIK Hispanic Population Abstract #: RP30045383 Senior Author: Jose A Nava-Garcia MD Purpose: To analyze safety and effectiveness of phacorefractive surgery in post-LASIK patients. Methods: Case series, evaluated after phacoemulsification and multifocal IOL during 2014. Patients had corneal refractive surgery previously. Changes in VA, refraction, and complications were evaluated. Results: Ten cases were analyzed and followed for 1 year. We observed uncorrected distance VA improvement in all cases; 50% of cases had an accuracy of SEQ intended target +0.14 to +0.50. Spherical equivalent of refraction, attempted vs. achieved, was 1.48 ± 0.58; refraction stability (% changed > 0.50 D) was 4%. Mean age was 51 (47-55) years. No cases of retinal detachment were found. Conclusion: Availability of multifocal IOL has increased phacorefractive procedures in patients with previous corneal procedures. Safety and efficacy of this procedure is still to be determined. Visual Outcomes and Patient Satisfaction Following Implantation of the Tecnis Symfony IOL The Effect of Angle Kappa on Clinical Outcomes With Pupil-Centered Wavefront-Guided LASIK to Correct Hyperopia Abstract #: RP30045376 Abstract #: RP30045384 Senior Author: David W Teenan MBChB Coauthor: Steven C Schallhorn MD Purpose: To assess outcomes and satisfaction following refractive lens exchange with a Tecnis Symfony IOL. Methods: A retrospective analysis was undertaken. Outcome measures were uncorrected distance visual acuity (UCDVA), uncorrected near visual acuity (UCNVA), patient satisfaction, and complications. Results: The study comprised 160 eyes of 80 patients with a mean age of 56 years. At 1 month in 93% of patients UCDVA was 20/32 or better, while UCNVA was 20/50 or better in 88%. On questioning, 83% of patients were satisfied/very satisfied. Only 7%, 6%, and 1% of patients reported severe difficulty with glare and haloes and ghosting, respectively. There were no reported complications. Conclusion: The Symfony IOL provides a high level of satisfaction and a low level of visual complaints while providing good visual outcomes. Senior Author: Steven C Schallhorn MD Purpose: To analyze the effect of angle kappa on optical and visual outcomes after hyperopic wavefront-guided (WFG) LASIK. Methods: 105 hyperopic eyes were treated with WFG (WaveScan) LASIK and followed for 6 months. Angle kappa was approximated by the chord length of the coaxially sighted corneal intercept of the center of the entrance pupil and the coaxially sighted corneal vertex. Analyses included uncorrected and best corrected vision, contrast sensitivity, and higher-order aberrations. Results: No correlation with angle kappa (mean 0.46 ± 0.17, range: 0.05 to 1.09 mm) and 6-month outcomes were observed. Even when stratified into low (< 0.25 mm) and high (> 0.55 mm) angle kappa levels, no differences were observed. Conclusion: Angle kappa did not influence outcomes of hyperopic WFG LASIK. Initial Results of Cornea Inlay Use for Presbyopia in a Single Center Following FDA Approval Abstract #: RP30045377 Senior Author: Phillip Hoopes Jr MD Purpose: To give an overview for an FDA-approved cornea inlay, Kamra (AcuFocus), and initial outcomes in a case series from a single center following FDA approval for presbyopic correction. Methods: Retrospective chart review of 20 initial cases of cornea inlay implantation for presbyopia. Results: Data are currently being gathered at time of submission, to include preoperative uncorrected distance and near visual acuities (UCDVA and UCNVA), postoperative UCDVA and UCNVA, patient satisfaction survey, and any adverse events. Conclusion: Cornea inlay for presbyopia appears to be a safe and effective treatment for presbyopia. Outcomes of a Large Population of WavefrontGuided LASIK Using a Recently Approved Aberrometer Abstract #: RP30045385 Senior Author: Steven C Schallhorn MD Coauthor: David W Teenan MBChB Purpose: To evaluate wavefront-guided (WFG) LASIK using a newly approved aberrometer. Methods: All patients that underwent WFG LASIK within the FDA-approved refractive range were evaluated. Results: There were 10,132 eyes of 6148 patients with preop sphere -3.10 ± 1.89 D (-0.25 D to -10.75 D) and cylinder -0.80 ± 0.73 D (0.00 D to -5.00 D). At last examination (mean: 3.8 months), 96.6% of eyes were within 0.50 D and 81.8%, 93.7%, and 97.5% achieved monocular UCVA of 20/16, 20/20, and 20/25 or better. More eyes gained BCVA than lost (mean change 0.02 LM gain; 11 eyes with a loss of 2 lines vs. 445 eyes with a gain of 2 lines). 94.5% of patients were satisfied, and 96.3% would recommend the procedure. Conclusion: The majority of eyes achieved an unaided vision of 20/16 or better with excellent refractive predictability. Patient satisfaction was high. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 104 E-poster Abstracts 2015 Subspecialty Day | Refractive Surgery Treatment of Hyperopic Presbyopes With Laser Vision Correction Combined With Corneal Inlay Implantation Bilateral Implantation of a Polyfocal Bioanalogic IOL: One-Year Outcomes Abstract #: RP30045387 Senior Author: Robert Edward T Ang MD Purpose: To evaluate the visual outcomes of a polyfocal bioanalogic IOL. Methods: This is a prospective study of patients bilaterally implanted with a polyfocal bioanalogic IOL (WIOL, Medicem; Czech Republic). Manifest refraction, distance, intermediate and near VA, defocus curve, and contrast sensitivity were measured. Results: Nine patients reached 1 year follow-up. Mean spherical equivalent was 0.02 D. UDVA was 20/25, UIVA was 20/20, and UNVA was J2. Vision was 20/40 or better over a range of +1.00 to -2.00 D of defocus. Conclusion: The WIOL provides good distance, intermediate, and near vision by extending the range of vision. Senior Author: Jeffrey J Machat MD Purpose: To evaluate effectiveness of combining hyperopic LASIK and corneal inlays. Methods: 2022 hyperopic presbyopes had a small-aperture corneal inlay implanted in the nondominant eye subsequent to bilateral laser vision correction. Uncorrected near and distance visual acuity (UNVA and UDVA) and best-corrected distance visual acuity (BCDVA) were evaluated preop and out to 18 months postop. Results: UDVA improved from 20/21 preop to 20/17 at 18 months (P < .0001). UCNVA improved from 20/78 preop to 20/28 (P < .0001). All patients achieved BCDVA > 20/25 at 18 months. Conclusion: Combining hyperopic laser vision correction and small aperture inlay implantation extends depth of focus by significantly improving both uncorrected near and distance visual acuity in treated eyes. Treatment of Myopic Presbyopes With Laser Vision Correction Combined With Corneal Inlay Implantation Abstract #: RP30045388 Senior Author: Jeffrey J Machat MD Purpose: To evaluate effectiveness of combining myopic LASIK and corneal inlays. Methods: 7421 myopic presbyopes had a small-aperture corneal inlay implanted in the nondominant eye subsequent to bilateral laser vision correction. Uncorrected near and distance VA (UNVA and UDVA), and best-corrected distance VA (BCDVA) were evaluated preop and out to 18 months postop. Results: UNVA improved from 0.42 ± 0.29 logMAR preop to 0.02 ± 0.13 at 18 months (P < .0001). UDVA improved from 0.05 ± 0.41 preop to -0.01 ± 0.14 (P < .0001). 