1. US Trends in Refractive Surgery: 2008 ASCRS Survey Richard J. Duffey, MD David Leaming, MD San Francisco: April 4, 2009

2. Duffey 2008 Disclosures n The authors actually spend some of their own hard-earned dollars to cover the annual printing and analyzing costs of this survey.

3. Duffey 2008 2008 ASCRS Survey n Sept. mailing to 4980 U.S. members of ASCRS n 634 responses representing 13% of the U.S. ASCRS membership n Thirteenth year of refractive data collection allowing analysis and comparison of trends amongst ASCRS U.S. surgeons n Alphabet soup of refractive surgery. n Added questions in recent years as the field has incorporated new laser and refractive technologies including premium IOL’s, astigmatism correction, etc.

4. Duffey 2008 > 5 Cases per Month

5. Duffey 2008 > 25 Cases per Month

6. Duffey 2008 > 75 Cases per Month

7. Duffey 2008 Preferred Surgery for 30 yo -10.00 Diopter Myope *

8. Duffey 2008 Preferred Surgery for 45 yo +3.00 D Hyperope *

9. Duffey 2008 Preferred Surgery for 45 yo +5.00 D Hyperope *

10. Duffey 2008 Currently are a Refractive Surgeon and had Refractive Surgery Performed on Yourself *Greater than 4 times the pene- tration compared to general public

11. Duffey 2008 Surgeon Willing to do Bilateral Surgery at the Same Visit *

12. Duffey 2008 Present or Future Practice Plans *

13. Duffey 2008 Topography Unit Owned -many practices own more than one unit * *

14. Duffey 2008 Microkeratome Used Most *

15. Duffey 2008 Epi-Keratome Use

16. Duffey 2008 Excimer Used Most *

17. Duffey 2008 Wavefront Analyzer

18. Duffey 2008 Wavefront-Guided Custom Ablations in Your Practice *

19. Duffey 2008 Preferred Surgery for Presbyopia *

20. Duffey 2008 Post-Op Antibiotic

21. Duffey 2008 Post-Op Anti-Inflammatory

22. Duffey 2008 Post-Op Non-Steroidal

23. Duffey 2008 Do You Intra-operatively Measure Flap Thickness? *

24. Duffey 2008 Preferred Flap Thickness (when no other constraints) *

25. Duffey 2008 Minimum Residual Stromal Bed Thickness Requirement *

26. Duffey 2008 Total Cases of Post LASIK Ectasia as the Primary Surgeon in Career *the numbers are not growing

27. Duffey 2008 Minimum Preop Corneal Pachymetry for LASIK (all other parameters normal) * * *

28. Duffey 2008 Minimum Final Corneal Thickness Allowable Following PRK (including epithelium) *

29. Duffey 2008 Mitomycin-C Use (MMC)

30. Duffey 2008 Will You Perform Refractive Surgery on One-Eyed Patients *

31. Duffey 2008 Comanagement

32. Duffey 2008 When Co-managed, Who Sees Postop LASIK Patient on Day 1 ?

33. Duffey 2008 Minimum “OR” Location for Phakic-IOL Surgery

34. Duffey 2008 Refractive Surgery Volumes (extrapolated data in thousands)

35. Duffey 2008

36. ’08 ASCRS Survey Conclusions n Volume of LVC (U.S.) in 2008: 0.988 M eyes (1.02M in ’06) n LASIK dominates between -8D and +3D. n Bilateral extraocular sx same O.R. visit is SOC. n P-IOL (40%) (and LASIK (23%) in high myopes. n RLE (54%) for high hyperopes. n LASIK, LASEK, Epi-LASIK, RLE, P-IOL, PRK, ICR, and LRI/AK all with apparent bright futures.

37. Duffey 2008 Conclusions continued... n VisX still at > 3:1 (73%) over all other lasers combined. n Occulus Pentacam at 23% usage amongst members (5% two years ago). n IntraLase is increasing market share (33%), but mechanical microkeratomes still dominate (66%). n Fourth generation fluroquinolones (96%) dominate the post-refractive surg. market (Z>V).

38. Duffey 2008 Conclusions continued... n Greater than 30% penetration of modern refractive surgery amongst refractive surgeons. n One-third of refractive surgeons (32%) measure true flap thickness in the OR. n 52% (still dropping) think 250 microns is adequate for RST. 47% say 275-300 microns is better (21% in ’04). n Most desired flap thickness is 120-130 microns (50%). 100 micron flap thickness is favored by 32% of surgeons (up from 11% three years ago). n 48% of surgeons not OK with LASIK in corneas <500 um.

39. Duffey 2008 Conclusions continued... n 83% (stable) use MMC for prophylaxis and/or haze. n 39% (stable) OK with refractive surgery on one-eyed pt. n 14% of respondents are OK with bilateral P-IOL (11% two years ago) and 5% with RLE at the same surgical setting. n Monovision is the most sought goal for presbyopic patients seeking refract surgery (43%). n ReStor (15%) and CrystaLens accommodative IOL (14%) have outpaced ReZoom (3%) IOL’s for preferred lens- based presbyopia options.

40. Duffey 2008 Conclusions continued... n ASC OR is preferred location for P-IOL surgery (84%). n Still only about one-third of surgeons surveyed (35%) have had one or more documented cases of post-LASIK ectasia in his/her surgical patients over a career. (Not Growing!) n Co-management is practiced by under one-half of respondents overall (44%) with most of these co-managing fewer than one-third of their patients. n When co-managing with another doctor, still 74% of surgeons see their own patients on the first post-op day.

41. Duffey 2008 2008 ASCRS SUMMARY n Volume of LVC (U.S.) in 2008: 0.988 M eyes. 11-12 M since 1996. n P-IOL (40%) and LASIK (23%) in high myopes. n VisX still at > 3:1 (73%) over all other lasers combined. n Greater than 30% penetration of modern refractive surgery amongst refractive surgeons (no data on surgeon family members this year). n 83% (stable) use MMC for prophylaxis/haze.

42. Duffey 2008 2008 ASCRS SUMMARY n Most desired flap thickness is 120-130 microns. 100 micron flap thickness is favored by 20% of surgeons (up from 11% three years ago). n 14% of respondents are OK with bilateral P-IOL (11% two years ago) and 5% with RLE at the same surgical setting. n ReStor (15%) and CrystaLens (14%) accommodative IOL’s are gaining popularity while the ReZoom (3%) is dropping off as lens-based presbyopia options.

43. Thanks to ASCRS leadership for their support and for your participation in the 2008 Survey We look forward to your responses in the 2009 survey this autumn. Complete results now at www.duffeylaser.com