Refractive Surgery 2015 The Vegas Player`s Guide of Refractive

Transcription

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
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
2006
Steven E Wilson MD
2005
2004
2003
2002
2001
2000
1999
1998
1995–1997
Jorge L Alió MD PhD
Steven E Wilson MD
John A Vukich MD
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
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
George Beiko MD
John So-Min Chang MD
Burkhard Dick MD
Alaa M Eldanasoury MD
Aylin Kılıç 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.
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
Bausch + Lomb: C
Clarvista: C
Massachusetts Eye and Ear Infirmary: P
Regeneron Pharmaceuticals, Inc.: C
Stealth: C
Program Director
Program Director
2015 Refractive Surgery Subspecialty Day Planning Group
Ronald R Krueger MD
Allergan: L
Carl Zeiss, Inc.: L
Mediphacos: L
Oculus, 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
Allergan, Inc.: S
Avedro: S
Bausch + Lomb Surgical: C
Bioptigen: C
Carl Zeiss Meditec: S
SLACK Incorporated: L
Transcend: C
iii
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
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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
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.
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
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.
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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 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.
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.
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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.
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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
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.”
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
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.
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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
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
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
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
xiii
Michael W Belin MD
Alan N Carlson MD
Marana, AZ
Professor of Ophthalmology & Vision
Science
University of Arizona Health Sciences
Durham, NC
Duke Eye Center
Hong Kong, Hong Kong
Clinical Associate Professor of
Ophthalmology
The Chinese University of Hong Kong
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
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
University of Brest - France
MD PhD
Faculty
xiv
Faculty Listing
No photo
available
Efekan Coskunseven MD
Burkhard Dick 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
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
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
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
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
University of Utah
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
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
Osama I Ibrahim MD PhD
Terry Kim MD
Waltham, MA
Partner, Ophthalmic Consultants of
Boston
Clinical Professor
Tufts University School of Medicine
Alexandria, Egypt
Chief of Cornea and Refractive Surgery
Past President
Alexandria University
Durham, NC
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
Bellaire, TX
Baylor College of Medicine, Houston
Athens, Greece
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
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
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
Flaum Eye Institute
University of Rochester
Moscow, Russia
Los Angeles, CA
Director, Maloney Vision Institute
Cleveland, OH
Medical Director
Department of Refractive Surgery
Cole Eye Institute – Cleveland Clinic
Cleveland Clinic Lerner College of
Medicine
Case Western Reserve University
George D Kymionis MD PhD
Heraklion, Greece
University of Crete
No photo
available
Sonia Manning MD
Dublin, Ireland
xviii
Faculty Listing
No photo
available
Stephanie Jones Marioneaux MD
Michael Mrochen PhD
Toshihiko Ohta MD
Chesapeake, VA
American Academy 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
University of Cincinnati School of
Medicine
Medical Director Emeritus
Cincinnati Eye Institute
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
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
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
Harvard Medical School
Director of Refractive Surgery
Massachusetts Eye and Ear Infirmary
Boston, MA
Director, Cornea and Cataract Service
New England Eye Center
Lisa Park MD
Marianne O Price PhD
Leonia, NJ
Indianapolis, IN
Executive Director
Cornea Research Foundation of America
Atlanta, GA
Emory University
Yaron S Rabinowitz MD
Ronald Luke Rebenitsch MD
Beverly Hills, CA
Director of Ophthalmology Research
Cedars Sinai Medical Center
David Geffen School of Medicine
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
Dan Z Reinstein MD
Steven I Rosenfeld MD FACS
Ahmed N Sedky FRCOphth
London, England
Medical Director
London Vision Clinic
Columbia University Medical Center,
New York
Delray Beach, FL
Voluntary Professor of Ophthalmology
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
Staff Member, Refractive Surgery
University of São Paulo
Zurich, Switzerland
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
USC Eye Institute
Keck School of Medicine
University of Southern California
Faculty Listing
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
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
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
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
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
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
University of South Dakota School of
Medicine
Ahmedabad, Gujarat, India
Raghudeep Eye Hospital
Director, Iladevi Cataract & IOL
Research Centre
Montreal, QC, Canada
Executive Vice President,
Co-National Medical Director and
Co-founder
LASIK MD
McGill University
Faculty Listing
xxiii
Robert J Weinstock MD
Helen K Wu MD
Mt. Pleasant, SC
Storm Eye Institute
Medical Director
Magill Vision Center
Largo, FL
Director of Cataract and Refractive
Surgery
The Eye Institute of West Florida
Chestnut Hill, MA
New England Eye Center
Steven E Wilson MD
Mitchell P Weikert MD
Houston, TX
Cleveland, OH
Staff Refractive and Corneal Surgeon
The Cole Eye Institute
The Cleveland Clinic Foundation
Sonia H Yoo MD
Miami, FL
University of Miami Miller School of
Medicine
xxiv
Program Schedule
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
11
8:57 AM
How to Design a Universal IOL Calculator
12
9:01 AM
Scheimpflug Analysis of Patients With Highly Asymmetric Keratoconus
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
23
9:20 AM
Panel Discussion
Stephen D Klyce PhD*
Marguerite B McDonald MD*
Roberto Pineda II 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.