99.8% of patients achieved > 20/25 BCDVA at 18 months. Conclusion: Combining LASIK and small aperture inlay implantation using a dual-interface technique significantly improves UNVA and UDVA without compromising BCDVA in myopic presbyopes. The Changes of Keratometric Values After Raindrop Corneal Inlay With LASIK in Hyperopic Presbyopia Abstract #: RP30045389 Senior Author: Choun-ki Joo MD Coauthor: Woong-Joo Whang Purpose: To analyze surgically induced refractive change (SIRC) after Raindrop corneal inlay implantation with hyperopic LASIK. Methods: Hyperopic LASIK was performed and the Raindrop (ReVision Optics, Inc.; California) was implanted in 9 nondominant eyes of 9 patients. Sim K, true net power (TNP), and total corneal refractive power (TCRP) were provided by Pentacam Scheimpflug camera (Oculus; Germany), and the changes of corneal power measurements were compared with SIRC by manifest refraction. Results: The SIRC was 2.25 ± 1.07 D. The changes of TNP and TCRP at center produced more dioptric power than SIRC, while TCRP at the 5.0-mm zone produced less dioptric power than SIRC. TCRP changes at the 4.0-mm zone did not produce a significant difference from SIRC (2.30 D, P = .25). Conclusion: TCRP 4.0-mm zone provided by Pentacam accurately reflected the surgically induced change in refractive power. Abstract #: RP30045390 Safety and Efficacy of Myopic LASIK Performed on Thin Corneas Abstract #: RP30045392 Senior Author: Jorge E Valdez-Garcia MD Coauthors: Victor M Preciado Jr, Javier Humberto GonzalezLugo BA MD, Julio Hernandez Camarena MD Purpose: To evaluate the visual outcomes of myopic LASIK performed in thin corneas (≤ 540 μm). Methods: Retrospective analysis: 102 myopic LASIK procedures (51 patients) performed with Technolas 217z. Inclusion criteria: > 18 years, SEQ up to -8.5 D, cylinder up to 6.0 D, corrected distance VA (CDVA) ≥ 20/25, and central corneal thickness (CCT) ≤ 540 μm. Flap thickness intended for 120 µm (Zyoptix XP microkeratome). Results: Mean age: 26.52 ± 8.06; 54.9% female. Follow up: 13.9 ± 1.2 months. Preop CCT: 515.44 ± 17.87 μm. Mean SEQ: -4.01 ± 2.62 D. Mean cylinder: -1.38 ± 1.29 D. Mean SEQ predictability: -0.21 ± 0.54 D. Postoperative SEQ: ±0.50 D in 69%, ±1.00 D in 93%. Postop UDVA was ≥ 20/20 in 84%, ≥ 20/25 in 95%. One line of CDVA was lost in 3% of eyes. No ectasia cases were observed. Conclusion: Myopic LASIK performed on corneas with CCT ≤ 540 μm is safe and efficient for correction of up to -8.25 of SEQ of myopia. Digitized Objective Excimer Laser Ablation Centration Evaluation: A Novel Postoperative Assessment Technique Abstract #: RP30045402 Senior Author: George Asimellis PhD Coauthor: A John Kanellopoulos MD Purpose: To objectively evaluate excimer laser centration in myopic LASIK by analysis of achieved vs. planned ablation patterns. Methods: 280 consecutive myopic LASIK cases, with 2 excimer lasers. Digital image analysis on Scheimpflug curvature maps (difference between preoperative and 3 months postoperative) was the digitation template. Centration was assessed via proprietary software technique measuring pixel-size radial displacements, 3 times for each case. Results: Surprisingly, while refractive surgery metrics were essentially equal, radial displacement in Group A was 360 ± 220 μm (0 to 1030), and in Group B, 120 ± 110 μm (0 to 580). Conclusion: This novel, objective digitation technique may indicate significant outcome differences not currently evaluated in corneal refractive surgery. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. E-poster Abstracts 2015 Subspecialty Day | Refractive Surgery Comparison of Wound Integrity Between Clear Corneal Incisions Created Using a Keratome or a Femtosecond Laser 105 did not change. By final visit, there were no cases with subjective haze. Conclusion: Our results demonstrated that TransPRK could be a safe and effective procedure in correction of myopia. Abstract #: RP30045407 Senior Author: Harvey S Uy MD Purpose: To compare wound integrity of keratome and femtosecond laser (FSL) clear corneal incisions (CCIs). Methods: CCIs were created with a 2.2-mm keratome or FSL in 62 eyes undergoing phacoemulsification. Wound integrity was graded at end of surgery: Grade 1, flat anterior chamber (AC) needing wound hydration and AC reformation; Grade 2, flat AC needing AC reformation only; Grade 3, formed AC. Results: The mean (SD) wound grade for the keratome group was 1.32 (0.65); and for the FSL group, 2.35 (0.84) (P < .0001). In the keratome group, the frequency of wound Grade 1, 2, and 3 was 77%, 13%, and 10%; while in the FLS group, 23%, 19%, 58%, respectively. Conclusion: FSL CCI wounds demonstrate better wound integrity than do keratome CCI wounds. Novel Objective Assessment of Cyclorotation Compensation in Topo-Guided Excimer Ablation in Highly Irregular Corneas Abstract #: RP30045408 Senior Author: George Asimellis PhD Coauthor: A John Kanellopoulos MD Purpose: To investigate cyclorotation compensation in topoguided partial PRK treatments in highly irregular corneas. Methods: Cyclorotation compensation, Group A (n = 110); no cyclo, Group B (n = 110). Digital curvature maps evaluated for vector (r,theta) to the peak-topographic point on the preoperative (r-p, theta-p) and the difference maps (r-d, theta-d). Delta theta (= |theta-p − theta-d|) and weighted WDelta (= Delta theta x delta r) were evaluated. Results: In Group A (cyclo), delta theta was 7.2 ± 7.5° (0 to 34) and WDelta was 3.4 ± 4.8 mm (0.0 to 21.4). In Group B (non-cyclo), delta theta was 14.5 ± 12.7° (0 to 49), and WDelta was 10.2 ± 15.2 mm (0.0 to 80.6) (P-values: Delta theta = .0058 and WDelta = .015). Conclusions: Cyclorotation compensation in customized topography-guided treatments leads to improved match between targeted and achieved changes. Eighteen-Month Follow-up Results of Single-Step Transepithelial Photorefractive Keratectomy in Myopia: Qualitative and Quantitative Visual Outcomes Abstract #: RP30045409 Senior Author: Soheil Adib Moghaddam MD Coauthors: Saeed Soleyman-Jahi MD MPH**, Fatemeh Adili-aghdam Purpose: To investigate the quantitative and qualitative optical outcomes of transepithelial photorefractive keratectomy (TransPRK). Methods: In this prospective study, 125 myopic eyes (66 patients) were enrolled. TransPRK was performed with an aspherical optimized profile. Eighteen-month follow-up results were considered. Results: Mean uncorrected distance VA (UDVA) improved (P < .001), and 95.53% reached logMAR UDVA of 0.1 or better; 98.21% of eyes were within ±0.5 D of targeted SE. Both photopic and mesopic