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1/31/2017 REFRACTIVE CANDIDATE? Case Studies …and other cornea cases ……and some updates CAROL J. HOFFMAN, MD MEDICAL DIRECTOR KREMER EYE CENTER CASE ONE • 26 Yr old female for refractive screening – Last used contact lenses one year ago – No past eye problems – No family history of eye problems – MRX -6.25 -.75 x 090 20/20 -4.50 – 1.25 x 060 20/30 SLE & FUNDUS Exam WNL CASE ONE CASE ONE • Refractive surgery candidate? – Posterior elevation OS – Inferior front surface steepening – Diagnosis: Keratoconus OS – Would not recommend Laser refractive surgery 1 1/31/2017 What Topography Makes a Patient a Non Candidate For Laser Refractive Surgery? • • • • KERATOCONUS Obvious keratoconus Forme Fruste Keratoconus Irregular Astigmatism Bad BAD Display Keratoconus • A bilateral progressive disease of the cornea characterized by ectasia, a thinning and forward protrusion of the cornea. – Partially genetic – Increased risk with • • • • • Eye rubbing Contact lens wear Connective tissue disorders Ocular allergy Down’s Syndrome FORME FRUSTE KERATOCONUS Forme Fruste Keratoconus • Subclinical Keratoconus defined by topographic changes which are some what loosely defined, but in general include – Posterior elevation – Inferior steepening – Asymmetric bow ties • Best corrected vision is still good Belin Ambrosio Enhanced Ectasia Display (BAD) – Combines elevation and pachymetric data comparing normal and ectatic corneas – The CTSP measures the distance between the thinnest point of the cornea and the geometric center..this distance is greater in ectatic disease. – PTI measures the percentage of increase from the thinnest point out to the periphery, ectatic corneas have a more abrupt progression of thickening from the thinnest point to the periphery 2 1/31/2017 BAD DISPLAY ABNORMAL BAD • RED FLAG-HIGH SENSITIVITY FOR ECTATIC DISEASE • YELLOW FLAG IS SUSPICIOUS: – Repeat to get better quality images • • • • Head position Lids and lashes out of the way Treat any surface abnormalities Out of contact lenses 2-4 weeks-or longer – Either no surgery or PRK • ABNORMAL BAD • • • • ABNORMAL BAD 49 YEAR OLD CORRECTS TO 20/20 STABLE REFRACION NORMAL PENTACAM 6 MAP DISPLAY • PLAN: PRK ABNORMAL BAD ABNORMAL BAD • 21 YEAR OLD • UNKNOWN STABILITY OF REFRACTION • ABNORMAL PENTACAM 6 MAP DISPLAY PLAN: NO REFRACTIVE SURGERY NOW, WAIT ONE YEAR, RECHECK PENTACAM 3 1/31/2017 CASE TWO • 30 yr old male for refractive screening – Wears soft daily contact lenses – Mrx +6.00 – .50 x 160 20/20 +6.00 – .50 x 040 20/20 Normal Topography SLE Fundus Exam CASE TWO • Candidate For Laser Refractive Surgery? – No, Rx too high for hyperopic wave front correction – Conventional treatment of hyperopia not good enough Parameters For Laser Vision Correction iDesign Myopia -5D- 11D, with up to -5D astigmatism Hyperopia not approved yet Mixed Astigmatism-Just approved, software installation soon Wave Front Hyperopia-up to +3.00 MRSE with between 0- 2 D of Astigmatism Mixed Astigmatism- Up to + 6.00 with 1- 5 D Astigmatism CASE THREE • 55 Yr old male for a refractive surgery screening – No contact lens wear – Mrx -3.75 -1.00 x 015 20/20 -4.25 -0.75 x 165 20/20 SLE 4 1/31/2017 CASE THREE CASE THREE CASE THREE CASE THREE • Diagnosis: – Posterior Crocodile Shagreen • A benign degenerative condition of the cornea that is usually asymptomatic • Bilateral symmetrical polygonal opacities with intervening clear spaces within the central posterior cornea • LASIK/PRK not contraindicated What Cornea Cornea Conditions Are a Contraindication for LASIK? • Absolute – Cornea thickness <500 • PRK/Visian and option – Cornea scar affecting vision – Keratoconus – Cornea Dystrophies 5 1/31/2017 CASE 4 • 47 yo male presents for an enhancement evaluation. – LASIK OU for high myopia 2000 – LASIK Enh OU 2004 – Vision decreased