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?”
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
45
xxvi
Program Schedule
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
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*
MBBS FRCS*
Collagen Crosslinking
Paolo Vinciguerra MD*
Corneal Inlays
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*
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
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
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
82
5:10 PM
JRS QwikFacts
5:15 PM
Closing Remarks
Keynote Lecture
Cornea Biomechanics and Its Application in
Refractive Surgery
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
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
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
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
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.
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.
Diagnostics for Dry Eye
Dry Eye and Refractive Surgery
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
Preop IOL Calculations and Challenging Cases
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.
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
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.
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.
11
Intraoperative IOL and Astigmatism Diagnostics
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
How to Design a Universal IOL Calculator
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.
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
Ectasia Detection: Scheimpflug Tomography Is the
Most Accurate
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.
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
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
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.
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
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.
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
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.
21
Ectasia Detection: Placido and Other Reflection
Topography Is the Most Accurate
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
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.
Ectasia Detection: Anterior-Segment OCT Is the
Most Accurate
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
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.
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
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.
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.
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
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.
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
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.
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.
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
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
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
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
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.
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
VI. D. Koch: Taking Into Account the Posterior Corneal
Contribution to Total Corneal Astigmatism
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.
Overview on Trifocal, Multifocal, and Enhanced Depth
of Focus IOLs
NOTES
39
40
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-
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.
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
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.
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.
Novel Lasers for Refractive Surgery
Michael Mrochen PhD
NOTES
43
44
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.
Section III: Interactive Doctor-Patient Consultations
45
Section III: Fair Game—Refractive Surgery Interactive
Doctor-Patient Consultations
NOTES
46
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
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
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.
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
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.
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
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.
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.
When Things Start Blowing, Try Beans
George Beiko MD
NOTES
53
54
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.
Corneal Inlay Complications
NOTES
55
56
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.
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
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.
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
60
Multifocal IOL Dissatisfaction: Causes and Solutions
Oliver Findl MD
NOTES
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
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.
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
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
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
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%
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
The Role of PTA in Screening
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.
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
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.
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
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
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.
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
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.
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.
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
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.
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
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.
Sedky Approach for RelExSMILE Retreatment
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
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.
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
PRESBV (Presbyopia Vejarano) TEARS Noninvasive
Solution for Presbyopia
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.