contrast sensitivities significantly improved (both P < .001). Defocus, spherical, and cylindrical aberrations improved. Other higher-order aberrations Monovision LASIK as a Treatment for Presbyopia Abstract #: RP30045413 Senior Author: Alejandro Tamez MD Coauthors: Jesus Lozano Cardenas MD, Manuel Alejandro deAlba MD, Julio Hernandez Camarena MD, Jorge E ValdezGarcia MD Purpose: To investigate the efficacy and safety of the LASIK micro-monovision technique as a treatment for ametropia and presbyopia. Methods: Retrospective case series study: 70 eyes of 35 ametropic and presbyopic patients treated with LASIK micro-monovision in our service. We evaluated the postoperative binocular UCVA for distance and near. The target refraction was emmetropia for the dominant eye and between -1.00 and -2.00 in the nondominant eye. Results: Average age: 50.9 years. Refractive error: 26 hyperopic astigmatism, 4 simple hyperopia, and 5 myopic astigmatism. Binocular distance UCVA was 20/25 or better in 94%, and binocular near vision was J2 or better in 97%. Mean follow-up of 6.4 months. Conclusion: The micromonovision technique has proven to be a well-tolerated, safe, and effective way to treat ametropia and presbyopia. Visual, Refractive, and Clinical Outcomes of SmallIncision Lenticule Extraction (SMILE) vs. Implantable Collamer Lens for High Myopia Abstract #: RP30045419 Senior Author: Jesus Cabral-Macias MD Coauthors: Arturo J Ramirez-Miranda MD, Alejandro Navas MD, Karla Olivia Vandick**, Enrique O Graue Hernandez MD Purpose: To compare visual acuity and refraction measurements before and after SMILE and implantable collamer lens (ICL). Methods: Retrospective case series. Eyes underwent high myopic treatments (-6.00 D to -10.00 D). UCVA and refraction followup was performed at 1, 7, 30, and 90 days. Results: Thirty-four eyes for each group were analyzed. Preoperative mean spherical equivalent was -7.43 D (range: -6.00 D to -9.75 D) in the SMILE group and -8.55 (range: -6.00 D to -10.00 D) in the ICL group (> 0.50). There was a statistically significant difference in spherical equivalent and visual acuity at Day 1 towards the ICL group. At 3 months spherical equivalent and visual acuity values were similar in both groups. Conclusion: ICL showed better visual acuity at Day 1 than SMILE. After 1 week the values were similar for both groups and continued during follow-up. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 106 E-poster Abstracts Visual Performance Following Bilateral LASIK and Monocular Corneal Inlay Implantation Abstract #: RP30045425 Senior Author: Wayne Crewe-Brown MD Purpose: To evaluate visual acuity in patients undergoing LASIK and same-day insertion of a small-aperture corneal inlay. Methods: Forty-one patients underwent bilateral LASIK, followed by inlay insertion 100 μm below the flap interface in the nondominant eye. Uncorrected distance, uncorrected near, and bestcorrected distance visual acuity (UDVA, UNVA, and BCDVA) were assessed. Results: Mean UNVA improved from 0.20 ± 0.16 preop to 0.63 ± 0.18 at 6 months in implant eyes, and remained unchanged in fellow eyes. Mean UDVA improved from 6/12 to 6/7.5 in inlay eyes and from 6/12 to 6/6 in fellow eyes. Mean BCDVA was unchanged. Conclusion: A small-aperture corneal inlay can be combined with same-day LASIK in ametropic presbyopes to significantly improve UNVA, with minimal change to UDVA. Bioptics: Toric Implantable Collamer Lens Following Intracorneal Ring Segments in Keratoconus Patients Abstract #: RP30045431 Senior Author: Tamer O Gamaly FRCS MD Purpose: To present the results of keratoconus cases that had intracorneal ring segments (ICRS) followed by toric implantable collamer lens (ICL) to correct their refractive errors. Methods: Four eyes of 2 patients had ICRS as a primary method to regularize their keratoconic corneas. After stabilization of their corneas, toric ICL was used to correct their residual refractive errors. Necessary investigations were done preoperatively and in follow-up visits. Results: One-year results showed improvement of the BCVA postoperatively as compared to preoperative measurements. All eyes gained at least 1 more line at their final result. Conclusion: Toric ICL after ICRS can be used in selected cases of keratoconus. Both procedures were safe, effective, and predictable in correcting refractive errors after regularizing the keratoconic corneas. Comorbidity of Dry Eye Syndrome in Patients Undergoing Allergy Skin Testing Abstract #: RP30045436 Senior Author: Mujtaba A Qazi MD Coauthors: Judah E Beck MD**, Jay Stuart Pepose MD PhD Purpose: To analyze the relationship between dry eye syndrome and ocular allergies in patients clinically selected for allergy skin testing. Methods: Patients (n = 35) scheduled for allergy skin testing completed ocular and allergy questionnaires and histories, tear film osmolarity (osm) testing, and biomicroscopy. Hyperosmolar (osm > 307) and normal osmolarity (osm < 308) patient results were statistically compared. Results: Of the 51% of patients (18/25) who were found to be hyperosmolar (mean: 321 ± 11), 67% (12/18) tested highly positive to at least 1 allergen. Of the 66% of patients (23/35) who were allergen positive, 52% (12/23) were hyperosmolar. Conclusion: Allergen skin testing should be coupled with dry eye evaluation, as there can be significant comorbidity requiring treatment for both conditions. 2015 Subspecialty Day | Refractive Surgery Outcomes of Femtolaser-Assisted LASIK With Breakthrough Gas Bubble in Anterior Chamber During Flap Creation Abstract #: RP30045440 Senior Author: Nagesh Bn MBBS MD Coauthors: Manpreet Kaur**, Namrata Sharma MD MBBS, Jeewan S Titiyal MD Purpose: To evaluate outcomes of LASIK in eyes with anterior chamber (AC) air bubble after femtosecond laser. Methods: Prospective evaluation of 2518 eyes and analysis of pre-, intra-, and postoperative parameters. Results: Air in AC was seen in 14 eyes, with incidence of 0.5%. Mean sphere, cylinder, and keratometry were -3 ± 2.4, -0.7 ± 1.3, and 43 ± 0.8 D, respectively. Mean white-to-white diameter was 11 ± 0.3 mm, and flap thickness was 111.4 ± 6.6 microns. No difference was seen in any parameter with and without AC bubble (P < .05). Ablation was done 1 week later due to large AC bubble (n = 3) or continued in small AC bubble with (n = 3) or without tracker (n = 8). Postoperatively, uncorrected distance VA was 20/20 in all eyes at 1 day, 1 week, and 1 month. Conclusion: Femto-assisted LASIK may be done in cases of small AC bubble, and surgery should be deferred in eyes with large AC bubble. Laser Bridge Astigmatic Keratotomy Novel Incision Architecture: Comparison and Validation of PatientSpecific Computational Modeling Abstract #: RP30045443 Senior Author: Anita Nevyas-Wallace MD Purpose: To validate patient-specific computational modeling of a novel incision architecture, the laser bridge astigmatic keratotomy (AK), and compare to results predicted for uniform AK. Methods: Finite element modeling simulated laser bridge AK (incision ends deeper than center to augment ends’ effect). Incision morphology of 76-year-old patient’s bridge AK was measured via OCT. Preop Galilei tomography was imported into Optimeyes software. Results: Simulated outcome closely matched the measured postoperative Galilei results. Compared to uniform AK, laser bridge AK had substantially less induced higher-order aberration, yet greater astigmatic effect. Conclusion: Patient-specific finite element modeling was validated for this patient. Laser bridge AK showed less induction of higherorder aberration, yet greater astigmatism correction. ** Has not submitted financial interest disclosures as of press date. Check the online program/mobile meeting guide for the most up to date financial disclosures. 