1. Refractive Surgery September 22, 2012 Matthew Carnahan, MD

2. Refractive Surgical Modalities RK PRK, LASEK, epi-LASIK LASIK Wavefront LASIK IntraLASIK Conductive Keratoplasty Phakic IOL Presbyopic IOL –multifocal –pseudo-accommodating Refractive Lens Exchange (monofocal, multifocal) Toric IOL

3. Radial Keratotomy http://www.youtube.com/watch?v =FzcKFvZuIqs&feature=related http://www.youtube.com/watch?v =i1AoFonNLwc

4. PRK or LASEK http://www.youtube.com/watch?v=QRNzDC 5xlc8 http://www.youtube.com/watch?v=gjnN481F vks

5. LASIK with microkeratome http://www.youtube.com/watch?v=Yel9QlQr56o

6. IntraLASIK Femtosecond laser With gas bubbles, bluntly dissect between corneal collagen lamellae create a plane which becomes the flap for LASIK without a blade http://www.youtube.com/watch?v=3-ry8mLaY8M

7. Conductive Keratoplasty (CK) FDA Approved for presbyopia Induces myopia in an emmetropic eye, achieving monovision http://www.youtube.com/watch?v=u39XvfOvhxA http://www.youtube.com/watch?v=89W4z08ZrdA

8. Phakic IOLs for High Myopes Sulcus - VisianIris - Verisyse/Artisan http://www. youtube.co m/watch?v =LIsZz5y7 QOY http://www. youtube.co m/watch?v =wzzAhcth hKo

9. Refractive Lens Exchange (RLE) Natural Lens Replacement –Monofocal IOL (+/- monovision) –Accommodating IOL – Crystalens –Multifocal IOL ReSTOR Tecnis Valuable for patients with thin corneas or high refractive errors (hyperopia / astigmatism)

10. Presbyopia correcting IOLs Multifocal IOL –Tecnis –ReSTOR Pseudo-accomodating IOL –Crystalens http://www.youtube.com/ watch?v=T1w1qEUPZPI &feature=related

11. Crystalens DistanceNear pseudo-accommodation http://www.youtube.com/ watch?v=xmP5FlQBmcM

12. Multifocal IOL – ReSTOR ® The AcrySof ® ReSTOR ® IOL incorporates an apodized diffractive optic with refraction to achieve a range of quality vision. http://www.youtube.com/watch ?v=7hcHO_1PF30&feature=rel ated http://www.youtube.com/watch ?v=mJgofz7NMbs&feature=rel ated

13. Tecnis MFIOL Diffractive, 1 or 3 piece, silicone or acrylic, aspheric Less pupil dependent, 4+add on posterior surface http://www.youtube.com/watch?v= AJ5_glCYVYo&feature=related

14. Contraindications to MFIOLs: Patient Considerations Subjective Exclusion Criteria – Hypercritical patients – Patients with unrealistic expectations – Those who want to wear glasses – Occupational night drivers – Individuals with a monofocal lens

16. Contraindications to MFIOLs: medical exclusion criteria Pre-existing ocular pathology Significant dry eye Corneal scarring, cornea guttata Glaucoma Macular disease Previous refractive surgery (not an absolute) Pupil size <2.5 mm Monofocal implant in first eye >1.0 D of corneal astigmatism (may need added LVC, maybe toric instead) Unstable capsular support

17. Managing the Total Condition Physical –Controlling astigmatism –Enhancing distance vision –Enhancing near vision –Managing common patient concerns Psychological –Concerns with halos –Adapting to a new visual system

18. Who is your MFIOL patient? Motivated to reduce dependency on glasses Candidate for bilateral implantation Cataract patients who want to retain the ability to see objects near and distant with reduced dependency on glasses (50+ who are considering LASIK: frustrated presbyopes)

19. Design –AcrySof Single-Piece platform –Open loop, modified-L haptics –Posterior toricity –Toric axis marks Dimensions –Overall length: 13.0 mm –Optic diameter: 6.0 mm Toric IOL

20. Synchrony accommodating IOL Single piece dual optic silicone accommodating lens, movement via ciliary body 5.5mm +32D anterior optic 6.0mm minus power post. optic FDA phase 3 2 year f/u – 90%+ 20/20 UCVA Better than ReSTOR at 60cm & 80cm distance corrected http://www.youtube.com/watch?v=d ll3rXrr9CY

21. Acri.LISA German single piece aspheric acrylic multifocal lens with toric option Can go through a 1.8mm incision L: light intensity (65% refractive/distance & 35 diffractive/near) I: independence from pupillary size S: smooth refractive/diffractie surface profile A: aspheric surface

22. MPlus “Sector-shaped near-vision section offering HD-Vision- natural contrast sensitivity and best-corrected distance and near visual acuity.” One piece aspheric, multifocal toric acrylic

23. M-Flex Multifocal IOL (& T-flex toric) Acrylic, 6.25mm multizone (4 or 5 depending on base power) aspheric optic Distance dominant with +3.0 or +4.0D add = +2.25 or +3.0D at spectacle plane Made for 2mm incision

24. Rayner Sulcoflex Acrylic injectable IOL with undulating haptics and posterior haptic angulation for secondary suclus placement in pseudophakic eyes Multifocal and toric versions are available

25. Multifocal laser ablation (presbyLASIK) Different power zones for varying distances Epstein in Chicago: distance center, near periphery – similar to PAC (Pseudo-Accommodative Cornea) by Telandro in France (>10K cases done since ’04) Alioi in Spain: center of cornea shaped for near vision, peripheral zone for distance (believe to reduce aberrations and allows for stronger near correction)

26. Laser Cataract Surgery Femtosecond laser creating -Capsulorhexis -Lens pre-dicing -Main incision -Paracentesis -Corneal relaxing incisions http://www.youtube.com/ watch?v=osegmN1E8JE& feature=related

27. Thank You http://www.youtube.com/watch?v=U3X_zVvRTn0&featu re=relatedhttp://www.youtube.com/watch?v=U3X_zVvRTn0&featu re=related