90, 100 & 110 Micron Flap Using Small Bubble Femtosecond Laser Scott M. MacRae MD Professor of Ophthalmology Professor of Visual Science University of Rochester Dr. MacRae is a paid consultant to Ziemer

Purpose: Compare Outcomes 90 vs 110 Micron Ziemer LDV Flaps 25 Eyes in each group Mean SE 90 micron group: - 6.3 D Sph. -1.0 D Cyl. 110 micron group: -4.2 D Sph. -0.6 D Cyl.

Visual Results: 90 vs 110 Micron LDV Flaps – 3 Months Postop 90 Micron Postop: SE -0.145 D + 0.34 D Sph. -O.01 Cyl. -0.22D Mean UCVA -0.02 (20/20) Mean BCVA -0.07 (20/16) 92% of eyes + 0.5 D of Plano 90 & 110 Micron Flaps obtained similar results 110 Micron SE -0.15 D + 0.30 D Sph. -0.05 D Cyl. -0.20 D Mean UCVA -0.04 (20/20) Mean BCVA -0.09 (20/16) 96% of eyes + 0.5 D of Plano

Univ. of Rochester/Ziemer LDV Nomogram Univ. of Rochester/Ziemer Keratometry Readings White to White Ring Size Hinge Width 90 µm flap 100 & 110 µm flap Steep K’s >46.5 11.5 & smaller 9.0mm 0.5 mm Steep K’s > 46.5 11.5 & larger 9.0 44.50 - 46.50 0.5 44.5 - 46.50 Average K’s 42.00- 44.50 Average K’s 42.00-44.5 11.5 and larger Flat K’s <42.00 11.5 and smaller 0.6 9.5

LDV Optimal Flap Management Control hydration – Dry LASIK Control flap thickness Ziemer: Dry ultrasound flap measurements reduces Standard Deviation LDV 110 µm separating @ 105 + 7.2 µm LDV 90 µm separating @ 90.2 + 5.7 µm Working at “Five sigma” Position flap optimally “as if it never moved” 90 micron: More delicate, drier – “potato chip Hourly prednisolone acetate day of surgery, no rainbow glare or haze compared to IL Stretch flap in “Butterfly Technique”, no microstria

Intraoperative Pachymetry: Dry Method- Dry Before First Measurement

Ziemer LDV Smaller Spot Size “Small Bubble” Strategy Less energy concentrated in one area Similar to spreading laser spots out with femto – reduces thermal energy and cavitation Cavitation rare No Transient Light Sensitivity Syndrome No rainbow glare, haze reactions No Opaque Bubble Layer

Advantages of Ziemer LDV Femtosecond Small Spot Strategy Thin flap - 90 µm strategy allows LASIK treatment thin corneas previously needing PRK Minimal or no risk of cavitation, inflammation, haze, or rainbow glare Allows deeper Rx with pockets, tunnels or deep lamellar RX without using high energy again reducing inflammation and corneal edema

90 Micron LDV Femto Small bubble technology: Makes epithelial breakthrough much less likely Opaque Bubble Layer (OBL) minor issue with LDV Start conservatively and handle like a EpiLASIK flap Patients appreciate avoiding PRK!

New Ziemer LDV 100 Micron Interspace Shields Best of both worlds LDV 100 µm separating @ 98 + 9 µm My Preferred flap thickness Minimizes PRK Easy to handle and greater comfort factor than 90 microns. Use same settings as 110 microns Flaps behave like 110 micron flaps Allows transition to 90 microns when needed with greater confidence Still use 90 microns confidently in to optimize thin flap strategy

Summary 90, 100 & 110 Micron Flaps with Ziemer LDV Outcomes Similar for 90 and 110 microns Flap thickness Ziemer LDV: LDV 110 µm separating @ 105 + 7.2 µm LDV 90 µm separating @ 90.2 + 5.7 µm LDV 100 µm separating @ 96.3 + 9 µm Working at “Five sigma” Small Bubble technology allows thinner flaps while avoiding inflammation