2015 Subspecialty Day | Refractive Surgery 107 Financial Disclosure Transparency through disclosure of relationships with companies is one step in the Academy’s process of ensuring that all its educational activities are fair, balanced, and not commercially biased. The Academy’s Board of Trustees supports the position that having a financial relationship should not restrict expert scientific, clinical or non-clinical presentation or publication or participation in Academy leadership or governance, provided that appropriate disclosure of such relationship is made. Similarly, it should not restrict participation in AAO leadership or governance, so long as appropriate disclosure is made. As an ACCME accredited provider of CME, the Academy seeks to ensure balance, independence, objectivity, and scientific rigor in all individual or jointly sponsored CME activities. All contributors to Academy educational and leadership activities must disclose all financial relationships (defined below) to the Academy annually. The ACCME requires the Academy to disclose the following to participants prior to the activity: • All financial relationships with Commercial Companies that contributors and their immediate family have had within the previous 12 months. A commercial company is any entity producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients. • Meeting presenters, authors, contributors or reviewers who report they have no known financial relationships to disclose. The Academy will request disclosure information from meeting presenters, authors, contributors or reviewers, committee members, Board of Trustees, and others involved in Academy leadership activities (“Contributors”) annually. Disclosure information will be kept on file and used during the calendar year in which it was collected for all Academy activities. Updates to the disclosure information file should be made whenever there is a change. At the time of submission of a Journal article or materials for an educational activity or nomination to a leadership position, each Contributor should specifically review his/her statement on file and notify the Academy of any changes to his/ her financial disclosures. These requirements apply to relationships that are in place at the time of or were in place 12 months preceding the presentation, publication submission, or nomination to a leadership position. Any financial relationship that may constitute a conflict of interest will be resolved prior to the delivery of the activity. Financial Relationship Disclosure For purposes of this disclosure, a known financial relationship is defined as any financial gain or expectancy of financial gain brought to the Contributor or the Contributor’s immediate family (defined as spouse, domestic partner, parent, child or spouse of child, or sibling or spouse of sibling of the Contributor) by: • Direct or indirect compensation; • Ownership of stock in the producing company; • Stock options and/or warrants in the producing company, even if they have not been exercised or they are not currently exercisable; • Financial support or funding to the investigator, including research support from government agencies (e.g., NIH), device manufacturers, and/or pharmaceutical companies; or • Involvement with any for-profit corporation that is likely to become involved in activities directly impacting the Academy where the Contributor or the Contributor’s family is a director or recipient Description of Financial Interests Category Code Description Consultant / Advisor C Consultant fee, paid advisory boards or fees for attending a meeting Employee E Employed by a commercial company Lecture Fees L Lecture and speakers bureau fees (honoraria), travel fees or reimbursements when speaking at the invitation of a commercial company Equity Owner O Equity ownership/stock options (publicly or privately traded firms, excluding mutual funds). Patents / Royalty P Patents and/or royalties that might be viewed as creating a potential conflict of interest Grant Support S Grant support from all sources 108 2015 Subspecialty Day | Refractive Surgery Financial Disclosures Amar Agarwal MD Ehud I Assia MD David F Chang MD Abbott Medical Optics: C Bausch + Lomb Surgical: C Dr. Agarwal’s Pharma: O Slack Incorporated: P Staar Surgical: C Thieme Medical Publishers: P APX Ophthalmology: O,P BioTechnology General: C Hanita Lenses: C IOPtions: O,P VisiDome: O,P VisionCare Ophthalmic Technologies: C Jorgé L Alió MD PhD Miltos O Balidis MD PhD DO Abbott Medical Optics: S Akkolens: C,S Bausch + Lomb Surgical: C,S Carl Zeiss Meditec: S CSO: C Dompe: S Hanita Lenses: C Jaypee Bros: P Mediphacos: C Novagali: S Oculentis: C,S Presbia: C Santen, Inc.: C Schwind eye-tech-solutions: L,S Slack Incorporated: C Springer Verlag: P Tekia, Inc.: P Thea: S Topcon: C Vissum Corp.: E,O Bausch + Lomb: L Abbott Medical Optics: C Allergan, Inc.: L Calhoun Vision Inc.: C,O Clarity: C,O Icon Bioscience: C,O LensAR: C,O Minosys: C,O PowerVision, Inc.: O Revital Vision: O Slack, Incorporated: P Transcend Medical: C,O Versant Ventures: O Renato Ambrósio Jr MD Alcon Laboratories, Inc.: C Allergan: L Carl Zeiss Inc.: L Mediphacos: L Oculus, Inc.: C Steve A Arshinoff MD Alcon Laboratories, Inc.: C Arctic Dx: C Carl Zeiss Meditec: C iMed Pharma: C George Asimellis PhD None Allon Barsam MBBS FRCOphth Alcon Laboratories, Inc.: L Allergan: L Carl Zeiss Meditec: L Rayner Intraocular Lenses, Ltd.: L Staar Surgical: L John So-Min Chang MD Abbott Medical Optics: L Alcon Laboratories, Inc.: L George Beiko MD Arturo S Chayet MD Abbott Medical Optics, Inc.: C,S Bausch + Lomb: C,S Infinite Vison: C None Michael W Belin MD Oculus, Inc.: C Roberto Bellucci MD Bausch + Lomb Surgical: C Physiol: C Sifi: C Carlos Buznego MD Beatrice Cochener MD Abbott Medical Optics, Inc.: C Alcon Laboratories, Inc.: C Bausch + Lomb: S RVO: C Santen, Inc.: C Théa: C Efekan Coskunseven MD None Allergan: C,L Bausch + Lomb: C,L Calhoun Vision, Inc.: O CXLO: O Glaukos Corp.: C,L,O Lensar: C,L Omeros: C,L RPS: O William W Culbertson MD Alan