over the last year, fit for contact lens, but vision fluctuates CASE 4 • VA sc OD 20/80, OS 20/100 • Mrx OD plano: – 3.25 x 160 20/25 – OS -1.25 – 1.50 x 180 20/20 – SLE 2.4 mm x .5mm plaque of epithelial ingrowth at 7 oclock – Treatment? Enh or Cell removal CASE 4 • Cell removal OD – 4months post op • • • • VA sc OD 20/80 Mrx OD -1.00 -1.75 x 165 20/20Few nests of cells at flap edge, not progressing. Plan? • PRK OD CASE 4 • 4 months post PRK OD – VA sc 20/30 – Mrx OD +.75 -1.25 x 015 20/20-2 – But..autorefraction +2.00-3.75 x 013 – Progression of nest of cells – Treatment? • ND:YAG laser • 1 month post op plano 20/20- ND:YAG FOR EPI INGROWTH • ND:YAG laser – Commonly used to treat posterior capsule opacification post CEIOL – First described for epithelial ingrowth 2008 – Set low .1-1.0mj – Post op-steroid taper – Result in most-marked reduction, halt progression, complete resolution • Can be repeated • Rare complication-surface breakthrough leading to new cells. 6 1/31/2017 ND:YAG FOR EPI INGROWTH ND:YAG FOR EPI INGROWTH • Main advantage – Avoid flap re lift • No reintroduction of new cells • Reduces risk of infection – Quicker recovery – Done in the office setting ND:YAG FOR EPI INGROWTH COLLAGEN CROSSLINKING UPDATE CXL is the therapeutic technique of using UV light and Riboflavin to strengthen chemical bonds in the cornea • FDA approval status – 4/2016 Avedro received FDA approval for it’s specific riboflavin formulation and UVA irradiation delivery system CXL • Indications – Progressive ectatic disease of the cornea based on vision, astigmatism, and topography • Contraindications – Cornea thickness <400 microns – History of herpetic eye disease – Cornea scarring or opacification – Severe ocular surface disease. – Advanced disease-may not be improving their life 7 1/31/2017 CXL • Kremer Hybrid Technique – Disrupt but do not remove epithelium – Instill riboflavin drops for 20-30 minutes – UV light 18mw x 5 minutes – FDA approved unit 3mw x 30minutes • Post op – Bandage contact lens – Antibiotic drops and Ketorolac for 2-3 days – Prednisolone taper over 1 month CASE 5 CASE 5 • 19 year old male with decreased vison OS for one year. Positive for Asthma, allergies, and aggressive eye rubbing. • Vacc 20/20 OD, 20/60 OS • Mrx OD -1.00 -.75 x 085 20/20 • OS +1.25 -3.00 x 090 20/25 • SLE: Clear corneas, no voigts, Fe Line or thinning OU CASE 5 • Keratoconus OS • Forme Fruste Keratoconus OD • Treatment options – Crosslink OU vs. OS CASE 5 • Collagen Cross Linking performed OU – Hybrid technique – Will need RGP cl fit for best vision. • 6 months post CXL – VA with RGP OD 20/20, OS 20/25 8 1/31/2017 CASE 5 CASE 5 CASE 5A CASE 5A • Patient #5’s twin sister presents for rule out KC-no visual complaints, non eye rubber • Vasc 20/20 OD, 20/25 OS • MRX: plano 20/20 OD, -.25 -.50 x 180 20/20-2 • SLE: WNL CASE 5A CASE 5A 9 1/31/2017 CASE 5A COLLAGEN CROSS LINKING • Forme Fruste Keratoconus OU • Take Home Points: – Plan ? • Crosslink ou • Observe Decided to recheck Pentacam 6 months if any progression would cross link at that time. If no change re check pentacam 6 months, then yearly. – Variety of ways to get crosslinking – Siblings should be screened – Aggressively treat atopy/allergies to stop eye rubbing – The earlier we catch the keratoconus the better REFRACTIVE UPDATE iDESIGN Methods of assessing visual system US Refractive Market overview • US patient pool largely untapped • More than half of U.S. population require some form of vision correction9 • Millennial group is the largest generational group with 86 million people, 7% larger than Baby Boomer group10 – ~5 million millennials have had LASIK11 Phoropter (Manifest) Method of Refractive Error Measurement WaveFront Method of Refractive Error Measurement One single data point Over 120 data points – ~25 million more (5x) are considering