Director: Gulani Vision Institute Jacksonville, Florida www.GulaniVision.com Multifocal IOL and Advanced Surface Ablation Combination for Radial Keratotomy: REVERSING the PAST Arun C. Gulani, M.D. Director: Gulani Vision Institute Jacksonville, Florida Financial Disclaimer: Dr. Gulani has no financial interest in this presentation

Raising the bar on RK-Cat Successful Laser ASA for RK Laser ASA Success in all forms of RK Multifocal IOL + Laser ASA + Cataract Success in all forms of RK = Consistent success using Laser ASA post-RK as well as Cataract surgery post-RK led us to approach RK in this detail-oriented, staged concept of refractive manipulation towards visual-freedom.

Post-RK Correction: A Refractive Challenge Surgical RK patterns, Incision placement & closure, RK fragility, Phaco technique, Myopic eye. Measurement Accuracy IOL power calculations, Ref stability, Laser measurements, Distance & Near vision outcomes Psychological Expectations RK patients are usually very knowledgeable, Type A and critical of their vision demands Vision end point for all levels Satisfactory quantity and qualitative vision with visual freedom that they were once used to. This is a pending refractive epidemic needing a consistent approach to “Turn back the Clock” - Gulani A C. 1997

“Gulani Classification” System for RK Correction: Presenting visual factors guiding surgical planning: Primary Visual factors: I. Quantitative: ∙Decreased visual acuity (Myopia, Hyperopia, Astigmatism) II. Qualitative ∙ Irregular astigmatism ∙ Small Optic Zone ∙ Radial K Scars Secondary (Associated) Visual Factors: ∙ Presbyopia ∙ Cataracts ∙ Corneal Scars ∙ Corneal Instability (thin / ectasia / trampoline effect) References: Gulani AC. Corneoplastique™. Techniques in Ophthalmology 5(1):11-20, 2007 Gulani AC. Irregular Astigmatism: Management in Unstable Cornea. Textbook of Irregular Astigmatism. Slack Inc. 2007 Gulani AC; McDonald M, Majmudar P, Koch D, Packer M, Waltz K. "Meeting the challenge of Post-RK patients”- Review of Ophthalmology, 2007; IV (10), 49-54

Hyperopia with Cataract S/P RK Two-Staged Plan Stage I: Cataract Surgery with ReStor IOL (To correct Hyperopia, Cataract & Presbyopia) Stage II: Laser Vision Surgery (ASA) (To correct Astigmatism, Residual Ref error, Expand Optical Zone and smoothen surface irregularity)

Surgical pearls Cataract Surgery Surface Laser Vision Surgery (ASA) (To correct Cataract, Ref error, Presbyopia and aim for Myopic Astigmatism) 1. Select the site of self-sealing incision based on astigmatism axis and available space between two radial incisions. If >16-32 incisions/AK crossings/instability, go limbal/scleral and use glue to seal incision. 2. Low flow techniques to keep the pressure in the eye down as you work 3. Do not move the phaco tip (Gulani Phaco-Feed technique) and instead feed the cataract and epi cortex via the second hand into the phaco so as to minimize incisional torsion and turbulence. 4. Always remember that these patients were once myopic (even though today they are presenting with hyperopia) and still have the myope’s ocular anatomy, so all the risks of cataract surgery in myopia [namely retinal issues] still apply. Surface Laser Vision Surgery (ASA) (To correct Astigmatism, Residual Ref error, Expand Optical Zone and smoothen surface Irregularity) 1. Large and Blend zones with accurate refractive axis 2. Aim for emmetropia * Role of CXL / C3R in the near future Self-sealing Corneal Incision Glued Limb-Scl Incision

Stage I: Phaco + ReStor Lens (Hyp +Astg+Presb+Cat s/p RK) -1.0D Myp,- 1.2D Astig +7.0D Hyp,- 1.2D Astig Cataract S/P RK Pre-op S/P ReStor Implant & Pre-Laser Cataract S/P RK Pre-op S/P ReStor Implant & Pre-Laser

Stage II: Laser ASA Pre op Stage I Stage II Post-Laser (Stage II) Pre-Laser (Stage I) Difference Map Astigmatism & Ant Irregularity corrected from 1.2D to 0.3D post-Laser Stage II

Pre-operative Data 9 eyes (4M, 1F) with Mean age of 59.8yrs Preop Range of Hyperopia +2.00 to +7.00 D Preop Range of Astigmatism -0.75 to -2.00D Preop SE: +2.75D Range of Follow up: 36 - 48 months RK Pattern: 8-16 incision Mean Preop VSC: 20/100 Mean Preop NVSC: 20/70 Mean Preop Vision Satisfaction: 2/10 (very poor quality & quantity of vision)

Post-operative Data Mean Post op Follow up: 39 Months (36-48 Months) Mean Post op SE: -0.2 D Mean Post op VSC: 20/25 Mean Post op NVSC: 20/25 Mean Post op Vision Satisfaction: 10/10 Improved Night Driving: 10/10 * All patients prepared for planned, two staged surgery: Cat surgery followed by Laser ASA (2 of 9 eyes did not proceed with Laser since very satisfied with vision following stage I) Professions of patients in this study: Physician, Engineer, Tri-athlete, CEO & Real Estate (All visually demanding).

Conclusion All 5 patients are very pleased with their vision at distance and near without any glasses or visual aids and in fact enjoy driving at night We are pleased with the long term stability over 3- 4 years. This Two-staged surgical approach could be the next wave of the future as we prepare to assist these challenging refractive cases.