Intraoperative Aberrometry Mark Packer, MD, FACS Clinical Associate Professor Oregon Health & Sciences University

Mark Packer, MD Financial Disclosure (*stock options) Abbott Medical Optics, Inc. Advanced Vision Science, Inc. Bausch & Lomb Surgical, Inc. Carl Zeiss Surgical, Inc. Celgene, Inc. GE Healthcare Haag-Streit USA Ista Pharmaceuticals LensAR, Inc.* Rayner Intraocular Lenses, Ltd. Surgiview LLC* Transcend Medical, Inc.* TrueVision Systems, Inc.* WaveTec Vision Systems* April 1, 2010

Purpose To determine the effect of intraoperative wavefront- guided enhancement of limbal relaxing incisions on the rate of postoperative excimer laser enhancement

ORange Aberrometer Talbot moire interferometry Fourier transform Calculation of spectacle correction

Methods Retrospective chart review Patients having limbal relaxing incisions (LRIs) at the time of cataract or RLE surgery May 2007 to June 2009 August 2008  ORange – WaveTec, Inc., Aliso Viejo, CA

Methods Standardized LRI technique –Sim Ks (EyeSys, Tracey, Inc) –Nichamin nomogram –After IOL insertion (IOP ≥ 25 mm Hg) –10 mm OZ –Ruminson Astigmatic Gauge and Marker (Rhein Medical, Tampa, FL) –90% depth Cornea Gage Plus (Sonogage, Cleveland, OH) Stealth Triamond (Mastel Precision, Rapid City, SD)

Methods Enhancement by extending arcs –measured axis ± 15º of expected (SIA º) –residual cylinder ≥ 1.0 D.

Results - Total 67 eyes of 48 patients –62.6 ± 9.0 years –Mean pre op ∆K = 1.4 –Mean steep axis = 85º –Mean 10 mm pachy = 674 µ Post op MR Cyl at 29 days (n = 66) = 0.42 D Post op MR Cyl at 7 months (n = 34) = 0.59 D

Results – Group 1 37 eyes of 27 patients Not measured with intraoperative aberrometry –63.5 ± 9.0 years –Mean pre op ∆K = 1.5 D (0.51 – 2.64) –Mean steep axis = 83º –Mean pre op 10 mm pachy = 679 µ Post op MR Cyl at 33 days (n =36 ) = 0.48 D Post op MR Cyl at 9 months (n = 20) = 0.53 D

Results – Group 2 Total 30 eyes of 21 patients Measured with intraoperative aberrometry –61.5 ± 9.1 years –Mean pre op ∆K = 1.28 D (0.52 – 3.25) –Mean steep axis = 87º –Mean pre op 10 mm pachy = 668 µ Post op MR Cyl at 24 days (n = 28) = 0.37 D Post op MR Cyl at 5 months (n = 14) = 0.41 D

Mean Preoperative Characteristics Group 1Group 2p-value Age, years ∆K, D Axis, º Pachy, µ

Postoperative Characteristics Group 1Group 2 Mean Sphere Mean MRSE Median UCVA20/2520/25 MR Cyl ≥ 0.75 D10 (27%)7 (23%) ≥ 1.00 D 9 (24%)2 (6.6%) ≥ 1.25 D 4 (11%)1 (3.3%)

Group 1: ∆K v MR Cyl

Group 2: ∆K v MR Cyl

Results – Group 2 Enhanced 8 eyes of 6 patients Enhanced with extended LRIs –62.2 ± 12.5 years –Mean pre op ∆K = 1.75 D (0.87 – 3.25) –Mean steep axis = 82º –Mean pre op 10 mm pachy at steep axis = 655 µ Post op MR Cyl at 29 days (n = 8) = 0.31 D Post op MR Cyl at 6 months (n = 3) = 0.42 D

Group 2 (LRI enhanced): ∆K v MR Cyl

Results – Laser Enhanced 7 eyes of 5 patients (7/67 = 10.5%)

Results – Laser Enhanced Without aberrometry (Group 1)  6/37 = 16.2% 59.8 ± 3.7 years Mean pre op ∆K = 1.70 D (0.76 – 2.32) Mean steep axis = 95º Mean 10 mm pachy at steep axis = 664 µ Before excimer at months MRSE = D (-1.1 – 0.38) MR Cyl = 1.45 D (1.0 – 2.5)

Results – Laser Enhanced With aberrometry (Group 2)  1/30 = 3.3% –58 years –Pre op ∆K = 2.61 D –Steep axis = 78º –Pre op 10 mm pachy at steep axis = 658 µ Before excimer (1 month) MRSE = D MR Cyl = 1.00 D

Laser enhanced: ∆K v MR Cyl

Comparison of Enhanced Eyes Non-ORange w/LASIK enh n = 6/37 (16.2%) ORange w/LASIK enh n = 1/30 (3.3%) ORange w/LRI enh n = 8/30 (26.7%) Age: Mean, SD Pre-Op Delta K 1.70 D ( ) 2.61 D1.75 D ( ) Steep Axis95º78º82º Pre-op 10mm Pachymetry 664 microns658 microns655 microns Post LRI 1.45 D ( ) 1 month (n = 6) 1.00 D 1 month (n = 1) 0.31 D (0.00 – 1.00) 1 month (n = 8) Post LASIK D 7-16 months (n = 6) 0.42D 6 months (n = 3)

Conclusion Intraoperative wavefront guided enhancement of LRIs reduced the rate of postoperative excimer laser enhancement from 16.2% to 3.3%, an odds ratio of 5.71 (p=0.12).

Conclusion Small case-control study indicates a trend Further research (prospective, randomized) indicated to validate effect