Refractive Surgery E-posters
83
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
94
RP30045399
Documentation of Stromal Strengthening in Myopic LASIK With Adjunct
Corneal Crosslinking: An Ex Vivo Comparison Study
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
84
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
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
85
RP30045329
Higher-Order Aberration Changes After Customized Femtolaser-Assisted
LASIK vs. Laser-Assisted Subepithelial Keratectomy for the Correction of
High Myopia and Astigmatism
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
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
99
86
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
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
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
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
Alicante, Spain
MD, PhD, Lecturer of Ophthalmology
AUH, Egypt
Postdoctorate Clinical Research Fellow
Vissum Corporation
Shahrak-E Gharb, Tehran, Islamic
Republic of Iran
General Physician
Tehran University of Medical Sciences
Alicante, Spain
Miguel Hernandez University
Medical Director
Vissum Corporation
Chicago, IL
Napoli, Italy
Assistant Professor in Ophthalmology
Seconda Università di Napoli
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
University of British Columbia
Robert Edward T Ang MD
Phillip Hoopes Jr MD
Makati City, Philippines
Senior Consultant
Asian Eye Institute
Draper, UT
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
Moscow, Russian Federation
Beirut, Lebanon
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
The Catholic University of Korea
Jeffrey J Machat MD
Edward E Manche MD
Palo Alto, CA
Byers Eye Institute
Stanford University School of Medicine
Samir A Melki MD PhD
Brookline, MA
Assistant Professor (part time)
Attending Physician
Massachusetts Eye and Ear Infirmary
Athens, Greece
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
Ankara University School of Medicine
Jose A Nava-Garcia MD
Natasha V Nayak MD
New York, NY
Anita Nevyas-Wallace MD
Bala Cynwyd, PA
Nevyas Eye Associates
Lap Ki Ng MBBS
Hong Kong, Hong Kong
Nasir Nisar MBBS
Riyadh, Saudi Arabia
88
E-poster Presenting Authors
Andrew Olivo
Huixquilucan, Mexico
Fellow, Cornea and Refractive Surgery
Conde de Valenciana
San Diego, CA
University of San Francisco
Ayr, Scotland, United Kingdom
Consultant Ophthalmologist
Optical Express
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
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
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
Columbia University Medical Center
New York, NY
Mount Pleasant, SC
Storm Eye Institute
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
Dean, Escuela de Medicina Tecnológico
de Monterrey
Cornelis Verdoorn MD
Vught, Netherlands
Milan, Italy
Ophthalmology Department
Istituto Clinico Humanitas Rozzano
Akihiro Yasuda MD
Montreal, QC, Canada
Tokyo, Japan
Alejandro Tamez MD
Qi Yu MD
Shanghai, Shanghai, China
Tamer Tandogan MD
Heidelberg, Germany
Ophthalmologist
University of Heidelberg
E-poster Presenting Author Financial Disclosures
Ahmed A Abdelmaksoud FRCS
Ramin Khoramnia MD
None
Not submitted by press date
None
None
None
None
Montserrat Garcia-Gonzalez MD
Akkolens: C,S
Bausch + Lomb Surgical: C,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
Alcon Laboratories, Inc.: S
Bausch + Lomb: S
Bayer Healthcare Pharmaceuticals: 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
None
Nagesh Bn MBBS MD
None
Maheen Haque MD
None
None
Marshall Hill
None
Simon P Holland MD
Allergan: C
Clarion: C
Phillip Hoopes Jr MD
AcuFocus, Inc.: O
Estera Igras MD
Choun-ki Joo MD
None
Allergan: C
Avedro, Inc.: C
Carl Zeiss AG: C
i-Optics: 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
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
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
Bausch + Lomb: 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
Carl Zeiss Meditec: C,L,S
Best Doctors, Inc.: C
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
Allergan: C
None
None
Qualsight: C
None
Dan Z Reinstein MD
None
Abbott Medical Optics: C
AcuFocus, Inc.: C
Allergan: C
Innovega: C
Optical Express: C
Zeiss: C
Natasha V Nayak 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
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
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
Allergan: L
Beaver-Visitec International, Inc.: S
LensAR: L,S
Novartis Pharmaceuticals Corp.: C,L
Santen, Inc.: L
None
None
Abbott Medical Optics: C,S
Avedro: C,O
LensGen: O
ReVision Optics: C
Rhein Medical, Inc.: P
None
None
Nidek, Inc.: C
Oculus, Inc.: C
Gregory J Pamel MD
Alejandro Tamez MD
Akihiro Yasuda MD
None
None
None
None
Andrew Olivo
Cornelis Verdoorn MD
Revision Optics: C
Gregory D Parkhurst MD
Qi Yu MD
Alcon Laboratories, Inc.: L
Oasis Medical, Inc.: C
ReVision Optics: C,L
Staar Surgical: C,L
None
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,
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
Senior Author: Karolinne M Rocha MD
Coauthors: Ryan N Mercer BS**, Richard A Hemings BA**,
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
Senior Author: Ahmed A Abdelmaksoud FRCS
Coauthors: Nigel Terk Howe Khoo BS,
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
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
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
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
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
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
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.
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 ±
disclosures.
E-poster Abstracts
Sequential Corneal Collagen Crosslinking and
Topography-Guided PRK in Keratoconus Treatment
93
may induce vitreous change to diminish posterior vitreocortical
pocket.
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
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
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
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
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.
disclosures.
94
E-poster Abstracts
Accommodative Response With a New
Accommodative IOL
able to provide a complete visual rehabilitation in eyes with preexisting corneal astigmatism.
