1. U.S. Trends in Refractive Surgery: 2014 ISRS Survey Richard J. Duffey, MD David Leaming, MD Refractive Subspecialty Day Chicago: October 17, 2014

2. The authors have no financial interests in this survey study. DUFFEY/LEAMING 2014

3. 2014 Survey ä ä Sixth year of ONLINE*** Survey ä ä E-mailed to 1022 U.S. ISRS members; 486 Opened ä ä Eighteenth year of refractive data collection overall ä ä 15% response rate of the membership’s opened e-mail requests analyzed by October 8, 2014. ä ä Alphabet soup of refractive surgery including corneal and lens-based surgeries, premium IOLs, and FS cataract surg.

4. DUFFEY/LEAMING 2014 > 5 Cases / Month 4 43 36 * 1 51 59 10

5. DUFFEY/LEAMING 2014 > 25 Cases / Month 4 3 4 1 12

6. DUFFEY/LEAMING 2014 > 75 Cases / Month * Peak in 2001; Valley in 2012-13

7. DUFFEY/LEAMING 2014 Preferred Surgery For a 30 yo -10.00 Diopter Myope * 40% LVC

8. DUFFEY/LEAMING 2014 Preferred Surgery For a 45 yo +3.00 D Hyperope *63% LVC 4 10 53 18 1 15

9. DUFFEY/LEAMING 2014 Preferred Surgery For 45 yo +5.00 D Hyperope * 7 1 8 61 4 19

10. DUFFEY/LEAMING 2014 Willing To Do Bilateral Surgery At Same O.R. Visit * 19 7 23

11. DUFFEY/LEAMING 2014 Had Refractive Surgery Performed on Yourself *40% Total 35 7 4

12. DUFFEY/LEAMING 2014 Family LVC Index: (LASIK or PRK Performed on Yourself and Family Members) 22 * >3X the general population

13. Family Presby-IOL Index: (Presby IOL Performed on Yourself and Family Members) 7 22 4 26 *

14. Family FS Cat Index: (FS Cat Performed on Yourselves and Family Members) 4 2 1 0 11 *

15. DUFFEY/LEAMING 2014 Excimer Laser Most Commonly Used 6 0 *

16. FemtoSecond Cataract Laser Most Commonly Used 58 21 12 6

17. DUFFEY/LEAMING 2014 Flapmaker Most Commonly Used * 71% femtoflaps

18. DUFFEY/LEAMING 2014 Topography Unit Used (some physicians use more than one) 42 20

19. DUFFEY/LEAMING 2014 Preferred Surgery for “Pre-Cataract” Presbyopia 59 23 5 9

20. DUFFEY/LEAMING 2014 Comanagement 45 55 11

21. DUFFEY/LEAMING 2014 Preferred Flap Thickness (when no other constraints) 1 68 30 1

22. DUFFEY/LEAMING 2014 Minimum Residual Stromal Bed Thickness Requirement for LASIK * 64% at 275 microns or greater 10 34 23 36 1 4

23. DUFFEY/LEAMING 2014 Total Cases of Post LASIK Ectasia as the Primary Surgeon in Career * Slight Growth Rate 32 1719 11 7 66 3

24. DUFFEY/LEAMING 2014 Minimum Cent. Corneal Pachymetry for LASIK (all other parameters normal) * 73% OK with 480 or less

25. DUFFEY/LEAMING 2014 Cataract/RLE Post-Op Antibiotic 33 94

26. DUFFEY/LEAMING 2014 LVC Post-Op Antibiotic 2 11 87

27. DUFFEY/LEAMING 2014 Cataract/RLE Post-Op Steroid

28. DUFFEY/LEAMING 2014 LVC Post-Op Steroid

29. Cat/RLE Post-OP Nonsteroidal 10 16 24 47 4

30. DUFFEY/LEAMING 2014 Location of Phakic-IOL Surgery

31. Threshold of Astigmatism Offered Correction at Cataract Surgery DUFFEY/LEAMING 2014 *68% will offer to correct astigmatism when it has reached 0.75 D and 97% when it has reached 1.25 D