N Carlson MD Abbott Medical Optics, Inc.: C Aquesys: C Bausch + Lomb: C Calhoun Vision, Inc.: O Morcher GmbH: P Ocular Surgery News: C Oculus, Inc.: P TearScience: O,C Francesco Carones MD AcuFocus, Inc.: C,O Alcon Laboratories, Inc.: C,L, Slack, Incorporated: C, WaveLight AG: L Abbott Medical Optics: C,L Carl Zeiss Meditec: L,S Arthur B Cummings MD Alcon Laboratories, Inc.: C,L WaveLight AG: C,L Burkhard Dick MD Kendall E Donaldson MD Abbott Medical Optics, Inc.: C,L Alcon Laboratories, Inc.: C,L Allergan: C Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures Faculty Financial Disclosures 2015 Subspecialty Day | Refractive Surgery David Donate MD Damien Gatinel MD John A Hovanesian MD Carl Zeiss Meditec: C Bausch + Lomb: C,L Hoya: L Nidek, Inc.: C,L Physiol: P Reichert Ophthalmic Instruments: L Toreasy: O Visiometrics: C 1-800-DOCTORS: C,O Abbott Medical Optics: C,L,O,P Allergan, Inc.: C Bausch + Lomb Surgical: C,L,O Bausch + Lomb: C,L,S Glaukos Corp.: S Halozyme: C IOP Inc.: C,L,S Ocular Therapeutix: C,L,O,S Reata: C ReVision Optics: C SarCode: C,L,S Sarentis Ophthalmics: C Sight Sciences: C,O Slack, Incorporated: C,L Tear Science: C,L,S TLC Laser Eye Centers: C,L,O TrueVision3D Systems: C,L,S Versant Ventures: O Vindico Medical Education: C,L Visiogen, Inc.: C,L,S Vista Research: C Vistakon Johnson & Johnson Visioncare, Inc.: C,P,S Eric D Donnenfeld MD Abbott Medical Optics: C,L,S AcuFocus, Inc.: C Alcon Laboratories, Inc.: C,L,S Allergan, Inc.: C,L,S Aquesys: C,O Bausch + Lomb Surgical: C,L,S CRST: C Elenza: C,O Glaukos Corp.: C,O Icon: C Kala: C Katena Products, Inc.: C Lacripen: C,O Lensx: C Mati Pharmaceuticals: C,O Mimetogen: C,O Novabay: C,O Ocuhub: O Odyssey: C PRN: C,O RPS: C,O Strathspey Crown: O Tearlab: C,O TLC Laser Eye Centers: L,O Truevision: C,O Versant Ventures: O Wavetec: C Luca Gualdi MD None Jose L Güell MD PhD Alcon Laboratories, Inc.: C Calhoun Vision, Inc.: O Carl Zeiss Inc.: C Ophtec: C Orca Surgical: O RVO Raindrop: C Thea: C Preeya K Gupta MD Abbott Medical Optics, Inc.: C Allergan: C Bio-Tissue, Inc.: C Novabay: C Shire: C Tear Science, Inc.: C A John Kanellopoulos MD None Alcon Laboratories, Inc.: C Allergan: C Avedro, Inc.: C Carl Zeiss AG: C i-Optics: C ISP Surgical, LLC: C KeraMed, Inc.: C David R Hardten MD None Abbott Medical Optics: C,L,S Allergan, Inc.: C,L,S Calhoun Vision, Inc.: S ESI, Inc.: C,O Oculus, Inc.: L OSD, Inc.: C,O TLC Vision: C Avedro: C,S Carl Zeiss Meditec: S Cleveland Clinic Innovations: P National Eye Institute: S Ziemer: C Carl Zeiss Meditec: C Sadeer B Hannush MD Richard J Duffey MD William J Dupps MD PhD Osama I Ibrahim MD PhD Aylin Kılıç MD None Bonnie A Henderson MD Terry Kim MD Abbott Medical Optics, Inc.: C Carl Zeiss Meditec: C Abbott Medical Optics, Inc.: C Alcon Laboratories, Inc.: C Bausch + Lomb: C Clarvista: C Massachusetts Eye and Ear Infirmary: P Regeneron Pharmaceuticals: C Stealth: C William J Fishkind MD FACS Jack T Holladay MD MSEE FACS Abbott Medical Optics: C Bausch + Lomb: C Thieme Medical Publishers: P Abbott Medical Optics, Inc.: C AcuFocus, Inc.: C,O Alcon Laboratories, Inc.: C ArcScan: C,O Carl Zeiss Inc.: C Elenza: C,O Oculus, Inc.: C Visiometrics: C,O Wavetec: C Acuity Advisors: C Alcon Laboratories, Inc.: C,L Allergan: C Bausch + Lomb: C,L CoDa Therapeutics: C Foresight Biotherapeutics: C Kala Pharmaceuticals: C Novabay Pharmaceuticals: C Ocular Systems Inc.: C Ocular Therapeutix: C,O Oculeve, Inc.: C Omerus: C,L,O Powervision: C Presbyopia Therapies: C Shire: C Stealth BioTherapeutics: C Tearlab: C TearScience: C Alaa M Eldanasoury MD Nidek, Inc.: C Staar Surgical: C Oliver Findl MD Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures 109 110 Faculty Financial Disclosures 2015 Subspecialty Day | Refractive Surgery Stephen D Klyce PhD Boris Malyugin MD PhD Rudy Nuijts MD Centervue: C Lensar: C Nidek, Inc.: C NTK Enterprises: C Oculus, Inc.: C Alcon Laboratories, Inc.: C,L Bausch + Lomb: C,L Morcher GmbH: P MST: P Novamedica: C Novartis Pharmaceuticals Corporation: L Zepto: C AcuFocus, Inc.: S Alcon Laboratories, Inc.: C,L,S Bausch + Lomb: S Ophtec: L,S Physio: L,S Thea Pharma: C Douglas D Koch MD Abbott Medical Optics: C Alcon Laboratories, Inc.: C I-optics: S PowerVision: O Revision Optics: C TrueVision: S Ziemer: S Sonia Manning MD None Stephanie Jones Marioneaux MD None Thomas Kohnen MD PhD FEBO Marguerite B McDonald MD Abbott Medical Optics, Inc.: C Alcon Laboratories: C,L,S Bausch + Lomb Surgical: L,S Carl Zeiss Meditec: C,L,S Hoya: C,L,S Neoptics: L,S Oculus, Inc.: L Rayner Intraocular Lenses Ltd.: C,L,S Schwind eye-tech solutions: C,L,S Abbott Medical Optics, Inc.: C Akorn, Inc.: C Alcon Laboratories, Inc.: C Allergan: C Bausch + Lomb: C Calhoun Vision, Inc.: O Focus Labs: C Oculus, Inc.: C OcuSoft: C Orca Surgical: C Shire: C TearLab: C TearScience Inc.: C Ronald R Krueger MD Alcon Laboratories, Inc.: C Calhoun Vision, Inc.: O Clarity Medical Inc.: C Cleveland Clinic Foundation: E LensAR Laser Systems: C,O Presbia: C Peter J McDonnell MD Allergan: O Graybug, Inc.: O,P George D Kymionis MD PhD Michael Mrochen PhD None Alcon Laboratories, Inc.: C Avedro: P ClearSight Innovations: O,C IROC Innocross: O IROC, Inc.: E WaveLight AG: C Bryan S Lee MD JD Allergan: C Joseph J Ma MD Abbott Medical Optics: C,L Alcon Laboratories, Inc.: C,L Bausch + Lomb: C Scott M MacRae MD Bausch + Lomb: C Parag A Majmudar MD Alcon Laboratories, Inc.: C Allergan, Inc.: C Bausch + Lomb: C CXL Ophthalmics LLC: O Rapid Pathogen Screening: O Tear Science: C,S Robert K Maloney MD Louis D Skip Nichamin MD Advanced Medical Optics: C Allergan, Inc.: C Bausch + Lomb Surgical: C Foresight Biotherapeutics: C Glaukos Corp.: C Harvest Precision Components: O iScience: C,O LensAR: C,O Liquidia Technologies, Inc.: C PowerVision: C,O RevitalVision, LLC: C,O Slack Incorporated: P WaveTec Vision System: C,O Abbott Medical Optics, Inc.: C Alcon Laboratories, Inc.: C Calhoun Vision, Inc.: C,O Stromal Medical: O Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures Toshihiko Ohta MD None Robert H Osher MD Abbott Medical Optics, Inc.: C Alcon Laboratories, Inc.: C Bausch + Lomb Surgical: C Beaver-Visitec International, Inc.: C Carl Zeiss Meditec: C Clarity: C Microsurgical Technology: C Omeros: C Video Journal of Cataract & Refract Surg: O Richard B Packard MD Alcon Laboratories, Inc.: C,L Ioannis G Pallikaris MD None Lisa Park MD None Jay Stuart Pepose MD PhD 1-800-Doctors: C,O Abbott Medical Optics: C AcuFocus, Inc.: O,S Alcon Laboratories, Inc.: C Allergan: C Bausch + Lomb: C,S Calhoun Vision, Inc.: O Clarity Medical: C,O CoDa: C DES, Inc.: O,C Elenza: C,O Envisia: C Mimetogen: C Shire: C TearLab: C,O Roberto Pineda II MD Amgen: C Beaver-Visitec International, Inc.: C Genzyme: C Novartis Pharmaceuticals Corp.: C Marianne O Price PhD Bausch + Lomb: L,S Calhoun Vision, Inc.: O Interactive Medical Publishing: O ReVital Vision: O Staar Surgical: C TearLab: O Faculty