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
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
Senior Author: Ahmed A Abdou MD PhD
Coauthors: Esperanza Sala OD, Ana Belen Plaza,
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
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
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
disclosures.
E-poster Abstracts
Intrastromal Corneal Ring Segment Implantation for
Ectasia After Refractive Surgery
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)
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
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
Senior Author: Ioanna Kontari MD
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.
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.
disclosures.
96
E-poster Abstracts
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.
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
Senior Author: Gregory J Pamel MD
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
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
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
disclosures.
E-poster Abstracts
97
Evaluation of Transepithelial Photorefractive
Keratectomy After Modification of Laser Beam
Profile
IOL Power Calculations Following Myopic LASIK: A
Systematic Review With Meta-analysis
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
Quality of Life After Refractive Surgery: SmallIncision Lenticule Extraction (SMILE) and
Implantable Collamer Lens
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
Senior Author: Arturo J Ramirez-Miranda MD
Coauthors: Flor Daniela Guzman, Alejandro Navas 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.
disclosures.
98
E-poster Abstracts
Epithelial-on Corneal Crosslinking in Thin Corneas
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
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
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.
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
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
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.
disclosures.
E-poster Abstracts
New Technique for Astigmatism: Beveled, FullThickness Astigmatic Keratotomy
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
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
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.
Combined With Astigmatic Keratotomy to Treat
High-Level and Mixed Astigmatism
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
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.
disclosures.
100
E-poster Abstracts
Evaluation of In Vitro Glistening Formation in
Different Hydrophobic Acrylic IOLs
Integrity of Intrastromal Arcuate Keratotomies
Performed by Femtosecond Laser
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
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
Senior Author: Ali Fadlallah Yahya MD
Coauthors: Stephanie Hopp BS MS, Daniel Cherfan MBBS,
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.
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.
disclosures.
E-poster Abstracts
Long-term Risk Factors for Dry Eyes and Visual
Aberrations After Corneal Refractive Surgery
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
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.
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
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
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.
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
disclosures.
102
E-poster Abstracts
Satisfaction Following Combined Small-Aperture
Corneal Inlay (Kamra) Implantation and LASIK for
Presbyopia Correction in an Irish Population
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
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
(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
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
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.
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
disclosures.
E-poster Abstracts
Comparison of Optical Quality in Monofocal, Bifocal,
and Trifocal IOLs of the Same Manufacturer
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
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
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
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
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.
disclosures.
104
E-poster Abstracts
Treatment of Hyperopic Presbyopes With Laser
Vision Correction Combined With Corneal Inlay
Implantation
Bilateral Implantation of a Polyfocal Bioanalogic IOL:
One-Year Outcomes
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
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
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.
Safety and Efficacy of Myopic LASIK Performed on
Thin Corneas
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
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.
disclosures.
E-poster Abstracts
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.
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
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
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
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
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.
disclosures.
106
E-poster Abstracts
Visual Performance Following Bilateral LASIK and
Monocular Corneal Inlay Implantation
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
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
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.
Outcomes of Femtolaser-Assisted LASIK With
Breakthrough Gas Bubble in Anterior Chamber
During Flap Creation
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
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.
disclosures.
