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2 How the eye works Light rays enter the eye through the clear cornea, pupil and lens. These light rays are focused directly onto the retina, the light- sensitive tissue lining the back of the eye. The retina converts light rays into impulses, sent through the optic nerve to your brain, where they are recognized as images. 70% of the eye's focusing power comes from the cornea and 30% from the lens.

3 Refractive errors Inability to see clearly is often caused by refractive error. Four types of refractive error:  Myopia (nearsightedness)  Hyperopia (farsightedness)  Astigmatism  Presbyopia

4 Refractive errors: myopia In myopia (nearsightedness), there is too much optical power in the eye  The distance between the cornea and the retina may be too long or the power of the cornea and the lens may be too strong. Light rays focus in front of the retina instead of on it. Close objects will look clear, but distant objects will appear blurred. Myopia, or nearsightedness

5 Refractive errors: hyperopia In hyperopia (farsightedness), there is too little optical power. The distance between the cornea and the retina may be too short. Light rays are focused behind the retina instead of on it. In adults (but not children), distant objects will look clear, but close objects will appear blurred. Hyperopia, or farsightedness

6 Refractive errors: astigmatism In astigmatism, the cornea is curved unevenly—shaped more like a football than a basketball. Light passing through the uneven cornea is focused in two or more locations. Distant and close objects may appear blurry. Astigmatism occurs when light passes through football-shaped cornea and/or lens

7 Refractive errors: presbyopia Presbyopia is an age-related condition in which your eyes gradually lose the ability to see things up close, because the lens of the aging eye can no longer change shape. When we are young, the lens in our eyes is flexible and is able to change focus easily between near and far objects, like an autofocus on a camera. At around age 40, this flexibility begins to gradually decrease, making it more difficult to see objects up close, unless the eye has nearsightedness.

8 What is refractive surgery? A group of outpatient surgical procedures used to alter how your eye focuses light rays on the retina, thereby improving vision and reducing dependence on glasses and contact lenses. In most cases, refractive surgery affects the shape of your cornea to redirect how light is focused onto the retina. Popular procedures include LASIK, LASEK, PRK and CK. Refractive surgery procedure on the cornea

9 What is refractive surgery? Most refractive surgery is performed on the cornea and affects only the front of your eye, while the rest of your eye will change naturally as you age. In some cases, refractive surgery procedures don’t reshape the cornea; instead, the eye’s natural lens is either replaced or enhanced by an implantable lens that helps correct vision.

10 What are Intrastromal Corneal Ring Segments (INTACS)? A non-laser, refractive surgery procedure used to treat patients with mild forms of nearsightedness (myopia). Intacs are crescent-shaped plastic segments surgically implanted in the eye to flatten the cornea. Intacs are implanted within layers of the cornea to change the shape of the cornea, adjusting the focusing power of the eye so that light falls directly on the retina. Intacs are made of biocompatible plastic, the same material used in contact lenses and intraocular lenses used for cataract surgery. Intacs in position within the corneal stroma

11 How is the Intacs procedure performed? A pre-operative eye exam includes measurements to give the surgeon the necessary information to perform the procedure:  Refractive error measurement.  Pupil evaluation and measurement.  Tonometry: measurement of your eye’s intraocular pressure (fluid pressure inside your eye).  Corneal topography: mapping the surface details of the cornea.  Keratometry: measurement of the form and curvature of the cornea.  Pachymetry: measurement of corneal thickness. A phoropter is used to measure refractive errors

12 How is the Intacs procedure performed? Your ophthalmologist (Eye M.D.) creates a tiny opening in the cornea. A circular tunnel to the right and left of the incision is then created in the corneal stroma.  The stroma is the middle, thickest layer of tissue in the cornea.

13 How is the Intacs procedure performed? The Intacs are inserted through the opening into these tunnels and rest between the layers of stromal tissue in the cornea (but outside the central optical zone).

14 How is the Intacs procedure performed? Once in place, the Intacs raise the outer edges, flattening the center of the cornea.

15 How is the Intacs procedure performed? This change in corneal shape shifts the light rays’ point of focus onto the retina.

16 Considerations for Intacs surgery Low degree of myopia. Intacs are reversible; if your ophthalmologist removes them, the cornea usually returns to its original shape after a few weeks. Less invasive procedure than intraocular surgery, thus reducing quality-of-vision complaints.

17 Considerations for Intacs surgery Keratoconus patients (requiring special approval from a medical review board). In order to be a candidate for Intacs, patients with keratoconus must meet all of these conditions:  A steady deterioration in their vision, so that they are no longer able to achieve adequate vision on a daily basis from contact lenses or spectacles.  21 years or older.  Clear central corneas.  Corneal thickness of 450 microns or greater at proposed incision site.  Must have corneal implantation as the only remaining option to improve their functional vision.

18 Considerations against Intacs surgery High degrees of myopia, hyperopia or astigmatism. Autoimmune or autoimmune deficiency diseases. Pregnant or nursing. History of eye disease or injury (except for keratoconus, for which Intacs can be considered). Taking prescription medications that may affect corneal healing or vision. May not be recommended for patients with corneas that are too thin.

19 Risks and possible side effects of Intacs surgery Infection. Induced astigmatism. Glare or halos. Over-correction or under-correction (with a possible need for a re- treatment).

20 To be a candidate for Intacs, you should… Have a stable eyeglass prescription for at least one year. Have no health issues affecting your eyes. Be at least 21 years old.

21 Is refractive surgery right for you? Advanced surgical procedures, like Intacs, are creating more opportunities for people who want to be less dependent on glasses or contacts. Surgery may not entirely eliminate your need for corrective lenses. Glasses/contacts may still be needed for activities such as fine or detailed work, reading and perhaps night driving.

22 Is refractive surgery right for you? A large part of the success of any refractive surgery depends on your understanding of the procedure and your expectations. Since refractive surgery is an elective procedure, you have the opportunity and responsibility to become fully informed about its risks and benefits. Your ophthalmologist will explain the specific technique, its benefits, as well as possible risks and side effects associated with your case.

23 Discuss options and questions with your ophthalmologist With the help of your ophthalmologist, it’s ultimately your responsibility to weigh the risks and side effects of a procedure with the benefits it has to offer. If you decide refractive surgery is right for you, you may join millions of people who have reduced their dependence on glasses or contacts.