Financial Disclosures 2015 Subspecialty Day | Refractive Surgery Yaron S Rabinowitz MD Michael E Snyder MD Audrey R Talley-Rostov MD None Alcon Laboratories, Inc.: S Bausch + Lomb: S Haag-streit: C Humanoptics: C Icon: S Xigen: S Allergan, Inc.: C,L Bausch + Lomb Surgical: C,L Michael B Raizman MD Alcon Laboratories, Inc.: C Allergan: C Avedro: C,O Bausch + Lomb: C Beaver-Visitec International, Inc.: C Boston Eye Surgery & Laser Center: O Eleven: C EyeGate Pharmaceuticals, Inc.: C,O,S Ocular Therapeutix: C,O Omeros: C,O Ophthalmic Consultants-Boston: O Seattle Genetics: C Shire: C Stealth Bio: C TearLab: C J Bradley Randleman MD None Ronald Luke Rebenitsch MD FDA Ophthalmic Devices Committee: C Dan Z Reinstein MD Arcscan, Inc.; Morrison, Colorado: O,P Carl Zeiss Meditec: C Olivier Richoz MD Emagine AG: P Karolinne M Rocha MD Abbott Medical Optics, Inc.: C Alcon Laboratories, Inc.: C Allergan: C Steven I Rosenfeld MD FACS Doctor’s Allergy Formula: C Modernizing Medicine: C NovaBay: C Marcony R Santhiago MD Ziemer: C Samir I Sayegh MD PhD None Ahmed N Sedky FRCOphth None Theo Seiler MD PhD None Neda Shamie MD Alcon Laboratories, Inc.: C Bausch + Lomb: C Shire: C Tissue Bank International: C Christopher E Starr MD Alcon Laboratories, Inc.: L Allergan: C,L Bausch + Lomb: C,L Glasses Off: C Rapid Pathogen Screening: C Shire: C TearLab: C,L,O Gustavo E Tamayo MD Abbott Medical Optics, Inc.: C,L,P,S Avedro: C Eyegenics Corp.: C Keramed Corp.: C Presbia Corp.: C Hunwon Tchah MD None Vance Michael Thompson MD Abbott Medical Optics, Inc.: C,L Alcon Laboratories, Inc.: C,L Bausch + Lomb: C,L TLC Laser Center: C,L Visx USA, Inc.: L WaveLight AG: C,L,S Abbott Medical Optics: C,L AcuFocus, Inc.: C,L,O Alcon Laboratories, Inc.: C,L Avedro: C Bausch + Lomb: C Calhoun Vision, Inc.: C,L Equinox: C,O Euclid Systems: C Forsight: C Imprimis: C Mynosys: C Oculeve: C,O OcuSoft, Inc.: C Ophtec: C Wavetec: C Zeiss: C Michael D Straiko MD Minoru Tomita MD PhD Bio-Tissue, Inc.: C Johnson & Johnson: C AcuFocus, Inc.: C Schwind eye-tech-solutions: C R Doyle Stulting MD PhD William B Trattler MD Abbott Medical Optics: C Alcon Laboratories, Inc.: C,L Allergan: L Calhoun Vision, Inc.: C Cambium Medical Technologies: C,O EyeYon: C,O Ophtec: C Optovue: C TearLab: C,O Abbott Medical Optics: C,L,S Allergan, Inc.: C,L,S Bausch + Lomb: S CXLO: C,O CXLUSA: C LensAR: C Oculus, Inc.: L Rapid Pathogen Screenings: S Tear Science: C Vmax Vision: C Roger F Steinert MD Abbott Medical Optics: C,S Avedro: C,O LensGen: O ReVision Optics: C Rhein Medical, Inc.: P Karl G Stonecipher MD Alan Sugar MD National Eye Institute: S Jonathan H Talamo MD Abbott Medical Optics, Inc.: C,S Cowen and Company: C CXL Ophthalmics: O Moelis Capital: C OptiMedica: O Rebiscan: O SV Life Sciences Advisors: C Wavetec Vision: C,O Abhay Raghukant Vasavada MBBS FRCS Alcon Laboratories, Inc.: S Luis Felipe Vejarano MD None Paolo Vinciguerra MD Nidek, Inc.: C Oculus, Inc.: C Schwind eye-tech-solutions: C Avi Wallerstein MD None Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures 111 112 Faculty Financial Disclosures 2015 Subspecialty Day | Refractive Surgery George O Waring IV MD Helen K Wu MD Francis S Mah MD Abbott Medical Optics, Inc.: C,L Accelerated Vision: C ACE Vision Group: C AcuFocus, Inc.: C,L,O Alcon Laboratories, Inc.: C,L Allergan: C Avedro: C Bausch + Lomb: C Focal Point, Asia: C Gerson Lehrman Group: C GlassesOff: C Minosys: C Oculus, Inc.: L Omega Ophthalmics: C Perfect Lens, LLC: C Refocus Group, Inc.: C Revitalvision: C Strasthpey Crown: O Visiometrics: C Allergan: C Iop, Inc.: L Abbott Medical Optics Inc.: L Alcon Laboratories, Inc.: C,S Allergan: C,L Bausch + Lomb: C,L CoDa: C ForeSight: C Imprimis: C Ocular Therapeutix: C,S Omeros: C PolyActiva: C Shire: C TearLab: C Mitchell P Weikert MD Ziemer Ophthalmic, Inc.: C Robert J Weinstock MD Abbott Medical Optics Inc.: L Alcon Laboratories, Inc.: C,L Bausch + Lomb: C,L Calhoun Vision, Inc.: O Doctor’s Allergy Formula: O I-Optics: L LensAR: L Omeros: L Rapid Pathogen Screening: O STAAR Surgical: C,L TissueTech, Inc.: O TrueVision: O Sonia H Yoo MD Abbott Medical Optics, Inc.: S Alcon Laboratories, Inc.: C Allergan, Inc.: S Avedro: S Bausch + Lomb Surgical: C Bioptigen: C Carl Zeiss Meditec: S Slack, Incorporated: L Transcend: C Subspecialty Day Advisory Committee William F Mieler MD Genentech: C Donald L Budenz MD MPH Alcon Laboratories, Inc.: C Ivantis: C Daniel S Durrie MD Abbott Medical Optics: S AcuFocus, Inc.: C,L,O,S Alcon Laboratories, Inc.: L,O,S Allergan: S Alphaeon: C,O Avedro: L,O,S Strathspey Crown LLC: C,L,O Wavetec: C,O,P Steven E Wilson MD Allergan: L,C Cambium Medical Technologies LLC: C Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures Jonathan B Rubenstein MD Alcon Laboratories, Inc.: C Bausch + Lomb: C,L R Michael Siatkowski MD National Eye Institute: S Nicholas J Volpe MD None AAO Staff Christa Fernandez None Ann L’Estrange None Melanie Rafaty None Debra Rosencrance None Beth Wilson None 2015 Subspecialty Day | Refractive Surgery 113 E-poster Coauthor Financial Disclosures Alexandra Abdala Figuerola MD Mary Attia MBBCH Glenn Ian Carp MBBCH None Abbott Medical Optics, Inc.: C,L,S Alcon Laboratories, Inc.: L,S Alimera Sciences, Inc.: S Bausch + Lomb: C,L,S Carl Zeiss Meditec: S,L Contamac: S Glaukos Corp.: S Heidelberg Engineering: S Hoya: S HumanOptics: S,L Kowa: S LensAr: S Mediphacos: S Novartis Pharmaceuticals Corp.: S Oculentis: L,S Powervision: S Rayner Intraocular Lenses Ltd.: L,S None Gerd U Auffarth MD Mark J Cohen MD Not submitted by press date None Rukiye Aydin Manuel Alejandro deAlba MD None None Judah E Beck MD Uday Devgan MD Not submitted by press date Not submitted by press date Accutome: P Alcon Laboratories, Inc.: C,L Bausch + Lomb: C,L Gerson Lehrman Group: C LensGen: C,O Omeros: C,L Specialty Surgical: O Alexander Angelov MD Ekaterina Branchevskaya Mohamed Elbahrawy MBBCH MS Not submitted by press date None Not submitted by press date Yavor Petrov Angelov MS Detlev R H Breyer MD Ali Fadlallah Yahya MD Not submitted by press date None None Abbott Medical Optics, Inc.: C,L Alcon Laboratories, Inc.: C,L Carl Zeiss Meditec: C,L Geuder: C Lensar: C Oculentis: C,L Topcon Medical Systems, Inc.: C George Asimellis PhD Jesus Cabral-Macias MD Matthias Gerl MD None None Not submitted by press date Fabrizio I Camesasca MD Ralf H Gerl MD None Not submitted by press date Michelle Abou-Jaoude MD None Eser Adiguzel PhD None Fatemeh Adili-aghdam None Jorgé L Alió MD PhD Abbott Medical Optics: S Akkolens: C,S Bausch + Lomb Surgical: C,S Carl Zeiss Meditec: S CSO: C Dompe: S Hanita Lenses: C Jaypee Bros: P Mediphacos: C Novagali: S Oculentis: C,S Presbia: C Santen, Inc.: C Schwind eye-tech-solutions: L,S Slack, Incorporated: C Springer Verlag: P Tekia, Inc.: P Thea: S Topcon: C Vissum Corp.: E,O Samuel Arba Mosquera Schwind eye-tech solutions: E,P Timothy J Archer MS Frederico Bicalho MD Not