107
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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
Financial Disclosures
Amar Agarwal MD
Ehud I Assia MD
David F Chang MD
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
Akkolens: C,S
CSO: C
Dompe: S
Hanita Lenses: C
Jaypee Bros: P
Mediphacos: C
Novagali: S
Oculentis: C,S
Presbia: C
Santen, Inc.: C
Slack Incorporated: C
Springer Verlag: P
Tekia, Inc.: P
Thea: S
Topcon: C
Vissum Corp.: E,O
Bausch + Lomb: L
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
Allergan: L
Carl Zeiss Inc.: L
Mediphacos: L
Oculus, Inc.: C
Steve A Arshinoff MD
Arctic Dx: C
iMed Pharma: C
None
Allon Barsam MBBS FRCOphth
Allergan: L
Carl Zeiss Meditec: L
Rayner Intraocular Lenses, Ltd.: L
Staar Surgical: L
Abbott Medical Optics: 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
Physiol: C
Sifi: C
Carlos Buznego MD
Beatrice Cochener MD
Bausch + Lomb: S
RVO: C
Santen, Inc.: C
Théa: C
Efekan Coskunseven MD
None
Allergan: C,L
Bausch + Lomb: C,L
CXLO: O
Glaukos Corp.: C,L,O
Lensar: C,L
Omeros: C,L
RPS: O
William W Culbertson MD
Alan N Carlson MD
Aquesys: C
Bausch + Lomb: C
Morcher GmbH: P
Ocular Surgery News: C
Oculus, Inc.: P
TearScience: O,C
AcuFocus, Inc.: C,O
Alcon Laboratories, Inc.: C,L,
Slack, Incorporated: C,
WaveLight AG: L
Abbott Medical Optics: C,L
Arthur B Cummings MD
Alcon Laboratories, Inc.: C,L
WaveLight AG: C,L
Burkhard Dick MD
Abbott Medical Optics, Inc.: C,L
Allergan: C
Faculty Financial Disclosures
David Donate MD
Damien Gatinel MD
John A Hovanesian MD
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
AcuFocus, Inc.: C
Alcon Laboratories, 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
Carl Zeiss Inc.: C
Ophtec: C
Orca Surgical: O
RVO Raindrop: C
Thea: C
Preeya K Gupta MD
Allergan: C
Bio-Tissue, Inc.: C
Novabay: C
Shire: C
Tear Science, Inc.: C
None
Allergan: C
Avedro, Inc.: C
Carl Zeiss AG: C
i-Optics: C
KeraMed, Inc.: C
David R Hardten MD
None
Calhoun Vision, Inc.: S
ESI, Inc.: C,O
Oculus, Inc.: L
OSD, Inc.: C,O
TLC Vision: C
Avedro: C,S
Cleveland Clinic Innovations: P
National Eye Institute: S
Ziemer: C
Sadeer B Hannush MD
Richard J Duffey MD
Aylin Kılıç MD
None
Terry Kim MD
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
Bausch + Lomb: C
Thieme Medical Publishers: P
AcuFocus, Inc.: C,O
ArcScan: C,O
Carl Zeiss Inc.: C
Elenza: C,O
Oculus, Inc.: C
Visiometrics: C,O
Wavetec: C
Acuity Advisors: C
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
Nidek, Inc.: C
Staar Surgical: C
Oliver Findl MD
109
110
Stephen D Klyce PhD
Rudy Nuijts MD
Centervue: C
Lensar: C
Nidek, Inc.: C
NTK Enterprises: C
Oculus, Inc.: C
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
I-optics: S
PowerVision: O
Revision Optics: C
TrueVision: S
Ziemer: S
Sonia Manning MD
None
Stephanie Jones Marioneaux MD
None
Alcon Laboratories: C,L,S
Bausch + Lomb Surgical: 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
Akorn, Inc.: C
Allergan: C
Bausch + Lomb: C
Focus Labs: C
Oculus, Inc.: C
OcuSoft: C
Orca Surgical: C
Shire: C
TearLab: C
TearScience Inc.: C
Ronald R Krueger MD
Clarity Medical Inc.: C
Cleveland Clinic Foundation: E
LensAR Laser Systems: C,O
Presbia: C
Allergan: O
Graybug, Inc.: O,P
Michael Mrochen PhD
None
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
Bausch + Lomb: C
Scott M MacRae MD
Bausch + Lomb: C
Parag A Majmudar MD
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
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
Calhoun Vision, Inc.: C,O
Stromal Medical: O
Toshihiko Ohta MD
None
Robert H Osher MD
Beaver-Visitec International, Inc.: C
Clarity: C
