1. US Trends in Refractive Surgery: The 2007 ISRS/AAO Survey Richard J. Duffey, MD ** David Leaming, MD Refractive Subspecialty Day New Orleans - November 10, 2007 ** TLCV provided partial funding for this survey

2. DUFFEY 2007 Why is this presentation LAST? ä Saving the best for last…flattering but NO ä Least damaging to attendance... Probably Not ä Data just arrived via email from Analyze yesterday and is literally…Hot Off the Press

3. DUFFEY 2007 Lou Holtz “Rule of Tens” ä Fewer than 10% of you will remember more than 10% of what I said more than 10 minutes after I said it… ä So, look for the *

4. DUFFEY 2007 2007 Survey ä August mailing to 1407 U.S. members of ISRS/AAO. ä 248 responses analyzed by October 1st for 18% of the U.S. ISRS/AAO membership. ä Eleventh year of refractive data collection. ä Alphabet soup of refractive surgery including corneal and lens based surgeries.

5. DUFFEY 2007 I Am Currently Doing This Surgery * *

6. DUFFEY 2007 > 5 Cases / Month *

7. DUFFEY 2007 > 25 Cases / Month

8. DUFFEY 2007 > 75 Cases / Month

9. DUFFEY 2007 Preferred Surgery For 30 yo -12.00 Diopter Myope

10. DUFFEY 2007 Preferred Surgery For 30 yo -10.00 Diopter Myope *

11. DUFFEY 2007 Preferred Surgery For 45 yo +3.00 D Hyperope *

12. DUFFEY 2007 Preferred Surgery For 45 yo +5.00 D Hyperope *

13. DUFFEY 2007 Surgery Done Bilateral At Same O.R. Visit *

14. DUFFEY 2007 Procedure Future Index (Doing Now and/or Plan in Future)

15. DUFFEY 2007 Had Refractive Surgery Performed on Yourself *32%

16. DUFFEY 2007 Excimer Laser Most Commonly Used *

17. DUFFEY 2007 Microkeratome Most Commonly Used *23% *33% *

18. DUFFEY 2007 Topography Unit Most Commonly Used * 1.43 units/respondent

19. DUFFEY 2007 Epi-Keratome Use

20. DUFFEY 2007 Pupil Gauge Instrument Use *

21. DUFFEY 2007 Preferred Surgery for Presbyopia *35% *61%

22. DUFFEY 2007 Wavefront Analyzer *

23. DUFFEY 2007 Wavefront-Guided Custom Ablations in Your Practice *

24. DUFFEY 2007 Comanagement *

25. DUFFEY 2007 Do You Intra-operatively Measure Flap Thickness?

26. DUFFEY 2007 When Did You Start Measuring?

27. DUFFEY 2007 Preferred Flap Thickness (when no other constraints) *

28. DUFFEY 2007 Minimum Residual Stromal Bed Thickness Requirement for LASIK *

29. DUFFEY 2007 Total Cases of Post LASIK Ectasia as the Primary Surgeon in Career * Not growing

30. DUFFEY 2007 Minimum Cent. Corneal Pachymetry for LASIK (all other parameters normal) *

31. DUFFEY 2007 Mitomycin-C Use (MMC) *

32. DUFFEY 2007 Will You Perform Refractive Surgery on One-Eyed Patients

33. DUFFEY 2007 Post-Op Antibiotic

34. DUFFEY 2007 Post-Op Anti-inflammatory

35. DUFFEY 2007 Post-Op Steroid

36. DUFFEY 2007 Post-Op Nonsteroidals

37. DUFFEY 2007 Location of Phakic-IOL Surgery

38. DUFFEY 2007 ’07 ISRS/AAO Survey Conclusions ä LASIK dominates between -8D and +3D. ä P-IOL (41%) for -10D myopes (32% choose LASIK here). ä RLE for high hyperopes (60%). ä Monovision or modified mono is still the #1 choice (42%) for surgeons offering presbyopia reduction surgery, but 35% will choose implanting a modern presbyopic IOL’s for cataract and RLE surgery (lead by Restor at 16%). ä Trend is toward thinner flaps (mechanical or laser) in LASIK.

39. DUFFEY 2007 Conclusions continued... ä VisX still at > 2:1 over all other lasers. ä Intralase market share rising (28%). ä 92% perform custom ablations…and at increasing frequencies (60% whenever possible).

40. DUFFEY 2007 Conclusions continued... ä Fourth generation fluoroquinolones dominate the post-refractive surgery market (97%). ä Co-management still on the rebound after several years of decline (increased from 40% to 61% from ’04 to ’07). ä Almost one-third of us (32%) have had modern refractive surgery done on our own eyes!

41. DUFFEY 2007 Conclusions continued... ä 40% of refractive surgeons now measuring true flap thickness in the OR. ä Less than half of surgeons surveyed (44%) have had a documented case of post-LASIK ectasia in his/her surgical patients over a career, and the number of new cases has slowed significantly. ä 62% think 250 microns is adequate for RSBT after LASIK. 37% recommend 275 microns or more. ä Trend is toward thinner flaps (between 100-125).

42. DUFFEY 2007 Conclusions continued... ä 82% use MMC for prophylaxis and/or haze (up from 62% from 3 years ago). ä 57% not OK with refractive surgery on one-eyed patients. ä Bilateral extraocular sx at same O.R. visit is SOC. ä 10% of respondents OK with bilateral P-IOL at the same surgical setting (4% with RLE). ä ASC OR is preferred location for P-IOL surgery (77%). 16% OK with “In Office” modified OR.

43. DUFFEY 2007 2007 ISRS/AAO SUMMARY ä P-IOL (41%) and LASIK (32%) in high myopes. ä VisX still > 2:1 (69%) over all other lasers ä Wavefront custom ablations are increasing with 92% of surgeons performing them (60% whenever possible). ä 32% penetration of modern refractive surgery amongst refractive surgeons; 4 times the general population.

44. DUFFEY 2007 2007 ISRS/AAO SUMMARY ä MMC use on the rise (82%). ä 10% of respondents are OK with bilateral P-IOL (6% last year) and 4% with bilateral RLE at the same surgical setting. ä ReStor (16%) and ReZoom (10%) IOL’s slightly out-paced the Crystalens IOL (9%) for preferred lens-based presbyopia option. ä Femtosecond laser use on the rise (28%).

45. DUFFEY 2007 2007 ISRS/AAO SUMMARY ä Thinner flaps on the rise; 100 micron flap thickness is favored by 27% of surgeons (up from 19%). ä RSB Thickness on the rise; 62% think 250 microns is adequate, but 37% recommend 275 microns or more. ä New post-LASIK ectasia cases are on the decline.

46. Thanks to the ISRS/AAO leadership for their support and for your participation in the 2007 Survey We look forward to your response to the 2008 survey next fall Complete results at www.duffeylaser.com