32. Procedure for Low Astigmatism Intervention (0.5 to 1.0 D) DUFFEY/LEAMING 2014 * 91% LRI/AK

33. Procedure for Medium Astigmatism Intervention (1.12 to 2.0 D) DUFFEY/LEAMING 2014

34. Procedure for High Astigmatism Intervention (2.0 D plus) DUFFEY/LEAMING 2014

35. Do You Currently Perform CXL? DUFFEY/LEAMING 2014

36. Overview of Cataract Surgery: % of All Cases of All Surgeons DUFFEY/LEAMING 2014 64 9 17 6 14 19 6

37. Overview of FS Cataract Surgery: % of All FS Cases of All FS Surgeons DUFFEY/LEAMING 2014 5449 84 82 54

38. DUFFEY/LEAMING 2014 Total LVC Volume in ISRS (x1000) *22% Increase in Total LVC from 2012-13. *Ratio of PRK / Total LVC remained at 22% over past four years.

39. DUFFEY/LEAMING 2014 2014 ISRS SUMMARY ä ä Sixth ONLINE ISRS SURVEY was a success with 15% response rate. ä ä VisX (50%) losing further marketshare to Wavelight (44%). ä ä Still about 35% penetration of modern refractive surgery amongst refractive surgeons…. 3-4 X the general population. Family Index rates also continue to be high.

40. DUFFEY/LEAMING 2014 2014 ISRS SUMMARY ä ä 23% of respondents are OK with bilateral P-IOL and 7% with bilateral RLE at the same surgical setting (stable). ä ä Multifocal IOL (14%) over accommodative IOL (6%) as a preferred lens-based presbyopia option when used for RLE. ä ä Femtosecond LASIK flaps dominate and are stable at 71%.

41. DUFFEY/LEAMING 2014 2014 ISRS SUMMARY ä ä Thinner flaps dominate: 100 micron or less flaps are favored by 68% of surgeons (up from 12% in ‘04). ä ä Preferred RSB thickness is stable: 34% think 250 microns is adequate, but 65% recommend 275 microns or more. ä ä New post-LASIK ectasia cases show a slight rise in rate.

42. 2014 ISRS SUMMARY ä ä Pentacam (42%) and Z-H (38%) about equal and Orbscan II dropped off to 28%. ä ä LVC Volume up over last two surveys in 2012 and 2013. ä ä Ratio of Surface Ablation / Total LVC stable near 22% over past five years. DUFFEY/LEAMING 2014

43. 2014 ISRS SUMMARY ä ä During cataract surgery 68% of surgeons will offer to correct astigmatism if it is 0.75 D or more; 97% if 1.25 D or more. ä ä LRI/AK preferred (91%) if K astigmatism <1.0D ä ä Toric IOL preferred (77%) if K astigmatism > 1.12D ä ä CXL offered by 23% of ISRS members surveyed in the U.S. (not FDA-approved). DUFFEY/LEAMING 2014

44. 2014 ISRS FINAL SUMMARY ä ä FemtoSecond Laser-assisted Refractive Cataract Surgery on the rise. ä ä FS, Toric and PresbyIOL are not high volume refractive surgeries yet like LASIK in its heyday, but moving forward. ä ä Multifocals trump Accomodative IOLs, but neither high penetration. ä ä More astigmatism management (even low astig.) in cataract surgery. ä ä Healthy LVC and Premium IOL Family Indices amongst refractive surgeons themselves and their families. ä ä Post-LVC ectasia on a slight rise. DUFFEY/LEAMING 2014

45. www.duffeylaser.com Additional Data at www.duffeylaser.com ä ä Types and volumes of refractive surgeries currently being performed. ä ä Post-operative use of antibiotics, steroids, and NSAIDs. ä ä Surgical venues for various procedures…and more. DUFFEY/LEAMING 2014

46. Thanks to the ISRS leadership for their support and for your participation in the 2014 Survey We look forward to your response to our seventh ONLINE survey and the nineteenth survey overall next fall. ***Complete 18 years of survey results found at www.duffeylaser.com