submitted by press date Mario Bitani MD Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures Tommy Chung Yan Chan FRCS(ED) MBBS Not submitted by press date George P M Cheng MD None Daniel Cherfan MBBS None Chul Young Choi Not submitted by press date Youngtaek Chung MD Not submitted by press date Joanna Galindo MS None Guillermo Garcia De La Rosa MD None 114 E-poster Coauthor Financial Disclosures 2015 Subspecialty Day | Refractive Surgery Marine Gobbe PhD Albert S Jun MD Florian T A Kretz MD None None Javier Humberto Gonzalez-Lugo BA MD A John Kanellopoulos MD Abbott Medical Optics: L,S Alcon Laboratories, Inc.: L,S Alimera Sciences, Inc.: L,S,C Allergan: L,S Bausch + Lomb: S Bayer Healthcare Pharmaceuticals: L Carl Zeiss Meditec: L,S Geuder AG: L,S Glaukos Corp.: S Heidelberg Engineering: S Hoya: L KOWA: L Mediphacos: S Novartis Pharmaceuticals Corp.: L,S Oculentis: L,S Ophtec: S Powervision: S Rayner Intraocular Lenses Ltd.: L,S None Enrique O Graue Hernandez MD None Anita Gupta MD None Flor Daniela Guzman Not submitted by press date Mona Harissi-Dagher MD None Richard A Hemmings BA Not submitted by press date Julio Hernandez Camarena MD None Erick Hernandez-Bogantes MD None Samuel G Hilbert BA MS Not submitted by press date Simon P Holland MD Alcon Laboratories, Inc.: C Allergan: C Clarion: C Stephanie Hopp BS MS None Lucia Hrckova None Osama I Ibrahim MD PhD Carl Zeiss Meditec: C Mariluz Iglesias Not submitted by press date Carlo Irregolare MD Not submitted by press date Svetlana Izmaylova MD PhD Not submitted by press date Samir Jabbour MD Alcon Laboratories, Inc.: C Allergan: C Avedro, Inc.: C Carl Zeiss AG: C I-Optics: C ISP Surgical, LLC: C KeraMed, Inc.: C Manpreet Kaur Not submitted by press date Hakan Kaymak MD Not submitted by press date Raynan Khan BS None Nigel Terk Howe Khoo BS Jimmy Shiu Ming Lai FCOphthHK FRCOphth FRCS(ED) MBBS MD None None Ramin Khoramnia MD Jaime Larrea Sr MD Abbott Medical Optics, Inc.: S Alcon Laboratories, Inc.: S Bausch + Lomb: S Bayer Healthcare Pharmaceuticals: S Carl Zeiss Meditec: S Contamac: S Hoya: S HumanOptics: S Kowa: S LensAr: S Mediphakos: S Novartis Pharmaceuticals Corp.: S Oculentis: S,L Powervision: S Rayner Intraocular Lenses Ltd.: L,S Not submitted by press date Buki Kim Luigi Mele MD None Not submitted by press date Douglas D Koch MD Samir A Melki MD PhD Abbott Medical Optics: C Alcon Laboratories, Inc.: C I-optics: S PowerVision: O Revision Optics: C TrueVision: S Ziemer: S Qualsight: C Junko Koshimizu MD Matthias Mueller PhD Not submitted by press date Not submitted by press date None Aida Jimenez None Daegyu Lee Not submitted by press date David T Lin MD PRN Physician Recommended Nutriceuticals: C SCHWIND eye-tech-solutions: C Jesus Lozano Cardenas MD None Katarina Majernova MD Not submitted by press date Ryan N Mercer BS Not submitted by press date Peter Mojzis MD PhD Not submitted by press date David Myung Not submitted by press date Joao J Nassaralla MD PhD None Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures E-poster Coauthor Financial Disclosures 2015 Subspecialty Day | Refractive Surgery Belquiz A Nassaralla MD PhD Tanja M Rabsilber MD Steven C Schallhorn MD Not submitted by press date Abbott Medical Optics Inc.: S Alcon Laboratories, Inc.: S Carl Zeiss Meditec: S Contamac: S Hoya: S HumanOptics: L,S Kowa: S Mediphacos: S Oculentis: S Powervision: S Rayner Intraocular Lenses Ltd.: S Abbott Medical Optics: C AcuFocus, Inc.: C Allergan: C Innovega: C Optical Express: C Zeiss: C Alejandro Navas MD Alcon Laboratories, Inc.: L Carl Zeiss Meditec: C Staar Surgical: L Paul D O’Brien MBBCH BA None Kishiko Okoshi MD None Delores Ortiz PhD Not submitted by press date Leticia Elizabeth Pacheco None Javier Paz Moreno-Arrones MD Arturo J Ramirez-Miranda MD Carl Zeiss Meditec: C,L,S Glauco H Reggiani Mello MD Not submitted by press date Dan Z Reinstein MD Namrata Sharma MD MBBS None Aazim A Siddiqui None Ronald H Silverman PhD Arcscan, Inc.: O Alexey Simonov PhD Akkolens International BV: E Arcscan, Inc.; Morrison, Colorado: O,P Carl Zeiss Meditec: C Saeed Soleyman-Jahi MD None Jay Stuart Pepose MD PhD Cynthia Roberts PhD Hyeck Soo Son 1-800-Doctors: C,O Abbott Medical Optics: C AcuFocus, Inc.: O,S Alcon Laboratories, Inc.: C Allergan: C Bausch + Lomb: C,S Calhoun Vision, Inc.: O Clarity Medical: C,O CoDa: C DES, Inc.: O,C Elenza: C,O Envisia: C Mimetogen: C Shire: C TearLab: C,O Carl Zeiss Meditec: S Euclid Systems Corp.: L Oculus, Inc.: C,L Ziemer Ophthalmic Systems AG: C,L,P Not submitted by press date Gabriela Perez Roy Scott Rubinfeld MD Not submitted by press date CXLO: O CXLUSA: O Ana Belen Plaza None William J Power MD None Kishore Raj Pradhan MD Not submitted by press date Victor M Preciado Jr None Karolinne M Rocha MD Abbott Medical Optics Inc.: C Alcon Laboratories, Inc.: C Allergan: C Isabel Rodriguez-Perez MHSA None Michiel Rombach Akkolens International: E Esperanza Sala OD Not submitted by press date Marcony R Santhiago MD Ziemer: C Pablo Sanz MS OD None Sandro Sbordone Not submitted by press date Not submitted by press date Roger F Steinert MD Abbott Medical Optics: C,S Avedro: C,O LensGen: O ReVision Optics: C Rhein Medical, Inc.: P Larissa Souza Stival Sr Not submitted by press date Harald Patrik Studer PhD Integrated Scientific Services: E Choon Hwai Johnson Tan MBBS None Tamer Tandogan MD Alcon Laboratories, Inc.: S Bausch + Lomb: S Bayer Healthcare Pharmaceuticals: L Carl Zeiss Meditec: S Contamac: S Hoya: L,S HumanOptics: S Kowa: S LensAr: S Mediphakos: S Oculentis: S PowerVision: S Rayner Intraocular Lenses Ltd.: S Joy Tellouck MD Not submitted by press date Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures 115 116 E-poster Coauthor Financial Disclosures 2015 Subspecialty Day | Refractive Surgery David Teenan MD Riccardo Vinciguerra MD Carl S Wilkins BA None None None Karolien M Termote MD Avi Wallerstein MD Victor Chi Pang Woo MBBS None None Not submitted by press date Miguel A Teus MD Weijun Wang MD Timothy E Yap None Not submitted by press date Not submitted by press date Jeewan S Titiyal MD George O Waring IV MD Pilar Yebana MD None Abbott Medical Optics, Inc.: C,L Accelerated Vision: C Ace Vision Group: C AcuFocus, Inc.: C,L,O Alcon Laboratories, Inc.: C,L Allergan: C Avedro: C Bausch + Lomb: C Focal Point, Asia: C Gerson Lehrman Group: C GlassesOff: C Minosys: C Oculus, Inc.: L Omega Ophthalmics: C Perfect Lens, LLC: C Refocus Group, Inc.: C Revitalvision: C Strasthpey Crown: O Visiometrics: C Not submitted by press date David Touboul MD None Silvia Trazza None Kentaro Tsuzuki MD Not submitted by press date Jorge E Valdez-Garcia MD None Karla Olivia Vandick Not submitted by press date Alfredo Vega-Estrada MD None Disclosures current as of 10/9/2015 Check the online program/mobile meeting guide for the most current financial disclosures Xun Xu MD None 2015 Subspecialty Day | Refractive Surgery Presenter Index Agarwal*, Amar 