Microsurgical Technology: C
Omeros: C
Video Journal of Cataract & Refract
Surg: O
Richard B Packard MD
None
Lisa Park MD
None
1-800-Doctors: C,O
AcuFocus, Inc.: O,S
Allergan: C
Bausch + Lomb: C,S
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
Genzyme: C
Novartis Pharmaceuticals Corp.: C
Marianne O Price PhD
Bausch + Lomb: L,S
Interactive Medical Publishing: O
ReVital Vision: O
Staar Surgical: C
TearLab: O
Michael E Snyder MD
Audrey R Talley-Rostov MD
None
Bausch + Lomb: S
Haag-streit: C
Humanoptics: C
Icon: S
Xigen: S
Allergan, Inc.: C,L
Bausch + Lomb Surgical: C,L
Allergan: C
Avedro: C,O
Bausch + Lomb: 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
None
Ronald Luke Rebenitsch MD
FDA Ophthalmic Devices Committee: C
Dan Z Reinstein MD
Arcscan, Inc.; Morrison, Colorado: O,P
Olivier Richoz MD
Emagine AG: P
Allergan: C
Steven I Rosenfeld MD FACS
Doctor’s Allergy Formula: C
Modernizing Medicine: C
NovaBay: C
Ziemer: C
None
None
Theo Seiler MD PhD
None
Neda Shamie MD
Bausch + Lomb: C
Shire: C
Tissue Bank International: C
Christopher E Starr MD
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
Bausch + Lomb: C,L
TLC Laser Center: C,L
Visx USA, Inc.: L
WaveLight AG: C,L,S
AcuFocus, Inc.: C,L,O
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
R Doyle Stulting MD PhD
Allergan: L
Calhoun Vision, Inc.: C
Cambium Medical Technologies: C,O
EyeYon: C,O
Ophtec: C
Optovue: C
TearLab: C,O
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
Avedro: C,O
LensGen: O
ReVision Optics: C
Karl G Stonecipher MD
Alan Sugar 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
MBBS FRCS
None
Nidek, Inc.: C
Oculus, Inc.: C
Avi Wallerstein MD
None
111
112
Helen K Wu MD
Francis S Mah MD
Accelerated Vision: C
ACE Vision Group: C
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
Ziemer Ophthalmic, Inc.: C
Abbott Medical Optics Inc.: L
Bausch + Lomb: C,L
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
Allergan, Inc.: S
Avedro: S
Bioptigen: C
Slack, Incorporated: L
Transcend: C
Subspecialty Day
Advisory Committee
William F Mieler MD
Genentech: C
Donald L Budenz MD MPH
Ivantis: C
Daniel S Durrie MD
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
Jonathan B Rubenstein MD
Bausch + Lomb: C,L
R Michael Siatkowski MD
Nicholas J Volpe MD
None
AAO Staff
Christa Fernandez
None
Ann L’Estrange
None
Melanie Rafaty
None
Debra Rosencrance
None
Beth Wilson
None
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
Alimera Sciences, Inc.: S
Bausch + Lomb: C,L,S
Carl Zeiss Meditec: S,L
Contamac: S
Glaukos Corp.: S
Hoya: S
HumanOptics: S,L
Kowa: S
LensAr: S
Mediphacos: S
Oculentis: L,S
Powervision: S
None
Gerd U Auffarth MD
Mark J Cohen MD
None
Rukiye Aydin
Manuel Alejandro deAlba MD
None
None
Judah E Beck MD
Uday Devgan MD
Accutome: P
Bausch + Lomb: C,L
LensGen: C,O
Omeros: C,L
Specialty Surgical: O
Alexander Angelov MD
Ekaterina Branchevskaya
Mohamed Elbahrawy MBBCH MS
None
Yavor Petrov Angelov MS
Detlev R H Breyer MD
None
None
Carl Zeiss Meditec: C,L
Geuder: C
Lensar: C
Oculentis: C,L
Topcon Medical Systems, Inc.: C
Matthias Gerl MD
None
None
Fabrizio I Camesasca MD
Ralf H Gerl MD
None
Michelle Abou-Jaoude MD
None
Eser Adiguzel PhD
None
Fatemeh Adili-aghdam
None
Jorgé L Alió MD PhD
Akkolens: C,S
CSO: C
Dompe: S
Hanita Lenses: C
Jaypee Bros: P
Mediphacos: C
Novagali: S
Oculentis: C,S
Presbia: C
Santen, Inc.: C
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
Mario Bitani MD
Tommy Chung Yan Chan
FRCS(ED) MBBS
George P M Cheng MD
None
Daniel Cherfan MBBS
None
Chul Young Choi
Youngtaek Chung MD
Joanna Galindo MS
None
Guillermo Garcia De La Rosa MD
