Intraoperative Aberrometry

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

3. 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* Mark Packer, MDFinancial Disclosure (*stock options) April 1, 2010

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

6. ORange Aberrometer • Talbot moire interferometry • Fourier transform • Calculation of spectacle correction

9. 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

10. 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)

11. Methods • Enhancement by extending arcs • measured axis ± 15º of expected • (SIA + 0.5 D @ 90º) • residual cylinder ≥ 1.0 D.

15. 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

16. 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

17. 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

18. Mean Preoperative Characteristics Group 1 Group 2 p-value Age, years 63.5 61.5 0.34 ∆K, D 1.5 1.28 0.40 Axis, º 83 87 0.21 Pachy, µ 679 668 0.42

19. Postoperative Characteristics Group 1 Group 2 Mean Sphere -0.27 -0.33 Mean MRSE +0.0 -0.15 Median UCVA 20/25 20/25 MR Cyl 0.48 0.37 ≥ 0.75 D 10 (27%) 7 (23%) ≥ 1.00 D 9 (24%) 2 (6.6%) ≥ 1.25 D 4 (11%) 1 (3.3%)

20. Group 1: ∆K v MR Cyl

21. Group 2: ∆K v MR Cyl

24. 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

25. Group 2 (LRI enhanced): ∆K v MR Cyl

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

27. 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 2 - 11 months MRSE = -0.39 D (-1.1 – 0.38) MR Cyl = 1.45 D (1.0 – 2.5)

28. 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 = -0.50 D MR Cyl = 1.00 D

29. Laser enhanced: ∆K v MR Cyl

30. Comparison of Enhanced Eyes

31. 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).

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