51 Alio*, Jorge L 35 Ambrosio Jr*, Renato 14 Asimellis, George 23 Balidis*, Miltos O 45 Barsam*, Allon 40 Beiko*, George 53 Bellucci*, Roberto 63 Buznego*, Carlos 45 Carlson*, Alan N 37 Chang*, David F 50 Culbertson, William W 45 Dick*, Burkhard 44 Donate, David 62 Donnenfeld*, Eric D 49 Duffey, Richard J 31 Dupps*, William J 1 Findl*, Oliver L 60 Gatinel*, Damien 70 Gualdi, Luca 78 Guell*, Jose L 61 Hannush, Sadeer B 57 Ibrahim*, Osama I 81 Kim*, Terry 2 Koch*, Douglas D 76 Kohnen, Thomas 45 Krueger*, Ronald R 56 Lee*, Bryan S 45 Ma*, Joseph J 80 Majmudar*, Parag A 3 Maloney*, Robert K 48 * Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest. Malyugin, Boris 39 Manning, Sonia 58 Marioneaux, Stephanie Jones 46 Mrochen*, Michael 43 Nuijts*, Rudy 59 Ohta, Toshihiko 75 Packard*, Richard B 77 Pepose*, Jay Stuart 34 Raizman*, Michael B 7 Randleman, J Bradley 13 Rebenitsch, Ronald Luke 45 Reinstein*, Dan Z 73 Richoz*, Olivier 66 Santhiago*, Marcony R 68 Sayegh, Samir I 12 Sedky, Ahmed N 79 Seiler, Theo 33 Shamie, Neda 45 Snyder*, Michael E 45 Starr*, Christopher E 45 Stonecipher*, Karl G 45 Talamo*, Jonathan T 21 Talley-Rostov, Audrey R 45 Tamayo*, Gustavo E 32 Trattler*, William 54 Vejarano, Luis Felipe 82 Wallerstein, Avi 4 Waring IV*, George O 55 Weikert*, Mitchell P 8 Weinstock, Robert J 11 Wu*, Helen K 45 117 D E A D L I N E : 3 1 A U G U S T 2 0 1 6 Application for ISRS Membership International Society of Refractive Surgery Applications must be received by 31 August 2016 to qualify for the discount for Refractive Surgery Subspecialty Day Meeting, the ISRS Annual Meeting, in Chicago. A Partner of the American Academy of Ophthalmology First Name Medical Degree (e.g. MD, MBBS, etc.) Family Name Mailing / Postal Address Date of Birth Home o Office o (Please check one) City State/Province Postal Code Country Office Phone Fax Website Email Medical School Name Completion Date (MM/YYYY) (Required) (Required) Ophthalmology Training School Name (Required) City State & Country (if outside U.S.) Beginning Date (MM/YYYY) Completion Date (MM/YYYY) (Required) (Required) AAO Member? (If yes, please provide Academy ID#) M E M B E R S H I P L E V E L S Applicants can pay their application fee to join this year, as well as their membership dues for the following year. U.S. and International Members o 1 year $240 USD o P A Y M E N T o American Express o MasterCard o Visa o Discover o JCB o Check or Money Order Enclosed For wire transfer information, please email [email protected] 2 years $465 USD The different dues rates are based strictly on the completion dates of your training (residency or fellowship). 1st Year in Practice o 1 year $155 USD o 2 years $315 USD 2nd Year in Practice o 1 year $165 USD o 2 years $335 USD 3rd Year in Practice o 1 year $175 USD o 2 years $410 USD Card Number Exp Date Name on Card Signature Cardholder’s Address Associate Members For non ophthalmologists (MD, DO, DVM or PhD) working in the field of ophthalmology or engaged in full-time ophthalmology research. o 1 year $240 USD o 2 years $465 USD Members in Training (includes online Journal only) o State/Province No cost A letter of verification from your Professor/Program Chair with your begin and end dates must be submitted with application. o Journal of Refractive Surgery Subscription (One Year) Total Amount Due: $ USD City $100 USD Postal Code Country Please return your completed application to: ISRS and AAO Member Services Dept. 34048 P.O. Box 39000 San Francisco, CA 94139 USA Tel: +1.415.561.8581 or toll-free (U.S. Only) 866.561.8558 Fax: +1.415.561.8575 Email: [email protected] Do not write in this space, for accounting only: Payment Received Date Lockbox Batch # (if applicable) Amount By International Society of Refractive Surgery A Partner of the American Academy of Ophthalmology Join ISRS www.isrs.org Become a member of the International Society of Refractive Surgery (ISRS), a partner of the American Academy of Ophthalmology. ISRS is the leading organization for refractive surgeons and keeps you up to date on the latest clinical and research developments in refractive, cornea, cataract and lens-based surgery. Members are connected to the world’s leading refractive surgeons from over 80 countries through ISRS’ innovative meetings, popular publications and online educational tools. Membership acceptance is subject to review and approval by the ISRS Executive Committee. Benefits of Membership • Subscription to the Journal of Refractive Surgery, the official publication of ISRS, a monthly forum for original research, review and evaluation of refractive, cataract, cornea and lens-based surgical procedures. (Online subscription for Members in Training.) Download the Journal to your iPad or iPhone. • Access to the exclusive ISRS Multimedia Library providing refractive, cataract and cornea videos, presentations and conversations shared by leading surgeons from around the world. • Access to the ISRS Online Community, a place to exchange clinical information, comment on the most recent advances and theories in refractive surgery and receive advice from colleagues worldwide. • Reduced registration fee for the 2016 Refractive Surgery Subspecialty Day, the ISRS Annual Meeting, an innovative meeting that assembles international leaders in refractive, cornea, contact and lens-based surgery, providing a forum for exchange of the latest information in the field. • Complimentary online listing for your practice in Find a Refractive Surgeon, a public online directory that allows patients and colleagues to easily find you. • Access to content on the ISRS website, www.isrs.org, including the latest trends, news and information on refractive and cataract surgery to further your knowledge and education. • Complimentary membership certificate (practicing ophthalmologists only). • Invitation to ISRS supported educational events around the world at international meetings with other ophthalmic societies. • Members of ISRS, who are not already members of the American Academy of Ophthalmology, receive a $100 discount on the Academy’s membership application fee. For more information and an application, go to the Academy website at www.aao.org or contact Member Services at [email protected]. How to Join • Access to refractive and cataract information on the Academy’s Ophthalmic News and Education (ONE®) Network, the world’s most comprehensive ophthalmic education resource. Please complete the application on the reverse side or join online at www.isrs.org. • Subscription to Refractive Surgery Outlook, a monthly clinical e-newsletter featuring expert opinion on the latest advances, highlights from peer-reviewed clinical journals, a calendar of events and ISRS information. If you have any questions or would like additional information on any of these programs and services, please email ISRS at [email protected] or call us at +1.415.561.8581 or toll-free (U.S. only) 866.561.8558.