None
114
Marine Gobbe PhD
Albert S Jun MD
None
None
Javier Humberto Gonzalez-Lugo
BA MD
Abbott Medical Optics: L,S
Alimera Sciences, Inc.: L,S,C
Allergan: L,S
Bausch + Lomb: S
Geuder AG: L,S
Glaukos Corp.: S
Hoya: L
KOWA: L
Mediphacos: S
Novartis Pharmaceuticals Corp.: L,S
Oculentis: L,S
Ophtec: S
Powervision: S
None
None
Anita Gupta MD
None
Flor Daniela Guzman
Mona Harissi-Dagher MD
None
Richard A Hemmings BA
Julio Hernandez Camarena MD
None
Erick Hernandez-Bogantes MD
None
Samuel G Hilbert BA MS
Simon P Holland MD
Allergan: C
Clarion: C
Stephanie Hopp BS MS
None
Lucia Hrckova
None
Mariluz Iglesias
Carlo Irregolare MD
Svetlana Izmaylova MD PhD
Samir Jabbour MD
Allergan: C
Avedro, Inc.: C
Carl Zeiss AG: C
I-Optics: C
KeraMed, Inc.: C
Manpreet Kaur
Hakan Kaymak MD
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
Bausch + Lomb: S
Bayer Healthcare Pharmaceuticals: S
Contamac: S
Hoya: S
HumanOptics: S
Kowa: S
LensAr: S
Mediphakos: S
Oculentis: S,L
Powervision: S
Buki Kim
Luigi Mele MD
None
Douglas D Koch MD
I-optics: S
PowerVision: O
Revision Optics: C
TrueVision: S
Ziemer: S
Qualsight: C
Junko Koshimizu MD
Matthias Mueller PhD
None
Aida Jimenez
None
Daegyu Lee
David T Lin MD
PRN Physician Recommended
Nutriceuticals: C
SCHWIND eye-tech-solutions: C
Jesus Lozano Cardenas MD
None
Katarina Majernova MD
Ryan N Mercer BS
Peter Mojzis MD PhD
David Myung
Joao J Nassaralla MD PhD
None
Belquiz A Nassaralla MD PhD
Tanja M Rabsilber MD
Abbott Medical Optics Inc.: S
Contamac: S
Hoya: S
HumanOptics: L,S
Kowa: S
Mediphacos: S
Oculentis: S
Powervision: S
Rayner Intraocular Lenses Ltd.: S
AcuFocus, Inc.: C
Allergan: C
Innovega: C
Optical Express: C
Zeiss: C
Alejandro Navas MD
Staar Surgical: L
Paul D O’Brien MBBCH BA
None
Kishiko Okoshi MD
None
Delores Ortiz PhD
Leticia Elizabeth Pacheco
None
Javier Paz Moreno-Arrones MD
Glauco H Reggiani Mello MD
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
Saeed Soleyman-Jahi MD
None
Cynthia Roberts PhD
Hyeck Soo Son
1-800-Doctors: C,O
AcuFocus, Inc.: O,S
Allergan: C
Bausch + Lomb: C,S
Clarity Medical: C,O
CoDa: C
DES, Inc.: O,C
Elenza: C,O
Envisia: C
Mimetogen: C
Shire: C
TearLab: C,O
Euclid Systems Corp.: L
Oculus, Inc.: C,L
Ziemer Ophthalmic Systems AG: C,L,P
Gabriela Perez
Roy Scott Rubinfeld MD
CXLO: O
CXLUSA: O
Ana Belen Plaza
None
William J Power MD
None
Kishore Raj Pradhan MD
Victor M Preciado Jr
None
Abbott Medical Optics Inc.: C
Allergan: C
Isabel Rodriguez-Perez MHSA
None
Michiel Rombach
Akkolens International: E
Esperanza Sala OD
Ziemer: C
Pablo Sanz MS OD
None
Sandro Sbordone
Roger F Steinert MD
Avedro: C,O
LensGen: O
ReVision Optics: C
Larissa Souza Stival Sr
Harald Patrik Studer PhD
Integrated Scientific Services: E
Choon Hwai Johnson Tan MBBS
None
Tamer Tandogan MD
Bausch + Lomb: 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
115
116
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
Miguel A Teus MD
Weijun Wang MD
Timothy E Yap
None
Jeewan S Titiyal MD
Pilar Yebana MD
None
Accelerated Vision: C
Ace Vision Group: C
Allergan: C
Avedro: C
Bausch + Lomb: C
Focal Point, Asia: 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
David Touboul MD
None
Silvia Trazza
None
Kentaro Tsuzuki MD
None
Karla Olivia Vandick
Alfredo Vega-Estrada MD
None
Xun Xu MD
None
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
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
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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.

Refractive Surgery 2015 The Vegas Player`s Guide of Refractive

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