LASIK11 • LASIK is the most commonly performed refractive procedure9 January 31, 2017 5 9 January 31, 2017 6 0 10 1/31/2017 Wavefront-guided lasik creating the wavefront map • Highly precise 3D maps are generated, detailing higher and lower order aberrations • This accurate assessment allows the surgeon to tailor the treatment that’s 100% personalized Patient wavefront measurement Each spot is analyzed as to how the light is traveling in that part of the eye Wavefront software calculates the wavefront map and generates a laser treatment plan Actual eye capture Images 6 2 January 31, 2017 What is the idesign system The new brain for lasik • An innovative approach to measuring and treating refractive errors - working like a computer “brain”, it captures over 1,200 points of data to create a complete picture of the eye’s unique imperfections and generate a 100% personalized treatment plan. • 5x the Resolution* • Ease of Use12 • Treat Broad Range of Patients • Quality Outcomes1,13 *Compared to the WaveScan System 5 measurements within a single capture 12 sequence • Wavefront refraction • • • • January 31, 2017 6 4 January 31, 2017 6 6 Pupillometry • Measures pupil diameter under variable lighting conditions—mesopic and photopic Wavefront aberrometry Corneal topography Keratometry Pupillometry Scotopic image January 31, 2017 6 5 Photopic image 11 1/31/2017 The idesign system helps you treat more patients The idesign system results in clearer, sharper vision your patients will enjoy • 99% of people were not limited in active sports or outdoor activities after surgery 13 – Correct a broad range of astigmatism (up to -5 D) in people with nearsightedness • 99% of people had little to no difficulty with the clarity of their vision after surgery 13 • 97% of people were satisfied with their vision after surgery13 • 93% of people had little to no difficulty driving at night after surgery 13 – Potential to capture complex, challenging eyes • Majority of people achieved 20/16 or better vision after surgery1 – Pupil capture range: 4mm – 9.5mm – 18 years of age or older January 31, 2017 Star S4 IR® laser Iris registration technology 68 Advanced customvue treatment • Replaces manual, ink-based methods of treatment alignment • Aligns treatment on the cornea and provides greater alignment accuracy • Centers the treatment correctly January 31, 2017 69 January 31, 2017 70 Star s4 ir® excimer laser features How the star s4 ir® laser works • Utilizes ultraviolet light to precisely reshape the cornea • Iris Registration (IR): Provides alignment accuracy and precise ablation placement • This reshaping is designed to correct vision problems • Variable Spot Scanning (VSS): Ensures that intricate shapes are precisely ablated • Sub micron amounts of tissue are removed with each laser pulse with the total treatment on the eye amounting to less than the width of a human hair • Variable Repetition Rate (VRR): Varies the laser’s pulse rate to minimize thermal effects • ActiveTrak 3-D Active Eye Tracking: Captures all 3 dimensions of intra-operative eye movements - no dilation required • ActiveTrak Automatic Centering: Locates, and then automatically sets the treatment center to the -center of the pupil January 31, 2017 71 January 31, 2017 72 12 1/31/2017 Discover the components of the iLASIK® technology suite THANK YOU! • iDESIGN system: Precise diagnosis gained through highly accurate wavefront measurement and truly personalized treatment planning to help doctors deliver improved quality of vision1 • iFS® femtosecond laser: Built from a legacy of innovative IntraLase® technology, greater precision and predictability for custom-designed LASIK flaps to enhance patient outcomes2,3,4,5 • STAR S4 IR® excimer laser: Industry trusted to deliver what you aim for with precise levels of ablation accuracy6,7,8 January 31, 2017 73 13